Sleep problems are common during pregnancy, and for some women they can be severe and persistent. We always start by emphasizing good sleep hygiene and non-medication approaches, but that is not always enough.

Non-pharmacological interventions, such as cognitive-behavioral therapy for insomnia (CBT‑I), are effective for many women. In‑person CBT‑I and apps or online programs delivering CBT-I have been shown to reduce insomnia severity and nighttime awakenings during pregnancy and may also lower the risk of postpartum depression. However, CBT-I may not work for everyone, and if sleep problems are persistent, you may want to consider medications to improve sleep.

Consequences of Persistent Sleep Problems During Pregnancy

There is a tendency for women to assume that they just have to “deal with it,” that poor sleep is simply part of pregnancy. However, ignoring sleep problems is not the best approach. Chronic insomnia is associated with higher levels of depression and anxiety symptoms in pregnancy and may also increase risk for postpartum depression. Severe sleep disruption can also impair daytime functioning, make it harder to manage work or caregiving responsibilities, and can erode a woman’s capacity to cope with other pregnancy-related stressors.

Sometimes, medications are necessary for managing severe or prolonged sleep disturbances during pregnancy. When considering medications, it is important to evaluate not only their efficacy and potential side effects but also their safety profile for pregnancy.

Over-the-Counter (OTC) Medications

Over-the-counter medications like doxylamine (found in Diclegis and some Unisom formulations) and diphenhydramine, another sedating antihistamine, are commonly used for promoting sleep during pregnancy. Antihistamines are commonly used in pregnancy and have not been associated with an increased risk of major congenital malformations in human studies, although they can cause next‑day grogginess and dry mouth.

While melatonin is often used to treat insomnia, data on its reproductive safety are limited, and formulations and doses vary widely. Because of this limited evidence, melatonin is not typically a first‑line recommendation for the treatment of insomnia during pregnancy.

Sedative-Hypnotic Medications or Z‑Drugs

Prescription sleep medications include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). These Z‑drugs are sometimes used during pregnancy on an as‑needed, short‑term basis. Recent data from several large studies do not suggest any meaningful increase in the overall risk of malformations in children exposed during early pregnancy to this class of medication. Among the Z-drugs, we have the most data to support the use of zolpidem and much less information on eszopiclone and zaleplon.

In our experience, Z‑drugs are a good option for those with intermittent sleep problems and not such a good choice for those with chronic insomnia. When Z‑drugs are taken on a nightly basis for a longer period of time (usually defined as more than 2 weeks), they may lose some of their effectiveness and can lead to tolerance or dependence, particularly at higher doses. For these reasons, we typically recommend using the lowest effective dose for the shortest possible duration, in combination with CBT‑I and other behavioral strategies.

SSRIs and SNRIs

When sleep problems are closely linked to depression and/or anxiety, treating the underlying condition is essential. Serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are commonly used to treat depression and anxiety during pregnancy and have a relatively well‑characterized reproductive safety profile. However, they may take several weeks to become effective, and in this setting, sedating medications like benzodiazepines may be considered for short‑term treatment of insomnia while waiting for the SSRI or SNRI to work.

Benzodiazepines

There are data to support the use of benzodiazepines, including lorazepam (Ativan) and clonazepam (Klonopin), during pregnancy, and most large cohort and meta‑analyses have not found a substantial increase in the overall risk of major malformations. Some earlier case‑control data had raised concerns about oral clefts, but more recent, larger studies suggest that if there is any increased risk, it is small in absolute terms.

One of the main advantages of benzodiazepines is their rapid onset of action; they can be very helpful for acute, severe insomnia or anxiety. However, with this class of medication there is the potential for abuse, as well as dependence, tolerance, and withdrawal symptoms in those taking benzodiazepines on a daily basis for a longer period of time. In late pregnancy or with higher doses, benzodiazepines may be associated with transient neonatal adaptation symptoms, although this has not been well-studied. Careful dosing and monitoring are important.

Trazodone and Other Options

Sedating antidepressants, such as tricyclic antidepressants (TCAs), trazodone, and mirtazapine (Remeron), can help with insomnia. Available data, although more limited than for SSRIs, do not suggest a large increase in risk of major birth defects with trazodone or mirtazapine. However, they may cause additional side effects like daytime drowsiness and orthostatic dizziness (trazodone) and appetite stimulation and weight gain (mirtazapine), which can be particularly problematic in late pregnancy.

Deciding on What’s the Best Option for You

Finding the best option for you involves a discussion with your provider. While this information is designed to help you understand the range of options, it is not intended to be a substitute for individualized medical care and supervision.

A thoughtful evaluation typically includes:

  • Reviewing your specific sleep problems: What is your usual schedule? Are you having problems falling asleep, staying asleep, or both?
  • Screening for underlying sleep disorders: Sleep apnea and periodic limb movements are more common during pregnancy and may require targeted treatment.
  • Evaluating for underlying depression or anxiety, including a history of recurrent mood disorders or trauma.
  • Reviewing non-pharmacologic options, like CBT‑I, relaxation training, and sleep hygiene, and making sure these strategies are fully optimized before or alongside medications.

Decisions regarding the use of medications involve weighing:

  • Severity and duration of your insomnia and its impact on functioning.
  • Your personal and family history of response to specific medications.
  • Gestational timing (early versus late pregnancy) and plans for breastfeeding.
  • Potential risks of the medication versus the risks of untreated insomnia, depression, or anxiety.

Whatever option you and your provider choose, it is important to arrange follow‑up in a few weeks to review how things are going. Sometimes the first choice does not work well enough, or side effects appear, or there needs to be some adjustment in timing or dose. Sleep during pregnancy is a moving target, and treatment plans often need to evolve over time.

Resources

References

  1. MGH Center for Women’s Mental Health – CBT for Insomnia During Pregnancy: Effective but Underutilized
  2. MGH Center for Women’s Mental Health – Sleep Problems During Pregnancy: Screening and Opportunities for Intervention
  3. MGH Center for Women’s Mental Health – Clinical Update 2026: Z-Drugs and Pregnancy
  4. Fung K, Straub L, Bateman BT, Hernandez-Diaz S, Brill G, Zhu Y, Cohen LS, Gray KJ, Huybrechts KF. Z-Drug Use in the First Trimester of Pregnancy and Risk of Congenital Malformations. JAMA Psychiatry. 2025 Dec 23:e253874.
  5. Tu X, Junna MR, Kolla BP. How do you Zzz during pregnancy? A brief review of Z-drug use and management of insomnia during pregnancy. J Clin Sleep Med. 2025 Aug 1;21(8):1499-1502. doi: 10.5664/jcsm.11740. PMID: 40259749; PMCID: PMC12320687.