What are the current guidelines for using Lexapro (escitalopram) during pregnancy?

Guidelines for Lexapro (Escitalopram) Use During Pregnancy

Lexapro (escitalopram) should be used during pregnancy only when the potential benefits outweigh the risks, as it carries FDA Category C classification and is associated with risks of persistent pulmonary hypertension of the newborn (PPHN) and poor neonatal adaptation syndrome. 1

Risks Associated with Escitalopram During Pregnancy

Fetal/Neonatal Risks

• Persistent Pulmonary Hypertension of the Newborn (PPHN): Increased risk, particularly with late pregnancy exposure 1
• Poor Neonatal Adaptation Syndrome: Complications requiring prolonged hospitalization, including:
  • Respiratory distress
  • Feeding difficulties
  • Temperature instability
  • Hypoglycemia
  • Tremor, jitteriness, irritability
  • Hypertonia or hypotonia 1

Animal Studies

• Decreased fetal body weight and delayed ossification at high doses (55+ times the maximum recommended human dose) 1
• Increased offspring mortality and growth retardation at high doses 1

Benefits of Treatment During Pregnancy

• Women who discontinue antidepressants during pregnancy have higher relapse rates of major depression 1
• Untreated maternal depression is associated with:
  • Increased rates of preterm birth
  • Increased maternal substance use 2
  • Potential negative effects on maternal-infant bonding

Decision-Making Algorithm for Escitalopram Use in Pregnancy

1. Assess Severity of Depression

   • Determine if benefits of treatment outweigh potential risks
   • Consider history of previous episodes and response to treatment

2. Consider Timing in Pregnancy

   • First trimester: Higher theoretical risk for structural malformations
   • Third trimester: Higher risk of PPHN and neonatal adaptation syndrome

3. Dosing Considerations

   • Use lowest effective dose
   • Monitor therapeutic drug levels (may need dose adjustments during pregnancy due to metabolic changes) 3

4. Monitoring During Pregnancy

   • Regular psychiatric assessment
   • Fetal growth monitoring
   • Prepare pediatric team for potential neonatal complications

Breastfeeding Considerations

• Escitalopram is excreted in breast milk at concentrations 2-3 times higher than maternal plasma 1
• Exclusively breastfed infants receive approximately 3.9% of maternal weight-adjusted dose 1
• Monitor breastfed infants for:
  • Excessive sedation
  • Restlessness or agitation
  • Poor feeding and weight gain 1

Practical Recommendations

• Patient Education: Inform pregnant women about potential risks and benefits
• Coordination of Care: Involve obstetrics, psychiatry, and pediatrics in management
• Delivery Planning: Alert pediatric team about medication exposure to monitor for neonatal adaptation syndrome
• Postpartum Monitoring: Continue close follow-up for both mother and infant

Special Considerations

• Limited case reports suggest generally favorable outcomes with escitalopram use during pregnancy 4, 5
• Consider alternatives like sertraline or citalopram which have more extensive safety data during pregnancy 6
• Avoid abrupt discontinuation of escitalopram if already being used effectively, as withdrawal symptoms and depression relapse may occur

The decision to use escitalopram during pregnancy requires careful weighing of the risks of untreated depression against the potential risks of medication exposure, with consideration of the individual patient's psychiatric history and severity of illness.