Insomnia in Pregnancy: Recommended Treatments
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for insomnia during pregnancy and should be initiated before any pharmacological intervention. 1, 2 This recommendation extends from general adult insomnia guidelines to the pregnant population, where the risk-benefit ratio of behavioral interventions is particularly favorable. 3
Evidence Supporting CBT-I in Pregnancy
Digital CBT-I demonstrates significant efficacy in pregnant women, reducing insomnia severity by approximately 5 points on the Insomnia Severity Index and improving sleep quality by 3 points on the Pittsburgh Sleep Quality Index during pregnancy, with sustained benefits extending 6 weeks postpartum including 40 minutes longer sleep duration compared to controls. 4
Group CBT-I delivered during pregnancy produces medium to large effect sizes, with significant reductions in insomnia symptoms, improved sleep efficiency, shorter sleep onset latency, and concurrent improvements in depression, pregnancy-specific anxiety, and fatigue. 5
Multiple delivery formats are effective, including in-person individual therapy, group sessions, telephone-based programs, web-based modules, and self-help books, addressing common barriers such as cost, geographic limitations, and provider availability during pregnancy. 1, 2
Core Components of CBT-I for Pregnant Women
Sleep restriction therapy limits time in bed to match actual sleep time, consolidating sleep and increasing sleep drive. 3
Stimulus control therapy re-establishes the bed as a cue for sleep rather than wakefulness by having patients leave bed when unable to sleep and return only when sleepy. 3
Cognitive restructuring addresses maladaptive thoughts about sleep and pregnancy-related sleep concerns, reducing anxiety about sleep loss. 3, 1
Sleep hygiene education includes avoiding excessive caffeine, evening alcohol (already contraindicated in pregnancy), late exercise, and optimizing sleep environment, though this is insufficient as monotherapy. 1, 2
Special Considerations for Pregnancy
Exercise caution with sleep restriction in pregnant women with seizure disorders or bipolar disorder due to potential effects of sleep deprivation. 2
Improvements are gradual but durable, with benefits sustained up to 2 years beyond treatment end, unlike pharmacotherapy which shows degradation after discontinuation. 1, 2
Treatment typically requires 4-8 sessions over 6 weeks, with initial mild sleepiness and fatigue typically resolving quickly. 2
Pharmacological Treatment: When and What to Consider
Critical Context for Medication Use
Pharmacological treatment should only be considered when CBT-I is insufficient, unavailable, or while CBT-I is being implemented, and should supplement—not replace—behavioral interventions. 1, 6 The evidence for medication safety in pregnancy is extremely limited, and most sleep medications lack robust pregnancy-specific data. 7
Medication Options with Pregnancy Considerations
Over-the-counter antihistamines (e.g., diphenhydramine) are not recommended despite being the most commonly recommended (53%) and utilized (39%) intervention by pregnant women with moderate to severe insomnia, due to lack of efficacy data, daytime sedation, and delirium risk. 1, 6, 8
Benzodiazepines and benzodiazepine receptor agonists (BzRAs) such as zolpidem, eszopiclone, and temazepam are first-line options in non-pregnant adults but carry significant concerns in pregnancy including potential teratogenicity, neonatal withdrawal, and floppy infant syndrome, requiring careful risk-benefit assessment. 6, 7
Ramelteon (8 mg) for sleep onset insomnia has a different mechanism of action (melatonin receptor agonist) and may be considered, though pregnancy-specific data are limited. 6
Low-dose doxepin (3-6 mg) for sleep maintenance insomnia is an option in non-pregnant adults, but tricyclic antidepressants in pregnancy require consideration of potential cardiac effects and neonatal adaptation syndrome. 6, 7
Trazodone is commonly used off-label for insomnia in pregnancy despite limited efficacy data and is not recommended by guidelines for general insomnia treatment. 6, 7
Melatonin has insufficient evidence to determine efficacy for chronic insomnia and lacks robust pregnancy safety data. 2, 7
Medications to Avoid
Long-acting benzodiazepines carry increased risks without clear benefit, including prolonged neonatal sedation. 1
Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects and lack of indication for primary insomnia. 1
Herbal supplements (e.g., valerian) are not recommended due to insufficient evidence of efficacy and unknown pregnancy safety profiles. 6
Treatment Algorithm for Pregnant Women with Insomnia
Step 1: Initial Assessment and Non-Pharmacological Intervention
Screen for insomnia using validated tools such as the Insomnia Severity Index, as insomnia is under-detected during pregnancy with only 39% of pregnant women reporting discussion of sleep with providers and only 28% of those with moderate to severe symptoms receiving a diagnosis. 8
Assess for underlying sleep disorders including obstructive sleep apnea (which increases in pregnancy), restless legs syndrome (common in pregnancy due to iron deficiency), and circadian rhythm disorders. 2
Initiate CBT-I immediately through the most accessible format (digital platforms may be particularly suitable for pregnant women with mobility or scheduling constraints). 1, 4
Step 2: Optimize Behavioral Interventions
Implement comprehensive sleep hygiene including regular sleep-wake schedule, optimized sleep environment (cool, dark, quiet), and avoidance of caffeine after early afternoon. 1
Address pregnancy-specific sleep disruptors such as nocturia, fetal movement, physical discomfort, and anxiety about childbirth. 5
Monitor response over 4-8 weeks, as improvements are gradual but sustained. 2
Step 3: Consider Pharmacotherapy Only When Necessary
Use shared decision-making to discuss limited pregnancy-specific safety data, potential risks to fetus and neonate, and alternative strategies. 2
Select medication based on symptom pattern: For sleep onset difficulty, consider ramelteon or short-acting BzRAs; for sleep maintenance, consider intermediate-acting BzRAs, though all carry pregnancy concerns. 6
Use the lowest effective dose for the shortest duration possible, typically less than 4 weeks for acute exacerbations. 1
Continue or intensify CBT-I alongside any pharmacotherapy, as medication should supplement behavioral treatment. 6
Step 4: Monitoring and Reassessment
Regular follow-up is essential to assess effectiveness, side effects, and need for medication adjustments, particularly as pregnancy progresses and physiological changes affect sleep. 6
Reassess for psychiatric comorbidities including depression and anxiety, which are common in pregnancy and may require integrated treatment. 5, 7
Plan for postpartum period, as insomnia often persists or worsens after delivery, and CBT-I benefits extend into the postpartum period. 4
Common Pitfalls to Avoid
Do not start with medications before attempting CBT-I, as this violates guideline recommendations and deprives pregnant women of more effective, durable therapy with no fetal risk. 1, 2
Do not rely on sleep hygiene education alone, as it lacks efficacy as a single intervention and must be combined with other CBT-I components. 1, 2
Do not prescribe over-the-counter antihistamines despite their common use, as they lack efficacy data and carry safety concerns. 1, 6
Do not continue pharmacotherapy long-term without periodic reassessment, particularly given the unknown long-term effects on fetal development. 6
Do not fail to screen for insomnia during prenatal visits, as current detection rates are inadequate with only 57% of women with moderate to severe symptoms discussing sleep with providers. 8
Critical Gap in Current Practice
There is a significant disconnect between evidence-based recommendations and actual clinical practice in pregnancy, with over-the-counter medications being the most commonly recommended intervention despite lack of supporting evidence, while CBT-I—the treatment with the strongest evidence—is rarely offered. 8, 9 This represents an urgent need for implementation of effective programs in standard prenatal care and increased provider education about pregnancy-specific insomnia management. 9