The risk of postpartum hemorrhage with selective serotonin reuptake inhibitors and other antidepressants

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

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.

Concomitant Use of Selective Serotonin Reuptake Inhibitors With Oral Anticoagulants and Risk of Major Bleeding

Importance

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed antidepressants associated with a small increased risk of major bleeding. However, the risk of bleeding associated with the concomitant use of SSRIs and oral anticoagulants (OACs) has not been well characterized.

Objectives

To assess whether concomitant use of SSRIs with OACs is associated with an increased risk of major bleeding compared with OAC use alone, describe how the risk varies with duration of use, and identify key clinical characteristics modifying this risk.

Design, Setting, and Participants

A population-based, nested case-control study was conducted among patients with atrial fibrillation initiating OACs between January 2, 1998, and March 29, 2021. Patients were from approximately 2000 general practices in the UK contributing to the Clinical Practice Research Datalink. With the use of risk-set sampling, for each case of major bleeding during follow-up, up to 30 controls were selected from risk sets defined by the case and matched on age, sex, cohort entry date, and follow-up duration.

Exposures

Concomitant use of SSRIs and OACs (direct OACs and vitamin K antagonists [VKAs]) compared with OAC use alone.

Main Outcomes and Measures

The main outcome was incidence rate ratios (IRRs) of hospitalization for bleeding or death due to bleeding.

Results

There were 42 190 patients with major bleeding (mean [SD] age, 74.2 [9.3] years; 59.8% men) matched to 1 156 641 controls (mean [SD] age, 74.2 [9.3] years; 59.8% men). Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OACs alone (IRR, 1.33; 95% CI, 1.24-1.42). The risk peaked during the initial months of treatment (first 30 days of use: IRR, 1.74; 95% CI, 1.37-2.22) and persisted for up to 6 months. The risk did not vary with age, sex, history of bleeding, chronic kidney disease, and potency of SSRIs. An association was present both with concomitant use of SSRIs and direct OACs compared with direct OAC use alone (IRR, 1.25; 95% CI, 1.12-1.40) and concomitant use of SSRIs and VKAs compared with VKA use alone (IRR, 1.36; 95% CI, 1.25-1.47).

Conclusions and Relevance

This study suggests that among patients with atrial fibrillation, concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OAC use alone, requiring close monitoring and management of risk factors for bleeding, particularly in the first few months of use.

Consensus Panel Recommendations for the Pharmacological Management of Pregnant Women with Depressive Disorders

INTRODUCTION

The initiative of a consensus on the topic of antidepressant and anxiolytic drug use in pregnancy is developing in an area of clinical uncertainty. Although many studies have been published in recent years, there is still a paucity of authoritative evidence-based indications useful for guiding the prescription of these drugs during pregnancy, and the data from the literature are complex and require expert judgment to draw clear conclusions.

METHODS

For the elaboration of the consensus, we have involved the scientific societies of the sector, namely, the Italian Society of Toxicology, the Italian Society of Neuropsychopharmacology, the Italian Society of Psychiatry, the Italian Society of Obstetrics and Gynecology, the Italian Society of Drug Addiction and the Italian Society of Addiction Pathology. An interdisciplinary team of experts from different medical specialties (toxicologists, pharmacologists, psychiatrists, gynecologists, neonatologists) was first established to identify the needs underlying the consensus. The team, in its definitive structure, includes all the representatives of the aforementioned scientific societies; the task of the team was the evaluation of the most accredited international literature as well as using the methodology of the "Nominal Group Technique" with the help of a systematic review of the literature and with various discussion meetings, to arrive at the drafting and final approval of the document.

RESULTS

The following five areas of investigation were identified: (1) The importance of management of anxiety and depressive disorders in pregnancy, identifying the risks associated with untreated maternal depression in pregnancy. (2) The assessment of the overall risk of malformations with the antidepressant and anxiolytic drugs used in pregnancy. (3) The evaluation of neonatal adaptation disorders in the offspring of pregnant antidepressant/anxiolytic-treated women. (4) The long-term outcome of infants' cognitive development or behavior after in utero exposure to antidepressant/anxiolytic medicines. (5) The evaluation of pharmacological treatment of opioid-abusing pregnant women with depressive disorders.

CONCLUSIONS

Considering the state of the art, it is therefore necessary in the first instance to frame the issue of pharmacological choices in pregnant women who need treatment with antidepressant and anxiolytic drugs on the basis of data currently available in the literature. Particular attention must be paid to the evaluation of the risk/benefit ratio, understood both in terms of therapeutic benefit with respect to the potential risks of the treatment on the pregnancy and on the fetal outcome, and of the comparative risk between the treatment and the absence of treatment; in the choice prescription, the specialist needs to be aware of both the potential risks of pharmacological treatment and the equally important risks of an untreated or undertreated disorder.

Concomitant Use of Selective Serotonin Reuptake Inhibitors and Oral Anticoagulants and Risk of Major Bleeding: A Systematic Review and Meta-analysis

BACKGROUND

 Selective serotonin reuptake inhibitors (SSRIs), the most prescribed antidepressants, are associated with a modestly increased risk of major bleeding. However, in patients treated with both SSRIs and oral anticoagulants (OACs), the risk of major bleeding may be substantial.

OBJECTIVE

 To assess the risk of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

METHODS

 We searched MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials (from inception to December 1, 2021) for clinical trials and observational studies assessing the association between concomitant use of SSRIs and OACs and the risk of major bleeding. Given sufficient homogeneity of studies, we conducted a random-effects meta-analysis to estimate a pooled hazard ratio (HR) of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

RESULTS

 The review comprised 14 studies, including 7 cohort and 7 nested case-control studies. Following assessment of clinical and methodological heterogeneity, eight studies with a total of 98,070 patients were eligible for the meta-analysis. The pooled HR of major bleeding associated with concomitant use of SSRIs and OACs was 1.35 (95% confidence interval [CI]: 1.14-1.58). In secondary analyses, the pooled HR for concomitant use of SSRIs and direct OACs was 1.47 (95% CI: 1.03-2.10).

CONCLUSION

 Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding. Overall, our findings suggest that physicians may need to tailor treatment according to individual patient risk factors for bleeding when prescribing SSRIs to patients using OACs.

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

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.

Patterns of prenatal antidepressant exposure and risk of preeclampsia and postpartum haemorrhage

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.

Risk-benefit balance assessment of SSRI antidepressant use during pregnancy and lactation based on best available evidence - an update

Introduction: Depression affects 300 million individuals worldwide. While selective serotonin reuptake inhibitors (SSRI) are one of the first-line pharmacological treatments of major depression in the general population, there is still uncertainty regarding their potential benefits and risks during pregnancy. Areas covered: Outcomes requisite for a proper risk/benefit assessment of SSRI in pregnancy and lactation were considered: (a) potential risks associated with untreated depression, (b) effectiveness of different treatment options of depression, (c) potential risks associated with SSRI. Expert opinion: Despite the growing amount of literature on SSRI use during pregnancy, no new trials assessing the benefits of SSRIs on maternal depression were found. In the light of new data regarding the potential risks, depressed SSRI-treated pregnant women and their children seem at increased risk for several complications (mostly of small absolute risk). The interpretation of these findings remains quite similar to our previous review as the available methodology does not allow to disentangle the potential effect of SSRIs from those of the disease itself or/and of its unmeasured associated risk factors. Thus, in pregnant or lactating women who require a pharmacological treatment, SSRIs can still be considered as appropriate when effective as the abundant data support their relative safety.

Postpartum Bleeding in Pregnant Women Receiving SSRIs/SNRIs: New Insights From a Descriptive Observational Study and an Analysis of Data from the FAERS Database

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.

Perinatal anxiety: approach to diagnosis and management in the obstetric setting

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.

Can we recommend mirtazapine and bupropion for patients at risk for bleeding?: A systematic review and meta-analysis

BACKGROUND

Many studies have reported that selective serotonin reuptake inhibitors (SSRI) are associated with an increased risk of bleeding. Mirtazapine and bupropion, which commonly lack serotonin reuptake inhibition, have been recommended as alternatives for patients who are at risk for bleeding. However, the evidence for these recommendations is insufficient.

METHODS

We conducted a systematic search, systematic review, and meta-analysis to investigate an evidence-based approach for the bleeding risks of mirtazapine and bupropion. From 1946 to May 2017, a total of 3981 studies were searched from PubMed, Embase, and the Cochrane Library. Among the studies, two independent reviewers selected studies per predefined eligibility criteria.

RESULTS

A total of five meta-analyses were conducted. Patients taking mirtazapine were at a greater risk of gastrointestinal bleeding (OR = 1.17, 95% CI = 1.01-1.38) than those who did not take antidepressants. No differences were observed in the bleeding risk between mirtazapine and SSRI or between bupropion and SSRI.

LIMITATIONS

The number of studies included in the meta-analysis was small.

CONCLUSION

Our results suggest that it is premature to recommend mirtazapine and bupropion for patients who have a bleeding risk. More studies with larger sample sizes and longitudinal follow-ups are warranted.

Increased postpartum haemorrhage, the possible relation with serotonergic and other psychopharmacological drugs: a matched cohort study

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.

Selective Serotonin Reuptake Inhibitors and Operative Bleeding Risk: A Review of the Literature

OBJECTIVE

This study aimed to review the data on the effect of selective serotonin reuptake inhibitors (SSRIs) on bleeding during or after operative procedures and to offer guidelines for clinical management.

DATA SOURCES

Search of PubMed and MEDLINE for all articles in English from 1990-2016 with key words depression, antidepressants, bleeding, platelets, and operation.

STUDY SELECTION

Studies were included if they reported information on bleeding complications during operative or childbirth procedures in patients taking antidepressants.

DATA EXTRACTION

Because of the limited number and heterogeneity of studies with respect to the range of operative procedures and definition of bleeding complications, a qualitative approach was taken to summarize results rather than abstracting and aggregating data.

RESULTS

The weight of the evidence is that SSRI use increases the risk of bleeding complications during and immediately after surgery. However, given the limited data, we cannot estimate the risk for a given patient having a given procedure.

CONCLUSIONS

Clinicians must consider the risk-to-benefit ratio of discontinuing an SSRI before an elective operative procedure. Discontinuing SSRI medications may result in discontinuation syndrome, symptom recrudescence, or relapse of depression, whereas continuing an SSRI during surgery exposes patients to significant bleeding risks. Antidepressant prescribers must be cognizant of and take responsibility for discussing this potential problem and considering different options. This issue must also be the responsibility of the doctor performing the procedure, but, frequently, it will be the prescribing physician who alerts the surgeon to the potential bleeding risk associated with SSRIs.

Antidepressant use during pregnancy and risk of postpartum hemorrhage: A systematic review and meta-analysis

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.

Selective serotonin reuptake inhibitors for depression in pregnancy

Perinatal depression is associated with a high risk of morbidity and mortality and may have long-term consequences on child development. The US Preventive Services Task Force has recently recognized the importance of identifying and treating women with depression in the perinatal period. However, screening and accessing appropriate treatment come with logistical challenges. In many areas, there may not be sufficient access to psychiatric care, and, until these resources develop, the burden may inadvertently fall on obstetricians. As a result, understanding the risks of perinatal depression in comparison with the risks of treatment is important. Many studies of selective serotonin reuptake inhibitors in pregnancy fail to control for underlying depressive illness, which can lead to misinterpretation of selective serotonin reuptake inhibitor risk by clinicians. This review discusses the risks and benefits of selective serotonin reuptake inhibitor treatment in pregnancy within the context of perinatal depression. Whereas selective serotonin reuptake inhibitors may be associated with certain risks, the absolute risks are low and may be outweighed by the risks of untreated depression for many women and their offspring.

Serotonin Reuptake Inhibitors and Risk of Abnormal Bleeding

Serotonin reuptake inhibitors (SRIs) increase the risk of abnormal bleeding by lowering platelet serotonin and hence the efficiency of platelet-driven hemostasis; by increasing gastric acidity and possibly gastric ulceration; and by other mechanisms. The upper gastrointestinal tract is the commonest site of SRI-related abnormal bleeding; bleeding at this location may be increased by concurrent nonsteroidal anti-inflammatory drug therapy and by treatment with antiplatelet or anticoagulant drugs. Bleeding at this location may be reduced by concurrent administration of acid-suppressing drugs.

Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management

OBJECTIVE

Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage.

METHODS

We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding.

RESULTS

The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06).

CONCLUSION

There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates.

Bleeding risk under selective serotonin reuptake inhibitor (SSRI) antidepressants: A meta-analysis of observational studies

Selective serotonin reuptake inhibitors (SSRIs) have been reported to be potentially associated with an increased risk of bleeding. A meta-analysis of observational studies was conducted to quantify this risk. Case-control and cohort studies investigating bleeding risk under SSRI therapy were retrieved by searching the Medline, Pascal, Google Scholar and Scopus databases. Case-control studies were included if they reported bleeding incidents with and without the use of SSRIs and cohort studies were included if they reported the rate of bleeds among SSRI users and non-users. The main outcome was severe bleeding, whatever the site. Only data concerning SSRI belonging to the ATC class N06AB were used. For both case-control and cohort studies, we recorded the adjusted effect estimates and their 95% confidence intervals (CI). Pooled adjusted odds ratio (OR) estimates were computed for case-control and cohort studies using an inverse-variance model. Meta-analysis of the adjusted ORs of 42 observational studies showed a significant association between SSRI use and the risk of bleeding [OR 1.41 (95% CI 1.27-1.57), random effect model, p<0.0001]. The association was found for the 31 case-control studies (1,255,073 patients), with an increased risk of 41% of bleeding [OR 1.41 (95% CI 1.25-1.60)], as well as for the 11 cohort studies including 187,956 patients [OR 1.36 (95% CI 1.12-1.64)]. Subgroup analyses showed that the association remained constant whatever the characteristics of studies. This meta-analysis shows an increased risk of bleeding of at least 36% (from 12% to 64%) based on the high-level of observational studies with SSRIs use.

Depression and Anxiety During Pregnancy: Evaluating the Literature in Support of Clinical Risk-Benefit Decision-Making

Depression and anxiety during pregnancy are common, and patients and providers are faced with complex decisions regarding various treatment modalities. A structured discussion of the risks and benefits of options with the patient and her support team is recommended to facilitate the decision-making process. This clinically focused review, with emphasis on the last 3 years of published study data, evaluates the major risk categories of medication treatments, namely pregnancy loss, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity. Nonpharmacological treatment options, including neuromodulation and psychotherapy, are also briefly reviewed. Specific recommendations, drawn from the literature and the authors' clinical experience, are also offered to help guide the clinician in decision-making.

Is third trimester serotonin reuptake inhibitor use associated with postpartum hemorrhage?

As serotonin reuptake inhibitor (SRI) use may decrease platelet function, previous research has shown a relationship between SRI use and an increased risk for bruising and bleeding. The literature regarding the association between SRI use during pregnancy and increased bleeding at delivery, referred to as postpartum hemorrhage (PPH), is mixed. In secondary analyses from two prospective observational studies of pregnant women with mood disorders, 263 women were exposed to an SRI (n = 51) or not (n = 212) in the third trimester. To be precise, we used the terminology estimated blood loss (EBL) >600 cc rather than the term PPH because the current definition of PPH differs. The occurrence of EBL >600 cc was determined using the Peripartum Events Scale (PES) completed from obstetrical records by a blinded medically trained member of the study team. EBL >600 cc occurred in 8.7% of women in this cohort. There was no statistically significant difference in the rates of EBL >600 cc in the 24 h after delivery in women taking SRIs during the third trimester (9.8%) compared to non-exposed women (8.5%). Utilizing generalizing estimating equations, the odds of EBL >600 cc in each group were not significantly different (OR 1.17, CI-0.41-3.32, p = 0.77). When the SRI group was limited to women with exposure at the time of delivery, the difference in the odds of EBL >600 cc was unchanged (OR 1.16, CI = 0.37-3.64, p = 0.79). In population, both third trimester and use at delivery of SRIs during pregnancy was not associated with an increased risk of excessive blood loss.

Can drug effects explain the recent temporal increase in atonic postpartum haemorrhage?

BACKGROUND

Rates of postpartum haemorrhage and atonic postpartum haemorrhage have increased in several high-income countries. We carried out a study to examine if drug use in pregnancy, or drug and other interactions, explained this increase in postpartum haemorrhage.

METHODS

The linked administrative and hospital databases of the Québec Pregnancy Cohort were used to define a cohort of pregnant women in Québec, Canada, from 1998 to 2009 (n = 138,704). Case-control studies on any postpartum haemorrhage and atonic postpartum haemorrhage were carried out within this population, with up to five controls randomly selected for each case after matching on index date and hospital of delivery (incidence density sampling). Conditional logistic regression was used to estimate the effects of drug use on postpartum haemorrhage and atonic postpartum haemorrhage.

RESULTS

There was an unexpected non-linear, declining temporal pattern in postpartum haemorrhage and atonic postpartum haemorrhage between 1998 and 2009. Use of antidepressants (mainly selective serotonin reuptake inhibitors) was associated with higher rates of postpartum haemorrhage [adjusted rate ratio (aRR) 1.48, 95% confidence interval (CI) 1.23, 1.77] and atonic postpartum haemorrhage [aRR 1.40, 95% CI 1.13, 1.74]. Thrombocytopenia was also associated with higher rates of postpartum haemorrhage [aRR 1.52, 95% CI 1.16, 2.00]. There were no statistically significant drug interactions. Adjustment for maternal factors and drug use had little effect on temporal trends in postpartum haemorrhage and atonic postpartum haemorrhage.

CONCLUSIONS

Although antidepressant use and thrombocytopenia were associated with higher rates of atonic postpartum haemorrhage, antidepressant and other drug use did not explain temporal trends in postpartum haemorrhage.

Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding.

OBJECTIVE

Study the risk of bleeding-related complications in relation to SSRI in pregnancy.

PATIENTS/METHODS

This was a hospital-based cohort study. All women who gave birth at Karolinska University Hospital in Stockholm over a 5-year period (2007 to 2011) were included in the study. Those women who the electronic maternal health record indicated were using SSRI (n = 500) were considered exposed, and all other women formed a control population (n = 39,594). The main outcome measures were blood loss, postpartum hemorrhage (PPH), PP anemia and length of hospitalization.

RESULTS

The absolute risk of PPH and PP anemia for the 1.2% exposed to SSRI were 18.0% and 12.8%, respectively. Women with a vaginal non-surgical delivery who reported use of SSRI during pregnancy had approximately a 2-fold increased risk of both PPH (OR, 2.6; 95% CI, 2.0-3.5) and PP anemia (OR, 2.1; 95% CI, 1.5-2.9), as compared with controls. Blood loss and length of hospitalization were significantly higher among women using SSRI than non-users (arithmetic mean 484 mL vs. 398 mL, 3.8 days vs. 2.4 days, respectively).

CONCLUSION

The use of SSRI during pregnancy increases blood loss and doubles the risk of PPH and PP anemia in a setting where SSRI had not been considered a risk factor for increased blood loss. Because PPH is a leading cause of maternal mortality and morbidity, the awareness of bleeding-related complications is important, both in relation to pregnancy and to surgery in general.

Risk of vaginal bleeding and postpartum hemorrhage after use of antidepressants in pregnancy: a study from the Norwegian Mother and Child Cohort Study

This study aimed to examine obstetric bleeding outcomes after exposure during pregnancy to selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic (TCAs), and other antidepressants (OADs).The Norwegian Mother and Child Cohort Study and the Medical Birth Registry of Norway constituted the data source for the present study. We included 57,279 pregnant women, of which 1.02% reported use of antidepressants during pregnancy, mostly SSRIs/SNRIs (0.92%). We categorized exposure according to antidepressant use in pregnancy (SSRIs/SNRIs, n = 527; TCAs/OADs, n = 59; nonexposed, nondepressed, n = 55,411) with inclusion of a disease comparison group (nonexposed, depressed, n = 1282). We used logistic regression to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI) for vaginal bleeding outcomes in pregnancy and postpartum hemorrhage.Compared with nonexposed subjects, first trimester exposure to SSRIs/SNRIs or TCAs/OADs did not confer any increased risk of vaginal bleeding in early pregnancy (aOR, 0.91; 95% CI, 0.72-1.16 and aOR, 0.83; 95% CI, 0.36-1.92, respectively). No increased risk for vaginal bleeding in midpregnancy was observed among users of SSRIs/SNRIs (aOR, 0.81; 95% CI, 0.50-1.31) or TCAs/OADs (aOR, 0.96; 95% CI, 0.26-3.53) in second trimester. Exposure to SSRIs/SNRIs during gestational week 30 to childbirth did not confer any increased risk of postpartum hemorrhage after vaginal (aOR, 0.90; 95% CI, 0.47-1.74) or cesarean (aOR, 1.47; 95% CI, 0.51-4.22) delivery. Women in the disease comparison group presented a significant moderate increased risk of vaginal bleeding in early pregnancy (aOR, 1.22; 95% CI, 1.06-1.39) and midpregnancy (aOR, 1.28; 95% CI, 1.07-1.55) but not postpartum.Among this Norwegian cohort of pregnant women, use of antidepressants in pregnancy was not associated with any obstetrical bleeding outcome.

Serotonin reuptake inhibitors and bleeding risks in major orthopedic procedures

BACKGROUND

Risk of abnormal bleeding in surgery patients prescribed serotonin reuptake inhibitors (SRIs) is unclear. Considering the quantity of literature on abnormal gastrointestinal (GI) bleeding with SRIs, relatively little exists on SRI bleeding risks in surgical procedures. We investigated whether SRIs increase the risk of surgical bleeding in patients undergoing knee and hip total joint replacement.

METHODS

RA retrospective case-control study was conducted among subjects undergoing primary total hip and knee replacement surgeries from January 2005 to March 2011 at a single institution. The experimental group was defined by utilization of SRIs at the time of surgery (the independent variable). The control group was matched for age, sex, ethnicity, and type of surgery (hip or knee). Any case with preoperative hematocrit <30, platelets <100,000; abnormal prothrombin time, partial-prothrombin time, and international normalized ratio (INR), primary bleeding disorder, medical conditions, or medications associated with increased bleeding was excluded. All cases were randomly selected.

RESULTS

RA total of 194 subjects (hip 104, knee 90) were included. Statistical analysis was performed on the SRI group (n = 71) and the control, non-SRI group (n = 123). No difference was found between the groups in estimated blood loss, hemoglobin, hematocrit, platelets, PT, PTT, and INR from preoperative to postoperative day 1, 2, and 3. Furthermore, no subjects in either group required blood transfusions.

CONCLUSION

SRIs were not associated with increased risk of bleeding in primary knee or hip replacement surgeries in this study. The hypothesis that SRIs increase the risk of bleeding based on presumptions about their action on platelet aggregation is uncertain and warrants further study.

Use of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States

OBJECTIVE

To determine whether use of serotonin or non-serotonin reuptake inhibitors near to delivery is associated with postpartum hemorrhage.

DESIGN

Cohort study.

SETTING

2000-07 nationwide Medicaid data (Medicaid Analytic eXtract).

POPULATION

106,000 pregnant women aged 12-55 with a diagnosis of mood or anxiety disorder. Women were categorized into four mutually exclusive exposure groups according to pharmacy dispensing data: current (delivery date), recent (1-30 days before delivery date), past (1-5 months before delivery date), and no exposure (reference group).

MAIN OUTCOME MEASURES

Risk of postpartum hemorrhage by timing of exposure and by serotonin or non-serotonin reuptake inhibitors, classes of antidepressant, and antidepressant types. Relative risks and 95% confidence intervals adjusted for delivery year, risk factors for postpartum hemorrhage, indicators of severity of mood/anxiety disorder, other indications for antidepressants, and other drugs. High dimensional propensity score (hdPS) methods were used to empirically identify and adjust for additional factors.

RESULTS

12,710 (12%) women had current exposure to serotonin reuptake inhibitor monotherapy, and 1495 (1.4%) women had current exposure to non-serotonin reuptake inhibitor monotherapy. The risk of postpartum hemorrhage was 2.8% among women with mood/anxiety disorders but no exposure to antidepressants, 4.0% in the current users of serotonin reuptake inhibitors, 3.8% in the current users of non-serotonin reuptake inhibitors, 3.2% in the recent users of serotonin reuptake inhibitors, 3.1% in the recent users of non-serotonin reuptake inhibitors, 2.5% in the past users of serotonin reuptake inhibitors, and 3.4% in the past users of non-serotonin reuptake inhibitors. Compared with no exposure, women with current exposure to serotonin reuptake inhibitors had a 1.47-fold increased risk of postpartum hemorrhage (95% confidence interval 1.33 to 1.62) and women with current non-serotonin reuptake inhibitor exposure had a 1.39-fold increased risk (1.07 to 1.81). Results were similar with hdPS adjustment. Women with current exposure to serotonin reuptake inhibitors had an adjusted excess risk of 1.26% (0.90% to 1.62%), with a number needed to harm of 80, and for women with current exposure to non-serotonin reuptake inhibitors the excess risk was 1.03% (0.07% to 1.99%), with a number needed to harm of 97. For exposure to serotonin reuptake inhibitors the relative risk was 1.19 (1.03 to 1.38) for recent exposure and 0.93 (0.82 to 1.06) for past exposure; for non-serotonin reuptake inhibitors the figures were 1.17 (0.80 to 1.70) and 1.26 (1.00 to 1.59), respectively. Current exposure to selective serotonin reuptake inhibitor monotherapy was also associated with postpartum hemorrhage (1.42, 1.27 to 1.57), as was current serotonin norepinephrine (noradrenaline) reuptake inhibitor (1.90, 1.37 to 2.63) and tricyclic monotherapy (1.77, 0.90 to 3.47). All types of selective serotonin reuptake inhibitors available for analysis and venlafaxine, a serotonin norepinephrine reuptake inhibitor, were significantly associated with postpartum hemorrhage.

CONCLUSIONS

Exposure to serotonin and non-serotonin reuptake inhibitors, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclics, close to the time of delivery was associated with a 1.4 to 1.9-fold increased risk for postpartum hemorrhage. While potential confounding by unmeasured factors cannot be ruled out, these findings suggest that patients treated with antidepressants during late pregnancy are more likely to experience postpartum hemorrhage.

Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study

OBJECTIVE

Increases in atonic postpartum haemorrhage (PPH) have been reported from several countries in recent years. We attempted to determine the potential cause of the increase in atonic and severe atonic PPH.

DESIGN

Population-based retrospective cohort study.

SETTING

British Columbia, Canada, 2001-2009.

POPULATION

All women with live births or stillbirths.

METHODS

Detailed clinical information was obtained for 371 193 women from the British Columbia Perinatal Data Registry. Outcomes of interest were atonic PPH and severe atonic PPH (atonic PPH with blood transfusion ≥1 unit; atonic PPH with blood transfusion ≥3 units or procedures to control bleeding), whereas determinants studied included maternal characteristics (e.g. age, parity, and body mass index) and obstetrics practice factors (e.g. labour induction, augmentation, and caesarean delivery). Year-specific unadjusted and adjusted odds ratios for the outcomes were compared using logistic regression.

MAIN OUTCOME MEASURES

Atonic PPH and severe atonic PPH.

RESULTS

Atonic PPH increased from 4.8% in 2001 to 6.3% in 2009, atonic PPH with blood transfusion ≥1 unit increased from 16.6 in 2001 to 25.5 per 10 000 deliveries in 2009, and atonic PPH with blood transfusion ≥3 units or procedures to control bleeding increased from 11.9 to 17.6 per 10 000 deliveries. The crude 34% (95% CI 26-42%) increase in atonic PPH between 2001 and 2009 remained unchanged (42% increase, 95% CI 34-51%) after adjustment for determinants of PPH. Similarly, adjustment did not explain the increase in severe atonic PPH.

CONCLUSIONS

Changes in maternal characteristics and obstetric practice do not explain the recent increase in atonic and severe atonic PPH.

Effects of selective serotonin reuptake inhibitors on platelet function: mechanisms, clinical outcomes and implications for use in elderly patients

Among the antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are often preferred to other classes of antidepressants in the treatment of depression in the elderly because of their better safety profile. Most of the known effects of SSRIs, either beneficial or adverse, are linked to their inhibitory action on the serotonin reuptake transporter (5-HTT). This reuptake mechanism is present not only in neurons but also in other cells such as platelets. Serotoninergic mechanisms seem to play an important role in haemostasis, and their importance in this regard has long been underestimated. Abnormal activation may lead to a pro-thrombotic state, as may occur in patients with major depressive disorder, whilst downregulation, as occurs in patients treated with SSRIs, may have two clinical consequences, both of particular interest in the elderly. On the one hand, there may be an increased risk of bleeding; on the other hand, a reduction in thrombotic risk may be possible. Polymorphism in the promoter region of the gene that transcribes the 5-HTT has been shown to have a relevant impact on its function and, in turn, on the beneficial and adverse effects of SSRIs. Bleeding has been a concern since the introduction of SSRIs, with multiple case reports published and communicated to the pharmacovigilance systems. The first epidemiological study was published in 1999 and since then, 34 epidemiological studies from different areas, most of them including elderly patients in their study populations, have been published with a variety of results. Broadly, the epidemiological evidence supports a moderately increased risk of bleeding associated with the use of SSRIs, which may be critically dependent on patient susceptibility and the presence of risk factors. The impairment of primary haemostasis induced by SSRIs may result, as a beneficial counterpart, in a reduction in the thrombotic risk. A small number of clinical trials and an increasing number of epidemiological studies that include elderly patients have been conducted to clarify whether SSRIs reduce the risk of primary and secondary ischaemic disorders. However, the results have been inconclusive with some studies suggesting a preventive effect and others no effect or even an increased risk. Behind such contradictory results may be the role of depression itself as a cardiovascular risk factor and, therefore, a major confounding factor. How to disentangle its effect from that of the antidepressants is the methodological challenge to be overcome in future studies. In this complex scenario, the elderly seem to be at a crossroads, because they are the group in which both the risks and the benefits can be the greatest. Studies performed to date have provided us with some clues that can help orient clinicians in taking the most appropriate course of action. For instance, as the gastrointestinal bleeding risk appears to increase with age, prudent advice in patients with a previous history of upper-gastrointestinal bleeding or peptic ulcer, and in those who take NSAIDs, oral anticoagulants, antiplatelet drugs or corticosteroids, would be to suggest addition of an acid-suppressing agent to the drug regimen in those elderly patients in whom SSRIs are indicated.

Selective serotonin reuptake inhibitors and oral bleeding complications after invasive dental treatment

OBJECTIVE

The purpose of this study was to examine the frequency of oral bleeding complications after invasive dental procedures in patients taking selective serotonin reuptake inhibitor (SSRI) medications.

STUDY DESIGN

In this retrospective cohort study, we included dental patients who had invasive dental treatment and were taking an SSRI medication. Data collected included demographics, medical history, dental visits and procedures, and use of adjunctive measures to control bleeding. Primary outcomes included documentation of return visits or phone calls to the dental clinic or emergency department (ED) for oral bleeding, and oral bleeding or use of blood products for inpatients.

RESULTS

There were 92 patients taking SSRIs who had 145 invasive procedure visits, consisting of extractions, implant surgery, alveoloplasty, periodontal surgery, subgingival scaling and root planning, and biopsy. There were 110 extraction visits yielding a total of 167 extractions. Among all patients, there was 1 return visit to the clinic and 1 telephone call with a chief complaint of oral bleeding.

CONCLUSIONS

The frequency of oral bleeding complications after invasive dental treatment is low to negligible in patients on SSRI medications.

Selective serotonin reuptake inhibitors and gastrointestinal bleeding: a case-control study

Background

Selective serotonin reuptake inhibitors (SSRIs) have been associated with upper gastrointestinal (GI) bleeding. Given their worldwide use, even small risks account for a large number of cases. This study has been conducted with carefully collected information to further investigate the relationship between SSRIs and upper GI bleeding.

Methods

We conducted a case-control study in hospitals in Spain and in Italy. Cases were patients aged ≥18 years with a primary diagnosis of acute upper GI bleeding diagnosed by endoscopy; three controls were matched by sex, age, date of admission (within 3 months) and hospital among patients who were admitted for elective surgery for non-painful disorders. Exposures to SSRIs, other antidepressants and other drugs were defined as any use of these drugs in the 7 days before the day on which upper gastrointestinal bleeding started (index day).

Results

581 cases of upper GI bleeding and 1358 controls were considered eligible for the study; no differences in age or sex distribution were observed between cases and controls after matching. Overall, 4.0% of the cases and 3.3% of controls used an SSRI antidepressant in the week before the index day. No significant risk of upper GI bleeding was encountered for SSRI antidepressants (adjusted odds ratio, 1.06, 95% CI, 0.57–1.96) or for whichever other grouping of antidepressants.

Conclusions

The results of this case-control study showed no significant increase in upper GI bleeding with SSRIs and provide good evidence that the magnitude of any increase in risk is not greater than 2.

Use of hospitalisation history (lookback) to determine prevalence of chronic diseases: impact on modelling of risk factors for haemorrhage in pregnancy

Background

Concern about the completeness of comorbidity information in hospital records has been raised as a limitation of using hospital discharge data for research. The aim of this study is to assess the impact of additional comorbidity information from prior hospital admissions on estimation of prevalence and modelling of risk factors for obstetric haemorrhage.

Methods

A range of chronic disease prevalence for 53,438 women who had their first birth in New South Wales (NSW), Australia, 2005-2006, were ascertained for up to five years prior to the birth admission (for pregnancy, 2-, 3-, 4- and 5-year periods) and obstetric haemorrhage was identified from maternal hospital records for 2005 and 2006.

Results

The ascertainment of chronic disease prevalence increased with increasing length of lookback. However, the rate of the increase was slower after 2 to 3 years than for the more recent periods. The effect size of chronic diseases on obstetric haemorrhage risk decreased with the increased case ascertainment associated with longer lookback. Furthermore, longer lookback did not improve the predictive capacity (C-statistic: 0.624) of a model that was based only on the birth admission records.

Conclusions

Longer ascertainment periods resulted in improved identification of chronic disease history among pregnant women, but the additional information from prior admissions did little to improve the modelling of risk factors for obstetric haemorrhage.

Safety of selective serotonin reuptake inhibitor use prior to coronary artery bypass grafting

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) have been shown to increase bleeding risks. This study examined the association of perioperative coronary artery bypass grafting (CABG) bleeding risks and SSRI use prior to CABG.

HYPOTHESIS

SSRI may be associated with increased bleeding risks after CABG resulting in elevated reoperation rates due to bleeding complications.

METHODS

Patients who underwent CABG between 1999 and 2003 (n = 4794) were identified in a tertiary medical center. SSRI use (n = 246) was determined using inpatient pharmacy records. Outcomes included primary end point of reoperation due to bleeding complications and other secondary measures. Multivariate regression models were constructed to adjust for baseline differences between SSRI and control groups.

RESULTS

Reoperation due to bleeding complications among SSRI users was not significantly different (odds ratio [OR]: 1.14 (0.52-2.47); P = 0.75) compared to the control group. Other secondary outcomes and 30-day mortality (2.0% in SSRI vs 2.1% in control group; P = 0.92) between the 2 groups were similar. However, the adjusted total volume of postoperative red blood cell (RBC) units transfused was higher in the SSRI group.

CONCLUSION

We conclude that there is no compelling evidence to limit the use of SSRIs among patients with coronary artery disease who undergo CABG given the current evidence. Further research may be needed on individual SSRI medications.

[SSRI - treatment and bleeding. What risks do we take?]

Treatment with selective serotonin reuptake inhibitors (SSRI) increases the risk of gastrointestinal bleeding. The combination with non-steroidal anti-inflammatory drugs (NSAIDs) further augments this hazard. Particular precaution is also necessary in patients on platelet aggregation inhibitors, with a known bleeding disorder or preceding gastrointestinal lesions. The incidence of bleeding events apart from the gastrointestinal tract, e.g. intracerebral hemorrhages, is not cumulated under SSRI treatment. This also applies for the combination of SSRI and coumarin or aspirin. Prescribing doctors have to be aware of the bleeding risks of SSRI and should explain this to their patients. High-risk patients have to be followed up closely and an SSRI with a low potential for drug interaction should be used. The prescription of gastroprotective agents and a change of the antidepressant should be considered in particular cases. We provide a literature survey and recommendations for the clinical routine.

Sex differences in the pharmacokinetics and pharmacodynamics of antidepressants: an updated review

BACKGROUND

An increasing number of studies have reported differences in the pharmacokinetics and/or pharmacodynamics of antidepressants between women and men.

OBJECTIVES

This article updates previously published literature describing sex differences in the pharmacokinetics and pharmacodynamics of antidepressants, and examines specific issues that face women with psychiatric illness.

METHODS

An English-language literature search was performed with the PubMed database (March 2003-December 2008) using combinations of the search terms sex, gender, and antidepressants. In addition, each antidepressant was identified in the 63rd edition of the Physicians' Desk Reference.

RESULTS

The current data suggest that the pharmacokinetics of antidepressants can be substantially different between women and men. Likewise, the response to antidepressants can be quite variable, including sex differences in adverse effects and time to response.

CONCLUSIONS

Despite the many sex differences reported, there is still little published work systematically evaluating potential sex differences in antidepressant pharmacokinetics and pharmacodynamics. More research is needed to guide the treatment of depression and other mental illnesses.

On categorizing gestational, birth, and neonatal complications following late pregnancy exposure to antidepressants: the prenatal antidepressant exposure syndrome

INTRODUCTION

Late in utero exposure to antidepressants has been suspected of adversely impacting pregnancy outcome and compromising neonatal adaptation. Hence, the necessity exists to analyze published information on antidepressant use during late pregnancy to individuate potential recurrent patterns of iatrogenic complications.

METHODS

Computerized searches on MEDLINE, PsycINFO, ENBASE, and Cochrane Library through February 10, 2010 were performed for selecting literature information and investigating the safety of antidepressants when used during late pregnancy.

RESULTS

Antidepressant treatment during late pregnancy may increase the rates of poor pregnancy outcome and neonatal withdrawal/toxic reactions.

CONCLUSIONS

Because both gestational complications and neonatal adverse events acknowledge the same etiology, the author suggests including such iatrogenic events under the definition of prenatal antidepressant exposure syndrome, in order to increase clinicians' awareness about the spectrum of risks which may concern the mother-infant pair when antidepressant treatment is deemed indispensable during late pregnancy.

Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study

OBJECTIVE

To characterise whether some selective serotonin reuptake inhibitor (SSRI) antidepressants reduce tamoxifen's effectiveness by inhibiting its bioactivation by cytochrome P450 2D6 (CYP2D6).

DESIGN

Population based cohort study.

PARTICIPANTS

Women living in Ontario aged 66 years or older treated with tamoxifen for breast cancer between 1993 and 2005 who had overlapping treatment with a single SSRI.

MAIN OUTCOME MEASURES

Risk of death from breast cancer after completion of tamoxifen treatment, as a function of the proportion of time on tamoxifen during which each SSRI had been co-prescribed.

RESULTS

Of 2430 women treated with tamoxifen and a single SSRI, 374 (15.4%) died of breast cancer during follow-up (mean follow-up 2.38 years, SD 2.59). After adjustment for age, duration of tamoxifen treatment, and other potential confounders, absolute increases of 25%, 50%, and 75% in the proportion of time on tamoxifen with overlapping use of paroxetine (an irreversible inhibitor of CYP2D6) were associated with 24%, 54%, and 91% increases in the risk of death from breast cancer, respectively (P<0.05 for each comparison). By contrast, no such risk was seen with other antidepressants. We estimate that use of paroxetine for 41% of tamoxifen treatment (the median overlap in our sample) would result in one additional breast cancer death within five years of cessation of tamoxifen for every 19.7 (95% confidence interval 12.5 to 46.3) patients so treated; the risk with more extensive overlap would be greater.

CONCLUSION

Paroxetine use during tamoxifen treatment is associated with an increased risk of death from breast cancer, supporting the hypothesis that paroxetine can reduce or abolish the benefit of tamoxifen in women with breast cancer.

The expanded biology of serotonin

Serotonin is perhaps best known as a neurotransmitter that modulates neural activity and a wide range of neuropsychological processes, and drugs that target serotonin receptors are used widely in psychiatry and neurology. However, most serotonin is found outside the central nervous system, and virtually all of the 15 serotonin receptors are expressed outside as well as within the brain. Serotonin regulates numerous biological processes including cardiovascular function, bowel motility, ejaculatory latency, and bladder control. Additionally, new work suggests that serotonin may regulate some processes, including platelet aggregation, by receptor-independent, transglutaminase-dependent covalent linkage to cellular proteins. We review this new "expanded serotonin biology" and discuss how drugs targeting specific serotonin receptors are beginning to help treat a wide range of diseases.