ADHD Medication and Pregnancy
Physicians often struggle to advise patients on the security of their ADHD medication during pregnancy. As long as research is not available, doctors must weigh the advantages of using medication during pregnancy against the possible risks for offspring in each unique circumstance.
A population-based study has followed 898 infants who were born to mothers who took ADHD medications during pregnancy (stimulants amphetamine methylphenidate ; dexamphetamine non-stimulants modafinil atomoxetine clonidine) until they were diagnosed as having a developmental disorder, passed away or left the country.
Risk/Benefit Discussion
CAP Smart Take:
Doctors are concerned about the long-term effects that exposure to drugs in utero may have, especially for centrally stimulating drugs such as those used to treat ADHD. It is therefore critical that women receive proper counseling from their physicians about the risk/benefit of using medication prior to conception and during pregnancy. In this CAP smart take we examine the most recent research in this area and how they might influence the clinical practice.
Animal studies as well as illicit drug use research suggest that stimulant drugs are passed to the fetus via the placenta, and could negatively impact fetal development and growth. However, there are limited information regarding the way that the fetus reacts to therapeutic doses of prescription stimulant medications during pregnancy, and most of this evidence is based on single-arm studies that have been underpowered to identify significant correlations.
The recent study by Cohen and co. is distinct from other studies, as it is the largest and most meticulously controlled. The study involved 364,012 births taken from the Danish Medical Registry. Information regarding medication use was collected by analyzing the redeemed medication. The researchers specifically excluded women who reported receiving SSRI drugs or clonidine since these drugs can interfere with the fetal NMDA receptor and increase the risk of developing neurodevelopmental disorders like autism and ADHD. The authors also adjusted their studies to take into account potential confounding factors as well as to account for the timing of the in utero exposure.
The data from this study, in addition to the results of other limited trials, indicate that the vast majority of women who continue to take their prescribed stimulant medication for ADHD during pregnancy do not experience any adverse effects on their foetuses. Therefore, it is likely that many pregnant women will continue to take their ADHD medication. However, it is important that physicians carefully evaluate the advantages and risks of these medications for their pregnant patients, and also be aware of the unique circumstances of each patient before suggesting that they stop taking their medication. It is essential that pregnant women suffering from ADHD inform their partners as well as extended families and employers of the choice they've made. This is because the symptoms of inattention, hyperactivity, and impulsivity could come back when the mother stops taking her medication.
Pregnancy Tests
Preconception counseling for women suffering from ADHD who wish to become pregnant should concentrate on a comprehensive plan of management that involves both pharmacologic and behavioral treatment and continuous monitoring throughout the postnatal period. Full Write-up should include a discussion on the current treatment regimens, especially in the first trimester, when the risks of harming the baby due to untreated ADHD are the highest. This should be a joint effort between obstetrics, psychiatry, and primary care.
The discussion of the risks and benefits should also cover how a woman will manage her ADHD symptoms during pregnancy, the impact of this on family functioning, and how she feels about a decision to stop psychostimulant treatment in the initial stages. This should be informed by a thorough review of available evidence, with consideration of the specific patient's needs and concerns.
The authors of a huge study that followed children who were exposed ADHD medications during utero concluded that "continuation psychostimulant use during the early stages of pregnancy was not associated with adverse birth outcomes and, if anything, it was associated with lower stress levels among mothers." However their conclusion isn't without limitations. The study did consider other factors, such as the duration of time stimulant medication was taken, the dose and the sociodemographics. Additionally, there isn't any controlled study that examines the safety of continued psychostimulant use in nursing mothers.
Although there is a dearth of evidence-based research on the safety of ADHD medications in pregnancy, many doctors are aware of what the research suggests and apply the best practices in consultation with each patient's unique needs. For example, it is well-known that there is a higher rate of cardiac malformations in infants born to mothers who take methylphenidate during the first trimester of pregnancy (Cooper and colleagues. 2018) It is also important to note that this result was based on a single study and did not take into account variations in patient demographics or underlying psychiatric comorbidity.
In an earlier survey of ADDitude readers, they found that they are more likely than ever to stop taking their ADHD medication in the early stages of pregnancy. However, women who stopped taking psychostimulants during the first trimester of pregnancy experienced a clinically significant increase in symptoms of depression. They also reported feeling less able to enjoy pregnancy and rated family functioning as more difficult than those who maintained their dosage of ADHD medication or increased it.
Work Functioning Test
The work function test is a vital component of the exam in that it determines whether the candidate is able to perform their duties. The test is designed for the evaluation of functional limitations. It includes graded material handling exercises (lifting at different heights, pulling and pushing) and tests for positional tolerance (sitting and standing while walking, balancing and walking, stooping and kneeling) and specialized tests. The examiner will analyse the results and come up with the return to the conclusion of the test. ROC curves are used to illustrate the point at which there is a minimum misclassification (MIC) for both physical and general work capability as well as 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 divides the scores of general and physical work ability and work-functioning difficulties based on the answer on an anchor question to prevent any change in the metric from biasing the overall average.
Driving Test
The most effective treatment for ADHD is psychostimulant medications. It reduces symptoms and improves functioning in work and other domains, notably driving safety. If left untreated, severe ADHD can have severe psychosocial and financial implications.
Psychotherapeutic treatments, like cognitive behavior therapy (CBT) or "coaching" methods have also been shown by research to help improve symptoms and increase function. These strategies can help women to tailor their routines, and use their coping abilities in ways that reduce the effects of ADHD on work and other aspects.
All of these aspects are important to consider when deciding whether or not to continue with psychostimulant therapy. As the best available data indicate, although there is some concern regarding the outcomes of pregnancy after in utero exposure to stimulant medications the risks are minimal, and the results are influenced by other treatments, maternal health care utilization and physical and mental health, and comorbidities. Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen T, Hove Thomsen P, Bergink V. In utero exposure to attention deficit hyperactivity disorder medication and long-term effects on offspring.