It is essential to consider that medications that cross the blood-brain barrier can cross the placenta, hence reaching the baby. It can also enter breast milk (to a less extent)

Unfortunately, the answer is not always clear-cut, so it is reasonable to consider various sources of clinical knowledge, like clinical guidelines of psychiatric and obstetric medical societies, systematic reviews, meta-analyses, and randomized clinical trials. 

Currently, here is the knowledge available for drug classes commonly used for anxiety:

Benzodiazepines

Benzodiazepines are drugs like triazolam, oxazepam, midazolam, alprazolam, lorazepam, temazepam, diazepam, chlordiazepoxide, flurazepam. Benzodiazepines are used for acute episodes of anxiety and panic attacks by reducing the stimulation of nerves. However, benzodiazepine use during pregnancy has led to some reports of orofacial clefts, apnea, hypotonia, and feeding difficulties in infants.¹

Some doctors may still prescribe benzodiazepines in pregnancy when the benefit exceeds the risks. ¹

Non-benzodiazepine anxiolytics and hypnotics

Buspirone and Zolpidem are the two drugs under this drug class that are relatively safe for pregnancy. On the other hand, drugs such as Eszopiclone and Zaleplon have more risks during pregnancy.²

Selective Serotonin Reuptake Inhibitors (SSRIs)

There is a lack of evidence of the ill effects of SSRIs on fetuses and breastfeeding. There have been short-term complications of SSRIs like maternal weight changes and premature delivery³. However, it should be weighed versus the risk of relapse if the medications are discontinued. The approach to modifying SSRIs should be individualized for each patient and discussed with a physician. 

Paroxetine, however, should be avoided by pregnant women and women who plan on conceiving because of heart defects in infants.²

Selective Norepinephrine Reuptake Inhibitors (SNRIs)

Another option during pregnancy would be SNRIs, like duloxetine and venlafaxine. These drugs are considered relatively low-risk. However, there is a small risk of postpartum hemorrhage (bleeding after giving birth) and congenital heart defects.⁴

Tricyclic Antidepressants (TCAs)

TCAs can help both anxiety and depression, most commonly when other medications have not helped. A TCA like clomipramine may lead to heart defects. However, an alternative TCA, like maprotiline, has no documented effects on fetuses and is considered safer during pregnancy.²

Takeaways

Women who are planning on conceiving and whose symptoms of anxiety are mild may be able to taper off their medications. However, if there is any history of severe anxiety, depression, bipolar disorder, or suicide attempts, it may be better to maintain medications than risk a relapse. It may be better for the baby overall. 

A consult with your psychiatrist and obstetrician can help reduce your risk as well as improve the health of your child by tapering, modifying, or discontinuing your medications while pregnant. Other than medications, it is also important to do other non-medical ways to help reduce your stress. 

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