USE OF ESCITALOPRAM IN PREGNANCY

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression, panic disorder, with or without agoraphobia, generalised and social anxiety disorder, and obsessive-compulsive disorder.

Although limited, data on the risk of congenital malformation following escitalopram use in early pregnancy are generally reassuring. The available studies, including two meta-analyses, provide no evidence of an increased rate of overall congenital malformation or overall cardiovascular malformation, and the majority of studies investigating specific cardiovascular malformations have not identified increased risks for escitalopram-exposed infants. However, two studies have associated escitalopram use in early pregnancy with possible increased risks of atrioventricular septal defects, with an increased risk of Ebstein’s anomaly also identified in one. These findings, which may be confounded, require confirmation in future studies.

The incidence of miscarriage, preterm delivery or intrauterine death has not been shown to be increased following escitalopram exposure in a small number of studies. However, a single study has provided evidence of a possible increase in the risk of low birth weight. As the available data are limited, the possibility of an increased risk for any of the above outcomes cannot be excluded, although the data are likely confounded.

In utero exposure to SSRIs in the weeks prior to delivery confers a risk of transient neonatal withdrawal syndrome and infants should be delivered in hospital and monitored for central nervous system, motor, respiratory and gastrointestinal symptoms.

An increased risk of persistent pulmonary hypertension of the newborn (PPHN) has been reported following exposure to SSRIs as a class beyond 20 weeks of gestation. The current estimate of the absolute risk of PPHN following SSRI exposure is <0.4% (background rate 0.1 to 0.2%), suggesting that it remains uncommon following exposure. However, as PPHN is potentially serious, this should be discussed with women considering SSRI use in pregnancy.

The Medicines and Healthcare products Regulatory Authority (MHRA) has advised that there is a small overall increased risk of postpartum haemorrhage (PPH) attributable to SSRI/SNRI use in the month prior to delivery, but this risk may be higher in women with other risk factors for abnormal bleeding. Studies have identified up to a 1.3-fold increased risk following gestational use of an SSRI; should this prove accurate, the absolute risk of PPH among SSRI-exposed women would range from 13 to 20% (background 10 to 15%). Careful assessment of the risk of PPH versus the risk of maternal relapse, should the medication be discontinued, is advised when considering continued SSRI/SNRI antidepressant use in late pregnancy. Prescribers are also encouraged to ensure maternal compliance with heparin self-administration in all pregnant women with risk factors for venous thromboembolism.

It is important to ensure that mental health conditions are treated appropriately. As such, escitalopram may be suitable for use in pregnancy following an individualised assessment of the risks and benefits. Where clinically appropriate, non-pharmaceutical management of depression and/or anxiety could be considered during pregnancy. However, where a patient is stabilised on escitalopram, either prior to conception or during pregnancy, the risk of discontinuing treatment, changing the medication or reducing the dose, should be carefully weighed against the risk of maternal relapse. In cases where treatment with escitalopram is continued in pregnancy, the lowest effective dose should be used.

Exposure to escitalopram at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy, or any additional fetal monitoring. Other risk factors may be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments.