Can Lexapro Be Taken During Pregnancy?
Lexapro (escitalopram) can be continued during pregnancy when clinically indicated, as the benefits of treating maternal depression typically outweigh the risks, though it should be used at the lowest effective dose with careful monitoring for neonatal complications. 1, 2
Key Clinical Guidance
Continuation vs. Discontinuation Decision
SSRI treatment, including Lexapro, should be continued during pregnancy at the lowest effective dose, because withdrawal of medication may have harmful effects on the mother-infant dyad. 1 This represents the consensus position from the American Academy of Pediatrics.
Depression during pregnancy itself is associated with premature birth and decreased initiation of breastfeeding, and untreated maternal depression poses significant risks to both mother and fetus. 1
Risk Profile During Pregnancy
Major Malformations:
Escitalopram does not appear to be associated with an increased risk for major congenital malformations. 3, 4, 5 The rate of major malformations following escitalopram exposure (1.7%) falls within the range reported in unexposed women. 3
A population-based cohort study of nearly 1 million pregnant women found no link between first-trimester antidepressant use and cardiac malformations, despite earlier FDA concerns about paroxetine. 1
Third Trimester Complications:
Taking Lexapro during the third trimester may cause neonatal withdrawal symptoms or adaptation syndrome, including continuous crying, irritability, jitteriness, tremors, hypertonia, tachypnea, feeding difficulty, sleep disturbance, hypoglycemia, and seizures. 1, 2
These neonatal signs typically appear within hours to days after birth and usually resolve within 1-2 weeks. 1
The FDA advisory regarding persistent pulmonary hypertension of the newborn (PPHN) after 20 weeks gestation remains unclear, with conflicting findings. A meta-analysis suggested a number needed to harm of 286-351 for late pregnancy SSRI exposure and PPHN. 1
Birth Weight Concerns:
- Escitalopram exposure appears to increase the risk for low birth weight (<2500g) and lower overall birth weight compared to controls. 3 This finding requires monitoring but must be weighed against the risks of untreated maternal depression.
Practical Management Algorithm
Preconception/Early Pregnancy:
- Continue escitalopram if the patient has moderate-to-severe depression or history of recurrent depression requiring maintenance therapy. 1
- Use the lowest effective dose to maintain maternal mental health. 1, 2
- Document informed consent regarding potential neonatal complications. 2
Throughout Pregnancy:
- Monitor maternal symptoms closely, as pregnancy-related physiological changes may affect drug concentrations, though escitalopram C/D ratios remain relatively stable until late pregnancy. 6
- Arrange for early neonatal follow-up after delivery to monitor for withdrawal/adaptation symptoms. 1
Delivery Planning:
- Clinicians should be aware that infants are at risk for manifesting clinical signs of drug toxicity or withdrawal over the first week of life. 1
- In severely affected infants, a short-term course of chlorpromazine has provided measurable relief of symptoms. 1
Neurodevelopmental Outcomes
Several recent reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy. 1 This provides reassurance regarding long-term cognitive development.
While some studies have suggested correlations with ADHD, speech delay, or autism, high-quality evidence is lacking and confounding by maternal psychiatric illness cannot be excluded. 1
Important Caveats
Lexapro may harm the unborn baby, particularly regarding third-trimester neonatal adaptation syndrome and potential for low birth weight. 2 However, this risk must be balanced against the substantial risks of untreated maternal depression.
Patients should be enrolled in the National Pregnancy Registry for Antidepressants (1-844-405-6185) to contribute to ongoing safety surveillance. 2
Abrupt discontinuation should be avoided as it may precipitate maternal relapse and poses its own risks to the pregnancy. 1