Is it safe for pregnant people to take Lexapro (escitalopram)?

Escitalopram (Lexapro) Use During Pregnancy

Escitalopram can be used during pregnancy when the benefits outweigh the risks, with sertraline being a preferred first-line option due to its more established safety profile. 1

Safety Profile of Escitalopram in Pregnancy

Risk Assessment

• Escitalopram is FDA category C, meaning it should be given only if potential benefits justify the potential risk to the fetus 1
• The FDA label for escitalopram warns that taking it late in pregnancy may lead to certain problems in newborns 2
• Limited data is available specifically for escitalopram compared to other SSRIs, but current evidence does not indicate a specific risk for major malformations 1, 3

Potential Risks

• Neonatal Adaptation Syndrome: Third-trimester exposure can lead to symptoms including:

  • Crying, irritability, tremors
  • Poor feeding, respiratory distress
  • Sleep disturbance, hypoglycemia
  • Seizures 1

• Other Potential Concerns:

  • Possible small increased risk of persistent pulmonary hypertension of the newborn (PPHN) with SSRIs in general
  • The rate of major malformations appears to be in the range of those reported in unexposed women 3

Comparison with Other Antidepressants

• Sertraline is generally recommended as the first-line SSRI during pregnancy due to its more established safety profile 1
• Paroxetine has more concerns due to potential cardiac malformations and is FDA category D 1
• Citalopram (parent compound of escitalopram) can be used during pregnancy according to limited studies 4, 5

Risk of Untreated Depression

• Untreated depression during pregnancy is associated with:
  • Premature birth
  • Decreased breastfeeding initiation
  • Increased risk of depression relapse 1
  • These risks must be weighed against potential medication risks

Clinical Recommendations

1. For women already on escitalopram:

   • If depression is well-controlled, continuing escitalopram may be appropriate as stopping antidepressants during pregnancy is associated with high risk of relapse 1

2. For women not yet on medication:

   • Consider sertraline as first-line option due to more established safety data 1
   • Escitalopram can be considered if the patient has previously responded well to it

3. Monitoring during pregnancy:

   • Regular assessment of maternal mental health
   • Inform obstetric providers about medication use
   • Prepare for potential neonatal adaptation syndrome if continuing through third trimester

Breastfeeding Considerations

• Limited data suggests escitalopram appears in breast milk at 2-3 times the maternal plasma concentration, but infant plasma levels are very low or undetectable 5
• No adverse effects have been reported in the few studies evaluating escitalopram safety during breastfeeding 3, 6

Important Caveats

• The decision to use escitalopram during pregnancy should balance maternal mental health needs against potential fetal risks
• Stopping medication abruptly can lead to withdrawal symptoms and depression relapse
• Always discuss medication changes with healthcare providers before making adjustments

Remember that while this guidance is based on current evidence, individual factors including severity of depression, previous response to medications, and personal preferences should be considered in the final decision.