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Viguera AC, Jones A, Szpunar MJ, Bernstein SN, Killenberg PC, Sojka ET, Rossa ET, Gaccione P, Freeman MP, Cohen LS. The Risk of Postpartum Hemorrhage with Selective Serotonin Reuptake Inhibitors and Serotonin Norepinephrine Reuptake Inhibitors: Preliminary Results from the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications. J Womens Health (Larchmt) 2024. [PMID: 39037008 DOI: 10.1089/jwh.2024.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background: Previous studies suggest an association between late pregnancy exposure to selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) and increased postpartum hemorrhage (PPH) risk. This is the first pregnancy registry study to compare PPH outcomes among women with psychiatric illness exposed or unexposed to SSRIs/SNRIs proximate to delivery. Methods: This study used data from the National Pregnancy Registry for Psychiatric Medications to evaluate the relationship between SSRI/SNRI exposure in late pregnancy and PPH risk. The sample included n = 953 participants with retrospectively collected medical record data on postpartum blood loss, n = 453 unexposed to SSRIs/SNRIs during pregnancy, and n = 500 exposed at least during the week of delivery. PPH was defined as an estimated blood loss ≥500 mL following vaginal delivery or ≥1,000 mL following cesarean section (C-section), with onset of excessive bleeding occurring within the first 24 hours postpartum. Univariate and multivariate logistic regression analyses were performed to determine odds ratios. Results: Overall PPH incidence was 13.1%. SSRI/SNRI exposure was associated with a PPH unadjusted odds ratio of 1.42 compared to no exposure (95% confidence interval [CI: 0.97, 2.08]) and an adjusted odds ratio of 1.33 (95% CI [0.90, 1.97]). When stratified by delivery type, the odds ratio following vaginal delivery among women exposed to SSRIs/SNRIs was 1.04 (95% CI [0.63, 1.70]) versus 2.31 (95% CI [1.25, 4.26]) for C-section delivery; the adjusted C-section odds ratio was 2.21 (95% CI [1.18, 4.13]). Conclusions: Although these findings align with accumulating evidence suggesting SSRI/SNRI exposure may confer a modestly increased risk of PPH, particularly after C-section, the study was underpowered to make definitive conclusions. These preliminary data highlight the need for further research with larger sample sizes. Nevertheless, the findings underscore the importance of greater clinical monitoring for PPH following C-section, especially in women who may have other known PPH risk factors and are exposed to SSRIs/SNRIs in late pregnancy.
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Affiliation(s)
- Adele C Viguera
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cleveland Clinic, Neurological Institute, Cleveland, Ohio, USA
| | - Alexia Jones
- School of Public Health, Boston University, Boston, Massachusetts, USA
| | | | - Sarah N Bernstein
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Memorial Presbyterian Hospital, Newport Beach, California, USA
| | - Parker C Killenberg
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ellen T Sojka
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ella T Rossa
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Gaccione
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marlene P Freeman
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee S Cohen
- Ammon-Pinizzotto Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts, USA
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Thela L, Paruk S, Bhengu B, Chiliza B. Psychiatric emergencies during pregnancy and puerperium in low - And middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102478. [PMID: 38401484 DOI: 10.1016/j.bpobgyn.2024.102478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
Pregnancy and puerperium are critical points in women's health, and various psychiatric emergencies may worsen or manifest (for the first time) during this period. In the presence of a psychiatric emergency, the pregnancy and puerperium outcomes may be compromised. In addition to the mother being at risk, the health of the fetus and the newborn may also be compromised if the psychiatric emergency is not managed appropriately. Early detection and collaborative approaches between mental health practitioners and obstetricians are of utmost importance in women who are at risk and those living with psychiatric illnesses during pregnancy and puerperium. Practitioners should also ensure that women with impaired capacity due to psychiatric disease are treated in a non-judgmental and respectful manner, even if their autonomies have been overridden.
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Affiliation(s)
- Lindokuhle Thela
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa.
| | - Saeeda Paruk
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
| | - Busisiwe Bhengu
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
| | - Bonginkosi Chiliza
- University of KwaZulu Natal, School of Clinical Medicine, Discipline of Psychiatry, South Africa
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Vaghef-Mehrabani E, Bell RC, Field CJ, Jarman M, Evanchuk JL, Letourneau N, Giesbrecht GF. Maternal pre-pregnancy diet and prenatal depression: the mediating role of pre-pregnancy weight status and prenatal inflammation. Br J Nutr 2024:1-15. [PMID: 38800987 DOI: 10.1017/s0007114524001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Depression is a common prenatal psychological complication. We aimed to investigate if maternal pre-pregnancy diet can impact prenatal depressive symptoms and the mediating role of pre-pregnancy BMI and inflammation. We used data (N 1141) from the Alberta Pregnancy Outcomes and Nutrition cohort study. We calculated Mediterranean diet adherence (MED) and dietary inflammatory index (DII) scores using data from pre-pregnancy FFQ. In the third-trimester, we assessed depressive symptoms using Edinburgh Postpartum Depression Scale (EPDS) and inflammation through serum C-reactive protein (CRP) levels. BMI was calculated from self-reported pre-pregnancy weight. Race-stratified analyses (white and people of colour) were run. We observed no association between MED or DII tertiles and depressive symptoms. However, white participants in the MED tertile-3 had lower risk of depression (EPDS < 10) compared with tertile-1 (OR = 0·56, 95 % CI, 0·33, 0·95). White individuals in MED tertile-3 had lower BMI (MD = -1·08; 95 % CI, -1·77, -0·39) and CRP (MD = -0·53; 95 % CI, -0·95, -0·11) than tertile-1, and those in DII tertile-2 (MD = 0·44; 95 % CI, 0·03, 0·84) and tertile-3 (MD = 0·42; 95 % CI, 0·01, 0·83) had higher CRP than tertile-1. Among people of colour, neither MED nor DII was associated with BMI or CRP, but BMI was negatively associated with depressive symptoms (β = -0·25, 95 % CI, -0·43, -0·06). We found no association between diet and depressive symptoms through BMI or CRP, in either race. Pre-pregnancy diet might affect the risk of prenatal depression in a race-specific way. Further research is required to explore the racial differences in the association between maternal diet and prenatal depressive symptoms/depression risk.
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Affiliation(s)
- Elnaz Vaghef-Mehrabani
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rhonda C Bell
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | - Catherine J Field
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | - Megan Jarman
- School of Psychology, College of Health and Life Sciences, Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
| | - Jenna L Evanchuk
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
| | | | - Gerald F Giesbrecht
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Psychology, University of Calgary, Calgary, AB, Canada
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Öndemark M, Nordström L, Lindqvist PG. Dose-dependent increase in risk of bleeding and bleeding complications in relation to SSRI use at delivery. Eur J Obstet Gynecol Reprod Biol 2024; 296:265-269. [PMID: 38490047 DOI: 10.1016/j.ejogrb.2024.02.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/06/2024] [Accepted: 02/28/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Depression during pregnancy is a severe state that increases the risk of suicide, as well as adverse newborn outcomes. Selective serotonin re-uptake inhibitors (SSRIs) are effective for the treatment of depression, but increase the risk of bleeding complications at delivery. Knowledge on the dose dependency of this association is lacking. METHODS A hospital-based cohort study of all women who gave birth at Karolinska University Hospital in Stockholm over the 5-year period from 2007 to 2011, with or without SSRI use, was undertaken. In total, 334 women who delivered vaginally and were exposed to SSRIs at delivery were identified. All other women who delivered vaginally formed the control group (n = 31,929). The electronic maternal health records of the 334 SSRI users were scrutinized, and the women were categorized into two groups: moderate (n = 246) or high (n = 88) SSRI dose at delivery. The main outcome was bleeding complications at delivery in relation to SSRI dose. RESULTS A dose-dependent increase in the rate of postpartum haemorrhage (≥1000 ml) was found, affecting 8.4 %, 14.6 % and 23.9 % (p ≤ 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. In addition, a dose-dependent increase in the rate of postpartum anaemia was found, affecting 7.0 %, 9.3 % and 15.9 % (p = 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. Mean blood loss of 406 ml, 483 ml and 482 ml (p ≤ 0.001) was found in the control group, the moderate-dose group and the high-dose group, respectively. Women exposed to SSRIs delivered earlier, but did not have higher prevalence of pre-eclampsia compared with the control group. CONCLUSIONS The dose-dependent relationship between SSRIs and bleeding complications may be clinically useful in the management of this vulnerable group of women.
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Affiliation(s)
- Malin Öndemark
- Department of Obstetrics and Gynaecology, Sodersjukhuset, Sweden
| | - Lennart Nordström
- Department of Pregnancy and Delivery, Karolinska University Hospital, Solna, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Pelle G Lindqvist
- Department of Obstetrics and Gynaecology, Sodersjukhuset, Sweden; Clinical Sciences and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
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Ruggiero C, Pioli G, Petruccelli R, Baroni M, Prampolini R, Pignedoli P, Antinolfi P, Rinonapoli G, Cappa M, Boccardi V, Bendini C, Mecocci P, Caraffa A, Sabetta E. The correlates of post-surgical haematoma in older adults with proximal femoral fractures. Aging Clin Exp Res 2023; 35:867-875. [PMID: 36773272 PMCID: PMC10115686 DOI: 10.1007/s40520-023-02354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/16/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients. AIMS This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients. METHODS Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma. RESULTS Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.
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Affiliation(s)
- Carmelinda Ruggiero
- Orthogeriatric and Geriatric Unit, Department of Medicine and Surgery, Gerontology and Geriatric Section, S. Maria Misericordia Hospital, University of Perugia, S. Andrea delle Fratte, 06156, Perugia, Italy.
| | - Giulio Pioli
- Orthogeriatric and Geriatric Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Rosario Petruccelli
- Orthopedic and Trauma Unit, Department of Medicine and Surgery, Orthopedic and Trauma Unit, Department of Medicine and Surgery, 06156, Perugia, Italy
| | - Marta Baroni
- Orthogeriatric and Geriatric Unit, Department of Medicine and Surgery, Gerontology and Geriatric Section, S. Maria Misericordia Hospital, University of Perugia, S. Andrea delle Fratte, 06156, Perugia, Italy
| | - Raffaella Prampolini
- Orthogeriatric and Geriatric Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Paolo Pignedoli
- Orthogeriatric and Geriatric Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Pierluigi Antinolfi
- Orthopedic and Trauma Unit, Department of Medicine and Surgery, Orthopedic and Trauma Unit, Department of Medicine and Surgery, 06156, Perugia, Italy
| | - Giuseppe Rinonapoli
- Orthopedic and Trauma Unit, Department of Medicine and Surgery, Orthopedic and Trauma Unit, Department of Medicine and Surgery, 06156, Perugia, Italy
| | - Michele Cappa
- Orthopaedic Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Virginia Boccardi
- Orthogeriatric and Geriatric Unit, Department of Medicine and Surgery, Gerontology and Geriatric Section, S. Maria Misericordia Hospital, University of Perugia, S. Andrea delle Fratte, 06156, Perugia, Italy
| | - Chiara Bendini
- Orthogeriatric and Geriatric Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Patrizia Mecocci
- Orthogeriatric and Geriatric Unit, Department of Medicine and Surgery, Gerontology and Geriatric Section, S. Maria Misericordia Hospital, University of Perugia, S. Andrea delle Fratte, 06156, Perugia, Italy
| | - Auro Caraffa
- Orthopedic and Trauma Unit, Department of Medicine and Surgery, Orthopedic and Trauma Unit, Department of Medicine and Surgery, 06156, Perugia, Italy
| | - Ettore Sabetta
- Orthopaedic Unit, Department of Neuromotor Physiology and Rehabilitation, ASMN-IRCCS Hospital, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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Domingues RR, Beard AD, Connelly MK, Wiltbank MC, Hernandez LL. Fluoxetine-induced perinatal morbidity in a sheep model. Front Med (Lausanne) 2022; 9:955560. [PMID: 35991651 PMCID: PMC9386076 DOI: 10.3389/fmed.2022.955560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Selective serotonin reuptake inhibitors (SSRI) are the most common antidepressants used by pregnant women. However, adverse pregnancy outcomes have been described in women taking SSRI during pregnancy—placental lesions, premature birth, poor neonatal adaptation. We aimed to investigate the effects of fluoxetine (Prozac® most commonly used SSRI) treatment during the last month of gestation on pregnancy complications, placental and neonatal health in a non-depressed sheep model. On day 119 ± 1 postbreeding (experimental day 0; E0) of a 151-day expected gestation, Hampshire ewes were randomly assigned to receive fluoxetine (n = 9 ewes, 15 lambs; daily intravenously treatment with 10 mg/kg on E0 and E1 and 5 mg/kg daily thereafter until parturition) or to a control group (n = 10; 14 lambs; vehicle only). Blood samples from ewes were collected throughout the experimental period and postpartum; blood from lambs were collected postpartum. Analysis of variance was used for statistical analysis. Fluoxetine treatment reduced placentome growth during the last month of pregnancy. Gestation length was decreased by 4.5 days in fluoxetine-treated ewes. Birthweight was reduced in lambs exposed to fluoxetine in utero; weights remained decreased until postnatal day 3. Placentome diameter by birthweight ratio was not different between groups suggesting that the decreased placentome diameter was accompanied by decreased lamb birthweight. During the first week postnatal, lambs exposed to fluoxetine in utero had decreased blood pH and decreased total carbon dioxide, bicarbonate, and base excess and increased lactate (days 3–6), collectively indicative of metabolic acidemia. Additionally, ionized calcium was decreased between postnatal days 0 to 4 in lambs exposed to fluoxetine in utero. Using a non-depressed animal model clearly defines a role for SSRI on the occurrence of perinatal complications and neonatal morbidity. The decreased placentome diameter, shortened gestation, decreased birthweight, decreased calcium levels, and neonatal acidemia suggest the occurrence of intrauterine growth restriction. The persistence of neonatal acidemia for several days postpartum suggests poor neonatal adaptation to extrauterine environment.
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Affiliation(s)
- Rafael R. Domingues
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, United States
- Endocrinology and Reproductive Physiology Program, University of Wisconsin-Madison, Madison, WI, United States
| | - Adam D. Beard
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, United States
- Endocrinology and Reproductive Physiology Program, University of Wisconsin-Madison, Madison, WI, United States
| | - Meghan K. Connelly
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, United States
| | - Milo C. Wiltbank
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, United States
- Endocrinology and Reproductive Physiology Program, University of Wisconsin-Madison, Madison, WI, United States
| | - Laura L. Hernandez
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI, United States
- Endocrinology and Reproductive Physiology Program, University of Wisconsin-Madison, Madison, WI, United States
- *Correspondence: Laura L. Hernandez
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A cross-sectional study of the relationship between CYP2D6 and CYP2C19 variations and depression symptoms, for women taking SSRIs during pregnancy. Arch Womens Ment Health 2022; 25:355-365. [PMID: 34231053 DOI: 10.1007/s00737-021-01149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
Depression during pregnancy affects 10-15% of women, and 5% of women take antidepressants during pregnancy. Clinical guidelines provide recommendations for selective serotonin reuptake inhibitor (SSRI) drug choice and dose based on CYP2D6 and CYP2C19 genotype; however, they are based on evidence from non-pregnant cohorts. This study aimed to test the hypothesis that women with function-altering variants (increased, decreased, or no function) in these pharmacogenes, taking SSRIs prenatally, would have more depression symptoms than women whose pharmacogenetic variants are associated with normal SSRI metabolism. Comprehensive CYP2D6 and CYP2C19 genotyping using a range of methods, including gene copy number analysis, was performed as secondary analyses on two longitudinal cohorts of pregnant women (N = 83) taking the SSRIs paroxetine, citalopram, escitalopram, or sertraline. The Kruskal-Wallis test compared mean depression scores across four predicted metabolizer groups: poor (n = 5), intermediate (n = 10), normal (n = 53), and ultrarapid (n = 15). There were no significant differences between mean depression scores across the four metabolizer groups (H(3) = .73, p = .87, eta-squared = .029, epsilon-squared = .0089). This is the first study of the relationship in pregnancy between CYP2C19 pharmacogenetic variations and depression symptoms in the context of SSRI use. Findings from this initial study do not support the clinical use of pharmacogenetic testing for SSRI use during the second or third trimesters of pregnancy, but these findings should be confirmed in larger cohorts. There is an urgent need for further research to clarify the utility of pharmacogenetic testing for pregnant women, especially as companies offering direct-to-consumer genetic testing expand their marketing efforts.
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Sha Q, Madaj Z, Keaton S, Escobar Galvis ML, Smart L, Krzyzanowski S, Fazleabas AT, Leach R, Postolache TT, Achtyes ED, Brundin L. Cytokines and tryptophan metabolites can predict depressive symptoms in pregnancy. Transl Psychiatry 2022; 12:35. [PMID: 35078975 PMCID: PMC8789799 DOI: 10.1038/s41398-022-01801-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 02/06/2023] Open
Abstract
Depression during and after pregnancy affects up to 20% of pregnant women, but the biological underpinnings remain incompletely understood. As pregnancy progresses, the immune system changes to facilitate fetal development, leading to distinct fluctuations in the production of pro-inflammatory factors and neuroactive tryptophan metabolites throughout the peripartum period. Therefore, it is possible that depression in pregnancy could constitute a specific type of inflammation-induced depression. Both inflammatory factors and kynurenine metabolites impact neuroinflammation and glutamatergic neurotransmission and can therefore affect mood and behavior. To determine whether cytokines and kynurenine metabolites can predict the development of depression in pregnancy, we analyzed blood samples and clinical symptoms in 114 women during each trimester and the postpartum. We analyzed plasma IL-1β, IL-2, -6, -8, -10, TNF, kynurenine, tryptophan, serotonin, kynurenic- quinolinic- and picolinic acids and used mixed-effects models to assess the association between biomarkers and depression severity. IL-1β and IL-6 levels associated positively with severity of depressive symptoms across pregnancy and the postpartum, and that the odds of experiencing significant depressive symptoms increased by >30% per median absolute deviation for both IL-1β and IL-6 (both P = 0.01). A combination of cytokines and kynurenine metabolites in the 2nd trimester had a >99% probability of accurately predicting 3rd trimester depression, with an ROC AUC > 0.8. Altogether, our work shows that cytokines and tryptophan metabolites can predict depression during pregnancy and could be useful as clinical markers of risk. Moreover, inflammation and kynurenine pathway enzymes should be considered possible therapeutic targets in peripartum depression.
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Affiliation(s)
- Qiong Sha
- grid.251017.00000 0004 0406 2057Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI USA
| | - Zach Madaj
- grid.251017.00000 0004 0406 2057Bioinformatics & Biostatistics Core, Van Andel Institute, Grand Rapids, MI USA
| | - Sarah Keaton
- grid.251017.00000 0004 0406 2057Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI USA ,grid.17088.360000 0001 2150 1785Division of Psychiatry & Behavioral Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI USA
| | - Martha L Escobar Galvis
- grid.251017.00000 0004 0406 2057Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI USA
| | - LeAnn Smart
- grid.415008.80000 0004 0429 718XPine Rest Christian Mental Health Services, Grand Rapids, MI USA
| | - Stanislaw Krzyzanowski
- grid.251017.00000 0004 0406 2057Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI USA
| | - Asgerally T. Fazleabas
- grid.17088.360000 0001 2150 1785Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, MI USA
| | - Richard Leach
- grid.17088.360000 0001 2150 1785Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, MI USA
| | - Teodor T. Postolache
- grid.411024.20000 0001 2175 4264Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD USA ,Rocky Mountain MIRECC for Suicide Prevention, Aurora, CO USA ,Military and Veteran Microbiome Consortium for Research and Education, Aurora, CO USA ,grid.484336.e0000 0004 0420 8773Capital MIRECC, VISN 5, Baltimore, MD USA
| | - Eric D. Achtyes
- grid.17088.360000 0001 2150 1785Division of Psychiatry & Behavioral Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI USA ,grid.415008.80000 0004 0429 718XPine Rest Christian Mental Health Services, Grand Rapids, MI USA
| | - Lena Brundin
- Department of Neurodegenerative Science, Van Andel Institute, Grand Rapids, MI, USA. .,Division of Psychiatry & Behavioral Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
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Robinson AC, January SE, Botkin KW, Vader JM, Hartupee JC, Tellor Pennington BR. Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support. Pharmacotherapy 2021; 42:4-13. [PMID: 34655495 DOI: 10.1002/phar.2632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE This study sought to determine whether SA use is associated with bleeding in patients receiving CF-LVAD support. DESIGN A retrospective cohort analysis was conducted of all adult patients who received CF-LVAD implantation at our institution. SETTING Barnes-Jewish Hospital between July 1, 2009, and October 1, 2018. PATIENTS Patients at least 18 years of age who received a HVAD™ (HeartWare Corp.), HeartMate II™ (St. Jude Medical), or HeartMate 3™ (St. Jude Medical) CF-LVAD and survived for at least 30 days postoperatively were included. INTERVENTION Patients who received SAs (n = 203) were compared to those who did not (n = 391) from 30 days to 18 months following implantation. The primary outcome was the incidence of first bleeding events including gastrointestinal bleed (GIB), epistaxis, or intracerebral hemorrhage (ICH). MEASUREMENTS AND MAIN RESULTS During follow-up, 219 patients had bleeding events: 93 of 203 (45.8%) in the SA group versus 126 of 391 (32.2%) in the control group (p = 0.001). After adjustment for age, angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) use, history of bleeding events, history of smoking, and CF-LVAD type, SA use remained associated with bleeding (adjusted odds ratio: 1.75, 95% confidence interval: 1.22-2.51, p = 0.002). HeartMate 3™ patients experienced less bleeding than HeartMate II™ patients (adjusted odds ratio 0.46, 95% confidence interval: 0.23-0.90, p = 0.024). CONCLUSIONS In this single-center, retrospective cohort of patients supported with CF-LVADs, SA use was associated with the incidence of first bleeding events, primarily driven by GIB. Further studies are needed to assess any differential risk of bleeding among SA agents and to assess the utility of altering antithrombotic strategies.
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Affiliation(s)
- Adam C Robinson
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kent W Botkin
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Justin M Vader
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Justin C Hartupee
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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Tan J, Xiong Y, Qi Y, Liu C, Huang S, Yao G, Sun W, Qian Y, Ye L, Xu Q, Liu H, Lee AH, Thabane L, Sun X. Data Resource Profile: Xiamen registry of pregnant women and offspring (REPRESENT): a population-based, long-term follow-up database linking four major healthcare data platforms. Int J Epidemiol 2021; 50:27-28. [PMID: 33367681 PMCID: PMC7938502 DOI: 10.1093/ije/dyaa161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Jing Tan
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Biostatistics Unit, St Joseph's Healthcare-Hamilton, Hamilton, Canada
| | - Yiquan Xiong
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yana Qi
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chunrong Liu
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shiyao Huang
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | | | - Wei Sun
- Xiamen Health Commission, Xiamen, China
| | | | - Lishan Ye
- Xiamen Health and Medical Big Data Center, Xiamen, China
| | - Qiushi Xu
- Xiamen Health and Medical Big Data Center, Xiamen, China
| | - Hui Liu
- Xiamen Health and Medical Big Data Center, Xiamen, China
| | - Andy H Lee
- School of Public Health, Curtin University, Perth, Australia
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Biostatistics Unit, St Joseph's Healthcare-Hamilton, Hamilton, Canada
| | - Xin Sun
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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11
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Patients with psychiatric disease: implications for anesthesiologists. Curr Opin Anaesthesiol 2021; 34:345-351. [PMID: 33935183 DOI: 10.1097/aco.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Psychiatric illness is common in patients presenting for surgery. Overall health and surgical outcomes are adversely affected by the presence of psychiatric comorbidities. RECENT FINDINGS As new treatment modalities become available, their perioperative implications need to be evaluated. These implications include drug-drug interactions, hemodynamic effects, bleeding risk, and factors affecting perioperative exacerbation of the underlying psychiatric illness. SUMMARY From our review of the recent literature we continue to support the continuation of psychoactive agents in the perioperative period, taking into consideration the effects these agents have on concomitant drug use in the perioperative period; and the risks of withholding them at a high-stress time.
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12
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Colombo A, Giordano F, Giorgetti F, Di Bernardo I, Bosi MF, Varinelli A, Cafaro R, Pileri P, Cetin I, Clementi E, Viganò CA, Dell'Osso B. Correlation between pharmacokinetics and pharmacogenetics of Selective Serotonin Reuptake Inhibitors and Selective Serotonin and Noradrenaline Reuptake Inhibitors and maternal and neonatal outcomes: Results from a naturalistic study in patients with affective disorders. Hum Psychopharmacol 2021; 36:e2772. [PMID: 33253437 DOI: 10.1002/hup.2772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Some studies have linked the use of selective serotonin reuptake inhibitors and selective serotonin and noradrenaline reuptake inhibitors (SSRIs/SNRIs) to the risk of perinatal complications. This study explored the relationship between pharmacokinetics and pharmacogenetics, SSRIs/SNRIs tolerability and effectiveness and maternal and newborn outcomes. METHODS Fifty-five pregnant women with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnoses of affective disorders, treated with SSRIs/SNRIs, were recruited and, during the third trimester, their blood samples were collected for pharmacokinetic and pharmacogenetic analyses. Plasma levels and metabolic phenotypes were then related to different obstetrical and maternal outcomes. RESULTS The pharmacokinetic data were more stable for Sertraline, Citalopram, and Escitalopram compared to other molecules (p = 0.009). The occurrence of postnatal adaptation syndrome onset was associated with higher plasma levels for Sertraline (median at delivery: 16.7 vs. 10.5 ng/ml), but not for fluoxetine and venlafaxine. Finally, the subgroup within range plasma concentrations had less blood loss than the below range subgroup (p = 0.030). CONCLUSIONS Plasma levels of Sertraline, Citalopram and Escitalopram were more frequently in range in late pregnancy when compared to other drugs. Drug plasma concentrations do not strictly correlate with worse perinatal outcomes, but with possible differences between the different drugs.
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Affiliation(s)
- Anna Colombo
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | | | - Federica Giorgetti
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Ilaria Di Bernardo
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Monica F Bosi
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Alberto Varinelli
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Rita Cafaro
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Paola Pileri
- Unit of Obstetrics and Gynecology, ASST Fatebenefratelli Sacco, V. Buzzi Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Irene Cetin
- Unit of Obstetrics and Gynecology, ASST Fatebenefratelli Sacco, V. Buzzi Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy.,E. Medea Scientific Institute, Bosisio Parini, Milan, Italy
| | - Caterina A Viganò
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Bernardo Dell'Osso
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, L. Sacco University Hospital, Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy.,Department of Health Sciences, 'Aldo Ravelli' Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan, Italy.,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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13
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Zhou C, Zhang L, Bao Y, Li L, Zhang T, Zhang X, Wang C. Effect of blood transfusion during cesarean section on postpartum hemorrhage in a tertiary hospital over a 4-year period. Medicine (Baltimore) 2021; 100:e23885. [PMID: 33545955 PMCID: PMC7837845 DOI: 10.1097/md.0000000000023885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 11/25/2022] Open
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and death worldwide. The history of cesarean section and the occurrence of placenta previa were significantly associated with the increase in blood transfusion. Therefore, to prevent PPH, it is important to understand the effect of blood transfusion during cesarean section on postpartum hemorrhage. The purpose of this study is to determine the cause of blood transfusion during cesarean section, especially large amounts of blood transfusion, and to take measures to reduce the blood demand caused by PPH with limited blood supply.This study was a retrospective study of patients who underwent blood transfusion during cesarean section in Qilu Hospital of Shandong University (China) from January 2013 to December 2016. Red blood cell infusion ≥10 U during cesarean section was defined as massive blood transfusion. The study collected the demographics of pregnant women, obstetric characteristics and reasons for blood transfusions, as well as blood components and blood transfusion results. Multivariate regression analysis was performed for evaluating the risk factors of PPN.From 2013 to 2016, a total of 587 patients received blood transfusions during cesarean section. The proportion of women receiving blood transfusion during cesarean section increased (from 3.21% to 7.40%, P < .001). The history of cesarean section (P = .005) and the occurrence of placenta previa were positively correlated with the increase in blood transfusion (P = .016). There were 72 cases of massive blood transfusion, accounting for 12.27% of blood transfusion patients. Among mass blood transfusions, 93.1% of cases had prior cesarean delivery, and placenta previa accounted for 95.8%. 19.4% of patients receiving massive blood transfusions underwent hysterectomy. There was no significant difference in maternal BMI and gestational age between the mass blood transfusion group and the non-mass blood transfusion group.From 2013 to 2016, the demand for blood transfusion, especially the demand for massive blood transfusion, increased. Repeated cesarean section and placental previa combined with uterine scar are positively correlated with increased blood transfusion. Reducing the initial cesarean section should help reduce the massive blood transfusion caused by placenta previa with a history of cesarean section.
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14
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Palmsten K, Chambers CD, Wells A, Bandoli G. Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage. Paediatr Perinat Epidemiol 2020; 34:597-606. [PMID: 32207549 PMCID: PMC7819597 DOI: 10.1111/ppe.12660] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/16/2020] [Accepted: 01/26/2020] [Indexed: 12/18/2022]
Abstract
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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Affiliation(s)
- Kristin Palmsten
- Health Partners Institute, Minneapolis, MN, Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA
| | - Christina D Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - Alan Wells
- Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla, CA, OptumLabs Visiting Fellow, Cambridge, MA, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
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15
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Skalkidou A, Sundström‐Poromaa I, Wikman A, Hesselman S, Wikström AK, Elenis E. SSRI use during pregnancy and risk for postpartum haemorrhage: a national register‐based cohort study in Sweden. BJOG 2020; 127:1366-1373. [DOI: 10.1111/1471-0528.16210] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 12/17/2022]
Affiliation(s)
- A Skalkidou
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
| | - I Sundström‐Poromaa
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
| | - A Wikman
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
| | - S Hesselman
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
- Center for Clinical Research Dalarna Falun Hospital Falun Sweden
| | - AK Wikström
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
| | - E Elenis
- Department of Children’s and Women’s Health Uppsala University Uppsala Sweden
- Reproduction Centre Uppsala University Hospital Uppsala Sweden
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16
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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17
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Perrotta C, Giordano F, Colombo A, Carnovale C, Castiglioni M, Di Bernardo I, Giorgetti F, Pileri P, Clementi E, Viganò C. Postpartum Bleeding in Pregnant Women Receiving SSRIs/SNRIs: New Insights From a Descriptive Observational Study and an Analysis of Data from the FAERS Database. Clin Ther 2019; 41:1755-1766. [PMID: 31371035 DOI: 10.1016/j.clinthera.2019.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/15/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To date, the available data on the relationship between the use of selective serotonin reuptake inhibitors (SSRIs) or the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine and postpartum hemorrhage (PPH) are conflicting and have not been extensively investigated, especially in terms of plasma drug concentrations. We performed data mining of antidepressant-induced PPH reported to the US Food and Drug Administration's Adverse Event Reporting System database, to assess the strength of the potential association between antidepressant pharmacotherapy and PPH in pregnant women. Concurrently, we carried out a descriptive observational population (pregnant women) analysis of the correlation between the plasma concentrations of SSRIs/SNRIs used during pregnancy and the extent of bleeding at delivery. METHODS A disproportionality analysis of individual case study reports of PPH associated with SSRIs or venlafaxine in pregnant women was performed. Reporting odds ratio was used as a measure of disproportionality analysis. Pregnant women treated with an SSRI or SNRI (venlafaxine) for depressive or anxiety disorder and who consented to plasma drug concentration monitoring at the time of delivery were recruited. Plasma drug concentration assay was performed according to validated LC-MS/MS. Based on plasma drug concentrations, patients were classified into 1 of 2 groups, in therapeutic range or below therapeutic range for the drug administered, in accordance with the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie guideline, and correlations with blood loss were identified, with PPH defined as a blood loss of >500 mL. FINDINGS Only 43 Individual Case Safety Reports (ICSRs) reported at least one SSRIs or venlafaxine as suspect drug in 14 years (database analyses). Forty-three women were enrolled in the study population (observational study). In 24 patients (55.8%) the plasma drug concentration was below the therapeutic threshold. Unexpectedly, the mean blood loss in the below-range group was significantly higher than that in the in-range group. PPH occurred in 30% of women: in 9.3% and in 20.7% of patients in the in-range and below-range groups, respectively. IMPLICATIONS Although preliminary, these data indicate a rather good tolerability profile of SSRIs/SNRIs regarding postpartum bleeding. Moreover, they suggest that keeping the plasma levels of SSRIs/SNRIs low as a precautionary measure does not reduce postpartum bleeding, which was higher in the below-range group. The findings from this study suggest that the use of therapeutic drug monitoring in pregnancy, a period in which multiple variables affect drug metabolism, may allow for better treatment customization, with subsequent advantages in terms of tolerability and efficacy of treatment.
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Affiliation(s)
- Cristiana Perrotta
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy
| | - Francesca Giordano
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy; Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Anna Colombo
- Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Carla Carnovale
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy
| | - Michele Castiglioni
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy; Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ilaria Di Bernardo
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy; Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Federica Giorgetti
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy; Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Paola Pileri
- Department of Gynecology and Obstetrics, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Emilio Clementi
- E. Medea Scientific Institute, Bosisio Parini, Italy; Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, National Research Council, Institute of Neuroscience, Luigi Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Caterina Viganò
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università degli Studi di Milano, Milan, Italy; Psychiatry Unit 2, ASST Fatebenefratelli Sacco, Milan, Italy.
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Abstract
Risks, benefits, alternatives, and appropriateness of psychotropic medications, including risks of no treatment, are discussed for antidepressants, mood-stabilizing medications, anxiolytic/sedative hypnotic medications, stimulants, and medication-assisted treatment of substance use disorders. Early screening, diagnosis, and intervention prior to and/or during pregnancy often reduce morbidity and mortality of mental health disorders for mothers and infants.
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Affiliation(s)
- Edwin R Raffi
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA.
| | - Ruta Nonacs
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA
| | - Lee S Cohen
- Perinatal and Reproductive Psychiatry Program, Massachusetts General Hospital Center for Women's Mental Health, Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2200, Boston, MA 02114, USA
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19
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Thorsness KR, Watson C, LaRusso EM. Perinatal anxiety: approach to diagnosis and management in the obstetric setting. Am J Obstet Gynecol 2018; 219:326-345. [PMID: 29803818 DOI: 10.1016/j.ajog.2018.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/09/2018] [Accepted: 05/16/2018] [Indexed: 11/16/2022]
Abstract
Anxiety is common in women during the perinatal period, manifests with various symptoms and severity, and is associated with significant maternal morbidity and adverse obstetric and neonatal outcomes. Given the intimate relationship and frequency of contact, the obstetric provider is positioned optimally to create a therapeutic alliance and to treat perinatal anxiety. Time constraints, absence of randomized controlled trials, mixed quality of data, and concern for potential adverse reproductive outcomes all limit the clinician's ability to initiate informed risk-benefit discussions. Clear understanding of the role of the obstetric provider in the identification, stabilization, and initiation of medication and/or referral to psychotherapy for women with perinatal anxiety disorders is critical to maternal and neonatal wellbeing. Informed by our clinical practice as perinatal psychiatric providers, we have provided a concise summary of current research on the approach to the treatment of perinatal anxiety disorders in the obstetric setting that includes psychotherapy and supportive interventions, primary and adjuvant psychiatric medication, and general prescribing pearls. Medications that we examined include antidepressants, benzodiazepines, sedative-hypnotics, antihistamines, quetiapine, buspirone, propranolol, and melatonin. Further research into management of perinatal anxiety, particularly psychopharmacologic management, is warranted.
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20
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Kawada T. Re: Antidepressant use in late gestation and risk of postpartum haemorrhage: a retrospective cohort study. BJOG 2017. [DOI: 10.1111/1471-0528.14605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Tomoyuki Kawada
- Department of Hygiene and Public Health; Nippon Medical School; Tokyo Japan
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21
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Heller HM, Ravelli ACJ, Bruning AHL, de Groot CJM, Scheele F, van Pampus MG, Honig A. Increased postpartum haemorrhage, the possible relation with serotonergic and other psychopharmacological drugs: a matched cohort study. BMC Pregnancy Childbirth 2017; 17:166. [PMID: 28577352 PMCID: PMC5457563 DOI: 10.1186/s12884-017-1334-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/18/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage is a major obstetric risk worldwide. Therefore risk factors need to be investigated to control for this serious complication. A recent systematic review and meta-analysis revealed that the use of both serotonergic and non-serotonergic antidepressants in pregnancy are associated with a higher risk of postpartum haemorrhage. However, use of antidepressants in pregnancy is often necessary because untreated depression in pregnancy is associated with adverse maternal and neonatal outcome, such as postpartum depression, preterm birth and dysmaturity. Therefore it is of utmost importance to unravel the possible association between postpartum haemorrhage and the use of serotonergic and other psychopharmacological medication during pregnancy. METHODS We performed a matched cohort observational study consecutively including all pregnant women using serotonergic medication (n = 578) or other psychopharmacological medication (n = 50) visiting two teaching hospitals in Amsterdam between 2010 and 2014. The incidence of postpartum haemorrhage in women using serotonergic medication or other psychopharmacological medication was compared with the incidence of postpartum haemorrhage in 641,364 pregnant women not using psychiatric medication selected from the database of the Netherlands Perinatal Registry foundation (Perined). Matching took place 1:5 for nine factors, i.e., parity, maternal age, ethnicity, socioeconomic status, macrosomia, gestational duration, history of postpartum haemorrhage, labour induction and hypertensive disorder. RESULTS Postpartum haemorrhage occurred in 9.7% of the women using serotonergic medication. In the matched controls this was 6.6% (p = 0.01). The adjusted odds ratio (aOR) before matching was 1.6 (95% CI 1.2-2.1) and after matching 1.5 (95% CI 1.1-2.1). Among the women using other psychopharmacological medication, the incidence of postpartum haemorrhage before matching was 12.0% versus 6.1% (p = 0.08) with OR 2.1 (95% CI 0.9-4.9), and after matching 12.1% versus 4.4% (p = 0.03) with aOR of 3.3 (95% CI 1.1-9.8). CONCLUSIONS Pregnant women using serotonergic medication have an increased risk of postpartum haemorrhage, but this high risk is also seen in pregnant women using other psychopharmacological medication. We suggest that this higher risk of postpartum haemorrhage could not only be explained by serotonin, but also by other mechanisms. An additional explanation could be the underlying psychiatric disorder.
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Affiliation(s)
- Hanna M Heller
- Department of Hospital Psychiatry, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anita C J Ravelli
- Department of Medical Informatics, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Andrea H L Bruning
- Department of Pediatric Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Christianne J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Fedde Scheele
- Department of Obstetrics and Gynaecology, OLVG Hospital (West), Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Maria G van Pampus
- Department of Obstetrics and Gynaecology, OLVG Hospital (East), Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Adriaan Honig
- Department of Hospital Psychiatry, OLVG Hospital (West), Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands
- Department of Hospital Psychiatry, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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22
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Latendresse G, Elmore C, Deneris A. Selective Serotonin Reuptake Inhibitors as First-Line Antidepressant Therapy for Perinatal Depression. J Midwifery Womens Health 2017; 62:317-328. [PMID: 28485526 DOI: 10.1111/jmwh.12607] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/22/2016] [Accepted: 01/06/2017] [Indexed: 01/22/2023]
Abstract
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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23
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McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V, Green L, Gregoire A, Howard LM, Jones I, Khalifeh H, Lingford-Hughes A, McDonald E, Micali N, Pariante CM, Peters L, Roberts A, Smith NC, Taylor D, Wieck A, Yates LM, Young AH. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. J Psychopharmacol 2017; 31:519-552. [PMID: 28440103 DOI: 10.1177/0269881117699361] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.
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Affiliation(s)
- R Hamish McAllister-Williams
- 1 Institute of Neuroscience, Newcastle University, Newcastle, UK.,2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David S Baldwin
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,4 University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Abby Easter
- 6 Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Eilish Gilvarry
- 2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,7 Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Vivette Glover
- 8 Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Lucian Green
- 9 Ealing, Hounslow, Hammersmith & Fulham Perinatal Mental Health Service, West London Mental Health Trust, London, UK
| | - Alain Gregoire
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,10 Hampshire Perinatal Mental Health Service, Winchester, UK
| | - Louise M Howard
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | - Ian Jones
- 13 National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Hind Khalifeh
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Elizabeth McDonald
- 15 Royal College of Psychiatrists, London, UK.,16 East London Foundation Trust, London, UK.,17 Tavistock and Portman NHS Foundation Trust, London, UK
| | - Nadia Micali
- 18 Behavioural and Brain Sciences Unit, GOSH Institute of Child Health, University College London, London, UK
| | - Carmine M Pariante
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Ann Roberts
- 20 St Martin's Healthcare Services CIC, Leeds, UK.,21 Hertfordshire Partnership University NHS Foundation Trust, Hatfield, Hertfordshire, UK.,22 Postgraduate School of Medicine, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Natalie C Smith
- 23 Tees, Esk and Wear Valleys NHS Foundation Trust, Darlington, County Durham, UK
| | - David Taylor
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,24 Institute of Pharmaceutical Science, King's College London, London, UK
| | - Angelika Wieck
- 25 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.,26 University of Manchester, Manchester, UK
| | - Laura M Yates
- 27 UK Teratology Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,28 Institute of Genetic Medicine, Newcastle University, Newcastle, UK
| | - Allan H Young
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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24
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Jiang HY, Xu LL, Li YC, Deng M, Peng CT, Ruan B. Antidepressant use during pregnancy and risk of postpartum hemorrhage: A systematic review and meta-analysis. J Psychiatr Res 2016; 83:160-167. [PMID: 27637098 DOI: 10.1016/j.jpsychires.2016.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/28/2016] [Accepted: 09/02/2016] [Indexed: 12/11/2022]
Abstract
Evidence about relationship between antidepressant use during pregnancy and the risk of postpartum hemorrhage (PPH) is conflicting. The aim of this meta-analysis was to systematically assess this relationship. To identify relevant studies, we conducted systematic searches in PubMed and Embase of articles published through May 2016. Random-effects models were adopted to estimate overall relative risk. In total, eight studies involving more than 40,000 PPH cases were included in our meta-analysis. After pooling the estimates, the odds for developing PPH were 1.32-fold higher (risk ratio, RR = 1.32; 95% confidence interval, CI = 1.17-1.48) in antidepressant users compared with individuals who had not taken antidepressants. In subgroup analyses, the associations still exist for women with exposure to non-SRI (RR = 1.31, 95% CI = 1.1-1.56), SRIs (RR = 1.23, 95% CI = 1.06-1.44), SSRIs (RR = 1.2, 95% CI = 1.04-1.38), and SNRIs (RR = 1.62, 95% CI = 1.41-1.85). Based on exposure window, we found an increased risk of PPH among current (RR = 1.37, 95% CI = 1.09-1.71) and recent users (RR = 1.32, 95% CI = 1.15-1.51), but not past users (RR = 1.08, 95% CI = 0.88-1.31). The findings of this meta-analysis support an increased risk of PPH in women exposure to antidepressant during late gestation.
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Affiliation(s)
- Hai-Yin Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Lian-Lian Xu
- Department of Psychiatry, Hangzhou Seventh People's Hospital, Hangzhou, 310013, China
| | - Yu-Cuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Min Deng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Chun-Ting Peng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Bing Ruan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China.
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25
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In Reply. Obstet Gynecol 2016; 128:406. [DOI: 10.1097/aog.0000000000001542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Postpartum Hemorrhage and Use of Serotonin Reuptake Inhibitor Antidepressants in Pregnancy. Obstet Gynecol 2016; 128:405-406. [PMID: 27454713 DOI: 10.1097/aog.0000000000001541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Nevels RM, Gontkovsky ST, Williams BE. Paroxetine-The Antidepressant from Hell? Probably Not, But Caution Required. PSYCHOPHARMACOLOGY BULLETIN 2016; 46:77-104. [PMID: 27738376 PMCID: PMC5044489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Paroxetine, also known by the trade names Aropax, Paxil, Pexeva, Seroxat, Sereupin and Brisdelle, was first marketed in the U.S. in 1992. Effective for major depression and various anxiety disorders, it quickly gained a sizable share of the antidepressant prescription market. By the late 1990s, paroxetine frequently was being associated with serious drug interactions and medication side effects. Most significantly, in a major Canadian epidemiological study examining the relationship between antidepressants and diseases, paroxetine was associated with a 620 percent increase in the rate of breast cancer in women who had taken it over a four-year period. Though re-analyses of this investigation discounted the magnitude of these findings, other studies have associated paroxetine with numerous side effects and adverse events not reported in clinical trials. Among these are effects on male fertility, birth defects, gestational hypertension, prolonged QT interval in infants, hyperprolactinemia, cognitive impairment in the elderly, autism, sexual side effects, weight gain, and suicidality, aggression, and akathisia in children and adolescents. Paroxetine has the highest inhibitory constant for the P450 2D6 isoenzyme of all antidepressants (Ki = 0.065-4.65 micromoles). This high affinity explains its high inhibitory interaction profile with substrates for 2D6. Paroxetine's potent 2D6 inhibition also implies that significant inhibition of the metabolism of 2D6 carcinogen substrates occurs which implies an increased probability of oncogenesis. Through 2D6 inhibition, tamoxifen metabolism is inhibited, which has been found to increase the risk of dying from breast cancer over a five-year period in women on both medications. Paroxetine also is a potent inhibitor of 3A4 with multiple 3A4 substrate interactions. Paroxetine has the highest known affinity for the serotonin transporter (0.13 nanomoles) of any currently used antidepressant. These characteristics and their potential negative consequences along with other adverse effects are considered and weighed against paroxetine's efficacious antidepressant and anxiolytic effects.
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Affiliation(s)
- Robert M Nevels
- Dr. Nevels, PhD, MP, The Counseling Center, Ridgeland, MS, Primary Care Solutions, New Roads, LA. Dr. Gontkovsky, PsyD, Mercy Health, St. Elizabeth Hospital, 1053 Belmont Ave, Youngstown, OH 44504. Dr. Williams, PhD, Jackson State University, Jackson, MS
| | - Samuel T Gontkovsky
- Dr. Nevels, PhD, MP, The Counseling Center, Ridgeland, MS, Primary Care Solutions, New Roads, LA. Dr. Gontkovsky, PsyD, Mercy Health, St. Elizabeth Hospital, 1053 Belmont Ave, Youngstown, OH 44504. Dr. Williams, PhD, Jackson State University, Jackson, MS
| | - Bryman E Williams
- Dr. Nevels, PhD, MP, The Counseling Center, Ridgeland, MS, Primary Care Solutions, New Roads, LA. Dr. Gontkovsky, PsyD, Mercy Health, St. Elizabeth Hospital, 1053 Belmont Ave, Youngstown, OH 44504. Dr. Williams, PhD, Jackson State University, Jackson, MS
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