ADHD Medication and Pregnancy
Physicians often struggle to advise patients about the security of their ADHD medication during pregnancy. In the meantime, until more research is available, physicians must weigh the advantages of medication use during pregnancy against the possible risks for offspring in each individual situation.
A recent population-based cohort study tracked 898 infants born to mothers who were who were taking ADHD medications throughout pregnancy (stimulants: methylphenidate, amphetamine, dexamphetamine; non-stimulants: modafinil, atomoxetine, clonidine) until they were diagnosed with a developmental disorder or passed away or left the country.
Risk/Benefit Discussion
CAP Smart Take:
Doctors are concerned with the long-term effects that drug exposure in utero can result in, especially for centrally stimulating medications like those used to treat ADHD. It is crucial that women receive proper counseling from their doctors about the risks and benefits of using medications during pregnancy and prior to conception. In this CAP smart approach, we review the most recent research on this topic and how they can inform the clinical practice.
Animal studies and illicit drug research suggests that stimulant drugs enter the fetus via the placenta, and may negatively impact fetal growth and development. However, there are limited information on the response of the fetus to the therapeutic doses of prescription stimulant medications during pregnancy, and the majority of this data comes from single-arm case-control studies that have not been sufficiently powered to identify significant associations.
The study by Cohen and colleagues4 is distinctive because it is the most comprehensive and carefully controlled. The study comprised a sample of 364,012 pregnant women from the Danish Medical Registry, and data on the use of medication was obtained by analyzing prescriptions that were redeemed. Researchers excluded women who had taken SSRIs or clonidine because these drugs could interact with fetal NMDA and increase the risk of developing neurodevelopmental disorders like autism and ADHD. The authors also adjusted their analysis to account for potential confounding factors and to account for the timing of in utero exposure.
The data from this study, as well as the results from other studies, show that the vast majority of women who continue to use their prescribed stimulant medications for ADHD during pregnancy don't experience adverse effects on their foetuses. Therefore, it is likely that many pregnant women will continue to use their ADHD medication. But it is essential that doctors weigh the risks and benefits of these medications for pregnant patients, as well as take into consideration the individual circumstances of each patient before suggesting that they stop taking their medication. It is essential that pregnant women with ADHD inform their parents, extended families, and employers of the decision they've made. This is because the symptoms of hyperactivity, inattention and impulsivity could come back after the mother ceases taking her medication.
Pregnancy Tests
Preconception counseling for women with ADHD who wish to become pregnant should focus on a comprehensive management plan that involves both behavioral and pharmacologic treatment and continuous monitoring throughout the postnatal period. The plan should include a review of current medication regimens, especially in the first trimester when risks of harm to the baby from untreated ADHD are greatest. types of adhd medication should be a joint effort between psychiatry and primary care and Obstetrics.
The discussion of risks and benefits should also cover the way a woman plans to manage her ADHD symptoms during pregnancy, the impact of this on the family's functioning and her feelings about a decision to stop psychostimulant treatment in the initial stages. This should be guided by a thorough analysis of evidence available, including consideration of the individual patient's requirements and concerns.
In a study of recent magnitude that examined children exposed to ADHD medications during utero The authors concluded that "continuation of use of psychostimulants in the early stages of pregnancy did not increase the risk of adverse birth outcomes, and if anything, it was associated with less stress for mothers." However this conclusion isn't without its flaws. The study did not consider the importance of the dosage of stimulant medication, nor the long it was used for, in addition to other sociodemographic and clinical variables. There is also no research conducted that is controlled and examines the safety of continuing use of psychostimulants in nursing mothers.
There isn't a clear evidence from a scientific study on the safety of ADHD medication during pregnancy. However, most doctors have a general knowledge of the research findings and can apply the best practices in consultation with each patient's specific needs. It is known, for example that infants born to mothers who take methylphenidate in the first trimester are more likely suffer from cardiac malformations (Cooper, et al. 2018). However this is based on a tiny study that did not consider the differences in the demographics of patients and the underlying psychiatric conditions.
In a recent survey ADDitude readers reported that they were more likely to quit their ADHD medication during early pregnancy than in the past. However, women who stopped psychostimulants within the first trimester of pregnancy experienced a clinically significant increase in symptoms of depression. They also felt less able to enjoy pregnancy and described family functioning as more difficult than those who remained on their dose of ADHD medication or increased it.
Work Functioning Test
The test of work function is an important component of the exam to determine if an individual is able to carry out their duties. The test is designed to assist in the evaluation of functional limitations. It includes graded material handling activities (lifting at different levels, pulling and pushing), tests for positional tolerance (sitting and standing while walking, balancing and walking, stooping and kneeling) as well as specialized tests. The evaluator will analyze the results and draw the return to the conclusion of the test. ROC curves can be used to determine the point of minimal classification (MIC) in both the general work ability, the physical work ability and the work-functioning problem score.
The MIC is calculated according to the COnsensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. This method differentiates scores for general physical work capabilities and work-functioning issues, by answering an anchor question. This will prevent a change in metrics from affecting the average.
Driving Test
Psychostimulant medications are a gold standard treatment for ADHD. It helps reduce symptoms and improves functioning in other domains, notably driving safety. If left untreated, severe ADHD can have significant financial and psychosocial consequences.
Psychotherapeutic treatments such as cognitive behavioral therapy (CBT) and "coaching" strategies have also been proven to reduce symptoms and improve functioning. These strategies can help women to tailor their schedules and utilize their strategies to cope in ways that minimize the impact of their ADHD on work and other domains.
All of these aspects are crucial to take into consideration when deciding whether or not to pursue psychostimulant therapy. As the best available data indicate, although there are some concerns about the outcomes of pregnancy after in utero exposure to stimulant medications the risks are minimal and the outcomes are influenced by other treatments, maternal health treatment and physical and mental health, and other comorbidities. Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen TL, Hove Thomsen P, Bergink V. In utero exposure to attention deficit hyperactivity disorder medication and long-term outcomes for offspring.