Citalopram (Celexa) Safety During and After Pregnancy
Citalopram can be continued during pregnancy at the lowest effective dose if clinically indicated, as the benefits of treating depression typically outweigh the potential risks to the mother-infant dyad, but sertraline should be considered as the preferred first-line SSRI due to superior safety data. 1, 2
Preferred SSRI Selection in Pregnancy
Sertraline is the recommended first-line SSRI during pregnancy and breastfeeding due to minimal excretion in breast milk, low infant-to-maternal plasma concentration ratios, and no demonstrated increased risk of cardiac malformations in large population-based studies. 1
Citalopram is considered an acceptable alternative if sertraline is not tolerated or ineffective, though it has less robust safety data compared to sertraline. 1
Paroxetine should be avoided specifically due to FDA pregnancy category D classification and cardiac malformation concerns. 1
Safety Profile of Citalopram During Pregnancy
Teratogenic Risk
The FDA classifies citalopram as Pregnancy Category C, indicating that animal studies have shown adverse effects on embryo/fetal development including cardiovascular and skeletal defects at doses approximately 18 times the maximum recommended human dose. 3
In animal studies, decreased embryo/fetal growth and survival occurred at maternally toxic doses, with a developmental no-effect dose at approximately 9 times the human dose. 3
Human data on citalopram specifically shows mixed evidence, with some studies suggesting it may be safer than paroxetine or fluoxetine, though less evidence exists compared to sertraline. 4
Neonatal Adaptation Syndrome
Third-trimester exposure to citalopram may cause neonatal adaptation syndrome, characterized by crying, irritability, jitteriness, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and rarely seizures. 2, 3
These symptoms typically appear within hours to days after birth and resolve within 1-2 weeks, generally being mild in severity. 2
The FDA label warns that neonates exposed late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. 3
Persistent Pulmonary Hypertension of the Newborn (PPHN)
Late pregnancy SSRI exposure has a possible association with PPHN, though the absolute risk is small (number needed to harm: 286-351). 1
PPHN occurs in 1-2 per 1,000 live births in the general population and is associated with substantial neonatal morbidity and mortality. 3
Long-term Neurodevelopmental Outcomes
Multiple reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy. 1, 2
However, some observational studies suggest possible associations with delayed motor development, social difficulties, and autism, though confounding by indication cannot be ruled out. 5
Clinical Management Algorithm During Pregnancy
Decision to Continue or Discontinue
Continue citalopram at the lowest effective dose rather than discontinuing, as withdrawal of medication may have harmful effects on the mother-infant dyad. 6, 2
Untreated depression during pregnancy carries significant documented risks including premature birth, decreased breastfeeding initiation, and harm to the mother-infant relationship. 1
If switching medications is considered, transition to sertraline as the preferred agent. 1
Dosing Considerations
Use the lowest effective dose throughout pregnancy to minimize fetal exposure. 2, 7
The maximum recommended dose is 40 mg/day due to QT prolongation risk; doses above 40 mg/day are not recommended. 3
For patients over 60 years, those with hepatic impairment, or CYP2C19 poor metabolizers, the maximum dose is 20 mg/day. 3
Therapeutic drug monitoring may be considered to minimize fetal exposure while maintaining maternal efficacy. 7
Third Trimester Management
Do not discontinue citalopram in the third trimester despite the risk of neonatal adaptation syndrome, as the benefits of continued treatment outweigh this transient, generally mild complication. 6, 2
Inform the pediatric team about maternal citalopram use so they can anticipate and manage neonatal adaptation syndrome if it occurs. 6
Arrange for early follow-up after hospital discharge to monitor infants for signs of drug toxicity or withdrawal over the first week of life. 1, 2
Safety During Breastfeeding
Citalopram in Breast Milk
Citalopram is excreted in human breast milk at concentrations 2- to 3-fold higher than maternal plasma concentrations. 3, 7
Despite higher milk concentrations, infant plasma concentrations of citalopram and metabolites are very low or undetectable during breastfeeding. 7
Two case reports describe infants experiencing excessive somnolence, decreased feeding, and weight loss associated with breastfeeding from citalopram-treated mothers. 3
Breastfeeding Recommendations
Sertraline is strongly preferred over citalopram during breastfeeding due to minimal excretion in breast milk (providing the infant with less than 10% of maternal daily dose) and superior safety data. 1
If continuing citalopram during breastfeeding, monitor the infant carefully for somnolence, feeding difficulties, and weight gain. 3
The decision to continue or discontinue either nursing or citalopram should weigh the risks of citalopram exposure against the well-documented benefits of breastfeeding for both mother and infant. 3
Common Pitfalls to Avoid
Do not abruptly discontinue citalopram due to fear of medication risks, as untreated maternal depression carries substantial documented risks to both mother and infant that often exceed medication risks. 1, 8
Do not assume all SSRIs have equivalent safety profiles—paroxetine and fluoxetine have stronger associations with negative outcomes compared to sertraline and citalopram. 4
Do not fail to arrange early pediatric follow-up for infants exposed to citalopram in the third trimester, as neonatal adaptation syndrome requires monitoring. 1, 2
Avoid doses above 40 mg/day due to QT prolongation risk, which is dose-dependent. 2, 3