Switching from Lexapro to Sertraline in Pregnancy
Continuing sertraline after discontinuing escitalopram upon discovering pregnancy is appropriate, as sertraline is considered first-line therapy for depression during pregnancy and breastfeeding due to its favorable safety profile and minimal excretion in breast milk. 1
Why Sertraline is the Preferred Choice
Sertraline should be considered first-line therapy during pregnancy due to minimal excretion in breast milk and low infant-to-maternal plasma concentration ratios, as recommended by the American Academy of Pediatrics 1
Large population-based studies have demonstrated no increased risk of cardiac malformations with first-trimester sertraline use 1, 2
Sertraline is one of the most commonly prescribed antidepressants during pregnancy and breastfeeding due to its favorable safety profile 2
Critical Management Principles
Use the lowest effective dose of sertraline throughout pregnancy rather than discontinuing treatment entirely, as abrupt discontinuation carries significant risks 1, 3, 2
Untreated depression during pregnancy is associated with premature birth, decreased breastfeeding initiation, and potential harm to the mother-infant relationship 3, 2
Women who discontinue antidepressant medication during pregnancy show a significant increase in relapse of major depression compared to those who remain on treatment 3, 4
Withdrawal of medication may have harmful effects on the mother-infant dyad that outweigh potential medication risks 1
Dosing Strategy
Start with low doses of sertraline (25-50 mg daily) and slowly titrate upward while monitoring maternal symptoms 1
Continue treatment at the lowest effective dose throughout pregnancy and postpartum 1, 2
Important Risks to Discuss and Monitor
Neonatal Adaptation Syndrome
Third-trimester SSRI use may lead to neonatal signs in approximately one-third of exposed newborns, including irritability, jitteriness, tremors, feeding difficulty, sleep disturbance, and respiratory distress 1, 3, 4
Symptoms typically appear within hours to days after birth and usually resolve within 1-2 weeks 1, 3
Arrange for early follow-up after initial hospital discharge and monitor infants for signs of drug toxicity or withdrawal over the first week of life 1, 3
Persistent Pulmonary Hypertension of the Newborn (PPHN)
Late pregnancy SSRI exposure has a possible association with PPHN, with a number needed to harm of 286-351 1, 2
PPHN occurs in 1-2 per 1000 live births in the general population 4
The absolute risk remains small, and evidence is conflicting across studies 2
Breastfeeding Considerations
Continue sertraline during breastfeeding as it is minimally excreted in breast milk, providing the infant with less than 10% of the maternal daily dose 1, 3
Sertraline and paroxetine are the most commonly prescribed antidepressants during breastfeeding due to their favorable safety profiles 1, 2
The benefits of breastfeeding for both mother and infant are well-documented, and untreated maternal depression poses significant risks to the mother-infant dyad 1
Common Pitfalls to Avoid
Do not discontinue sertraline abruptly upon discovering pregnancy, as this increases relapse risk significantly 3, 4, 5
Do not avoid treatment altogether due to fear of medication risks, as untreated maternal depression carries substantial documented risks to both mother and infant 1, 2
Do not switch medications unnecessarily once stable on sertraline, as it has one of the best safety profiles available 1, 6
Monitoring Plan
Monitor maternal depressive symptoms closely throughout pregnancy 2
Ensure infants exposed to sertraline are monitored for at least 48 hours after birth 3
In severely affected infants with persistent symptoms, a short-term course of chlorpromazine has provided measurable relief 1, 3
Several recent reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1