What are the implications of using Citalopram during pregnancy?

From the Guidelines

Citalopram is generally considered safe for use during pregnancy, particularly when the benefits of treatment outweigh the potential risks 1.

Key Considerations

• The recommended dose during pregnancy is typically 20-40 mg per day, with some studies suggesting that doses above 40 mg per day may increase the risk of adverse outcomes 1.
• Women taking citalopram during the third trimester may be at increased risk of neonatal complications, such as respiratory distress and jitteriness, and should be closely monitored by their healthcare provider 1.
• Neonatal signs that may occur after birth include continuous crying, irritability, jitteriness, and/or restlessness; shivering; fever; tremors; hypertonia or rigidity; tachypnea or respiratory distress; feeding difficulty; sleep disturbance; hypoglycemia; and seizures 1.
• The onset of these signs ranged from several hours to several days after birth and usually resolved within 1 to 2 weeks 1.
• Clinicians should be aware that infants are at risk for manifesting clinical signs of drug toxicity or withdrawal over the first week of life and arrange for early follow-up after the initial hospital discharge 1.

Breastfeeding Considerations

• A mother on treatment with an SSRI who desires to nurse her infant should be counseled about the risks and benefits 1.
• Antidepressants transfer in low concentrations into breast milk, with paroxetine and sertraline being the most commonly prescribed antidepressants during breastfeeding 1.

From the FDA Drug Label

Pregnancy Category C In animal reproduction studies, citalopram has been shown to have adverse effects on embryo/fetal and postnatal development, including teratogenic effects, when administered at doses greater than human therapeutic doses Neonates exposed to citalopram tablets and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester, have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN).

The implications of using Citalopram during pregnancy include:

• Adverse effects on embryo/fetal and postnatal development
• Teratogenic effects at doses greater than human therapeutic doses
• Neonatal complications, such as respiratory distress, cyanosis, and seizures
• Increased risk of persistent pulmonary hypertension of the newborn (PPHN) 2 Therefore, citalopram should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

From the Research

Implications of Using Citalopram During Pregnancy

The use of citalopram during pregnancy has been studied to assess its safety and potential risks.

• A study published in 2005 3 found that citalopram use during the first trimester was not associated with an increased risk of major malformations, but late pregnancy use was associated with an increased risk of poor neonatal adaptation syndrome.
• Another study published in 2019 4 found that depressed SSRI-treated pregnant women and their children seem to be at increased risk for several complications, but the available methodology does not allow to disentangle the potential effect of SSRIs from those of the disease itself or/and of its unmeasured associated risk factors.
• A study on Sprague-Dawley rats published in 2016 5 found that perinatal exposure to citalopram causes persistent neurobehavioral effects, including impaired learning and memory, increased anxiety and depression-like behavior, and altered startle response.
• A literature review published in 2017 6 found that paroxetine and fluoxetine have the strongest association with negative outcomes, while the associations between sertraline and citalopram with negative outcomes remain mixed and generally unsubstantiated when studies that show an association are controlled for the effects of maternal depression and associated factors.
• It is worth noting that citalopram overdose can be fatal, as reported in a case study published in 2015 7, highlighting the importance of careful monitoring and management of citalopram use during pregnancy.

Potential Risks and Benefits

The potential risks and benefits of using citalopram during pregnancy must be carefully considered.

• The risks include poor neonatal adaptation syndrome, increased risk of complications, and potential neurobehavioral effects on the offspring.
• The benefits include the effective treatment of depression and anxiety in pregnant women, which is essential for their mental health and well-being.
• Sertraline and citalopram are considered to be first-line drug treatments for anxiety and depression in pregnant women in the SSRI class, as they have a relatively safer profile compared to other SSRIs 6.