What are safe sleep medications for pregnant women?

Safe Sleep Medications During Pregnancy

Non-pharmacological approaches should be the first-line treatment for sleep disorders during pregnancy, as most medications carry some risk to the developing fetus.

Non-Pharmacological Approaches (First-Line)

• Implement sleep hygiene measures including maintaining a regular sleep schedule, keeping the sleep environment dark and comfortable, avoiding heavy meals near bedtime, and limiting exposure to screens before bedtime 1
• Engage in regular physical activity, which may improve sleep quality during pregnancy 1
• Consider cognitive behavioral therapy (CBT), which has shown effectiveness for treating sleep disturbances 1
• Use relaxation techniques and mind-body interventions such as mindfulness meditation 1
• Address physical discomforts that may be contributing to sleep problems (lower back pain, gastroesophageal reflux, frequent urination) 2

Sleep Disorders in Pregnancy

• Sleep disturbances affect more than 50% of pregnancies and tend to worsen as pregnancy progresses 3, 2
• Common sleep disorders during pregnancy include insomnia, obstructive sleep apnea, and restless legs syndrome 3
• Poor sleep during pregnancy is associated with reduced quality of life 4 and may increase risk for adverse pregnancy outcomes 5
• Educational interventions about sleep healthy behaviors have been shown to improve quality of life in pregnant women with sleep disorders 6

Pharmacological Options (When Non-Pharmacological Approaches Fail)

Antihistamines

• Doxylamine: FDA labeling advises to consult a healthcare professional before use during pregnancy 7
• Diphenhydramine: FDA labeling indicates pregnant women should ask a healthcare professional before use 8
  • Both medications carry warnings about potential drowsiness and should be used with caution

Antidepressants (for comorbid depression and sleep issues)

• Sertraline is one of the preferred antidepressants during pregnancy due to its favorable safety profile 9
  • Use the lowest effective dose and monitor maternal mental health closely 9
  • Arrange for early follow-up after hospital discharge for infants exposed to sertraline in the third trimester to monitor for neonatal adaptation syndrome 9

Medications to Avoid or Use with Extreme Caution

• Mavacamten is contraindicated during pregnancy due to potential teratogenic effects 1
• Sodium oxybate has insufficient safety data for use during pregnancy 1
• Pitolisant may cause fetal harm based on animal data and may reduce the effectiveness of oral contraceptives 1
• Methylphenidate may cause fetal harm based on animal data 1
• SSRIs (other than sertraline) in the third trimester may be associated with neonatal adaptation syndrome including irritability, tremors, feeding difficulties, and respiratory distress 1

Special Considerations

• Sleep disorders during pregnancy should be taken seriously as they can impact maternal and fetal health 2, 5
• Untreated sleep disorders may contribute to pregnancy complications, including gestational hypertension and diabetes 2
• For pregnant women with pre-existing sleep disorders, a multidisciplinary approach involving maternal-fetal medicine specialists may be beneficial 1
• Regular monitoring with serial echocardiography may be reasonable for pregnant women with certain cardiovascular conditions that affect sleep 1

Algorithm for Management

1. Begin with comprehensive sleep hygiene education and non-pharmacological approaches 1
2. If sleep disturbance persists and requires medication:
   • For occasional use: Consider doxylamine or diphenhydramine after consulting healthcare provider 7, 8
   • For comorbid depression and sleep issues: Consider sertraline at lowest effective dose 9
3. Monitor for effectiveness and side effects regularly throughout pregnancy 9
4. Arrange for appropriate follow-up after delivery, especially if medications were used in the third trimester 1, 9