What is the recommended treatment for restless leg syndrome (RLS) in pregnant women?

Treating Restless Leg Syndrome in Pregnancy

In pregnant women with RLS, prioritize iron supplementation when ferritin ≤75 ng/mL or transferrin saturation <20%, followed by non-pharmacological interventions, with gabapentin reserved only for severe refractory cases after careful risk-benefit discussion. 1

Initial Assessment and Iron Status

The American Academy of Sleep Medicine explicitly states that RLS is common in pregnancy and prescribers must consider pregnancy-specific safety profiles for each treatment. 1 This fundamentally changes the treatment algorithm compared to non-pregnant adults.

Check morning fasting serum ferritin and transferrin saturation as the first diagnostic step, avoiding iron-containing supplements for at least 24 hours before blood draw. 1 The iron supplementation threshold for RLS differs from general population guidelines:

• Supplement with oral or IV iron if ferritin ≤75 ng/mL or transferrin saturation <20% 1
• Consider IV iron alone if ferritin is between 75-100 ng/mL 1
• Iron deficiency is particularly common in pregnancy and addressing this can significantly improve symptoms without medication exposure 2, 3

Non-Pharmacological Management (First-Line in Pregnancy)

Before considering any medications, address all exacerbating factors: 1

• Eliminate or reduce caffeine and alcohol 1
• Discontinue antihistaminergic medications (common in pregnancy for nausea) 1
• Avoid serotonergic and antidopaminergic medications 1
• Screen for and treat obstructive sleep apnea if present 1
• Implement moderate exercise and consider smoking cessation 4

Non-pharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. 2

Pharmacological Treatment (When Non-Pharmacological Fails)

Medications with Better Safety Data in Pregnancy

While the 2025 American Academy of Sleep Medicine guidelines strongly recommend gabapentin, gabapentin enacarbil, and pregabalin as first-line therapy for RLS in general adults 1, the pregnancy context requires extreme caution. Older literature suggests that medications with more extensive safety records in pregnancy include opioids, antiepileptics such as carbamazepine and gabapentin, and certain benzodiazepines. 3

For severe, refractory cases in pregnancy:

• Gabapentin may be considered after thorough discussion of risks and benefits, as it has a more established (though not perfect) safety profile compared to newer agents 3, 5
• Start at the lowest effective dose and titrate cautiously 1
• Monitor for somnolence and dizziness, which are common side effects 1

Medications to Avoid in Pregnancy

Dopamine agonists (pramipexole, ropinirole, rotigotine) are NOT recommended during pregnancy despite being previously used for RLS, as there is very little information on teratogenic risks and the American Academy of Sleep Medicine now recommends against their standard use even in non-pregnant adults due to augmentation risk. 1, 3, 6

Clinical Algorithm for Pregnancy-Related RLS

1. Confirm diagnosis using the four essential RLS criteria 4
2. Check morning fasting ferritin and transferrin saturation 1
3. Supplement iron if ferritin ≤75 ng/mL or transferrin saturation <20% (oral ferrous sulfate or IV formulations) 1
4. Eliminate exacerbating factors (caffeine, alcohol, antihistamines, etc.) 1
5. Implement non-pharmacological interventions (exercise, sleep hygiene) 2, 7
6. For severe refractory cases only: Consider gabapentin after detailed informed consent discussion 3, 5
7. Reassess after delivery, as pregnancy-related RLS often resolves postpartum 2, 7

Critical Pitfalls to Avoid

• Do not skip iron studies - approximately 20% of pregnant women develop RLS, and iron deficiency is a major reversible contributor 2, 3
• Do not use dopamine agonists as first-line despite older literature suggesting them, given lack of pregnancy safety data and current guidelines recommending against standard use 1, 3
• Do not assume all RLS in pregnancy requires medication - many cases respond to iron supplementation and non-pharmacological measures alone 2, 7
• Do not forget that symptoms often improve or resolve after delivery, making aggressive pharmacological intervention during pregnancy less justified 2, 7