What are the clinical guidelines for a 29-year-old female on dextroamphetamine-amphetamine (amphetamine) extended release 10mg who just found out she is pregnant?

Management of Amphetamine-Dextroamphetamine in Newly Diagnosed Pregnancy

Discuss discontinuation versus continuation of amphetamine-dextroamphetamine with this patient, strongly considering non-pharmacological interventions for ADHD management during pregnancy, as the American College of Obstetricians and Gynecologists recommends this approach. 1

Immediate Clinical Decision-Making

Risk Assessment Framework

The FDA classifies dextroamphetamine as Pregnancy Category C, meaning it should be used only if the potential benefit justifies the potential risk to the fetus 2, 3. The decision hinges on:

• Severity of ADHD symptoms and functional impairment: If the patient cannot maintain daily functioning, employment, or safety without medication, continuation may be warranted 1
• Ability to implement non-pharmacological interventions: Behavioral strategies, organizational coaching, and environmental modifications should be attempted first 1
• Patient's psychiatric comorbidities: Many women on stimulants have co-occurring conditions that complicate discontinuation 4

Documented Pregnancy Risks

Amphetamines cross the placental barrier, and while they do not appear associated with major congenital malformations including cardiac defects, there are specific risks to discuss 1:

• Gastroschisis: Adjusted odds ratio 3.0 (95% CI, 1.2-7.4) - a small but measurable increased risk 1
• Preeclampsia: Adjusted relative risk 1.29 (95% CI, 1.11-1.49) when used in first half of pregnancy 1, 5
• Preterm birth: Adjusted relative risk 1.30 (95% CI, 1.10-1.55) with continued use in second half of pregnancy 1, 5
• Possible increased risk of spontaneous abortion, though confounding by indication cannot be ruled out 1

The absolute increases in these risks are small 5. One case report exists of severe congenital bony deformity, tracheoesophageal fistula, and anal atresia (VATER association) in an infant exposed to dextroamphetamine with lovastatin in the first trimester 2, 3.

Clinical Management Algorithm

If Discontinuing Medication

1. Taper gradually if the patient has been on chronic therapy to avoid withdrawal symptoms and functional decompensation 2, 3
2. Implement non-pharmacological ADHD management: structured routines, external reminders, organizational tools, workplace accommodations 1
3. Monitor for psychiatric decompensation: depression, anxiety, functional impairment that could affect prenatal care adherence 4
4. Schedule closer follow-up during first trimester to assess coping and safety 1

If Continuing Medication

1. Use the lowest effective dose that maintains functioning - she is currently on 10 mg extended release, which is a relatively low dose 1
2. Avoid use in second half of pregnancy if possible due to increased preterm birth risk with continued use after 20 weeks 1, 5
3. Establish baseline and monitor for:
   • Blood pressure at each visit (preeclampsia risk) 1, 5
   • Fetal growth via serial ultrasounds in third trimester 1
   • Signs/symptoms of preterm labor 1, 5
4. Counsel about neonatal monitoring needs: Infants require careful observation for irritability, insomnia, and feeding difficulties after delivery 1

Critical Timing Consideration

The risk profile differs by gestational timing: Early pregnancy exposure (conception to 21 weeks) carries gastroschisis and preeclampsia risks, while continued use after 22 weeks specifically increases preterm birth risk 1, 5, 6. This creates a decision point at mid-pregnancy to reassess continuation.

Important Caveats

• This guidance applies only to therapeutic prescribed use, not to amphetamine use disorder or non-prescribed use 1
• Birthweight does not appear significantly affected: One study found only a 26.9 g difference (95% CI -141 to 195 g, p=0.75) between exposed and unexposed infants 4
• No evidence of major malformations: Unlike some medications, amphetamines have not been linked to cardiac or other major structural defects 1
• Functional impairment from untreated ADHD can significantly impact prenatal care adherence, nutrition, safety behaviors, and ability to prepare for parenting 7

Documentation Requirements

Document in the medical record:

• Discussion of risks and benefits with specific mention of gastroschisis, preeclampsia, and preterm birth 1, 5
• Patient's functional status and severity of ADHD 1
• Shared decision-making process 1
• Plan for enhanced monitoring if continuing medication 1