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
5 Comments
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”?
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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.
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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?
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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!
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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.
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