106 - Postpartum haemorrhage

Postpartum haemorrhage

436 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 were three times more at risk of PPH compared with mothers who did not take any medications, suggesting that the occurrence of PPH might not be entirely due to serotonergic activity. In 2021, the UK Medicines and Healthcare products Regulatory Agency issued a warning regarding the use of SSRIs and postpartum blood loss.47 However, a 2024 meta-­ analysis of 20 studies concluded that SSRI use was a ‘minor risk factor for postpartum haemorrhage’.48 Surgical and postoperative bleeding Use of SSRIs in the preoperative period has been associated with a 20% increase in inpatient mortality (absolute risk 1 in 1,000), although patient factors rather than drug factors could not be excluded as the cause.49 One study50 found that patients prescribed SSRIs who underwent orthopaedic surgery had an almost four-­fold risk of requiring a blood transfusion. This equated to 1 additional patient requiring transfusion for every 10 patients taking an SSRI and undergoing surgery and was double the risk of patients who were taking NSAIDs alone. It should be noted in this context that treatment with SSRIs has been associated with a 2.4-­fold increase in the risk of hip fracture51 and a two-­ fold increase of fracture in old age51 (mirtazapine52 and TCAs50 also increase risk of hip fracture). One study recognised preoperative treatment with SSRIs, other antidepressants or antipsychotics as independent risk factors for blood transfusion in elective fast-­ track hip and knee arthroplasty.54 Table 3.22 shows the risk of perioperative blood loss and blood transfusion in patients taking SSRIs compared with those not taking SSRIs. The combination of advanced age, SSRI treatment, orthopaedic surgery and NSAIDs clearly presents a very high risk. However, there does not seem to be an increased risk of bleeding in patients who undergo coronary artery bypass surgery.55 During a 10-­year review of women who underwent cosmetic breast surgery procedures, the use of SSRIs increased the risk of postoperative bleeding by a factor of 4.14 compared with those who did not take SSRIs. The authors emphasised the importance of balancing the risks and benefits of stopping antidepressants prior to elective surgeries, particularly in psychologically vulnerable patients.56 Table 3.22  Risk of perioperative blood loss and blood transfusion in SSRI users compared with non-­SSRI users.57 Surgical procedure Need for reoperation due to bleeding event in users of SADs vs non-­users, OR (95% CI) Need for blood product or red blood cell transfusion in users of SADs vs non-­users, OR (95% CI) Increased risk of mortality in users of SADs vs non-­users, OR (95% CI) CABG 1.07 (0.66–1.74) 1.06 (0.90–1.24) 1.53 (1.15–2.04) Breast cancer-­directed surgery 2.7 (1.6–4.56) – – Orthopaedic surgery – 1.61 (0.97–2.68)* 0.83 (0.69–1.00) Major surgery – 1.19 (1.15–1.23) 1.19 (1.03–1.37) CABG, coronary artery bypass graft; CI, confidence interval; OR, odds ratio; SADs, serotonergic antidepressants. * In one study,58 absolute risk of blood transfusion was 5.7% for people on SSRIs and 5.1% for those not on SSRIs.