What medications are safe for a pregnant woman to take for sleep disturbances?

Medications for Sleep in Pregnancy

Non-pharmacological interventions should be the first-line treatment for sleep disturbances in pregnancy, as there is insufficient safety data for most sleep medications during gestation, and the risks of pharmacotherapy must be carefully weighed against potential teratogenic effects. 1, 2

First-Line Approach: Non-Pharmacological Interventions

Start with sleep hygiene measures and behavioral interventions before considering any medication. 1

• Implement comprehensive sleep hygiene: Maintain a regular sleep schedule, keep the sleep environment dark and comfortable, avoid heavy meals and screens near bedtime, and limit caffeine intake 1
• Encourage regular physical activity: Morning or afternoon exercise and daytime exposure to bright light may improve sleep quality during pregnancy 1
• Consider cognitive behavioral therapy (CBT): CBT has demonstrated effectiveness for treating sleep disturbances and should be prioritized over pharmacotherapy 1
• Utilize relaxation techniques: Mindfulness meditation and other mind-body interventions can reduce sleep disturbance 1

These approaches are recommended because they avoid medication exposure entirely while addressing the underlying sleep issues. 2, 3

Pharmacological Options: Limited and Problematic

If non-pharmacological approaches fail, medication options during pregnancy are severely limited due to safety concerns. 2, 4

Medications to Avoid

• Diphenhydramine (antihistamine): The FDA label specifically states "If pregnant or breast-feeding, ask a healthcare professional before use," indicating uncertain safety 5
• Doxylamine: Similarly requires consultation with a health professional before use in pregnancy per FDA labeling 6
• Benzodiazepines and Z-drugs: May be associated with adverse neonatal outcomes and should generally be avoided 4
• Sodium oxybate: Has insufficient safety data for pregnancy and may cause fetal harm based on animal data 7, 1
• Other sleep medications: Most lack adequate safety data in pregnancy 7, 2

Special Consideration: Sertraline for Comorbid Depression

If sleep disturbance is related to depression or anxiety, sertraline is the preferred antidepressant during pregnancy due to its favorable safety profile. 1

• Use at the lowest effective dose with close monitoring of maternal mental health 1
• Arrange early follow-up after delivery for infants exposed in the third trimester to monitor for neonatal adaptation syndrome (irritability, tremors, feeding difficulties, respiratory distress) 1
• Other SSRIs in the third trimester carry similar risks of neonatal adaptation syndrome 1

Clinical Algorithm

1. Screen for underlying causes: Evaluate for restless legs syndrome, sleep-disordered breathing, depression, and anxiety—all common in pregnancy and requiring specific treatment 3, 8

2. Implement non-pharmacological interventions first: Sleep hygiene, CBT, physical activity, and relaxation techniques for at least 2-4 weeks 1, 3

3. If psychiatric comorbidity exists: Consider sertraline if depression/anxiety is contributing to insomnia 1

4. If purely insomnia without response: The evidence does not support routine use of sleep medications in pregnancy due to insufficient safety data 7, 2

5. Multidisciplinary consultation: Involve maternal-fetal medicine specialists for complex cases or when medication is being considered 1

Critical Pitfalls to Avoid

• Do not prescribe traditional sleep medications without extensive counseling: Most hypnotics lack adequate pregnancy safety data, and the risks of untreated insomnia must be weighed against unknown medication risks 2, 4
• Do not overlook treatable sleep disorders: Obstructive sleep apnea, restless legs syndrome, and psychiatric conditions are common in pregnancy and require specific management beyond simple hypnotics 3, 8, 9
• Do not assume over-the-counter means safe: Even antihistamines like diphenhydramine and doxylamine require medical consultation during pregnancy per FDA labeling 5, 6

The evidence consistently shows that sleep disturbances in pregnancy are associated with adverse maternal and fetal outcomes (preterm birth, low birth weight, increased cesarean sections), making treatment important—but the lack of proven-safe pharmacological options means non-pharmacological approaches must be optimized first. 4, 9