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First you go into a store and can’t remember what you needed to buy. Then you miss an appointment. Maybe you can’t find your keys. And then you just get irritable or short-tempered with the world.

Am I describing a woman with ADHD or one who’s pregnant?

For women with Attention-deficit/hyperactivity disorder, life is already a daily struggle, and that’s without a baby growing inside. ADHD is caused by the brain’s inability to make enough of the neurotransmitters it needs, specifically dopamine and norepinephrine. So take that deficit and all the symptoms it brings, then add pregnancy brain. Throw in hormonal changes just for kicks. Then imagine your doctor telling you to go off medicine: the only thing keeping you together.

What would you do?

Because their brains don’t make enough neurotransmitters, people with ADHD seek ways to take all the stimuli life throws at them and bring it under control. That’s why many ADHD experts recommend a boilerplate list of coping skills. Meditate, they say, as if sitting in lotus will suddenly remind you to pay the Verizon bill. Or make lists, which is the worst advice you can give anyone with ADHD. We’ve made lists, we’ve lost those lists.

Let’s face it. The surest way to get the neurotransmitters you need is to take medicine that helps make neurotransmitters. That’s what Ritalin and Adderall do: They’re stimulants that increase dopamine.

As you can guess, though, there’s not a long line of pregnant women excited about piping 30 mg of stimulants that bunk around with neurotransmitters into their unborn baby’s brain. “There was never a debate on whether I would continue to take my medicine or not. The day I found out I was pregnant — both times — I stopped taking it,” says two-time mother Amanda Long.

Rachael Seda quit taking Adderall after she stopped using birth control. She wasn’t even trying to have a baby yet, but as soon as she told her doctor, “she wouldn’t prescribe me Adderall at all, even though I wasn’t trying for a few more months. She shared the complications it could cause if one was [sic] to accidentally get pregnant on Adderall.”

What are those complications exactly? Well, every doctor I interviewed for this piece pointed out the dearth of information on how ADHD medication impacts a human fetus, which Eva Martin of Elm Tree Medical in San Francisco attributes to obvious ethical considerations.

What we do know, though, according to Martin, is that when pregnant rabbits take methylphenidate (Ritalin), their offspring are born with “an increased risk of spina bifida, and extremely high doses in rats result in skeletal abnormalities.” Her assessment of Adderall’s risks is even less delightful, citing studies in mice that “result[ed] in fetal malformations and death.”

Just because Long and Seda stopped taking meds, though, doesn’t mean it was easy for either to do. Long says being off medication was “very difficult” during both her pregnancies. “In my first pregnancy, the first trimester was terrible. I felt like I was constantly in a fog.”

For Seda, pregnancy wasn’t easy, but she had “a harder time” while staying off medication to nurse. “There was a very noticeable difference for me in how I felt and my concentration,” she explains. “I didn’t feel like I accomplished very much, I was distracted and actually felt pretty down about myself.”

Baby blues are standard for any mom, but they serve as another example of ADHD and pregnancy’s comorbidity. This compounding of symptoms is why some expectant mothers do stay medicated. It all comes down to how severe a woman’s ADHD is and how it manifests.

Christina Wichman, associate professor of psychiatry and obstetrics and gynecology at the Medical College of Wisconsin, says that pregnant women with milder ADHD symptoms can go off meds and “do quite well.” But she also makes the very real point that “there are other women with more severe symptoms which interfere significantly with their daily functioning, including ability to work, go to school or impact their relationships, and may potentially affect their pregnancy.”

Catherine Harrison-Restelli, a psychiatrist at Sheppard Pratt Health System in Baltimore, puts it more bluntly: “[I]f a woman’s ADHD is very severe, I would much rather her take the lowest effective dose of medication to treat her symptoms, rather than to crash her car, burn down the house by leaving the stove on, get fired from work for poor performance, start smoking or using alcohol or drugs to manage stress, or have her other children injured in accidents because her ADHD is untreated.”

As unappealing as malformed rabbits make taking ADHD medications during pregnancy sound, burning down the house doesn’t seem like a healthy scenario either. So perhaps Wichmann puts it best: “It truly depends on a woman’s ability to function without medication management.”

For those who do elect to spend nine months medicine free, doctors, of course, recommend meditation and lists. But on a much more helpful level, Martin suggests taking vitamin D, and Harrison-Restelli recommends bupropion (Wellbutrin). Unlike stimulants, she says, “Safety data on bupropion in pregnancy is very reassuring.”

Of course reassurance may also be a partial cure. Whether she has ADHD or not, that’s something every expecting mother needs.

Terena Bell is a freelance journalist writing most often on tech, entertainment, public affairs, ADHD, and the upcoming 2017 total solar eclipse. A Kentucky native, she is based in New York. She tweets @TerenaBell.

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