Can a pregnant woman safely continue Wellbutrin (bupropion) for depression or smoking cessation, and what are the recommendations?

Wellbutrin (Bupropion) Use in Pregnancy

Pregnant women can safely continue bupropion (Wellbutrin) for depression or smoking cessation, as current evidence shows no increased risk of major congenital malformations overall, though careful monitoring is warranted. 1

Safety Profile for Major Malformations

• Bupropion does not appear to increase the overall risk of major congenital malformations above baseline rates. 1, 2, 3
• The FDA drug label confirms that epidemiological studies of first-trimester bupropion exposure have not identified an increased risk of congenital malformations overall. 2
• Meta-analysis shows the pooled estimated proportion of congenital malformations among live-born infants exposed to bupropion is 1.0% (95% CI = 0.0%-3.0%), which is within the general population background risk of 2-4%. 4

Specific Cardiovascular Concerns

While overall malformation risk is not elevated, there are two specific cardiac defects that warrant discussion:

• A small absolute increase in risk has been associated with left ventricular outflow tract obstruction (LVOTO) heart defects and ventricular septal defects (adjusted odds ratio 2.9; 95% CI, 1.5-5.5) with first-trimester exposure. 1
• The FDA label notes that study findings on LVOTO are inconsistent and do not allow definitive conclusions regarding possible association. 2
• The absolute risk remains low given that the background rate of cardiovascular malformations is approximately 1%. 2

Other Potential Risks

• There is a possible increased risk for diaphragmatic hernia (aOR 2.77; 95% CI, 1.34-5.71), though the absolute risk is extremely small given this condition's rarity (population prevalence 0.012%-0.031%). 1
• A possible increased risk for spontaneous abortion has been reported, though rates remain within the general population range. 1, 3
• One case report documented poor neonatal adaptation with seizures due to prolonged hypoglycemia from severe hyperinsulinism. 1

Clinical Management During Pregnancy

If a woman is already taking bupropion before pregnancy:

• Engage in a risk-benefit discussion regarding continuing at the current well-tolerated, effective dose versus considering intermittent use. 5, 1
• Do not abruptly discontinue if the medication is required for daily functioning, as untreated depression carries its own risks to both mother and fetus. 5

Monitoring requirements during pregnancy:

• Monitor pregnancy carefully, including fetal growth assessments. 5, 1
• Perform regular blood pressure checks. 5, 1
• Ensure appropriate maternal weight gain. 5, 1

Bupropion as Alternative to Stimulants

For pregnant women with ADHD who require medication:

• Bupropion can be considered as an alternative to stimulants in the perinatal period, particularly for individuals requiring treatment for co-occurring depression, given the available safety data. 5
• However, bupropion is not as efficacious as stimulants for ADHD treatment. 5

Breastfeeding Considerations

Bupropion can be maintained during breastfeeding with appropriate infant monitoring:

• Maintain therapeutic dose at the time of delivery and during breastfeeding. 5
• Bupropion is present in human milk and has been detected in infant serum, though typically at very low or sometimes undetectable levels. 1
• Two case reports have documented seizures in breastfed infants whose mothers were taking bupropion, despite generally low transfer into breast milk. 1

Infant monitoring during breastfeeding:

• Monitor infant development carefully, particularly for vomiting, diarrhea, jitteriness, sedation, and/or seizures. 1
• Ensure infants are gaining weight appropriately and meeting developmental milestones. 5, 1

Important Caveats

• Confounding by indication cannot be ruled out in many studies, as the underlying condition (depression or smoking) may contribute to observed risks rather than the medication itself. 1, 6
• The benefits of treating maternal depression or supporting smoking cessation may outweigh potential risks in many cases, as untreated depression carries significant risks for both mother and infant. 7
• For smoking cessation specifically, the U.S. Preventive Services Task Force found inadequate evidence on the benefits of bupropion to achieve tobacco cessation in pregnant women or to improve perinatal outcomes. 5