Is escitalopram (Lexapro) safe to use during pregnancy?

Safety of Escitalopram During Pregnancy

Escitalopram should be continued during pregnancy at the lowest effective dose if clinically indicated, as the benefits of treating depression often outweigh potential risks to the mother-infant dyad. 1

Risks and Benefits Assessment

Potential Risks

• Neonatal Adaptation Syndrome: Third-trimester use of escitalopram may lead to a constellation of symptoms in newborns including:

  • Crying, irritability, jitteriness, tremors, poor feeding, sleep disturbance 1
  • Symptoms typically appear within hours to days after birth 1
  • Most symptoms resolve within 1-2 weeks 1

• Cardiac Concerns:

  • QT prolongation is a dose-dependent concern with escitalopram 1
  • FDA recommends not exceeding doses of 20 mg per day in adults over 60 years 1

• Perinatal Complications:

  • Some studies suggest possible association with lower birth weight 2, 3
  • Limited evidence of association with persistent pulmonary hypertension of the newborn (PPHN) with SSRI class, though risk is low (number needed to harm: 286-351) 1

Benefits of Treatment

• Maternal Mental Health: Untreated depression during pregnancy is associated with:
  • Premature birth 1
  • Decreased initiation of breastfeeding 1
  • Potential harmful effects on the mother-infant relationship 1

Safety Evidence

• Congenital Malformations:

  • Current data does not indicate a specific risk of major malformations with escitalopram use during pregnancy 4, 2, 3
  • Rate of malformations is generally within the range observed in unexposed women 2, 3

• Neurodevelopmental Outcomes:

  • Several reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1
  • Limited long-term follow-up data specifically for escitalopram 2, 5

Management Recommendations

During Pregnancy

• Dosing: Use the lowest effective dose of escitalopram 1
• Monitoring:
  • Consider therapeutic drug monitoring to minimize fetal exposure 6
  • Arrange for early follow-up after hospital discharge for infants exposed to escitalopram 1

Breastfeeding Considerations

• Safety Profile:
  • Limited data suggests escitalopram may be used during breastfeeding 4, 2, 5
  • Escitalopram transfers into breast milk at higher concentrations than maternal plasma, but infant plasma levels are typically very low or undetectable 6
  • No short-term adverse effects in breastfed infants have been reported in available studies 2, 3

Special Considerations

First Trimester Exposure

• Unlike paroxetine (which was classified as pregnancy category D due to concerns about cardiac malformations), escitalopram has not been associated with a specific pattern of congenital malformations 1, 4

Third Trimester Exposure

• Clinicians should be aware of the risk for neonatal adaptation syndrome and monitor newborns accordingly 1
• In severely affected infants, short-term pharmacological management may be required 1

Practical Approach

• For women already on escitalopram: Continue treatment if clinically indicated, using lowest effective dose 1
• For women requiring new antidepressant treatment: Consider escitalopram as a reasonable option, with sertraline and citalopram being other well-studied alternatives 4
• Monitor newborns: Be vigilant for signs of adaptation syndrome in the first week of life 1

Conclusion

Based on current evidence, escitalopram appears to have an acceptable safety profile during pregnancy when clinically indicated, with the benefits of treating depression often outweighing potential risks. Close monitoring of the newborn is recommended, particularly following third-trimester exposure.