Is Lexapro (escitalopram) safe to use during pregnancy?

Lexapro (Escitalopram) Use During Pregnancy

Primary Recommendation

Escitalopram should be continued during pregnancy at the lowest effective dose if clinically indicated, as the benefits of treating depression typically outweigh the potential risks to both mother and infant. 1, 2

Risk-Benefit Framework

The decision to continue escitalopram centers on a critical principle: untreated depression during pregnancy carries substantial risks including premature birth, decreased breastfeeding initiation, and harmful effects on the mother-infant relationship 1. These maternal risks often exceed the fetal risks associated with escitalopram exposure.

Evidence for Safety

• No definitive association exists between escitalopram use during pregnancy and major congenital malformations 3
• The rate of major malformations in escitalopram-exposed pregnancies falls within the range observed in unexposed women 3
• Prospective studies demonstrate uncomplicated pregnancy outcomes in mothers using escitalopram, with normal neurodevelopment in infants followed up to 1 year 4

Specific Risks and Management

Third-Trimester Considerations

Neonatal adaptation syndrome is the primary concern with third-trimester escitalopram exposure 1. This syndrome manifests as:

• Crying, irritability, jitteriness, and tremors 1
• Poor feeding and sleep disturbances 1
• Symptoms typically appear within hours to days after birth 1
• Most symptoms resolve within 1-2 weeks without intervention 1

Monitoring Requirements

• Arrange early follow-up after hospital discharge to monitor for neonatal adaptation syndrome 1
• In severely affected infants, short-term pharmacological management may be required 1
• Monitor for perinatal complications, which appear more common than major malformations 3

Dosing Strategy

Use the lowest effective dose throughout pregnancy 1, 2:

• The FDA recommends not exceeding 20 mg daily in adults over 60 years due to QT prolongation risk 1
• Maternal therapeutic drug monitoring should be considered to minimize fetal exposure 4
• Trough plasma concentrations during pregnancy remain therapeutic at standard doses (20-40 mg daily) 4

Pregnancy Registry

Women taking escitalopram who become pregnant should be encouraged to register with the National Pregnancy Registry for Antidepressants 2:

• Registration: 1-844-405-6185
• Website: https://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/antidepressants/ 2

Critical Contraindications

Do not combine escitalopram with MAOIs 2:

• Allow 2 weeks between discontinuing an MAOI and starting escitalopram 2
• Allow 2 weeks between stopping escitalopram and starting an MAOI 2
• Concurrent use risks life-threatening serotonin syndrome with high fever, muscle spasms, confusion, and loss of consciousness 2

Breastfeeding Considerations

• Escitalopram concentrations in breast milk are 2-3 fold higher than maternal plasma concentrations 4
• However, infant plasma concentrations remain very low or undetectable during breastfeeding 4
• No adverse effects have been reported in studies evaluating escitalopram safety during breastfeeding 3
• Escitalopram may pass into breast milk, requiring discussion with the healthcare provider 2

Common Pitfalls to Avoid

• Do not discontinue escitalopram abruptly, as this causes withdrawal symptoms including anxiety, irritability, headache, nausea, dizziness, and electric shock-like sensations 2
• Do not assume all SSRIs carry identical pregnancy risks—escitalopram has specific safety data that differs from other agents 3
• Do not delay treatment of depression due to pregnancy concerns—untreated maternal depression poses significant risks 1