September 15, 2001
September 1, 2001 from ObGyn News By Lee S. Cohen, M.D.
Over the past decade, adults have been increasingly diagnosed with attention-deficit hyperactivity disorder (ADHD), including many women in their childbearing years. ADHD patients can be successfully treated with medications such as stimulants, the mainstay of treatment, followed by tricyclic antidepressants and bupropion (Wellbutrin). Women who have been stabilized on one of these medications and want to become pregnant often come to see us with questions about whether they should remain on the drug. What we advise these patients depends in part on the severity of their disorder. For women with mild to moderate symptoms that do not interfere dramatically with their life we frequently recommend a switch to a nonpharmacologic intervention even though there’s a fair amount of information on the reproductive safety of one therapeutic option, the tricyclic antidepressants. For these women, the risk of not being treated does not justify fetal exposure to a drug that we do not know much about or even a drug for which we have reassuring reproductive safety data.
The more difficult clinical scenario is with women who unequivocally have severe ADHD that, if left untreated, could dramatically interfere with their functioning and potentially affect the outcome of their pregnancy. Stimulants such as methylphenidate (Ritalin) do not appear to be teratogenic as a class. But there are some data suggesting an association between in utero exposure to psychostimulants and poor fetal or neonatal outcomes, such as small for gestational age or intrauterine growth retardation. These data, however, are not from reports of women with ADHD, but largely from women abusing stimulants such as amphetamines who had other risk factors for poor neonatal or fetal outcomes. This makes it difficult to discern the independent risk associated with fetal exposure to stimulants.
When we see patients with more severe symptoms who have done well on a stimulant, we share these data with them, pointing out that it’s not entirely clear whether exposure is associated with impaired fetal outcome. For women who need treatment in pregnancy, we often recommend a switch to a tricyclic antidepressant because of the robust data supporting the efficacy of these agents for treating ADHD and solid data supporting their reproductive safety. These data include studies showing no increased rate of major congenital malformations with first-trimester exposure. Another study followed exposed children through age 6 and found no differences in long-term neurobehavioral effects between those exposed to tricyclics in utero and those who weren’t.
A switch to a tricyclic antidepressant would also be preferable for a woman on Wellbutrin despite evidence supporting its effectiveness in treating ADHD. Because there are only sparse data on its reproductive safety, we discourage use of this drug during pregnancy. Wellbutrin is a pregnancy category B compound, meaning that it has been categorized as fairly safe in pregnancy. However, this categorization is based on limited information that does not indicate a risk but is insufficient to rule risk out entirely. There are some data suggesting that selective serotonin reuptake inhibitors (SSRIs) are effective for ADHD in some people, but most studies do not show efficacy. For those who have responded to an SSRI, the safest such agents to use during pregnancy are fluoxetine (Prozac) or citalopram (Celexa). Still, the use of a stimulant is not absolutely contraindicated during pregnancy. We occasionally have a treatment-dependent woman with ADHD who did not tolerate or respond to treatment with an antidepressant but was stabilized on a stimulant. We have not observed any problems using stimulants in pregnancy over the past 15 years, but the sample size is small and we have not investigated this question in a controlled fashion.
There are no data on the postpartum course of ADHD, but since worsening of psychiatric disorders during the postpartum period is the rule, we typically reintroduce medications at this time in women who went off them before or during pregnancy. We do not counsel women who have remained on stimulants, tricyclics, or Wellbutrin to defer breast-feeding. The data on stimulant use during breast-feeding are incomplete. At our center we would not consider a stimulant as absolutely contraindicated in women who are breast-feeding, because the amount of the drug secreted into breast milk is small.
Dr. Lee Cohen is a psychiatrist and director of the perinatal psychiatry program at Massachusetts General Hospital,