What are the safety concerns and recommendations for a 3-month pregnant woman taking Welbutrin (bupropion), Buspar (buspirone), hydroxyzine, and magnesium gluconate?

Medication Management for Pregnant Woman at 3 Months

Continue the bupropion (Wellbutrin) at the current effective dose if she is stable on it, discontinue hydroxyzine immediately, continue magnesium gluconate, and discuss with her psychiatrist about continuing or stopping buspirone based on severity of her anxiety disorder.

Bupropion (Wellbutrin) - Continue

• If she is already stable on bupropion before pregnancy, the American College of Obstetricians and Gynecologists recommends continuing at the current effective dose 1, 2
• The benefits of treating maternal depression typically outweigh the small absolute risks in most clinical scenarios 3, 2
• While first-trimester bupropion exposure carries a small absolute increased risk of specific cardiac defects (left ventricular outflow tract obstruction and ventricular septal defects with adjusted OR 2.9), the absolute risk remains low given baseline rarity 3, 1
• The incidence of LVOTO is 0.279% with bupropion versus 0.07% with other antidepressants - still a very small absolute difference 1
• There is a possible increased risk of diaphragmatic hernia (aOR 2.77) and spontaneous abortion, though confounding by indication cannot be ruled out 3, 2
• Bupropion does not increase overall risk of major congenital malformations 3, 1, 4

Hydroxyzine - Discontinue Immediately

• Hydroxyzine should be stopped in pregnancy, particularly in the first trimester, as antihistamines with sedative properties carry risks 5
• Alternative safer options for anxiety or sleep include cognitive behavioral therapy or, if medication is absolutely necessary, consultation with psychiatry for pregnancy-compatible alternatives 5

Buspirone (Buspar) - Individualized Decision Required

• There is limited high-quality data on buspirone safety in pregnancy from the provided evidence
• This requires a risk-benefit discussion with her prescribing psychiatrist about the severity of her anxiety disorder versus potential unknown risks 5
• If anxiety is mild to moderate, consider discontinuation and use of non-pharmacologic interventions
• If anxiety is severe and significantly impacting function, continuation may be warranted with close monitoring

Magnesium Gluconate - Continue

• Magnesium supplementation is generally considered safe in pregnancy 5
• Continue at current dose unless there are specific contraindications

Monitoring Requirements

• Monitor pregnancy carefully with attention to fetal growth, maternal blood pressure, and appropriate weight gain 3, 2
• Consider fetal echocardiography at 18-22 weeks given the small increased risk of cardiac defects with bupropion 1
• Regular prenatal visits to assess maternal mental health status and medication effectiveness 2

Critical Pitfall to Avoid

• Do not abruptly discontinue bupropion without psychiatric consultation - untreated maternal depression poses significant risks to both mother and fetus, and the absolute risks from bupropion are small 1, 2
• Avoid the common mistake of stopping all psychiatric medications due to pregnancy anxiety, as this often leads to relapse of maternal psychiatric illness with worse outcomes 2