SSRI use during pregnancy and risk for postpartum haemorrhage: a national register‐based cohort study in Sweden

Abstract

Objective Evaluate whether selective serotonin reuptake inhibitor (SSRI) use during pregnancy, as well as prior or current untreated psychiatric illness is associated with postpartum haemorrhage (PPH). Design National register‐based cohort study based on data from the Swedish Pregnancy Register. Setting Sweden, nationwide coverage. Population A total of 31 159 pregnant women with singleton deliveries after gestational week 22+0 between January 2013 and July 2017. Methods Pregnant women with self‐reported SSRI use at any time point during pregnancy were compared with non‐SSRI‐treated women with prior or current psychiatric illness, as well as wiith healthy women with no psychiatric illness or reporting SSRI use. Main outcome measures Postpartum haemorrhage defined as blood loss >1000 ml during the first 2 hours postpartum reported by the delivering midwife or obstetrician. Results Postpartum haemorrhage prevalence was 7.0% among healthy women, 7.6% among women with prior or current psychiatric illness and 9.1% among women treated with SSRI. The unadjusted odds for PPH among women with prior or current psychiatric illness and women on SSRI treatment were increased by 9 and 34%, respectively, compared with healthy unmedicated women without a history of psychiatric illness (odds ratio [OR] 1.09, 95% CI 1.04–1.14 and OR 1.34, 95% CI 1.24–1.44, respectively). The estimates remained unchanged after adjustment for several confounders (such as maternal age, body mass index [BMI], parity, prior caesarean section, smoking, occupation and country of birth) and potential covariates (such as delivery mode, polyhydramnion, preterm delivery, labour dystocia and infant birthweight >4000 g). Conclusions Higher risk for PPH was observed both among women treated with SSRI during pregnancy and among women with prior or current psychiatric illness. Tweetable abstract SSRI use at any point during pregnancy and prior or current history of psychiatric illness was associated with an increased likelihood for PPH.

Authors' reply re: SSRI use during pregnancy and risk for postpartum hemorrhage: a national register‐based cohort study in Sweden

“…What is a clinically relevant effect size is still a topic for debate. We would argue that an odds ratio of about 1.3 for having a postpartum bleeding of more than 1000 ml (a strictly pre‐defined outcome in our study) 2 is not minimal. When dealing with prevalent exposures such as depression with/without use of SSRIs (at 20%), the public health impact of relatively small effect sizes is considerable.…”

Re: SSRI use during pregnancy and risk for postpartum haemorrhage: a national register‐based cohort study in Sweden

“…Thus, the reported rhetorical conclusion of this study 1 that ‘its results prompt design and implementation of studies testing effectiveness of risk evaluation of using SSRIs and the psychiatric illness itself with regard to reducing PPH’ seems incongruous with its findings. Birth attendants do not become distracted by any formal ‘PPH‐risk‐stratifying‐matrix’.…”

“…A further unnoticed crucial limitation of the current study 1 is the incomplete data, i.e. the actual blood loss (average and SD) has not been mentioned/analysed; despite the midwives recording it as a continuous variable and binary data (≤1000 ml, >1000 ml) in the register.…”

“…The Swedish national register‐based study by Skalkidou et al, 1 despite critical drawbacks, adds worthwhile information on the increased postpartum haemorrhage (PPH) with selective serotonin reuptake inhibitors (SSRIs). Previous studies have shown increased as well as decreased risk of PPH, 1 as is common when the effect is small or nil. The painstaking analysis in this study creates the opportunity for valuable debate and conclusions.…”

Mental disorder in pregnancy and the early postpartum

“…One systematic review suggested that the evidence remained inconclusive but, if present, the absolute risk is low. More recently, a national register‐based cohort study suggested an odds ratio of 1.09 (95%CI 1.04–1.14) for women with prior mental illness, and 1.34 (95%CI 1.24–1.44) for women with current mental illness, when compared with healthy unmedicated women with no psychiatric history [32].…”