Postpartum Hemorrhage and Use of Serotonin Reuptake Inhibitor Antidepressants in Pregnancy

Hanley, Gillian E.; Smolina, Kate; Mintzes, Barbara; Oberlander, Tim F.; Morgan, Steven G.

doi:10.1097/aog.0000000000001200

Cited by 43 publications

(26 citation statements)

References 43 publications

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“…Previous studies have reported differing risks of preeclampsia and PPH according to antidepressant class, for example, serotonin-norepinephrine reuptake inhibitors (SNRI) and tricyclic antidepressants were associated with stronger risks for preeclampsia than selective serotonin reuptake inhibitors (SSRI), 9,10 and SNRIs were associated with a stronger risk for PPH than SSRIs. 18 In a sensitivity analysis, we restricted to pregnancies exposed to SSRIs only; the study size was insufficient to compare non-SSRIs.…”

Section: Discussionmentioning

confidence: 99%

“…[5][6][7] Some studies have found antidepressant exposure during pregnancy to be associated with a range of adverse perinatal outcomes including preeclampsia, especially for exposures into the second trimester, and postpartum haemorrhage (PPH), for late-pregnancy exposures. [8][9][10][11][12][13][14][15][16][17][18][19] Other studies,generally those with smaller numbers of exposed cases, conclude no association between antidepressants and preeclampsia and PPH. [20][21][22][23] Recently, studies have used longitudinal cluster analysis to classify medication use during pregnancy instead of a dichotomous "any use" versus "no use" approach.…”

Section: Introductionmentioning

confidence: 98%

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Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage

Palmsten

Chambers

Wells

et al. 2020

Paediatric Perinatal Epid

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Background Antidepressant use later in pregnancy has been associated with preeclampsia and postpartum haemorrhage (PPH) in some studies. Objectives To evaluate the association between patterns of prenatal antidepressant dose across gestationand risk of precclampsia and PPH. Methods We utilised OptumLabs® Data Warehouse (2012‐2016) administrative health care claims, identifying 226 932 singleton liveborn deliveries for this retrospective cohort study. Antidepressant dispensing doses were converted to fluoxetine equivalents. Using k‐means longitudinal, we identified women with similar patterns of antidepressant exposure, that is, trajectory groups, during the first 20 and 35 gestational weeks. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between trajectory groups and preeclampisa (20‐week groups) and PPH (35‐week groups), adjusting for demographics, co‐morbidities, and other psychotropic medications. Linear trend tests assessing increasing risk of the outcomes across groups were performed. Results Among 15 041 (6.6%) pregnancies exposed to an antidepressant, the following trajectory groups were identified: A‐low exposure, starting pregnancy at ~10 mg/d, with 1st trimester reduction/discontinuation, B‐low sustained exposure of ~20 mg/d, C‐moderate exposure (~40 mg/d) with 1st trimester reduction/discontinuation, D‐moderate sustained exposure of ~40 mg/d, and E‐high sustained exposure of ~75 mg/d. In the low exposure with reduction/discontinuation trajectory, risks were 8.2% for preeclampsia and 2.7% for PPH. Compared with this group, low, moderate, and high sustained trajectories were associated with preeclampsia (adjusted RR 1.17, 95% CI 1.01, 1.34; RR 1.31, 95% CI 1.12, 1.54; and RR 1.41, 95% CI 1.05, 1.90, respectively) and PPH (RR 1.32, 95% CI 1.05, 1.66; RR 1.35, 95% CI 1.03, 1.78; RR 2.51, 95% CI 1.69, 3.71, respectively); P < .01 for linear trend tests for both outcomes. There was no increased risk for either outcome for moderate exposure with reduction/discontinuation (trajectory C). Conclusions Women with sustained antidepressant exposure, especially at higher doses, were at increased risk for preeclampsia and PPH, but underlying depression and anxiety may contribute to the increased risk.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 98%

Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage

Palmsten

Chambers

Wells

et al. 2020

Paediatric Perinatal Epid

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“…When taken in late pregnancy, SSRIs may increase the risk of pulmonary hypertension in newborns and of postpartum bleeding in mothers (21). Sertraline, fluoxetine or citalopram at initial doses of 20 mg, with gradual dosage titration, are often recommended as a first-line therapy, since they pass into breast milk in minimal concentrations (22). Citalopram (at a maximum dose of 40 mg), escitalopram (at a maximum dose of 20 mg) and sertraline (at a maximum dose of 100 mg) are shown to be the safest during pregnancy, while fluvoxamine (at a daily dose of up to 300 mg), paroxetine (at a daily dose of up to 30 mg) and sertraline (at a daily dose of up to 100 mg) are recommended during the postpartum period in women who breast feed (23).…”

Section: Antidepressantsmentioning

confidence: 99%

Therapy of peripartum mental disorders

Stanković¹,

Stojanov²,

Antonijević³

2019

Acta fac medic Naissensis

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S U M M A R YDuring the peripartum period, women are at a greater risk of developing a mental disorder or experiencing an exacerbation of the pre-existing mental disorders. Therapeutic interventions are based primarily on psychotherapy, but if the symptoms are severe and pose a risk to the mother and the child, then the use of drugs, hospitalization or electroconvulsive therapy is considered. Cognitive-behavioral psychotherapy is the first line of treatment in postpartum blues and postpartum depression, panic disorder, generalized anxiety disorder, and mild to moderate obsessive-compulsive disorder. More recent conceptions regarding the use of drugs during the postpartum period indicate that medications should be prescribed if the risk of using them is lower than the risk of complications caused by the symptoms of mental disorders. Nortriptyline or desipramine are recommended from the group of tricyclic antidepressants, but newer generation antidepressants are shown to be safer during pregnancy. Fluvoxamine, paroxetine and sertraline can be used in postpartum period during breastfeeding, while fluoxetine and citalopram should be avoided. The use of first-generation antipsychotics haloperidol and trifluoperazine is recommended in the antepartum period, during which some of second-generation antipsychotics such as quetiapine, olanzapine, risperidone and aripiprazole can also be used. Clozapine should be avoided during breast-feeding. The use of mood stabilizers during pregnancy requires a thorough knowledge of the recommendations, and it is not advised to use them during the postpartum if the patient is breastfeeding. From the group of benzodiazepines, it is recommended to uselorazepam. Every form of therapeutic approach has proven to be more effective in the presence of emotional support from partners and other family members.

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“…One study reported no increased risk . However, controlled studies of SSRI use during late pregnancy have reported a significant increased risk for PPH (relative risk [RR], 1.53; 95% CI, 1.25‐1.86) and severe PPH (RR, 1.84; 95% CI, 1.39‐2.44) …”

Section: Ssris As First‐line Therapy During Pregnancy and Lactationmentioning

confidence: 99%

Selective Serotonin Reuptake Inhibitors as First‐Line Antidepressant Therapy for Perinatal Depression

Latendresse

Elmore²,

Deneris³

2017

J Midwife Womens Health

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One in 7 women experience depression during the prenatal and/or postpartum period. Nonpharmacologic approaches are known to be as effective as pharmacologic therapies for mild to moderate depression. However, for women who suffer from moderate to severe depression, antidepressant therapy may be the best option, in combination with nonpharmacologic approaches. Considering the substantial negative impact of untreated perinatal depression, providers of prenatal care need to be prepared to diagnose depression, prescribe first-line antidepressants, and refer to other professionals. The purpose of this article is to assist providers to select the safest, most effective selective serotonin reuptake inhibitor (SSRI) as the first-line antidepressant during pregnancy and lactation. Information about side effects, adverse effects, contraindications, and clinical considerations associated with the use of SSRIs is provided. A brief discussion of nonpharmacologic therapies is provided but is not the focus of this article.

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Postpartum Hemorrhage and Use of Serotonin Reuptake Inhibitor Antidepressants in Pregnancy

Abstract: Serotonin-norepinephrine reuptake inhibitor exposure in late pregnancy was associated with a 1.6- to 1.9-fold increased risk of postpartum hemorrhage.

Cited by 43 publications

References 43 publications

Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage

Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage

Therapy of peripartum mental disorders

Selective Serotonin Reuptake Inhibitors as First‐Line Antidepressant Therapy for Perinatal Depression

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