Is Lexapro (escitalopram) safe to take during pregnancy?

Safety of Lexapro (Escitalopram) During Pregnancy

Lexapro (escitalopram) should be used during pregnancy only when the benefits of treating depression or anxiety outweigh the potential risks to the fetus, with sertraline generally being a preferred first-line SSRI option for pregnant women.

Risk Assessment of Escitalopram in Pregnancy

The FDA classifies escitalopram in pregnancy category C, meaning animal studies have shown adverse effects on the fetus, but there are no adequate well-controlled studies in humans 1. This classification indicates that potential benefits may justify the risks in certain situations.

Potential Risks:

• Late pregnancy use of SSRIs including escitalopram may lead to neonatal adaptation syndrome, characterized by symptoms such as irritability, tremors, feeding difficulties, respiratory distress, and hypoglycemia that typically resolve within 1-2 weeks after birth 2
• The FDA label specifically warns that "taking Escitalopram late in pregnancy may lead to an increased risk of certain problems in your newborn" 1
• A systematic review of meta-analyses found evidence for increased risks with SSRI use during pregnancy for:
  • Major congenital malformations (though no specific evidence for sertraline)
  • Preterm birth
  • Neonatal adaptation symptoms
  • Persistent pulmonary hypertension of the newborn 3

Benefits of Treatment:

• Untreated depression during pregnancy can have serious negative consequences for both mother and baby 4
• Abrupt discontinuation of antidepressants upon becoming pregnant can lead to withdrawal symptoms and relapse of depression 5

Recommendations for Management

First-Line Approach:

1. Consider sertraline as first-line option: Sertraline has a more established safety profile during pregnancy compared to escitalopram 2
2. Use lowest effective dose: If escitalopram is continued, use the lowest dose that effectively manages symptoms 2
3. Avoid abrupt discontinuation: If a woman decides to stop taking escitalopram, it should be gradually tapered to avoid discontinuation syndrome 5

Monitoring During Pregnancy:

• Close monitoring of maternal symptoms throughout pregnancy
• For women taking escitalopram in late pregnancy, prepare for potential neonatal adaptation syndrome
• Consider registering with the National Pregnancy Registry for Antidepressants (1-844-405-6185) 1

Special Considerations

First Trimester Use:

• One study of citalopram (the parent compound of escitalopram) found no significant increase in major malformations when used in the first trimester 6
• If possible, antiarrhythmic drugs and other medications should be avoided in the first trimester when risk of congenital malformations is greatest 7

Breastfeeding:

• The FDA notes that escitalopram may pass into breast milk 1
• Discussion with healthcare provider about risks and benefits is essential before continuing escitalopram during breastfeeding

Clinical Decision Algorithm

1. Assess severity of maternal depression/anxiety

   • Determine if symptoms require pharmacological intervention
   • Consider non-pharmacological options when appropriate

2. If medication is necessary:

   • Consider switching to sertraline if patient is not already on escitalopram
   • If patient is stable on escitalopram, weigh risks of changing medication versus continuing current treatment

3. For patients continuing escitalopram:

   • Use lowest effective dose
   • Monitor closely throughout pregnancy
   • Prepare for potential neonatal adaptation syndrome if used in third trimester
   • Arrange for appropriate neonatal monitoring after delivery

Remember that the decision to use escitalopram during pregnancy should involve careful consideration of both the risks of untreated maternal depression and the potential risks of medication exposure to the fetus.