Is it safe for a pregnant woman to continue taking dextroamphetamine-amphetamine (Adderall) and lexapro (escitalopram) for Attention Deficit Hyperactivity Disorder (ADHD) during pregnancy?

ADHD Medication Safety During Pregnancy

Continuing dextroamphetamine-amphetamine (Adderall) during pregnancy is generally safe based on the most recent 2024 guidelines, as amphetamines do not appear to be associated with major congenital malformations, and discontinuing treatment can lead to worse maternal outcomes that may harm both mother and fetus. 1

Dextroamphetamine-Amphetamine (Adderall) Safety Profile

Reassuring Evidence on Major Malformations

• Amphetamines are not associated with major congenital malformations, including cardiac malformations, or other significant adverse obstetrical or developmental outcomes 1
• The research on potential teratogenicity of ADHD medications, particularly stimulants, is largely reassuring 1

Small Potential Risks to Monitor

The following risks exist but are small in magnitude and not consistently found across studies:

• Gastroschisis: Possible increased risk (adjusted OR 3.0; 95% CI, 1.2-7.4), but this comes from one study with possible confounding, and the absolute risk remains extremely small given the population prevalence of only 0.05% 1
• Preeclampsia: Possible small increased risk (adjusted RR 1.29; 95% CI, 1.11-1.49), though other studies have not found this association 1
• Preterm birth: Possible small increased risk when stimulant use continues in the second half of pregnancy (adjusted RR 1.30; 95% CI, 1.10-1.55) 1

Risks of Discontinuing Treatment

• Discontinuing psychostimulant treatment during pregnancy leads to worse mental health outcomes and significant functional impairments in the pregnant individual 1
• Untreated ADHD is associated with increased risks for spontaneous abortion and preterm birth 1
• Recent research from 2024 found that women who ceased dexamphetamine during pregnancy had greater odds of threatened abortion (OR 2.28; 95% CI 1.00-5.15) compared to those who continued 2

Lexapro (Escitalopram) Considerations

The evidence provided does not specifically address escitalopram safety in pregnancy. However, the general principle from the ADHD guidelines applies: treatment should not be stopped if required for daily functioning, as the risks of untreated psychiatric illness during pregnancy can negatively impact both mother and fetus 1.

Management Recommendations

Decision Framework

The consensus is that the magnitude of documented risks is very low and that treatment with medications should not be stopped if they are required for the daily functioning of the pregnant person 1.

Practical Strategies

• Consider intermittent use on an as-needed basis to maximize functioning while reducing overall fetal exposure, given that stimulants have rapid effects 1
• Use the lowest effective dose that maintains adequate daily functioning 1
• Monitor pregnancy carefully, including fetal growth, blood pressure checks, and ensuring appropriate weight gain 1

Alternative Considerations

• Switching to bupropion is a possibility, particularly for individuals requiring treatment for co-occurring depression, given available safety data in the perinatal period 1
• However, bupropion is not as efficacious as stimulants for ADHD treatment 1
• Methylphenidate may be preferred over amphetamines if switching stimulants is considered 3

Non-Pharmacological Options

• Dialectical Behavior Therapy (DBT) can be considered as an adjunct or alternative, with four modules addressing mindfulness skills, distress tolerance, interpersonal effectiveness, and emotion regulation 1
• DBT has shown decreased ADHD symptoms, improved neuropsychological functioning, and reduction of co-existing anxiety and depression 1

Critical Monitoring During Pregnancy

Maternal Monitoring

• Blood pressure checks for preeclampsia risk 1
• Appropriate weight gain throughout pregnancy 1
• Fetal growth monitoring 1

Neonatal Monitoring at Birth

• Monitor infant carefully for irritability, insomnia, and feeding difficulty 1

Important Caveats

• This information applies to therapeutic use of amphetamines during pregnancy and does not apply to non-prescribed amphetamine use in persons with stimulant use disorder 1
• The functional impairment from untreated ADHD can significantly impact the ability to care for the child safely, quality of parent-child interactions, and overall mental health 3
• Engage in a risk-benefit discussion regarding continuing the currently well-tolerated, effective dose versus considering intermittent use 1