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 consider a trial of gradually discontinuing the medication before pregnancy if it is not likely to severely impact daily functioning. However, if unable to discontinue the medication, she should continue with the current medication or reduce to the lowest effective dose or consider intermittent use or consider switching to a nonstimulant option.

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.
• Amphetamine mixed salts may have a possible increased risk for gastroschisis, preeclampsia, and preterm birth, but these risks seem to be small 1.
• Breastfeeding does not seem to adversely affect infants, but monitoring for irritability, insomnia, and feeding difficulty is recommended 1.
• Intermittent use of stimulants on an as-needed basis or switching to bupropion may be considered to minimize fetal or infant exposure 1.

Management Plan

• Consult with both a psychiatrist and obstetrician to develop a management plan.
• Prioritize non-medication alternatives, including behavioral therapy, organizational strategies, adequate sleep, regular exercise, and nutritional support.
• Limit caffeine intake to less than 200mg daily.
• Avoid illicit stimulants like cocaine and methamphetamine due to significant risks of miscarriage, placental abruption, preterm birth, and birth defects.

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 is a growing concern, with an estimated 30-40% of patients with attention deficit hyperactivity disorder (ADHD) continuing to experience symptoms into adulthood 3.
• Methylphenidate, a common stimulant used to treat ADHD, has been associated with a small but significant increased risk of major malformations, particularly cardiac malformations, in offspring exposed during early pregnancy 3, 4, 5.
• The risk of cardiac malformations associated with methylphenidate exposure has been reported to be around 1.26-1.59 times higher than in the general population 3, 5.
• Other stimulants, such as amphetamines, may also increase the risk of premature birth, low birth weight, and other pregnancy complications 4.
• The use of non-stimulant medications, such as bupropion, may be a safer alternative for pregnant women with ADHD, although more research is needed to confirm this 4.
• Exposure to ADHD medication during pregnancy has been associated with an increased risk of neonatal intensive care unit (NICU) admission, but not with other adverse maternal or neonatal outcomes 5.

Maternal and Neonatal Outcomes

• The risk of adverse maternal and neonatal outcomes associated with stimulant use during pregnancy is not well understood and requires further research 6, 5.
• The limited available data suggest that stimulant use during pregnancy may be associated with an increased risk of NICU admission, but not with other adverse outcomes 5.
• More research is needed to fully understand the effects of stimulant use during pregnancy on maternal and neonatal outcomes 6, 5.

Treatment Considerations

• The decision to continue or discontinue stimulant medication during pregnancy should be made on a case-by-case basis, taking into account the severity of the patient's symptoms and the potential risks and benefits of treatment 3, 4, 7.
• Fetal echocardiography may be recommended for pregnant women using methylphenidate during pregnancy to monitor for potential cardiac malformations 3.
• Breastfeeding is possible for women taking methylphenidate, but more research is needed to confirm the safety of this practice 4, 7.