My Ob/Gyn’s eyes widened as she looked at the list of medications I take for depression and anxiety — Paxil, Lamictal, Klonopin. And then she let loose with a lecture I’d never heard from any doctor before. “You CANNOT get pregnant on these medications,” she warned while taking my history, and then again for good measure before letting me leave. I promised her I wasn’t planning on it. I’m 24, single, and until I met my now 1-year-old niece, I’d never even really seen the appeal of kids to begin with.
When Poppy was born, I sprinted in platform shoes through the hospital to get to my sister, whom I found looking as blissful as she did exhausted, staring down at the tomato-faced baby who just exited her womb. I’d never seen her look at anything or anyone else that way. This is what everybody talks about, I thought. I had always thought that love-at-first-sight feeling was nothing more than a myth to encourage procreation but here it was, happening right before my eyes. My brother-in-law had the look, too.
They asked if I wanted to hold the baby and I obviously said yes, even though I was scared shitless of dropping her and being denied all future aunt privileges. She was all swaddled up like a burrito, asleep. And then she opened her eyes, looked at mine, and just like that I was in love. If I felt this as an aunt, I couldn’t imagine the ecstasy of being a mum. Maybe I did want that some day.
What if the drugs I rely on to keep me sane also make me unfit for motherhood — which I’ve only recently realised I want someday?
I was only 12 when I was diagnosed with generalised anxiety disorder and put on medication. I thought little of it at the time. It felt no different from when I was prescribed an antibiotic for strep throat. I figured I’d take the pills, get better, and that’d be all.
Except I didn’t get better. I had near daily anxiety attacks, for which Klonopin helped but long-term drugs didn’t seem to. In college, I developed major depressive disorder, which I found to be even more debilitating. During my worst episodes, I physically couldn’t leave my bed, let alone eat. I would bail on plans, and sleep for 14 hours just to escape. Some mornings, I would walk to class, get inside the building, cry, turn right around, and go back to sleep in my dorm. It took years to find the drug cocktail that worked for me, and now that I finally feel stable, I shudder to think about having to come off of it. But what about that maybe-someday baby?
What if the drugs I rely on to keep me sane also make me unfit for motherhood — which I’ve only recently realised I want someday? I do want to get married (not yet, I’m still having fun) and have a child. I want to have my very own Poppy to fall in instant love with, one day, but I want to be stable enough to actually enjoy the experience. If it’s not too much to ask, I’d like to feel mentally strong when I take on that life-changing responsibility, too.
I couldn’t stop thinking about what my gynaecologist had said at that appointment: that I’d be dooming a child to certain birth defects if I were to get pregnant on these medications. I became consumed with anxiety about the choice I’d one day have to make. I started having recurring dreams of a pregnancy gone wrong. I had to get answers as soon as possible — from sources other than the one doctor who almost scared me eggless.
“Having a baby is a big decision for anyone, one that should be made carefully,” Erin Higgins, MD, clinical instructor in the Department of Obstetrics and Gynecology at NYU Langone Health, tells me. “Women with a significant history of depression or anxiety have an additional factor to consider when planning their pregnancy.” I mean, I’d say so!
She adds, “You have to weigh the risks of being unmedicated, and potential for relapse, against the risks of your baby being exposed during pregnancy, with the benefit of your depression or anxiety being controlled.” She explains that those who stop taking their medications prior to getting pregnant unsurprisingly have an increased risk of recurrence of depression. And that untreated depression in pregnancy is associated with difficulty keeping prenatal visits (which are crucial to foetal health, so missing them for any reason is cause for concern), inadequate nutrition, poor mother-infant bonding, preterm delivery, and a low birth weight. Just hearing this, I was already feeling less guilty for hoping to continue treating my depression with meds.
Marra Ackerman, MD, psychiatrist at NYU Langone Health breaks down the risk of using SSRIs (a class of drugs commonly used to treat anxiety and depression, including Paxil, which I take, and others like Zoloft and Lexapro) by trimesters. “All in all, the data is largely reassuring for the risks in the first trimester which is when the fundamental organs and structures are forming. There have been some studies that have raised a concern of a very small increased risk of cardiac defect with exposure to SSRIs.”
A small risk, though, is still a risk, and that's what Dr. Higgins was getting at when she said patients like me have a lot to consider before choosing to try for a baby. A study in the New England Journal of Medicine on the risk of foetal heart defect when antidepressants were used during pregnancy found there to be 72.3 cardiac malformations per 10,000 infants in the group who were not exposed to any antidepressants, compared to a slightly higher 90.1 per 10,000 infants who were exposed. That means it was about one-fifth of one percent more likely in those who used medication.
“Later in pregnancy, the second and third trimester, you're thinking about birth outcome, like if the baby is born at term, and if the baby is appropriate weight for its gestational age," Dr. Ackerman continues. "These are really complicated questions to answer, but overall, the data is reassuring!” The main concern when medicating later in pregnancy, she says, is the risk of neonatal adaptation syndrome (NAS), or the infant going through a sort of withdrawal from the SSRI they were exposed to in utero. “The good news is that it’s self-limited. It usually presents within the first days to hours of birth and self-resolves with supportive care. If your baby has NAS it can be unnerving and alarming, because they can be fussier or more difficult to soothe. They might need more monitoring by a paediatrician in the hospital, but usually they go home with mum, and there aren’t long term consequences,” she says.
Meanwhile, studies have also shown that there are risks associated with abrupt discontinuation of SSRIs. Choosing to quit cold turkey mid-pregnancy can lead to difficulties like physical withdrawal or psychological symptoms (e.g. suicidal thoughts). For some people, it may feel safer to simply continue use.
And then there are benzodiazepines, like Xanax and Klonopin. These, Dr. Higgins explains, “are anti-anxiety medications that can be taken on a regular basis for general anxiety or as needed for stressful situations, like flying or a big presentation. They can be used safely in pregnancy and are not known to be teratogenic [harmful to foetal development].” That’s reassuring, since pregnancy seems like it can be a stressful situation in itself. That said, some smaller studies have shown an increased likelihood of preterm birth linked to use of benzodiazepines — a 2009 NIH study of 300 women on this type of medication found 23% gave birth prematurely, while 9.4% of the group who were unmedicated did.
“The other thing we worry about with benzodiazepines," Dr. Ackerman adds, "is if patients are taking them daily, then in the third trimester we could have some concerns about infant withdrawal.” This could result in the baby being more anxious or agitated, just as an adult would feel coming off of this kind of drug. She adds, “But typically you would see that on high doses of benzodiazepines, which we typically avoid in pregnant mothers.”
Both doctors reassured me that it's protocol to carefully craft a treatment plan for each individual patient, taking into account their personal health history — which, yes, includes mental health and any medication needed for it. Neither said it was impossible, or used threatening language like that first Ob/Gyn — that I should never get pregnant while on my meds. They simply explained that there are risks, which by the way unmedicated pregnancies aren't immune to, and that when the time comes, my doctors and I will figure out the way forward.
Like many life changes, pregnancy may require adjusting a prescription plan, but it can be as simple as that. And should I choose to breastfeed, meds need not prevent that, either. “Women with depression or anxiety that requires medication should not be discouraged from breastfeeding, as the benefits of breastfeeding typically outweigh the risks," Dr. Higgins says. Small amounts of anti-anxiety meds can seep into the milk and into the baby’s system, but she says short-acting forms, such as my old friend Xanax, are safe.
Following my chats with Dr. Ackerman and Dr. Higgins, it became possible for me to think about the potential of pregnancy without feeling like I had to pop a Klonopin (and I've also stopped feeling guilty about needing to do that from time to time). I know that I can stay on my medications without cursing my hypothetical future baby to poor health, and I won’t have to put myself in danger in order to one day have her (or him or them). A relatively normal pregnancy can be in my future. Who would’ve thought?
Now all I have to worry about is how in the hell I can make a baby as perfect as Poppy — and who the lucky guy will be who gets to do it with me.