Published: 3 June 2021

Publications

Small increased risk of postpartum haemorrhage with use of serotonergic antidepressants close to delivery

Published: 3 June 2021
Prescriber Update 42(2): 23–24
June 2021

At their 185^th meeting in March 2021, the Medicines Adverse Reactions Committee (MARC) reviewed the risk of postpartum haemorrhage when SSRIs (citalopram, escitalopram, fluoxetine, sertraline and paroxetine) and SNRIs (venlafaxine) are used during the month up to delivery.

The MARC considered that an increased risk of postpartum haemorrhage was biologically plausible, as serotonin plays a role in platelet function.¹

Observational studies have shown a small increased risk of postpartum haemorrhage (less than a two-fold increase) when SSRIs and SNRIs were used in the month up to delivery. The risk may also apply to vortioxetine, a newer antidepressant.^2,3

The increase in absolute risk of postpartum haemorrhage was considered to be small. One observational study estimated there may be about one excess case of postpartum haemorrhage for every 80 to 100 women taking these antidepressants close to the time of delivery.⁴

A 2015 systematic review noted that information on the exact amount of blood loss and the clinical and therapeutic consequences of the blood loss (such as transfusion and prolonged hospital stay) was not available in any of the studies included in the review.⁵

In the context of the above information, healthcare professionals are reminded to continue to consider the benefits of treating depression for the mother with this new, small risk of postpartum bleeding.²

The MARC recommended that all data sheets for SSRIs, SNRIs and vortioxetine be updated,⁶ and Medsafe is working with the sponsors to do this.

References

1. Hirsch M, Birnbaum RJ. 2020. Selective serotonin reuptake inhibitors: pharmacology, administration, and side effects. In: UpToDate 16 March 2020. URL: uptodate.com/contents/selective-serotonin-reuptake-inhibitors-pharmacology-administration-and-side-effects (accessed 16 March 2021).
2. Medicines and Healthcare products Regulatory Agency. 2021. SSRI/SNRI antidepressant medicines: small increased risk of postpartum haemorrhage when used in the month before delivery. Drug Safety Update 14(6): 5. URL: gov.uk/drug-safety-update/ssri-slash-snri-antidepressant-medicines-small-increased-risk-of-postpartum-haemorrhage-when-used-in-the-month-before-delivery (accessed 8 April 2021).
3. European Medicines Agency. 2020. PRAC recommendations on signals 26 October 2020. URL: ema.europa.eu/en/documents/prac-recommendation/prac-recommendations-signals-adopted-28-september-1-october-2020-prac-meeting_en.pdf (accessed 8 April 2021).
4. Palmsten K, Hernández-Diaz S, Huybrechts KF, et al. 2013. Use of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States. British Medical Journal 21(347): DOI: 10.1136/bmj.f4877 (accessed 12 February 2021).
5. Bruning AHL, Heller HM, Kieviet N, et al,. 2015. Antidepressants during pregnancy and postpartum hemorrhage: a systematic review. European Journal of Obstetrics & Gynecology and Reproductive Biology 189: 38-47. DOI: 10.1016/j.ejogrb.2015.03.022 (accessed 12 February 2021).
6. Medsafe. 2021. Minutes of the 185^th Medicines Adverse Reactions Committee meeting 11 March 2021. URL: medsafe.govt.nz/profs/adverse/Minutes185.htm (accessed 5 May 2021).