From the FDA Drug Label
The clinical significance of the above findings is not known However, an increased risk of congenital malformations associated with the use of minor tranquilizers (chlordiazepoxide, diazepam, and meprobamate) during the first trimester of pregnancy has been suggested in several studies. Because the use of these drugs is rarely a matter of urgency, the use of lorazepam during this period should be avoided
The best treatment for insomnia in a patient in the first trimester of pregnancy is not lorazepam, as its use should be avoided during this period due to the potential increased risk of congenital malformations.
- Alternative treatments should be considered for managing insomnia in pregnant women.
- The decision to use any medication during pregnancy should be made after consulting a physician and weighing the potential benefits and risks 1.
From the Research
For a first trimester pregnant patient with insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment, as it has been shown to be effective in improving insomnia severity and sleep quality, with high-quality evidence supporting its use 2. Non-pharmacological approaches should be tried first, including maintaining good sleep hygiene by establishing a regular sleep schedule, creating a comfortable sleep environment, avoiding caffeine and electronic devices before bedtime, and practicing relaxation techniques such as meditation or deep breathing exercises. If medication becomes necessary, diphenhydramine (Benadryl) 25-50mg at bedtime can be used short-term as it has a long safety record in pregnancy, as noted in previous studies 3. Other options that may be considered under medical supervision include doxylamine (Unisom) 12.5-25mg at bedtime. Prescription medications like low-dose trazodone (25-50mg) might be considered in severe cases when benefits outweigh risks. Benzodiazepines and newer sleep medications like zolpidem should generally be avoided during pregnancy, especially in the first trimester, due to potential risks to the developing embryo. The preference for CBT-I over pharmacotherapy is also supported by studies examining treatment preferences among pregnant women and their partners 4. Additionally, the prevalence of insomnia symptoms during pregnancy is significant, with a meta-analysis estimating an overall prevalence of 38.2% 5. Key considerations in managing insomnia during pregnancy include:
- Prioritizing non-pharmacological approaches to minimize medication exposure
- Using CBT-I as the first-line treatment
- Selecting medications with a known safety record in pregnancy, if necessary
- Avoiding benzodiazepines and newer sleep medications, especially in the first trimester
- Monitoring and discussing individual risks and benefits with a healthcare provider.