Antidepressant Use Linked to Hemorrhage After Pregnancy

Evidence still needed to figure out if they are the cause

Published on January 22, 2014by Elaine Meyer

Medical professionals should pay attention to a recent study that reported a significant association between the use of antidepressants during pregnancy and the risk of hemorrhage after giving birth, say two professors at Columbia University’s Department of Obstetrics and Gynecology, in an editorial. Use of this type of medication is not a commonly recognized risk factor for abnormal bleeding during pregnancy or childbirth.

“The findings from this study add considerably to limited prior research on this subject, which has found similar associations despite methodological shortcomings,” wrote Dr. Cande Ananth (a professor also in the Department of Epidemiology at Mailman School of Public Health) and Alexander Friedman in late November issue of the BMJ group journal Evidenced-Based Nursing. “The magnitude of increased hemorrhage risk in relation to serotonin exposure demonstrated in this study is clinically relevant.”

The study, which was published in BMJ in August by epidemiologists at Harvard’s School of Public Health, adds to a growing body of research that has connected the popular class of antidepressants known as SSRIs (selective serotonin re-uptake inhibitors) to hemorrhage, as well as excessive bleeding in the gastrointestinal system and during surgery.

Hemorrhage during pregnancy is one of the leading causes of maternal death in the United States. Postpartum hemorrhage is an excessive amount of blood loss after delivery. Hemorrhage has been on the rise in the U.S. and several other developed countries since the 1990s, despite no change in the frequency of multiple pregnancies or induction of labor, established risk factors for postpartum hemorrhage.

The Harvard study looked at seven years of Medicaid data on 106,000 low-income women who were pregnant and had a diagnosis of mood or anxiety disorder, comparing those who had been prescribed antidepressant medication against those who had not.

Risk for postpartum hemorrhage was greatest (4 percent) for women on SSRIs compared with 3.8 percent for women using anti-depressants that were not SSRIs and 2.8 percent for women who were not on medication.

These are significant enough numbers for medical professionals to take notice, wrote Drs. Ananth and Friedman: “While the benefits of antidepressants may outweigh the relatively small attributable maternal and neonatal risks for many women, clinicians should be aware of a modestly increased risk for this serious adverse obstetric outcome.”

More evidence is needed to establish whether antidepressants directly cause hemorrhage, they say. Research has suggested that SSRIs might deplete serotonin that is stored in platelets, which are cells in blood that reduce bleeding. Yet a 2008 study by scientists at the University of Toronto found that SSRIs do not put women at greater risk of postpartum hemorrhage than non-SSRI antidepressants. Comparisons of risk between SSRI and non-SSRI antidepressants are generally limited by the relatively infrequent use of drugs in the non-SSRI class during pregnancy.

Celexa, Lexapro, Prozac, Paxil, and Zoloft, and their generic versions are all popularly-prescribed SSRIs. These drugs are commonly used to treat psychiatric problems such as anxiety and depression that may occur during or predate a women’s pregnancy.

Rates of maternal mortality and severe morbidity are high in the U.S. compared to other developed countries, and findings from this study may help clinicians anticipate increased risk in a specific subset of patients.

Edited by Joshua Brooks