Is amitriptyline safe in pregnancy?

When you find out you are pregnant, it can be confusing (and even scary) to figure out exactly what medications you should and shouldn’t take. To complicate matters, many drugs don’t have conclusive results as to whether they are safe or not. It raises the question: Do you prioritize your own health, even if there’s a potential risk to your baby?

This dilemma may be of special concern to women who are taking antidepressants, before or during pregnancy. Luckily, physicians are well-versed in explaining the potential benefits and dangers of any prescription. Here’s what you should discuss with your healthcare provider if you are taking, or considering taking, amitriptyline during pregnancy or while breastfeeding.

What is amitriptyline used for?

This tricyclic antidepressant has a variety of uses from migraine to pain control, but it is primarily for patients with unipolar major depressive disorder. Valeria Contreras-Crowley, MD, a board-certified OB-GYN at Women’s Specialists of New Mexico says it has other off-label uses as well. It is sometimes prescribed to treat:

• Chronic fatigue syndrome-related sleep disturbances and pain
• Fibromyalgia
• Recurring indigestion
• Headache and migraine prevention
• Interstitial cystitis (bladder pain syndrome)
• Irritable bowel syndrome
• Neuropathic pain, chronic (including diabetic neuropathy)
• Postherpetic neuralgia (a shingles complication)
• Sialorrhea (excessive salivation)

Dr. Contreras-Crowley says this medicine isn’t the most commonly prescribed antidepressant, by her or other doctors, and she doesn’t see patients commonly listing this as something they take at their first prenatal appointment. 

“I personally do not prescribe amitriptyline as a first-line agent for women with depressive disorder during pregnancy primarily because I have more experience with SSRIs [Selective Serotonin Reuptake Inhibitors],” she says. “More studies are available for SSRIs than other antidepressant drugs.” 

If a patient visits her and is already on the medicine for another off-label use, she refers them back to their primary care doctor to determine if they should discontinue that medicine or find an alternative.

Is amitriptyline safe to take during pregnancy?

Like many medicines, there’s not a clear-cut answer on the safety of taking amitriptyline while pregnant. 

Amitriptyline pregnancy category

It’s considered a Category C drug by the U.S. Food and Drug Administration (FDA). Meaning, animal reproduction studies have shown possible adverse effects on the fetus, and there are no adequate or well-controlled studies in humans. Potential benefits may warrant use of the drug in pregnant women despite risks. 

Potential risks of amitriptyline and pregnancy

“There are few studies that have reported safety of this medication in pregnancy,” says Emily DeFranco, DO, director of maternal-fetal medicine at the University of Cincinnati College of Medicine. “Of the limited data available from humans, it does not appear that use in the first trimester is associated with a higher than average risk of birth defects. However, there are some reports that similar medications in its class may interfere with embryo development in experimental animal studies.” 

In addition, some small studies have reported slightly higher rates of high blood pressure complications of pregnancy in the pregnant person, and withdrawal symptoms of the newborn when amitriptyline was taken throughout the gestational period. A 2019 study published in BMJ also found a connection between antidepressants and gestational diabetes. The risk was the most heightened with amitriptyline of the antidepressants they studied, showing a 52% increased risk compared to those not on antidepressants.

Amitriptyline and miscarriage 

Pregnant women often worry that their medicines may increase their risk of miscarriage. There are no studies specifically on amitriptyline and miscarriage. “We do know that women with depression have slightly higher miscarriage rates,” says Dr. DeFranco. “We don’t know if this risk is primarily attributable to the medications used for depression treatment, or the depression itself even without medication use.” 

Dr. Contreras-Crowley adds that a Danish National registry study examining cases of women who were diagnosed with depression concluded there was not a difference in risk of miscarriage in women who were treated with antidepressants and those who were not treated with antidepressants. The study concludes that antidepressants were not associated with miscarriage among women with a diagnosis of depression.

Should I stop taking amitriptyline if I find out I’m pregnant?

Both experts caution against abruptly stopping use of an antidepressant. Weaning off of the medication should only happen under the direction of your healthcare provider, so alert your OB-GYN when you find out you are pregnant if you are on an antidepressant, including amitriptyline. The best course of action is to determine the risk of discontinuing versus continuing with your healthcare team.

“Depression in pregnancy can be serious so the patient’s history is important,” Dr. Contreras-Crowley says. The questions she will ask are: “Has she ever tried to commit suicide? Has she ever been hospitalized? What other medications has she been on before?” 

“If she has been stable on this medication, then the benefit to her baby and the pregnancy may be worth continuing,” she explains. Some of the risks of leaving depression untreated during pregnancy can include fetal growth restriction, poor fetal growth, preterm delivery, poor language development, and decreased IQ. 

What happens if a pregnant person quits amitriptyline abruptly?

Abruptly stopping this medication can lead to intense symptoms including: agitation, anxiety, chills, diaphoresis (sweating), headache, insomnia, irritability, malaise, myalgia (muscle pain) and nausea and may rarely cause cardiac arrhythmia, and parkinsonism. Slowly tapering off of the medication is recommended by decreasing the dose weekly. It may take two to four weeks or more to fully wean off the medication without experiencing withdrawal symptoms.

Is amitriptyline and breastfeeding safe?

Amitriptyline might be safe to use while breastfeeding. While it does cross through into the breast milk, Dr. DeFranco says the amount the baby is exposed to through breastfeeding is reported to be a fraction of the maternal levels. The American Academy of Pediatrics classified the lactation effects of this medication “unknown but may be of concern,” she explains, stating that there have been some reports of sedation in the baby. Dr. Contreras-Crowley says that it is safe, but the baby should be monitored for signs of sedation. She typically recommends nortriptyline or amitriptyline for breastfeeding mothers.

For any stage of trying to conceive, pregnancy, or breastfeeding, it’s best to consult with your provider about your medication choices.