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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