Is escitalopram (Lexapro) safe to use during pregnancy?

Safety of Escitalopram During Pregnancy

Escitalopram can be used during pregnancy when clinically indicated, but should be prescribed at the lowest effective dose as it may cause neonatal adaptation syndrome in the third trimester. 1

Benefits vs. Risks Assessment

• The American Academy of Pediatrics recommends that 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
• Untreated depression during pregnancy is associated with serious outcomes including premature birth, decreased initiation of breastfeeding, and potential harmful effects on the mother-infant relationship 1
• While some cases of major malformations have been reported after maternal exposure to escitalopram during early pregnancy, the rate is substantially similar to those reported in unexposed women 2, 3

Potential Risks

• 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 without specific treatment 1
• QT prolongation is a dose-dependent concern with escitalopram, and the FDA recommends not exceeding doses of 20 mg per day in adults 4
• Escitalopram exposure seems to be significantly associated with some perinatal complications such as lower birth weight 3

Management Recommendations

• Use the lowest effective dose of escitalopram during pregnancy to minimize fetal exposure while maintaining maternal mental health 1
• For women already taking escitalopram who become pregnant, continuation of treatment is generally recommended if clinically indicated 1
• Arrange for early follow-up after hospital discharge for infants exposed to escitalopram in the third trimester to monitor for neonatal adaptation syndrome 1
• Close monitoring of maternal therapeutic drug levels during pregnancy may be beneficial to minimize fetal exposure while maintaining efficacy 5

Breastfeeding Considerations

• Escitalopram passes into breast milk at 2-3 times the concentration found in maternal plasma, but infant plasma levels are typically very low or undetectable 5
• No adverse effects have been reported in the few studies evaluating escitalopram's safety during breastfeeding 2, 3
• The limited data available suggests that breastfeeding while taking escitalopram is generally considered safe 3, 5

Clinical Decision Algorithm

1. Assess severity of maternal depression and necessity of medication treatment
2. If treatment is indicated, use escitalopram at the lowest effective dose 1
3. Monitor maternal mental health closely throughout pregnancy 1
4. Prepare for potential neonatal adaptation syndrome, particularly following third-trimester exposure 1
5. Arrange early pediatric follow-up after birth to monitor for potential adverse effects 1
6. Continue breastfeeding if clinically appropriate, as infant exposure appears minimal 5

Special Considerations and Pitfalls

• Abrupt discontinuation of escitalopram can cause withdrawal symptoms including anxiety, irritability, high or low mood, headache, sweating, nausea, dizziness, and electric shock-like sensations 4
• If discontinuation is necessary, gradual tapering is recommended to minimize withdrawal effects 4
• The FDA pregnancy category for escitalopram is not explicitly stated in the provided evidence, but SSRIs generally fall into category C, indicating that potential benefits may justify potential risks 6