Serotonin Reuptake Inhibitors and Postpartum Hemorrhage: Maybe There Are Other Factors Involved

Serotonin Reuptake Inhibitors and Postpartum Hemorrhage: Maybe There Are Other Factors Involved

 

Serotonin reuptake inhibitor (SRI) antidepressants may affect platelet aggregation and thus may increase the risk of bleeding.  Over the last few years, we have seen several studies which have sought to determine if exposure to SSRI antidepressants in pregnancy is associated with an increased risk of postpartum hemorrhage.

The most recent study was a matched cohort observational study including all pregnant women who used serotonergic antidepressants (n?=?578) or other psychotropic medications (n?=?50) at two teaching hospitals in Amsterdam between 2010 and 2014.  The incidence of postpartum hemorrhage was calculated in these two groups of women was calculated and compared to the incidence of postpartum hemorrhage in 641,364 pregnant women not taking psychiatric medications who were selected from the database of the Netherlands Perinatal Registry foundation.

Postpartum hemorrhage occurred in 9.7% of the women taking serotonergic medications. In the matched controls (who were not exposed to psychiatric medication), the incidence was 6.6%. The adjusted odds ratio (aOR) after matching was 1.5 (95% CI 1.1-2.1). The findings from this study are similar to those observed in previous reports from Palmsten et al (2013) and Hanley et al (2016); however, other large studies conducted in Norway and Canada have documented no increase in risk of postpartum hemorrhage (Lupattelli 2013, Salkeld 2008).

One of the interesting findings of this study was that women taking non-serotonergic psychotropic medications also experienced a higher risk of postpartum hemorrhage.  Among women using other psychotropic medications, the incidence of postpartum hemorrhage was 12.1% versus 4.4% in the non-exposed controls with an aOR of 3.3 (95% CI 1.1-9.8).  What this finding suggests is that while the risk of postpartum hemorrhage may be slightly higher in women taking serotonergic medications, there may be others factors contributing to this risk, including the underlying psychiatric illness or behaviors associated with the illness.

What Are the Clinical Implications of These Findings?

While postpartum hemorrhage is a potentially serious complication, the data suggest that the risk of postpartum hemorrhage, if we assume these findings are correct, appears to be slightly increased in women taking SRIs near the time of delivery.  

Given the inconsistencies across these findings and the relatively small increase in risk observed in these studies, we do not have compelling evidence to change our practices regarding the use of SRIs and other antidepressants during pregnancy.  Obstetricians, however, should be alert to the possibility of an increased risk of PP hemorrhage in this population, so that hemorrhage, should it occur, may be managed aggressively, with the goal of minimizing maternal morbidity.

Ruta Nonacs, MD PhD

 

Hanley GE, Smolina K, Mintzes B, Oberlander TF, Morgan SG. Postpartum Hemorrhage and Use of Serotonin Reuptake Inhibitor Antidepressants in Pregnancy. Obstet Gynecol. 2016 Mar;127(3):553-61.

Heller HM, Ravelli ACJ, Bruning AHL, de Groot CJM, Scheele F, van Pampus MG, Honig A. Increased postpartum haemorrhage, the possible relation with serotonergic and other psychopharmacological drugs: a matched cohort study. BMC Pregnancy Childbirth. 2017 Jun 2;17(1):166. Free Article

Lupattelli A, Spigset O, Koren G, Nordeng H.  Risk of Vaginal Bleeding and Postpartum Hemorrhage After Use of Antidepressants in Pregnancy: A Study From the Norwegian Mother and Child Cohort Study.  J Clin Psychopharmacol. 2013 Oct 16. [Epub ahead of print]

Palmsten K, Hernández-Díaz S, Huybrechts KF, et al.  Use of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States.  BMJ 2013; 347:f4877.

Salkeld E, Ferris LE, Juurlink DN. The risk of postpartum hemorrhage with selective serotonin reuptake inhibitors and other antidepressants.  J Clin Psychopharmacol 2008; 28(2):230-4.

 

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