One patient, two pregnancies, identical fetal outcomes — but different maternal mental health
A case report published in Therapeutic Advances in Reproductive Health in April 2026 documents the pregnancy and postpartum outcomes of a 26-year-old woman with ADHD across two pregnancies. The first pregnancy was unmedicated. The second was on lisdexamfetamine (Vyvanse or Elvanse) 40mg daily throughout. The obstetric and fetal outcomes were nearly identical. The maternal mental health outcomes were not.
In both pregnancies, the patient experienced chronic hypertension and preterm delivery via caesarean section — at 36 weeks in the first pregnancy, 33 weeks in the second. Both infants were born with cleft palate and micrognathia. Both required NICU admission. The medical history, support systems, and coping mechanisms remained constant across pregnancies. The only variable that changed was ADHD treatment.
The contrast in maternal experience was stark. First pregnancy, unmedicated: “quality of life was garbage,” “emotional rollercoaster the entire time,” “extreme emotional dysregulation,” “barely functioning.” The patient reports she would not eat unless food was placed in front of her. The first four months postpartum “felt like a cloud where I was fuzzy and disengaged.” She experienced sustained postpartum depression with passive death wishes, irritability, increased sleep, and variable appetite.
Second pregnancy, on lisdexamfetamine: Edinburgh Postnatal Depression Scale score of zero during pregnancy. “Able to get things done.” Postpartum: “feeling better than what I was after the birth of my first baby,” “not a sniff of postpartum depression this time,” “I cannot express enough how I am more capable in taking care of myself in this pregnancy and in the postpartum period.” The patient described herself as feeling “fantastic.”
The case report, led by researchers at Penn State Milton S. Hershey Medical Center, does not claim causation. It is a single patient. But the within-person comparison — same medical history, same obstetric complications, same fetal anomalies, different medication status — is as controlled as case reports get.
Discontinuing ADHD medication did not protect the fetus
The default assumption in perinatal ADHD care is that discontinuing stimulant medication is the cautious choice. The logic is intuitive: if the risks of medication exposure are uncertain, removing the exposure removes the risk. This case challenges that assumption directly.
Both infants presented with cleft palate and micrognathia. Both required NICU admission. The fetal outcomes were not better in the unmedicated pregnancy — they were identical. Discontinuation did not protect the fetus from congenital anomalies. It did not prevent preterm delivery. It did not reduce NICU admission.
The authors contextualise this against the broader evidence base. Current research suggests that in utero exposure to amphetamines or methylphenidate is not associated with significant increased risk of major congenital or cardiac malformations. Studies have shown no significant increase in risk of long-term neurodevelopmental disorders in infants. Amphetamine exposure has not been associated with significant differences in infant birth weight, NICU admission, or neonatal abstinence syndrome.
The case also addresses the preeclampsia question. Previous studies have suggested a potential association between psychostimulants and preeclampsia, though after adjustment for confounding factors the association attenuates. This patient had chronic hypertension and preeclampsia with severe features in her first pregnancy — without lisdexamfetamine. The recurrence in her second pregnancy is more parsimoniously explained by her medical history than by medication exposure.
The practical implication is uncomfortable but important: discontinuation may feel like risk reduction, but the fetal outcomes in this case suggest it was not. The patient discontinued medication in her first pregnancy and experienced the same fetal anomalies as in her second pregnancy when she continued treatment.
Untreated ADHD in pregnancy has costs that teratogenicity studies miss
Teratogenicity studies ask a specific question: does medication exposure cause fetal malformation? This is the right question for some drugs. It is not the only question that matters for ADHD medication in pregnancy.
The case report demonstrates what untreated ADHD did to this patient. First pregnancy: couldn’t eat, couldn’t function, couldn’t organise herself enough to decide what to make for dinner, went to bed early, experienced four months of postpartum fog, developed sustained depressive symptoms with passive death wishes. These outcomes do not appear in teratogenicity databases. They are not captured by congenital malformation registries. They are invisible to the studies that inform prescribing guidance.
The research literature supports this broader framing. Inattentive symptoms during pregnancy are the strongest predictors of daily-life impairments, including difficulties completing household chores, caring for family members, and managing driving-related responsibilities. Women who experience high levels of psychosocial stress during pregnancy are at increased risk for obstetric complications including preterm labour, preterm delivery, and low birth weight. An observational cohort study found that women who discontinued psychostimulant treatment during pregnancy had clinically significant increases in depression and anxiety, increased family conflict, found parenting more challenging, and felt more isolated.
ADHD is an independent risk factor for depression and anxiety postpartum. This patient’s first pregnancy illustrates the mechanism: untreated ADHD produced functional impairment, which produced stress, which produced depression. The second pregnancy broke the chain. ADHD was treated. Function was preserved. Depression did not develop.
The authors note that individualized risk-benefit assessments are fundamental when prescribing stimulants during pregnancy. But risk-benefit requires accounting for both sides of the equation. If the only risks considered are fetal risks from medication exposure, and the maternal risks from non-treatment are invisible, the assessment is incomplete.
Breastfeeding on lisdexamfetamine with no observed infant effects
The patient continued lisdexamfetamine while breastfeeding. She reported no concerns with the infant — no jitteriness, no sleep changes. Breastfeeding concerns were assessed twice in the postpartum period at approximately two and two-and-a-half months postpartum.
This is exactly the kind of evidence the neurodivergent perinatal research gap has identified as missing. The Elliott systematic review found that only one of eleven studies on neurodivergent pregnancy and birth focused on ADHD — the field has concentrated on autism while largely ignoring ADHD perinatal experience. Practical guidance on ADHD medication during lactation is sparse.
The broader literature on stimulants and breastfeeding is reassuring. A recent study observing lactating women taking either lisdexamfetamine or mixed racemic amphetamine salts identified mild adverse effects in five of thirteen infants — somnolence, crying, restlessness, colic, constipation — and concluded that amphetamine use is likely compatible with breastfeeding. Methylphenidate appears to have minimal risk. The LactMed database notes that amphetamine is transferred into breastmilk in small amounts.
The case report’s limitation is acknowledged: due to the infrequency of follow-up visits regarding breastfeeding, the authors note limited ability to fully evaluate for potential delayed effects. This is a single patient, assessed twice. It is not a longitudinal study. But it is a documented instance of successful breastfeeding with maternal lisdexamfetamine use — and documented instances are what the evidence base currently lacks.
For clinicians and patients making decisions about ADHD medication and breastfeeding, the question is not whether the evidence is complete. It is not. The question is whether available evidence supports categorical avoidance. This case suggests it does not.
Citations
Tran, T. H., Beal, M. L., Free, M. F., & Baweja, R. (2026) — To use or not use lisdexamfetamine in pregnancy and breastfeeding: a case report highlighting ADHD management and maternal–fetal outcomes
