What Medications Can I take for Insomnia During Pregnancy?

Insomnia during pregnancy is extremely common--a 1998 poll done by the National Sleep Foundation found that 78% of women report experiencing insomnia during pregnancy. There is a lot of information available about behavioral changes to improve insomnia while pregnant, and in fact, strategies like establishing a bedtime routine, avoiding stimulating substances like caffeine, and using pillows for support may solve the problem for many women. However, some pregnant women with severe insomnia require medications, which we will discuss below.

Choosing the right medication first depends on the cause of insomnia, and there are many. In the first trimester, rising progesterone levels lead to daytime fatigue and disturbed sleep at night; further, breast tenderness, nausea, and increased nighttime urination also interfere with a good night's sleep. In the third trimester, the size of the growing fetus makes it difficult to lie down comfortably, puts pressure on the bladder, and also increases the risk of obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD). In the third trimester there is also an increased risk of restless leg syndrome. And throughout pregnancy, many women experience an increase in anxiety, due to concerns about labor and delivery, changes in relationships after the birth of a child, financial strain, childcare, etc. 

In psychiatry, frequently used medications for sleep include antidepressants, sedative-hypnotics (e.g., Ambien, Sonata, Lunesta, and benzodiazepines), and antihistamines (e.g., Benadryl).

Antidepressants
The topic of antidepressant safety in pregnancy is very broad. The results of research are often mixed, and based on observational studies (rather than randomized controlled trials, which more clearly demonstrate cause and effect). In general, the SSRIs (like escitalopram, sertraline, fluoxetine) have not been consistently shown to lead to specific congenital malformations (birth defects) with the possible exception of paroxetine (Paxil) and cardiac malformations, but there likely are associations between taking antidepressants during pregnancy and preterm birth, and between antidepressants and neonatal adaptation syndrome. The effects are generally small, and serious consequences are very rare. Sedating tricyclic antidepressants that are often used for insomnia (like amitriptyline or nortriptyline) have not been clearly shown to lead to any increased risk of congenital malformations above baseline rates in the general population. The topic of antidepressants and possible increased risk of autism is discussed in this blog post.

Sedative-hypnotics
In terms of the safety of sedative-hypnotics in pregnancy, it has long been thought that benzodiazepines lead to an increased risk of cleft lip/ palate. However, more recent studies, including a large population-based study conducted in the UK, have shown that there is no clear evidence that taking benzodiazepines and non-benzodiazepine hypnotics during the first trimester of pregnancy leads to an increased risk of major birth defects. However, there is a possible increased risk of preterm birth, low birth weight, and neonatal adaptation syndrome, similar to antidepressants.

Antihistamines
A 2014 review of the safety of antihistamines in pregnancy found no clear association between prenatal antihistamine exposure led and birth defects. More research exists for older, H1 blockers like diphenhydramine, promethazine or hydroxyzine, which are commonly used for sleep, and these are generally thought to be safer in pregnancy.