What is the preferred choice between Lexapro (escitalopram) and sertraline during pregnancy?

Sertraline vs. Lexapro (Escitalopram) in Pregnancy

Sertraline is the preferred choice over Lexapro (escitalopram) during pregnancy due to its established safety profile, lower risk of adverse outcomes, and extensive documentation in pregnancy. 1

Safety Profiles During Pregnancy

Sertraline

• First-line recommendation for treating depression during pregnancy 1
• Associated with lower risk of adverse pregnancy outcomes
• Provides infant exposure of less than 10% of maternal daily dose through breast milk 1
• Placental passage is low, with median infant concentrations at 25-33% of maternal levels 2
• Requires dose adjustments during pregnancy due to pharmacokinetic changes:
  • Extensive/ultrarapid metabolizers: 100-150 mg daily throughout gestation
  • Poor metabolizers: 50 mg in first trimester, 100 mg in second/third trimesters 3

Lexapro (Escitalopram)

• Associated with QT prolongation 4
• Less data available compared to sertraline regarding pregnancy safety 5
• Current data doesn't indicate specific risks, but evidence base is smaller 5

Considerations for Antidepressant Use in Pregnancy

First Trimester Concerns

• Risk of congenital malformations is highest in first trimester 1
• Recent evidence suggests no link between first-trimester SSRI use and cardiac malformations 4
• Paroxetine (not sertraline or escitalopram) has been specifically associated with cardiac malformation concerns 4

Late Pregnancy Considerations

• Third-trimester SSRI use may be associated with persistent pulmonary hypertension of the newborn (PPHN) 4
  • Number needed to harm: 286-351 4
• Neonatal adaptation syndrome possible with third-trimester use, including:
  • Irritability, jitteriness, tremors
  • Feeding difficulties
  • Respiratory distress
  • Symptoms typically resolve within 1-2 weeks 1

Breastfeeding Considerations

• Sertraline and paroxetine are most commonly prescribed during breastfeeding 4
• Sertraline provides infant exposure <10% of maternal daily dose 1
• Milk-to-plasma ratio for sertraline is influenced by milk fat content 6
• Median daily infant dosage with sertraline is approximately 6.9 μg/kg (0.95% of weight-adjusted maternal dose) 6

Clinical Approach

1. Assess depression severity and treatment necessity

   • Untreated depression during pregnancy is associated with:
     • Premature birth
     • Decreased breastfeeding initiation 4

2. Choose sertraline as first-line option when medication is needed 1

   • Starting dose: 50 mg daily
   • Adjust based on CYP2C19 metabolizer status if known 3, 2

3. Monitor throughout pregnancy

   • Consider therapeutic drug monitoring to identify poor metabolizers at risk for adverse effects 2
   • Adjust dosage as pregnancy progresses due to pharmacokinetic changes 3

4. Prepare for delivery

   • Monitor infant for signs of drug toxicity or withdrawal during first week of life 1
   • Arrange early follow-up after hospital discharge 1

Important Caveats

• Individual risk-benefit assessment remains essential
• ACOG recommends that treatment with SSRIs during pregnancy be individualized 7
• The decision to use medication must balance maternal risk of untreated illness versus potential fetal risk 1
• CYP2C19 poor metabolizers have 42% reduced sertraline clearance, requiring dose adjustments 6