Late gestation antidepressant use linked to postpartum hemorrhage

1. Women exposed to antidepressants in late gestation were at greater risk of postpartum hemorrhage than unexposed controls.

2. No increased risk was seen for women with psychiatric illness but no antidepressant use.

Evidence Rating Level: 2 (Good)

Study Rundown: Worldwide, the number of women on antidepressants in pregnancy has increased dramatically over the last decade. Antidepressant use has been associated with a range of adverse pregnancy outcomes, including preterm birth, persistent pulmonary hypertension, and other rare birth defects. However, untreated depression is also associated with adverse pregnancy outcomes, including premature birth, low birth weight and markedly increased risk for maternal postpartum depression. Ethical considerations disallow randomized trials that could directly compare the risks and benefits of treatment vs. expectant management such that practitioners and pregnant women are left with the difficult choice of whether or not to treat in pregnancy. In non-pregnant adults, some studies suggest that antidepressant use may be linked to increased bleeding risk due to depletion in platelet serotonin stores that interfere with activation and aggregation. Prior studies evaluating the impact of antidepressant use on post-partum hemorrhage produced mixed results. In this study, researchers investigated the link between antidepressant use in late pregnancy and incidence of postpartum hemorrhage.

In this large Australian cohort, antidepressant use in late pregnancy was associated with an increased risk of postpartum hemorrhage. Strengths of this study included large sample size and stratification by delivery type (vaginal or cesarean). One major limitation is lack of consideration of severity of psychiatric illness, which may introduce bias since psychiatric illness affects health-seeking behaviors. Other limitations include low frequency of antidepressant use in the study population. Future studies accounting for the severity of depression and type of antidepressant would provide additional detail.

Click to read the study in BJOG

Relevant Reading: Use of antidepressants near delivery and risk of postpartum hemorrhage

In-Depth [retrospective cohort study]: All women who delivered at a single institution in Australia from 2002-2008 were included in the analyses (n = 30 198). The primary outcome of postpartum hemorrhage (≥500 mL for vaginal and ≥1000mL for cesarean delivery) was compared among women with psychiatric illness who took antidepressants late in gestation (n = 558), women with psychiatric illness who didn’t take antidepressants (n = 1292) and women with neither exposure (n = 28 348).

Compared to healthy women, women on antidepressants in pregnancy were more likely to experience postpartum hemorrhage (RR:1.53, 95%CI 1.25-1.86) while those with a history of psychiatric illness not on medications were not at increased risk. Antidepressant use in pregnancy was also associated with increased risk of severe postpartum hemorrhage (RR:1.84, 95%CI 1.39-2.44) and postpartum anemia (RR:1.80, 95%CI 1.46-2.22).

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