When you're pregnant and struggling with anxiety or insomnia, the pressure to feel better can be overwhelming. Many women turn to benzodiazepines-medications like lorazepam, alprazolam, and diazepam-because they work quickly and effectively. But what happens when you're not just treating yourself anymore? You're also treating a developing baby. And that changes everything.
What Are Benzodiazepines, and Why Are They Used in Pregnancy?
Benzodiazepines are a class of drugs first made in the 1950s. They calm the nervous system, helping with anxiety, panic attacks, muscle spasms, and sleep problems. About 1.7% of pregnant women in the U.S. get a prescription for one during the first trimester, and that number is rising. For some, it’s the only thing that brings relief when therapy and lifestyle changes aren’t enough.
But here’s the catch: these drugs cross the placenta. That means whatever you take, your baby takes too. By the time the first trimester ends, the baby’s organs are forming-and that’s when they’re most vulnerable to outside chemicals. Even small amounts can interfere with development.
The Real Risk: What the Data Shows
Let’s cut through the noise. Some studies say benzodiazepines are safe. Others say they’re dangerous. The truth? It’s somewhere in between-and it depends on the drug, the dose, and when you take it.
A 2022 study of over 3 million pregnancies in South Korea found a small but real increase in birth defects. For every 1,000 women who took benzodiazepines in the first trimester, about 8 more babies were born with major malformations compared to those who didn’t. Heart defects were even more noticeable-about 14 extra cases per 1,000 exposed pregnancies.
But the bigger red flags show up in rare, severe defects. The CDC’s National Birth Defects Prevention Study found a strong link between alprazolam and two rare conditions: anophthalmia or microphthalmia (when a baby is born without eyes or with very small eyes) and esophageal atresia (when the tube from the mouth to the stomach doesn’t form properly). The odds were 4 times higher with alprazolam. That’s not common-but when it happens, it’s life-changing.
Dandy-Walker malformation-a rare brain defect-was also tied to benzodiazepine use. And while the overall risk is low, the fact that it showed up consistently across multiple studies can’t be ignored.
Not All Benzodiazepines Are the Same
Alprazolam (Xanax) keeps popping up in the data as the riskiest. That’s likely because it’s fast-acting, crosses the placenta quickly, and stays in the system longer than others. Lorazepam (Ativan) and diazepam (Valium) are also used, but they don’t show the same strong links to eye or esophageal defects.
Still, the dose matters. The Korean study found that women taking more than 2.5 mg of lorazepam-equivalent per day had a higher risk of heart defects. That’s about two 1mg tablets of lorazepam, or three 0.5mg tablets of alprazolam. Even lower doses aren’t risk-free-but the higher the dose, the higher the chance of harm.
It’s Not Just Birth Defects
Birth defects aren’t the only concern. Benzodiazepine use during pregnancy is linked to:
- 85% higher risk of miscarriage
- Increased chance of preterm birth
- Babies born smaller than expected
- Lower Apgar scores at 5 minutes
- Higher likelihood of NICU admission
And here’s something many don’t talk about: the risk starts before you even know you’re pregnant. One study found that women who took benzodiazepines in the 90 days before conception had a higher chance of ectopic pregnancy. That means the drug could be affecting egg quality or early implantation-long before the first ultrasound.
What Do Experts Really Say?
The American College of Obstetricians and Gynecologists (ACOG) says benzodiazepines may be used for short-term treatment-but only if absolutely necessary, and preferably avoided in the first trimester. The FDA labels them as Pregnancy Category D: positive evidence of fetal risk. The European Medicines Agency and Canadian guidelines agree: avoid them in early pregnancy unless there’s no other option.
But here’s the hard part: for some women, the risk of not treating anxiety or severe insomnia is greater than the risk of the medication. Untreated anxiety can lead to poor prenatal care, substance use, preterm labor, and even postpartum depression. So the question isn’t just “Is it safe?” It’s “Is it safer than the alternative?”
What Should You Do If You’re Pregnant and Taking Benzodiazepines?
If you’re already taking one and just found out you’re pregnant, don’t panic. Don’t stop cold turkey-that can trigger seizures or severe withdrawal in you and your baby. Talk to your doctor right away.
Here’s what a real-world plan might look like:
- Get a full medication review with your OB and psychiatrist. Bring your pill bottles.
- Switch to a safer alternative if possible. SSRIs like sertraline have more safety data in pregnancy and are often preferred.
- If you must continue, use the lowest effective dose for the shortest time.
- Avoid alprazolam if you can. Choose lorazepam or oxazepam instead-they clear faster and have less evidence of harm.
- Use non-drug tools: therapy (CBT), mindfulness, yoga, sleep hygiene. These work-and they’re free.
Some women successfully taper off benzodiazepines during pregnancy with support. Others need to stay on them. There’s no one-size-fits-all. But you need a plan-not guesswork.
What If You’re Trying to Get Pregnant?
If you’re planning a pregnancy and taking benzodiazepines, start the conversation now. Don’t wait until you miss your period. Talk to your doctor about:
- Alternatives that are safer in early pregnancy
- How long it takes for the drug to leave your system
- Whether your anxiety can be managed with therapy alone
Many women find that cognitive behavioral therapy (CBT) helps more than they expected. It doesn’t work overnight, but it builds skills that last long after the baby is born.
The Bottom Line
Benzodiazepines aren’t a deal-breaker for pregnancy. But they’re not a casual choice either. The data shows small but real risks-especially for alprazolam, high doses, and use in the first trimester. The absolute risk for most defects is low, but the consequences are severe.
The best move? Don’t start them during pregnancy unless there’s no other way. If you’re already on them, don’t quit alone. Work with your care team to make a smart, safe plan. And always, always consider therapy, sleep support, and stress reduction as your first line of defense.
Pregnancy isn’t the time to wing it with medications. But it’s also not the time to suffer in silence. There’s a middle path-and it starts with asking the right questions.
