Summary
Citalopram is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression and panic disorder.
Two studies have suggested that the risk of any major malformation is increased following maternal citalopram use in pregnancy, and a small number of studies have identified statistically significant increased risks of specific congenital malformations, including cardiac malformation. However, the majority of primary data studies and meta-analyses have failed to demonstrate a statistically significant increase in the risk of overall malformation rate or of cardiac malformations specifically. A causal association between citalopram use in pregnancy and congenital malformation in the fetus therefore remains unproven.
Studies which have investigated the risk of spontaneous abortion, intrauterine death, preterm delivery, low birth weight and neurodevelopmental delay following citalopram use in pregnancy provide no good evidence for increased risk of any of these outcomes. However, much of the available data are too limited to rule out an increased risk.
In utero exposure to any SSRI in the weeks prior to delivery confers a risk of transient neonatal withdrawal syndrome and infants should be monitored for associated central nervous system, motor, respiratory and gastrointestinal symptoms. An increased risk of persistent pulmonary hypertension (PPHN) of the newborn has also been reported following exposure to SSRIs as a class beyond 20 weeks of gestation and, although this remains an uncommon event (0.2-1.2% vs. 0.1-0.2% in the background population), it represents a potentially serious neonatal complication.
It is important to ensure that maternal mental health is treated appropriately. As such, citalopram may be suitable for use in pregnancy, but the risks and benefits of use must be considered on a case-by-case basis. Where possible, non-pharmaceutical management of depression and/or anxiety is preferable in pregnancy. Where a patient is stabilised on citalopram, 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 maternal relapse during pregnancy may pose to both mother and child. In cases where treatment with citalopram is continued in pregnancy, the lowest effective dose should be used.
At present there is insufficient evidence to warrant additional fetal monitoring. Exposure to citalopram at any stage in pregnancy would not usually be regarded as medical grounds for termination of pregnancy. However, 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.
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