What are the effects of stimulants on pregnancy?

From the Guidelines

Stimulants should be used with caution during pregnancy, and the decision to continue or initiate treatment should be made on a case-by-case basis, considering the potential risks and benefits to both the mother and the fetus. According to the most recent study by Scoten, published in the American Journal of Obstetrics and Gynecology in 2024 1, if a woman is taking a psychostimulant, she should engage in a risk-benefit discussion with her healthcare provider regarding continuing her currently well-tolerated, effective dose or considering intermittent use.

Key Considerations

• The study suggests that methylphenidate does not seem to be associated with major congenital malformations or other significant adverse obstetrical or developmental outcomes 1.
• However, possible increased risks for cardiac malformations, gastroschisis, preeclampsia, preterm birth, and poor neonatal adaptation have been reported, although these risks seem to be small and not consistently found across studies 1.
• Amphetamine mixed salts and dextroamphetamine may also be associated with small increased risks for certain adverse outcomes, but the evidence is limited and inconclusive 1.
• Non-stimulant alternatives like bupropion may be considered in some cases, particularly for individuals requiring treatment for co-occurring depression, given the available safety data for this drug in the perinatal period 1.

Management Plan

• Women with ADHD who are pregnant or planning pregnancy should consult with both their psychiatrist and obstetrician to develop a management plan that takes into account their individual needs and circumstances.
• The plan should include careful monitoring of pregnancy, fetal growth, blood pressure checks, and ensuring appropriate weight gain.
• If stimulant treatment is necessary, the lowest effective dose should be used, and intermittent use or switching to a non-stimulant option may be considered.
• Breastfeeding safety should be discussed, and monitoring of infant development and weight gain should be ensured.

From the FDA Drug Label

Published studies and postmarketing reports on methylphenidate use during pregnancy have not identified a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. There may be risks to the fetus associated with the use of CNS stimulants use during pregnancy No effects on morphological development were observed in embryo-fetal development studies with oral administration of methylphenidate to pregnant rats and rabbits during organogenesis at doses up to 12 and 19 times, respectively, the maximum recommended human dose (MRHD) of 60 mg/day given to adults on a mg/m2 basis CNS stimulants, such as methylphenidate hydrochloride oral solution, can cause vasoconstriction and thereby decrease placental perfusion

The use of methylphenidate during pregnancy has not been directly associated with a risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. However, CNS stimulants may pose risks to the fetus, including vasoconstriction and decreased placental perfusion. Key points to consider include:

• Embryo-fetal development studies in rats and rabbits showed no morphological development effects at doses up to 12 and 19 times the maximum recommended human dose (MRHD), respectively.
• Risks to the fetus may be associated with CNS stimulant use during pregnancy.
• Pre- and post-natal development studies in rats showed decreased offspring body weight gain at high doses, but no other effects on postnatal development were observed. It is essential to weigh the potential benefits and risks of methylphenidate use during pregnancy, considering the individual patient's circumstances and consulting the National Pregnancy Registry for Psychostimulants 2.

From the Research

Stimulants and Pregnancy: Key Findings

• The use of stimulants during pregnancy has been associated with increased risks of adverse perinatal, neonatal, and childhood outcomes 3.
• Methylphenidate, a commonly used stimulant for ADHD, has been linked to a small but significant increased risk of major malformations, particularly cardiac malformations, in exposed offspring 4.
• Amphetamines, another type of stimulant, may slightly increase the risk of premature birth, low birth weight, and other pregnancy complications 5.

Safety of Specific Stimulants

• Methylphenidate: generally considered safe, but may increase the risk of cardiac malformations 4, 5.
• Amphetamines: may increase the risk of premature birth, low birth weight, and other pregnancy complications 5.
• Bupropion: appears to be safe in pregnancy, with no increased risk of congenital anomalies 5, 6.

Breastfeeding and Stimulants

• Methylphenidate: considered safe for breastfeeding, with low concentrations in infant's blood 6, 7.
• Amphetamines: contraindicated for breastfeeding due to high concentrations in infant's blood 6.
• Bupropion: considered safe for breastfeeding, with low concentrations in infant's blood 6.

Clinical Implications

• The treating physician should carefully evaluate the need for treatment during pregnancy, considering the severity of clinical symptoms and the potential risks and benefits of stimulant use 5, 6.
• If treatment is necessary, methylphenidate, amphetamines, and bupropion are preferred drugs, with careful monitoring of fetal development and maternal health 5, 6.