Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital‐based cohort study

Abstract

SwedenTo cite this article: Lindqvist PG, Nasiell J, Gustafsson LL, Nordstrom L. Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study. J Thromb Haemost 2014; 12: 1986-92.Summary. Background: Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding. Objective: Study the risk of bleeding-related complications in relation to SSRI in pregnancy. Patients/ Methods: This was a hospital-based cohort study. All women who gave birth at Karolinska University Hospital in Stockholm over a 5-year period (2007 to 2011) were included in the study. Those women who the electronic maternal health record indicated were using SSRI (n = 500) were considered exposed, and all other women formed a control population (n = 39 594). The main outcome measures were blood loss, postpartum hemorrhage (PPH), PP anemia and length of hospitalization. Results: The absolute risk of PPH and PP anemia for the 1.2% exposed to SSRI were 18.0% and 12.8%, respectively. Women with a vaginal non-surgical delivery who reported use of SSRI during pregnancy had approximately a 2-fold increased risk of both PPH (OR, 2.6; 95% CI, 2.0-3.5) and PP anemia (OR, 2.1; 95% CI, 1.5-2.9), as compared with controls. Blood loss and length of hospitalization were significantly higher among women using SSRI than non-users (arithmetic mean 484 mL vs. 398 mL, 3.8 days vs. 2.4 days, respectively). Conclusion: The use of SSRI during pregnancy increases blood loss and doubles the risk of PPH and PP anemia in a setting where SSRI had not been considered a risk factor for increased blood loss.Because PPH is a leading cause of maternal mortality and morbidity, the awareness of bleeding-related complications is important, both in relation to pregnancy and to surgery in general.

Is third trimester serotonin reuptake inhibitor use associated with postpartum hemorrhage?

“…The investigators were unable to control for BMI, smoking, or alcohol use in this cohort. Lindqvist et al (2014) used a Swedish university hospital’s records from 2007-2011 to compare women who reported SRI use at their first prenatal visit (n=500) to those without SRI exposure (n=39,594). They found that women exposed to an SRI in pregnancy with vaginal non-surgical deliveries had significantly higher rates of PPH (OR, 2.6; 95% CI, 2.0-3.5), greater blood loss (484 mL vs. 398 mL, p<0.001), and longer hospitalizations (3.8 days vs. 2.4 days, p<0.001).…”

“…Reis and Kallen (2010) and Lupattelli et al (2014) assessed depression with rating scales, Palmsten et al (2013) used medical record diagnoses of depression, Grzeskowiak et al (2015) used medical record diagnoses of any psychiatric illness, and Salkeld et al (2008) and Lindqvist et al (2014) did not assess psychiatric diagnosis or depressive symptoms. It is plausible that the association between antidepressants and increased risk of PPH or increased EBL at delivery may be due to factors related to depression, based on the observation that positive associations were reported with non-serotonergic antidepressants.…”

“…Estimation of blood loss by calibrated bags or a decline in hematocrit of at least 10% increases the accuracy of measurement (American College of Obstetricians and Gynecologists, 2006). Among the six reviewed previously published cohorts, Grzeskowiak et al (2015) used data recorded in the Perinatal Statistics Collection where PPH was defined as blood loss >500 mL following vaginal delivery and >1000 mL following a caesarean section, Palmsten et al (2013) defined PPH by International Classification of Diseases, Ninth Revision (ICD-9) coding, Salkeld et al (2008) and Lindqvist et al (2014) used PPH as defined by ICD-10 coding, Lupattelli et al (2014) used medical records to obtain information on PPH defined as > 500 ml blood loss, and Reis and Kallen (2010) referred to “bleeding during partus” without further definition. Our definition was set as > 600 ml blood loss according to the PES and was visually estimated by the attending obstetrician.…”

“…Antidepressant use during pregnancy increased from less than 1% prior to 1990 to 7.5% in 2006-08 (Alwan et al, 2011). Some investigations (Grzeskowiak et al, 2015, Lindqvist et al, 2014, Palmsten et al, 2013) but not all (Lupattelli et al, 2014, Salkeld et al, 2008) have shown an association between third trimester SRI or antidepressant use and postpartum hemorrhage (PPH). In some non-pregnant populations SRI use is associated with an increased bleeding risk (Anglin et al, 2014, Hankey, 2014, Harirchian et al, 2012, Jiang et al, 2015, Tavakoli et al, 2012).…”

Effects of depression pharmacotherapy in fertility treatment on conception, birth, and neonatal health: A systematic review

“…Pharmacological therapies for depression have been linked to adverse outcomes for mothers and children. Women receiving antidepressants during pregnancy have been said to face an increased risk of post-partum hemorrhage and anemia [11,12]. Their children were also more likely to be delivered preterm (i.e., under 37 weeks gestation) and with a low birth-weight (i.e., under 2500 g) [13].…”