Attention-Deficit Hyperactivity Disorder.

Over the past decade adults have been increasingly diagnosed with attention-deficit hyperactivity disorder (ADHD), including many women in their childbearing years. ADHD patients can be successfully treated with medications such as stimulants, the mainstay of treatment, followed by tricyclic antidepressants and bupropion (Wellbutrin).

Women who have been stabilized on one of these medications and want to become pregnant often come to see us with questions about whether they should remain on the drug.

What we advise these patients depends in part on the severity of their disorder. For women with mild to moderate symptoms that do not interfere dramatically with their life we frequently recommend a switch to a nonpharmacologic intervention even though there's a fair amount of information on the reproductive safety of one therapeutic option, the tricyclics.

For these women, the risk of not being treated does not justify fetal exposure to a drug that we don't know much about or even a drug for which we have reassuring reproductive safety data.

The more difficult clinical scenario is with women who unequivocally have severe ADHD that, if left untreated, could dramatically interfere with their functioning and potentially affect the outcome of their pregnancy. Stimulants such as methylphenidate (Ritalin) do not appear to be teratogenic as a class. But there are some data suggesting an association between in utero exposure to stimulants and poor fetal or neonatal outcomes, such as small for gestational age or intrauterine growth retardation.

These data, however, are not from reports of women with ADHD but largely from women abusing stimulants such as amphetamines who had other risk factors for poor neonatal or fetal outcomes. This makes it difficult to discern the independent risk associated with fetal exposure to stimulants.

When we see patients with more severe symptoms who have done well on a stimulant, we share these data with them, pointing out that it's not entirely clear whether exposure is associated with impaired fetal outcome.