Propranolol for Anxiety During Pregnancy: Is It Safe?

What does the evidence say about propranolol for anxiety during pregnancy?

1. Propranolol is a beta-blocker most often prescribed for high blood pressure, certain heart conditions, overactive thyroid, tremor, glaucoma, and migraines. MotherToBaby's review found it is not known whether propranolol raises the chance of birth defects, and research on beta-blockers as a group has not shown an increased chance of birth defects. 1
2. Propranolol use has been linked to lower birth weight, under 5 pounds 8 ounces (2500 grams) at birth, though it is unclear whether the medication or the underlying condition being managed is responsible. Separately, using propranolol late in pregnancy might raise the chance of a newborn showing beta-blockade symptoms shortly after birth, such as a slowed heart rate, low blood pressure, and low blood sugar, which is why delivery teams need to know about propranolol use in advance. 2
3. LactMed reports that propranolol passes into breastmilk at low levels, with a fully breastfed infant estimated to receive between 0.1 percent and 0.9 percent of the weight-adjusted maternal dose. Published studies during breastfeeding found no adverse reactions in infants clearly linked to propranolol, though rare case reports include infant sleepiness, low blood sugar, and a slowed heart rate that resolved once the medication was stopped. 3
4. Evidence on propranolol and fetal growth is mixed: one study found mothers taking propranolol or atenolol had roughly double the chance of fetal growth restriction, while a larger study of more than 378,000 pregnancies found no association between metoprolol or propranolol exposure and small-for-gestational-age infants. The same review describes propranolol as generally considered the preferred beta-blocker during breastfeeding, due to lower levels passing into breastmilk. 4
5. Propranolol blocks beta-adrenergic receptors, blunting the physical effects of adrenaline and noradrenaline; this is the basis for its off-label use for the physical symptoms of anxiety, such as a racing heart, palpitations, sweating, and tremor, including situational anxiety around public speaking or medical procedures. SSRIs remain the first-line prescribed medication for anxiety disorders overall, with propranolol used as a distinct, narrower off-label option for physical symptoms rather than a substitute. 5

Is propranolol for anxiety safe in each trimester?

• First trimester. Propranolol is FDA-approved for conditions such as high blood pressure, certain heart conditions, overactive thyroid, tremor, glaucoma, and migraines, and it is also prescribed off-label for the physical symptoms of anxiety, such as a racing heart or shaking. MotherToBaby's review found it is not known whether propranolol raises the chance of birth defects, and beta-blockers as a group have not shown an increased chance of birth defects. Whether to start or continue propranolol in the first trimester is an individualized decision made with your prescriber.
• Second trimester. Evidence on propranolol and fetal growth in mid-pregnancy is mixed. One study found mothers taking propranolol or atenolol had roughly double the chance of fetal growth restriction, while a much larger study of more than 378,000 pregnancies found no link between metoprolol or propranolol exposure and small-for-gestational-age babies. Your provider may add growth-focused ultrasounds if you continue propranolol, which is a routine precaution rather than a sign of a known problem.
• Third trimester. The main third-trimester consideration involves the newborn: MotherToBaby notes that propranolol used late in pregnancy might raise the chance of a baby showing beta-blockade symptoms shortly after birth, including a slowed heart rate, low blood pressure, and low blood sugar. Not every baby exposed to propranolol will have these symptoms, but tell your delivery team you are taking it so hospital staff can watch your newborn and respond if needed. Propranolol is generally considered a preferred beta-blocker if you plan to breastfeed afterward, since comparatively low levels pass into breastmilk.