Is Lexapro (escitalopram) safe to use during pregnancy?

Safety of Escitalopram (Lexapro) During Pregnancy

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

Benefits vs. Risks Assessment

• Untreated depression during pregnancy is associated with premature birth, decreased initiation of breastfeeding, and potential harmful effects on the mother-infant relationship 1
• The American Academy of Pediatrics recommends that escitalopram should be continued during pregnancy at the lowest effective dose if clinically indicated 1
• Although some cases of major malformations have been reported after maternal exposure to escitalopram during early pregnancy, the rate is substantially in the range of those reported in unexposed women 2, 3

Potential Risks and Complications

• Third-trimester use of escitalopram may lead to neonatal adaptation syndrome, characterized by symptoms such as crying, irritability, jitteriness, tremors, poor feeding, and sleep disturbance in newborns 1
• Symptoms of neonatal adaptation syndrome typically appear within hours to days after birth and most resolve within 1-2 weeks 1
• There is an increased risk (relative risk of 4.2) for neonates exposed to similar SSRIs close to term to be admitted to special-care nurseries compared with unexposed infants 4
• QT prolongation is a dose-dependent concern with escitalopram, and the FDA recommends not exceeding doses of 20 mg per day in adults 1, 5

Management Recommendations

• Use the lowest effective dose of escitalopram during pregnancy 1
• If a woman becomes pregnant while taking escitalopram, the FDA recommends discussing registration with the National Pregnancy Registry for Antidepressants 5
• Arrange for early follow-up after hospital discharge for infants exposed to escitalopram in the third trimester to monitor for potential adverse effects 1
• Monitor for neonatal adaptation syndrome in newborns, particularly following third-trimester exposure 1

Breastfeeding Considerations

• Limited studies evaluating the safety of escitalopram during breastfeeding have not reported adverse effects in infants 2, 3
• Escitalopram may pass into breast milk, so discussing the benefits and risks with healthcare providers is important 5

Alternative Options

• If escitalopram is not suitable, sertraline is one of the most commonly prescribed antidepressants during pregnancy and breastfeeding due to its favorable safety profile 6
• Citalopram, paroxetine, and sertraline can be used during breastfeeding, while fluoxetine probably should be avoided 7

Clinical Decision Algorithm

1. Assess severity of depression and necessity of medication treatment
2. If already on escitalopram and clinically stable, continue at the lowest effective dose 1
3. If initiating treatment during pregnancy, consider sertraline as a first option due to more extensive safety data 6
4. Monitor closely for maternal mental health throughout pregnancy
5. Prepare for potential neonatal adaptation syndrome if used in third trimester 1
6. Arrange early follow-up after birth for exposed infants 1

Remember that while there are potential risks associated with escitalopram use during pregnancy, these must be weighed against the well-documented risks of untreated depression during pregnancy, which include premature birth and negative impacts on the mother-infant relationship 1.