Can Lexapro (escitalopram) be taken during pregnancy?

Escitalopram (Lexapro) Use During Pregnancy

Escitalopram (Lexapro) can be used during pregnancy when the benefits outweigh the risks, with sertraline being a preferred first-line option if starting antidepressant therapy during pregnancy due to its better established safety profile. 1

Safety Classification and Risk Assessment

• Escitalopram, like most SSRIs, falls under FDA pregnancy category C, meaning that animal studies have shown adverse effects on the fetus, but there are no adequate well-controlled studies in humans 2
• The decision to use escitalopram during pregnancy requires careful consideration of:
  • Severity of maternal depression
  • Risk of depression relapse if medication is discontinued
  • Potential fetal risks associated with medication exposure

Potential Risks of Escitalopram During Pregnancy

Congenital Malformations

• Meta-analyses show a small increased risk of major congenital malformations with some SSRIs, with paroxetine and fluoxetine showing the strongest association 3
• Escitalopram has less evidence of teratogenicity compared to paroxetine, which is classified as FDA category D due to concerns about cardiac malformations 1

Neonatal Adaptation Syndrome

• Third-trimester exposure to escitalopram may lead to neonatal adaptation syndrome, characterized by 1, 2:
  • Irritability, crying, jitteriness
  • Tremors, shivering
  • Feeding difficulties
  • Respiratory distress
  • Sleep disturbances
  • Hypoglycemia
  • Seizures (rare)

Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Late pregnancy SSRI exposure has been associated with PPHN, though the absolute risk is small (number needed to harm: 286-351) 1
• This risk must be weighed against the risks of untreated maternal depression

Risks of Untreated Depression During Pregnancy

Untreated depression during pregnancy is associated with:

• Premature birth
• Decreased breastfeeding initiation
• High risk of depression relapse during pregnancy 1
• Potential negative effects on maternal-infant bonding

Management Recommendations

For Women Already Taking Escitalopram

• If a woman is already taking escitalopram and becomes pregnant, abrupt discontinuation is not recommended due to the high risk of depression relapse 1
• Consider continuing escitalopram if the depression is severe or has been recurrent

For Women Starting Treatment During Pregnancy

• Sertraline is generally considered the preferred first-line SSRI during pregnancy due to its established safety profile 1
• If escitalopram is chosen, use the lowest effective dose

Monitoring During Pregnancy

• Regular assessment of maternal mental health status
• Ultrasound monitoring as per standard obstetric care
• Prepare the pediatric team for potential neonatal adaptation syndrome if escitalopram is continued in the third trimester

Postpartum Considerations

• Monitor infants exposed to escitalopram during late pregnancy for signs of neonatal adaptation syndrome during the first week of life 1
• Arrange early follow-up after initial hospital discharge
• Escitalopram passes into breast milk but is generally considered compatible with breastfeeding 2
• Monitor breastfed infants for irritability, poor feeding, or sleep disturbances 1

Clinical Algorithm for Decision-Making

1. Assess severity of maternal depression

   • For mild depression: Consider non-pharmacological approaches first (psychotherapy)
   • For moderate to severe depression: Medication benefits likely outweigh risks

2. If already on escitalopram:

   • Continue if depression is well-controlled and history of severe/recurrent depression
   • Consider switching to sertraline if early in pregnancy and clinically appropriate

3. If initiating treatment during pregnancy:

   • Consider sertraline as first-line option
   • Use escitalopram if patient had previous good response or intolerance to sertraline

4. Third trimester considerations:

   • Inform pediatric team about SSRI exposure
   • Prepare for monitoring of neonatal adaptation syndrome

Key Takeaway

The decision to use escitalopram during pregnancy should balance maternal mental health needs against potential fetal risks. While there are some concerns with SSRI use during pregnancy, the risks of untreated depression can be significant for both mother and child. When antidepressant treatment is necessary during pregnancy, sertraline is generally preferred for new starts, but escitalopram remains a reasonable option, particularly for women already stabilized on this medication.