Is Adderall (amphetamine and dextroamphetamine) safe to use during pregnancy?

Adderall and Pregnancy

Adderall can be continued during pregnancy if required for daily functioning, as the available safety data is largely reassuring and the magnitude of documented risks is very low, particularly when weighed against the risks of untreated ADHD. 1

Risk-Benefit Framework

The 2024 American Journal of Obstetrics and Gynecology guidelines emphasize that the decision to use ADHD medications during pregnancy must weigh the risks of medication exposure against the risks of untreated or inadequately treated ADHD. 1 The consensus from the most recent evidence is that treatment with medications should not be stopped if they are required for the daily functioning of the pregnant person. 1

Safety Profile for Adderall (Amphetamines) in Pregnancy

Congenital Malformations

• A recent large, well-controlled study demonstrated no increased risks for the use of amphetamine or dexamphetamine during pregnancy on long-term outcomes. 1
• The majority of studies do not find an increased risk for congenital malformations with amphetamine exposure. 1
• The FDA classifies amphetamines as Pregnancy Category C, indicating animal studies showed embryotoxic and teratogenic effects at 41 times the maximum human dose in mice, but there are no adequate well-controlled studies in pregnant women. 2

Pregnancy Complications

• In adjusted analyses, amphetamine exposure during early pregnancy was associated only with an increased risk of preeclampsia, with a number needed to harm of approximately 63. 3
• Amphetamines were NOT associated with increased risk of placental abruption, small for gestational age, or preterm birth in fully adjusted analyses. 3
• One 2024 study found that ceasing dexamphetamine during pregnancy was associated with increased odds of threatened abortion compared to continuing treatment (OR: 2.28; 95%CI: 1.00,5.15). 4

Neonatal Outcomes

• Infants born to mothers dependent on amphetamines have an increased risk of premature delivery and low birth weight, and may experience withdrawal symptoms including dysphoria, agitation, and significant lassitude. 2
• However, these risks must be contextualized against the functional impairment from untreated ADHD. 1

Treatment Algorithm During Pregnancy

Preconception Planning

• Encourage pregnancy planning for all patients with ADHD. 1
• If taking Adderall, consider a trial of gradually discontinuing the medication before pregnancy ONLY if it will not severely impact daily functioning. 1
• If unable to discontinue, continue with current medication at the lowest effective dose or consider intermittent use. 1

During Pregnancy

• Continue Adderall if required for daily functioning, using the lowest effective dose. 1
• Consider intermittent use on an as-needed basis to maximize functioning while reducing overall fetal exposure, as stimulants have rapid onset and offset. 1
• Monitor pregnancy carefully, including fetal growth, blood pressure checks (given preeclampsia risk), and ensuring appropriate weight gain. 1

Alternative Approaches

• For mild to moderate ADHD, consider non-pharmacologic treatments first, including cognitive behavioral therapy (CBT), which has the strongest evidence base. 1
• Consider switching to bupropion in the perinatal period, particularly for individuals requiring treatment for co-occurring depression, though it is less efficacious than stimulants for ADHD. 1
• Methylphenidate is an alternative stimulant with similar safety data. 1

Breastfeeding Considerations

• Amphetamines are excreted in human milk, and the FDA label states mothers taking amphetamines should be advised to refrain from nursing. 2
• However, the 2024 AJOG guidelines state that treatment with ADHD medications should not be stopped if required for daily functioning of the breastfeeding person, as the magnitude of documented risks is very low. 1, 5
• Methylphenidate may be preferred over amphetamines for breastfeeding, with a relative infant dose of less than 1% and no reported adverse effects in breastfed infants. 1, 5
• If continuing Adderall while breastfeeding, take immediately after a breastfeeding session and use the lowest effective dose. 5
• Monitor infant for irritability, sleep disturbances, feeding difficulties, and appropriate weight gain. 5

Critical Caveats

• 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. 5
• Consider referral to a reproductive psychiatrist if you have concerns about safety or need support with ongoing management. 1
• Develop an individualized treatment plan that includes education about signs of deteriorating mental health and strategies for supporting mental wellness, particularly prioritizing sleep and nutrition. 1
• Both medications are Schedule II controlled substances with abuse potential and should be avoided in patients with uncontrolled hypertension, coronary artery disease, tachyarrhythmias, or active substance use disorders. 6