Medscape Medical News
Neil Osterweil
September 09, 2014
Women who take selective serotonin reuptake inhibitors (SSRIs) for depression during early pregnancy and those who stop taking the drugs up to a year before becoming pregnant have similar risks for miscarriage, investigators in a large, population-based study have found.
The results suggest there is no causal relationship between SSRIs and miscarriage and that factors associated with mood disorders, such as smoking, alcohol use, and poor compliance with prenatal care, may explain the increased risk among women who take antidepressants, write Jon Trærup Andersen, MD, PhD, and colleagues from the University of Copenhagen, Denmark.
“We conclude that the increased hazard found both for women exposed to SSRIs in early pregnancy and for women discontinuing SSRIs is most likely confounded by factors associated with the redemption of an SSRI prescription. Because the risk of miscarriage is elevated in both groups compared with an unexposed population, there is likely no benefit in discontinuing SSRI use before pregnancy to decrease one’s chances of miscarriage,” they write in an article published online September 5 in Obstetrics & Gynecology.
Although women who continued or interrupted SSRI use during pregnancy had an approximately 25% greater relative risk for miscarriage compared with women who did not take the drugs, the obstetrics risks have to be weighed against the risk to the mother of interrupting therapy for a mood disorder, according to Samantha Meltzer-Brody, MD, MPH, from the Perinatal Psychiatry Program at the University of North Carolina’s Center for Women’s Mood Disorders in Chapel Hill.
“Antenatal depression is associated with significantly worse obstetric outcomes, including prematurity, low birth weight, and preeclampsia,” she writes in an accompanying editorial. “Antenatal depression is also the greatest risk factor for postpartum depression, which has been associated consistently with adverse consequences for mothers, babies, and families.”
Women with untreated postpartum depression are at significant risk for suicide, she notes, adding that stopping antidepressants during pregnancy is associated with both exacerbation of symptoms and the risk for recurrence of the mood disorder.
1 Million Plus Pregnancies
Dr. Andersen and colleagues analyzed data from Denmark’s medical registries, which allow anonymous linkage of hospital and prescription records for each patient. They identified a total of 1,279,840 pregnancies from 1997 through 2010. Of these, 911,569 resulted in births, 142,093 resulted in miscarriages, and 226,178 were ended with induced abortions.
The authors found that of the 22,884 (1.8%) pregnancies in which the mother was exposed to an SSRI during the first 35 days of pregnancy, 12.6% (2883) ended in miscarriage compared with 11.1% among women who had never been exposed to an SSRI (adjusted hazard ratio [AOR], 1.27; 95% confidence interval [CI], 1.22 – 1.33). The researchers adjusted for year of outcome or censoring, maternal age, education, income, and number of previous miscarriages.
Women who discontinued SSRIs from 3 to 12 months before pregnancy had a similar increase in risk for miscarriage (AOR, 1.24; 95% CI, 1.18 – 1.30) compared with women not exposed to SSRIs.
There were no differences in risk between women who took low or high doses of SSRIs and no increase in risk for women who took more than 1 SSRI compared with those who took just 1.
“The increased risk of miscarriage in our study may be explained by the underlying illness or lifestyle factors such as alcohol use, smoking, or poor compliance to folic acid supplementation during pregnancy,” the authors write.
Dr. Meltzer-Brody comments that the study “has important clinical implications regarding preconception counseling and guidance of women with histories of mood and anxiety disorders undergoing treatment with SSRIs. Obstetric providers must be aware of the risks of discontinuing treatment and need to actively combat the double standard associated with treatment of psychiatric illness compared with other forms of disease.”
The study was funded by The Capital Region of Denmark, Copenhagen. The authors and Dr. Meltzer-Brody have disclosed no relevant financial relationships.
Obstet Gynecol. Published online September 5, 2014. Full text