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 due to its better established safety profile. 1

Safety Classification and Risk Assessment

Escitalopram, like most antidepressants, requires careful consideration during pregnancy:

• The FDA does not provide a specific pregnancy category for escitalopram in the provided evidence, but SSRIs generally fall into category C (drugs should be given only if potential benefits justify the potential risk to the fetus) 2
• Risk assessment should balance maternal mental health needs against potential fetal risks 1
• Untreated depression during pregnancy is associated with serious complications including:
  • Premature birth
  • Decreased breastfeeding initiation
  • High risk of depression relapse 1

Potential Risks of Escitalopram During Pregnancy

Congenital Malformations

• While some cases of major malformations have been reported with escitalopram exposure during early pregnancy, the rate appears to be within the range reported in unexposed women 3
• Paroxetine and fluoxetine have stronger evidence for increased risk of cardiac malformations, while sertraline has better safety data 1, 4

Perinatal Complications

• Third trimester exposure to SSRIs including escitalopram may lead to neonatal adaptation syndrome, characterized by:
  • Crying, irritability, tremors
  • Poor feeding, hypertonia, tachypnea
  • Sleep disturbance, hypoglycemia
  • Seizures 1
• Persistent pulmonary hypertension of the newborn (PPHN) is a rare but serious potential complication (number needed to harm: 286-351) 1

Clinical Decision-Making Algorithm

1. Assess severity of maternal depression

   • Evaluate risk of untreated depression vs. medication risks
   • Consider history of previous episodes and response to treatment

2. Consider alternative treatments first

   • Psychotherapy as first-line for mild-moderate depression
   • Reserve medication for moderate-severe depression or when psychotherapy is insufficient

3. If medication is necessary:

   • Consider sertraline as first-line due to better established safety profile 1
   • Escitalopram may be used when benefits outweigh risks, particularly if the patient has previously responded well to it
   • Avoid switching medications during pregnancy if the patient is stable on escitalopram

4. Monitoring during pregnancy:

   • Regular assessment of maternal mental health
   • Fetal monitoring as per standard obstetric protocols
   • Plan for neonatal monitoring after delivery

Important Considerations for Clinicians

• Discontinuation risk: Stopping antidepressants during pregnancy is associated with a high risk of depression relapse 1
• Abrupt discontinuation symptoms: If medication changes are necessary, taper slowly to avoid withdrawal symptoms including anxiety, irritability, headache, dizziness, and electric shock-like sensations 5
• Neonatal monitoring: For infants exposed to escitalopram during pregnancy, monitor for signs of drug toxicity or withdrawal during the first week of life 1
• Breastfeeding: Limited data available on escitalopram during breastfeeding, but generally appears to be safe 3

Common Pitfalls to Avoid

1. Abrupt discontinuation: Never stop escitalopram suddenly due to risk of withdrawal symptoms and depression relapse
2. Ignoring maternal mental health: Untreated depression carries significant risks to both mother and baby
3. Failure to monitor the neonate: Infants exposed to escitalopram in the third trimester should be monitored for adaptation syndrome
4. Not discussing the treatment plan: Involve the patient in decision-making, explaining both risks of medication and risks of untreated depression

When making treatment decisions about escitalopram during pregnancy, the most recent evidence suggests that while there are some risks, these must be weighed against the substantial risks of untreated maternal depression.