Mass General Hospital

Harvard Medical School

Treatment of Insomnia During Pregnancy

Most women experience some degree of sleep disturbance during pregnancy, and for a significant number of women sleep disruption may be quite severe. There are many different causes for sleep disturbance during pregnancy, and choosing the appropriate intervention relies on an accurate diagnosis of the problem.

Certain sleep disorders, such as restless leg syndrome and sleep apnea, are more common during pregnancy and may cause significant sleep disruption.

Sleep disturbance may also be a symptom of depression or an anxiety disorder, thus it is important to screen for these problems. Many women with depression or anxiety have difficulty falling asleep or they wake early and are unable to return to sleep. Treating the underlying disorder may improve sleep quality. (More information on the treatment of depression and anxiety during pregnancy can be found here.) Typically antidepressants, including fluoxetine (Prozac) and the older tricyclic agents (including nortriptyline and amitriptyline) are used in this setting.

While certain strategies may help to improve sleep quality, some women may require some type of pharmacologic intervention. Although Ambien (zolpidem) and other sedative-hypnotic agents, including Lunesta (eszopiclone) and Sonata (zalepion), are commonly prescribed to women with sleep disturbance, the data regarding their reproductive safety is limited and generally we try to avoid their use during pregnancy.

Sedating tricyclic antidepressants, such as amitriptyline or nortriptyline, may be a better choice for women with sleep disturbance and have not been associated been associated with an increase in risk of congenital malformation. Benzodiazepines, including Ativan (lorazepam) and Klonopin (clonazepam) may also be useful. There is some controversy regarding the use of benzodiazepines during pregnancy. Although initial reports suggested that there may be an increased risk of cleft lip and cleft palate, more recent reports have shown no association between exposure to benzodiazepines and risk for cleft lip or palate. Pooling the data suggests that this risk– if it exists — is estimated to be 0.7%. The risk of malformation is confined to the first trimester when lip and palate formation take place; thus, benzodiazepines when used later in pregnancy do not carry this tertogentic risk.

Ruta Nonacs, MD PhD

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24 Responses to Treatment of Insomnia During Pregnancy

  1. concerned_husband December 4, 2007 at 10:58 am #

    My wife and I are TTC. It’s taking longer than we hoped, though the outlook right now is pretty positive.

    The problem is that she’s suffered from anxiety and depression in the past, and went off of Prozac (20 mg) because we’re TTC.

    Due to the stress of it taking awhile to conceive, plus other things (job-related, etc) she’s having quite a bit of insomnia. Her symptoms certainly don’t fall in the “severely/extremely depressed” category, but having been depressed myself in the past, I think in a relative sense that she’s suffering quite a bit.

    Looking at the literature, I think it might be reasonable for her to go back on Prozac.

    Will she be able to discuss the pros and cons off that treatment option rationally with her providers (gyn, etc), or will she be repeatedly met with “no, you can’t take SSRIs during pregnancy”?

  2. cwmh December 5, 2007 at 5:28 pm #

    The information regarding antidepressant use during pregnancy is growing and is actually a little conflicting. But I think it is really important for you and your wife to develop a relationship with an OB and psychiatrist who are familiar with this area and know the available info re: the safety of these medicines. Also, a great resource is our Perinatal Information Resource Center at http://www.womensmentalhealth.org ; see the extensive library and columns across the website, including our most recent newsletter.

  3. Daphne June 6, 2008 at 4:50 pm #

    I am 24 weeks pregnant and prior to pregnancy have taken Ambien. I held off taking it during my first trimester, but just can not fall asleep at night. Is is safe to take Ambien again?

  4. Shannon October 29, 2008 at 4:19 pm #

    I’ve had primary insomnia (idiopathic) since childhood. I have worked with my doctors for 15+ years on proper medications for sleep. I’ve spent years of my life on Ambien and other sleep medications, but about five years ago was able to go off all of those and simply stay on Trazodone. I have also spent years refining my sleep hygiene, doing biofeedback and behavioral therapy to do everything possible to try and ensure good sleep (which I am generally able to do now, though it’s still hard). My husband and I are now trying to get pregnant and my OB says no to Trazodone. I have gone off of it and gone back to my horrible insomnia of 2-3 hours of sleep a night. I can’t live like this – I can’t take care of myself properly in this state and can’t imagine nurturing a baby in my womb when I am like this. But over the counter sleep medication (Tylenol PM, Unisom, Benadryl) simply keeps me awake and prescription sleep medication is off limits, according to my doc. What are my choices if I want to have a baby? For all those suffering out there, I hear you!

  5. Rebecca November 19, 2008 at 1:27 pm #

    Ditto Shannon! My doc just took me off the trazodone yesterday after I found out I was pregnant last week. I just spent a horrible night of tossing and turning, and don’t know how I can do this for a prolonged period. Before trazodone I never slept, and if I missed a pill, I didn’t sleep… and now I have 9 months to look forward to of this? There has to be something that I can take. I can’t do the benadryl thing either… it gives me restless leg syndrome and makes me extremely anxious.

  6. cathy jefferies November 25, 2009 at 7:09 pm #

    @Rebecca, what did you do? was there anything safe to take for sleep during pregnancy?

  7. nicole December 9, 2009 at 1:08 pm #

    @Shannon,
    It was so refreshing to read your post and know that I’m not alone. I am barely pregnant (5 weeks) and up until this point took a Klonopin and a Seroquel every night to sleep. Since I am not taking them now, I am not sleeping. Did anyone resopnd with helpful suggestions? My OB said that Ambien from time to time wasn’t necessarily a bad thing, but I only sleep “okay” with Ambien.

    Any help you could provide would be greatly appreciate. Thanks so much.

  8. Overcome insomnia March 20, 2010 at 2:09 pm #

    Thank you, I really needed it, almost did the wrong thing.

  9. Lindsey March 25, 2010 at 9:05 pm #

    I really wish someone had replied to the above two posts… I also don’t get more than 2-3 hours of sleep without Trazodone. I’m going to want to be pregnant soon, and my husband (a doctor) wants me to try nortriptyline or amytriptyline. I guess I’ll just have to see how it goes…

  10. Name April 22, 2010 at 12:42 pm #

    I too am thinking about having a baby soon and I take trazodone. I have recently consulted with a couple of psychiatrists/OBGYNs who have indicated that it is safe to take trazodone during pregnancy – it has been around since the 1960s.

  11. MGH Center for Women's Mental Health April 25, 2010 at 11:59 pm #

    While it is reassuring to know that a medication has been around since the 1960s, this does not necessarily mean that a particular medication is safe when used during pregnancy. Many of these older medications have never been systematically studied in pregnant populations.

    There is nothing to suggest that Trazodone is unsafe; however, the data is limited. There has been one small study including 58 women taking Trazodone. This study detected no increase in the risk of malformation, but the study was too small to rule out small increases in risk.

  12. Name April 26, 2010 at 10:16 am #

    Are you suggesting that trazodone is not safe during pregnancy? Do you recommend that I consult further with the physicians who told me it was ok?

  13. Lindsey May 18, 2010 at 7:08 pm #

    My MGH OB consulted with perinatal psych who told her it was okay for me to stay on trazodone. Thank goodness!

  14. Susan Sweeney January 6, 2011 at 10:50 pm #

    I too had dreadful insomnia both before and during pregnancy. It became unbearable during pregnancy because I couldn’t take anything. In the end I ended up crying at the doctor’s and he prescribed me valium (diazepam) and it was a godsend. I just used it occasionally when I couldn’t bear another day of feeling shattered. (About once a week). I went through two pregnancies, was really tired and stressed throughout both, but both babies were fine, and unaffected by my stress. Being told that the babies were unaffected by my stress helped me a lot, as that would have just added to my stress and insomnia.

  15. Meghan February 24, 2011 at 11:30 am #

    I have suffered a genetic form of chronic insomnia all my life and have been on Trazodone for the past 10 years – and like some of you, I don’t sleep without it. This is my second pregnancy and doctors have all agreed (in my case) that the benefits outweigh the risks and I have continued to take the medication throughout both pregnancies. If you are able to go off of it or at least cut back then you probably should, but if you’re like me and are unable to sleep without it then staying on it may be the only option. I believe it’s a personal choice but you may be doing more harm to the baby by not sleeping. Your doctor may suggest trying something safer like Unisom or even Ambien but for me they don’t have any effect (I have literally tried everything). Good luck!

  16. Betsy Rosenfeld June 29, 2011 at 2:57 pm #

    @Meghan, I appreciated your post and am wondering how your babies did since you took the Trazodone throughout both pregnancies. It would be so helpful to know if either of them suffered withdrawal or otherwise had any negative effects which could be attributed to the Trazodone. Thanks so much for sharing your experience. -Betsy

  17. TXCPA July 18, 2011 at 9:53 am #

    My gym trainer told me that she takes Melatonin to help her fall asleep. I’m 8 weeks preg and haven’t slept in a week. I’m thinking about melatonin because it’s natural but I want to check with my OB first. I will let everyone know what he says.

  18. samina January 29, 2012 at 5:29 pm #

    I was on trazodone sine last 1 year. Just found out two days ago that I am 4 weeks pregnant. I have stopped taking the medication. Just worried if there are any risks to baby… Please comment, if any mom was on Trazodone and before the start of pregnancy and had successful pregnancy with no harm to the baby.

  19. Liz March 9, 2012 at 6:30 am #

    I took 100mg of Trazadone my entire pregnancy and I have a beautiful, perfect baby boy. I was seeing a fetal maternal medicine specialist who told me it was just fine to stay on Trazadone !

  20. Mona Bishara December 17, 2012 at 4:15 pm #

    If sedating tricyclic antodepressant e.g. amitryptaline is safe during pregnancy how about trazodone. I know that Trazodone is class C by the FDA. Is Amitryptaline is class C too?
    Please let me know

  21. Mona Bishara December 17, 2012 at 4:16 pm #

    Assuming that amitryptaline is safe during pregnancy, how about trazodone? I know that Trazodone is class C. Is Amitryptaline is class C too.

  22. Dee January 31, 2013 at 7:00 pm #

    @Mona Bishara,

    Did anybody ever answer your question about trazodone?
    I would also like to know.

  23. Jdub May 16, 2014 at 6:43 am #

    Just found out I was pregnant and have been on Trazodone for years for insomnia. I was also recently put on amitriptyline because I was still not sleeping well. When I found out I was pregnant my doctor said to immediately stop taking both medications cold turkey as they were harmful to the fetus. The doctor is a regular MD as well as an ND. He looked up Amitriptyline in a medical book directly in front of me and this medication was listed as a class D drug. This means it is proven to be harmful to a fetus.

  24. MGH Center for Women's Mental Health May 29, 2014 at 9:04 pm #

    The current system used to classify the safety of medications during pregnancy is often confusing. You can read more about it in this post.

    Neither Trazodone nor amitriptyline have been proven to harm the developing fetus, if you look at all of the data in the literature.

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