Is it safe to take Ativan (lorazepam) while pregnant?

Ativan (Lorazepam) Use During Pregnancy

Lorazepam should be avoided during pregnancy, particularly in the first trimester, due to potential risks of congenital malformations and neonatal complications, and should only be used when the benefits clearly outweigh the risks to both mother and fetus. 1

Key Safety Concerns

Congenital Malformations

• An increased risk of congenital malformations has been suggested with benzodiazepines (including lorazepam, diazepam, and chlordiazepoxide) during the first trimester of pregnancy. 1
• Animal studies have shown occasional anomalies including reduction of tarsals, tibia, metatarsals, malrotated limbs, gastroschisis, malformed skull, and microphthalmia in drug-treated rabbits, though the clinical significance remains uncertain. 1
• At higher doses (40 mg/kg and above), evidence of fetal resorption and increased fetal loss was observed in animal studies. 1

Neonatal Complications

• Infants born to mothers who used benzodiazepines during late pregnancy or at delivery may experience withdrawal symptoms during the postnatal period. 1
• Neonates may present with hypoactivity, hypotonia, hypothermia, respiratory depression, apnea, feeding problems, and impaired metabolic response to cold stress. 1
• Lorazepam and its metabolite (lorazepam glucuronide) cross the placenta, as evidenced by umbilical cord blood levels. 1

Clinical Decision-Making Algorithm

If Anxiety Treatment is Needed During Pregnancy:

First-line approach:

• Attempt non-pharmacological interventions before considering medication. 2
• If medication is absolutely necessary, consider benzodiazepines with longer safety records (such as chlordiazepoxide, which appears safer based on available data). 2

If lorazepam must be used:

• Avoid use during the first trimester entirely to minimize risk of congenital malformations. 1, 2
• Use the lowest effective dose for the shortest possible duration. 2, 3
• Divide daily dosage into 2-3 doses to avoid high peak concentrations. 2
• Use as monotherapy rather than in combination with other medications. 2, 3

Timing considerations:

• The FDA label explicitly states: "Because the use of these drugs is rarely a matter of urgency, the use of lorazepam during this period should be avoided." 1
• Women of childbearing potential should be counseled about pregnancy risk before starting lorazepam. 1

Monitoring Requirements

During Pregnancy:

• Patients who become pregnant while taking lorazepam should immediately communicate with their physician about discontinuing the drug. 1
• If continued use is deemed necessary in late pregnancy, prepare neonatal care team for potential complications. 1

At Delivery and Postpartum:

• Monitor newborns closely for withdrawal symptoms including irritability, tremors, and feeding difficulties. 1
• Watch for signs of neonatal toxicity: hypoactivity, hypotonia, hypothermia, respiratory depression, apnea, and feeding problems. 1

Lactation Considerations

Lorazepam should not be administered to breastfeeding women unless the expected benefit clearly outweighs the potential risk to the infant. 1

• Lorazepam is detected in human breast milk. 1
• Sedation and inability to suckle have been reported in neonates of lactating mothers taking benzodiazepines. 1
• Infants should be observed for sedation and irritability if breastfeeding continues. 1
• Based on older literature, lorazepam during lactation may cause lethargy, sedation, and weight loss in infants. 2

Critical Caveats

Confounding by Indication:

• The underlying anxiety disorder itself may contribute to adverse pregnancy outcomes independent of medication use. 4, 5
• Untreated maternal psychiatric illness carries significant risks including poor prenatal care adherence, substance use, and adverse pregnancy outcomes. 6
• However, this does not negate the documented risks of benzodiazepine exposure, particularly for lorazepam. 1

Abrupt Discontinuation Risk:

• While abrupt discontinuation of psychiatric medications can precipitate relapse, the FDA label for lorazepam specifically indicates that use during pregnancy should be avoided when possible. 1
• Any discontinuation should be done gradually under medical supervision to prevent withdrawal in the mother. 2

Alternative Considerations:

• If concurrent opioid use disorder is present, methadone may be more appropriate than buprenorphine when benzodiazepines are being used, though buprenorphine should not be withheld solely due to benzodiazepine use. 7