SSRIs and SNRIs and postpartum bleed

SSRIs and SNRIs are known to increase bleeding risks due to their effect on platelet function.

An EU review was undertaken (1) and it was noted that (2):

• Despite heterogeneous data and differences in definitions of postpartum haemorrhage, the review concluded that the data suggested a slightly increased risk of postpartum bleeding with use of SSRIs and SNRIs during the month before delivery. The review concluded that this risk might also apply to the newest antidepressant vortioxetine

Rates of postpartum haemorrhage vary by geographical region with one study suggesting rates in Europe of 12.7% with a blood loss greater than 500 millilitres and 2.8% with a blood loss greater than 1000 millilitres (2)

• estimated that the use of antidepressant medicines in the month before delivery increases the risk by less than two-fold

Advice for healthcare professionals:

• SSRIs and SNRIs are known to increase the bleeding risk; observational data suggest that the use of some antidepressants in the last month before delivery may increase the risk of postpartum haemorrhage

• continue to consider the benefits and risks for use of antidepressants during pregnancy, and the risks of untreated depression in pregnancy

• healthcare professionals, including midwives, should continue to enquire about the use of antidepressant medicines, particularly in women in the later stages of pregnancy

• consider the findings of the review in the context of individual patient risk factors for bleeding or thrombotic events

• do not stop anticoagulant medication in women at high risk of thrombotic events in reaction to these data but be aware of the risk identified

• report any suspected adverse reactions associated with medicines taken during pregnancy via the Yellow Card scheme

Medicines affected

Taking the evidence into account, the review (1) considered there to be sufficient evidence to update the product information for:

• SSRIs: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
• SNRIs: desvenlafaxine, milnacipran, venlafaxine
• Vortioxetine

Reference:

• European Medicines Agency. ‘PRAC recommendations on signals. Adopted at the 28 September-1 October 2020 PRAC meeting’. Accessed December 2020.
• MRHA. SSRI/SNRI antidepressant medicines: small increased risk of postpartum haemorrhage when used in the month before delivery Drug Safety Update volume 14, issue 6: January 2021: 5