Evidence on milnacipran exposure during pregnancy is sparse, complicating treatment decisions when maternal stability depends on this antidepressant. We report a 31-year-old primigravida with severe post-traumatic stress disorder and a severe major depressive episode with psychotic features in the context of a chronic, difficult-to-treat psychiatric course marked by self-harm, dissociation, and recurrent suicidal behavior. Milnacipran 150 mg/day led to marked clinical improvement before pregnancy. After pregnancy confirmation, treatment was changed to sertraline plus quetiapine because of limited pregnancy safety data, but depressive symptoms and suicidal behavior reemerged within 2 weeks. Milnacipran was therefore re-established after risk-benefit evaluation and shared decision-making, with renewed improvement. Moderate hyperemesis gravidarum during the second trimester led to discontinuation of milnacipran by gestational week 22. Delivery occurred at gestational week 38 via primary cesarean section. No congenital anomalies or neonatal adaptation problems were observed. At 3-year follow-up, pediatric developmental screenings remained within expected limits. This case illustrates the challenge of balancing relapse risk, prior treatment response, and treatment feasibility during pregnancy when evidence for the effective medication is limited.
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