Maternal Metabolites Associated with Gestational Diabetes Mellitus and a Postpartum Disorder of Glucose Metabolism

Objective To identify circulating metabolites present at ~28 weeks’ gestation associated with gestational diabetes mellitus (GDM) and development of a disorder of glucose metabolism 10-14 years later. Methods Conventional clinical and targeted metabolomics analyses were performed on fasting and 1-hr serum samples following a 75g glucose load at ∼28 weeks’ gestation from 2,290 women who participated in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Postpartum metabolic traits included fasting and 2-hr plasma glucose following a 75g glucose load, insulin resistance estimated by homeostasis model assessment, and disorders of glucose metabolism (prediabetes and type 2 diabetes) during the HAPO Follow-Up Study. Results Per-metabolite analyses identified numerous metabolites, ranging from amino acids and carbohydrates to fatty acids and lipids, before and 1-hr after a glucose load that were associated with GDM as well as development of a disorder of glucose metabolism and metabolic traits 10-14 years postpartum. A core group of fasting and 1-hr metabolites mediated, in part, the relationship between GDM and postpartum disorders of glucose metabolism, with the fasting and 1-hr metabolites accounting for 15.7% (7.1%-30.8%) and 35.4% (14.3%-101.0%) of the total effect size, respectively. For prediction of a postpartum disorder of glucose metabolism, addition of circulating fasting or 1-hr metabolites at ~28 weeks’ gestation showed little improvement in prediction performance compared to clinical factors alone. Conclusions The results demonstrate association of multiple metabolites with GDM and postpartum metabolic traits and begin to define the underlying pathophysiology of the transition from GDM to a postpartum disorder of glucose metabolism.

Prevention of Postpartum Disorders

This chapter on prevention of postpartum disorders reviews the factors that can decrease the risks of developing a postpartum psychiatric disorder. The primary risk for postpartum or perinatal depression is a personal history of depression during or after a previous pregnancy. Maintenance during pregnancy of treatment for a pre-existing mental health disorder is essential. Building support networks is also important. Ensuring good health practices during the postpartum such as getting adequate exercise, eating well, and exposure to light can all be helpful. Sleep is an important component in reducing risks. Working with a partner who can help with some overnight bottle feeding can also be very beneficial.

Risk Factors for Postpartum Disorders

This chapter on risk factors for postpartum disorders describes how the postpartum period is a time in women’s lives when they are at an especially high risk for developing mental health problems. The massive hormonal changes experienced after birth can interact with other risk factors to result in a postpartum disorder. Poor sleep due to infant care can exacerbate these vulnerabilities. There are many factors that may increase the risk of developing a postpartum disorder. Depression or anxiety during pregnancy, a personal or family history of a psychiatric disorder, current stressors, and lack of social supports may all increase the risk of developing a postpartum depression or anxiety disorder. Women with a history of bipolar disorder are particularly at risk for developing a depression or manic episode postpartum. Recognition of factors that may predispose women to the development of a postpartum disorder can allow preventative factors to be put in place.

Postpartum Mental Health Disorders: A Casebook

Postpartum Mental Health Disorders: A Casebook describes the recognition and management of psychiatric disorders that present in the postpartum period. Case vignettes illustrate the type of complaints that may present to the psychiatrist, primary care physician, obstetrician, nurse practitioner, doula, or other health care professionals. Chapters cover depression, anxiety disorders, obsessive compulsive disorder, psychotic disorders, bipolar disorders, posttraumatic stress disorders, personality disorders, and drug abuse. Each chapter includes information about differential and provisional diagnoses, epidemiology, treatment, and prognosis with advice as to when to refer to a specialist. More general chapters address risk factors for developing postpartum disorders, prevention, and the uses and safety of psychotropic medication during breastfeeding. Two frequently used screening questionnaires are included with instructions as to use. Some key references or links are included.

Psychopharmacology in Pregnancy and Breastfeeding

This chapter on psychopharmacology in pregnancy and postpartum discusses the decisions women must make about taking psychiatric medications when pregnant or breastfeeding. Although mild illness during pregnancy or postpartum may respond to psychotherapy and support, medication is often necessary for more serious psychiatric illness. Untreated illness can have deleterious effects on the baby and the mother. This chapter reviews the evidence that indicates it is generally safe to use the majority of psychotropic medications during pregnancy and while breastfeeding. Although it may be ideal to breastfeed, this may become complicated for women who have a psychiatric illness. Women with postpartum disorders should first be evaluated to assess whether the demands of breastfeeding are too onerous for them. Those women who can’t or don’t wish to breastfeed should not be made to feel guilty. Mothers who are suffering but wish to breastfeed can be reassured that many psychotropic medications are safe to use during breastfeeding. They may also benefit from supplementing with formula feeding with a bottle to allow the mother to get more sleep. Mothers who require medication but are afraid to use it while breastfeeding should be educated to understand that the negative effects on the baby of being depressed or psychotic outweigh any concerns about the dangers of taking medication.

Psychiatric disorders in pregnancy and the postpartum

Obstetricians will frequently look after women with the new onset or recurrence of a psychiatric illness. Perinatal psychiatric disorders, in fact, are common, affecting over 15% of women in pregnancy or in the months after delivery, and have an impact not only on the health of the mother, but also on the well-being of their offspring. Untreated, severe postpartum disorders are associated with an increased risk of both suicide and, in rare but tragic cases, infanticide. Despite their importance, maternal psychiatric disorders are underdiagnosed and undertreated. This chapter provides a concise introduction to perinatal psychiatric disorders and emphasizes the role of prevention, early detection, and collaborative care.

Genetic risk scores for major psychiatric disorders and the risk of postpartum psychiatric disorders

Postpartum psychiatric disorders are heritable, but how genetic liability varies by other significant risk factors is unknown. We aimed to (1) estimate associations of genetic risk scores (GRS) for major depression (MD), bipolar disorder (BD), and schizophrenia (SCZ) with postpartum psychiatric disorders, (2) examine differences by prior psychiatric history, and (3) compare genetic and familial risk of postpartum psychiatric disorders. We conducted a nested case-control study based on Danish population-based registers of all women in the iPSYCH2012 cohort who had given birth before December 31, 2015 (n = 8850). Cases were women with a diagnosed psychiatric disorder or a filled psychotropic prescription within one year after delivery (n = 5829 cases, 3021 controls). Association analyses were conducted between GRS calculated from Psychiatric Genomics Consortium discovery meta-analyses for MD, BD, and SCZ and case-control status of a postpartum psychiatric disorder. Parental psychiatric history was associated with postpartum psychiatric disorders among women with previous psychiatric history (OR, 1.14; 95% CI 1.02–1.28) but not without psychiatric history (OR, 1.08; 95% CI: 0.81–1.43). GRS for MD was associated with an increased risk of postpartum psychiatric disorders in both women with (OR, 1.44; 95% CI: 1.19–1.74) and without (OR, 1.88; 95% CI: 1.26–2.81) personal psychiatric history. SCZ GRS was only minimally associated with postpartum disorders and BD GRS was not. Results suggest GRS of lifetime psychiatric illness can be applied to the postpartum period, which may provide clues about distinct environmental or genetic elements of postpartum psychiatric disorders and ultimately help identify vulnerable groups.

Effect of age at first calving and heat stress at parturition on reproductive efficiency and postpartum disorders in Holstein heifers

The objective of this study was to evaluate the impact of age at first calving (AFC) and climatic conditions at calving on peripartum disorders and reproductive performance in Holstein heifers in a hot environment. A total of 3000 reproductive records from a large highly technified dairy farm were used; the variables evaluated were temperature humidity index (THI; <77, 77-83, >83) at calving and AFC (<2.0, 2.0-2.2 and >2.2 years). Across age groups, the cases of dystocic parturition increased (p<0.05) when the deliveries occurred with severe heat stress (4.3% vs. 3.3% for THI >83 and <83 units, respectively). Across THI, conception rate at the first postpartum artificial insemination (AI) was lower (p=0.02) for heifers calving for the first time >2.2 years compared to heifers calving between 2.0 and 2.2 and <2.0 years (9.8, 15.3 and 13.7%, respectively). Conception rate at first AI postcalving was higher (p<0.01) in heifers calving with THI less than 83 units than in heifers calving with a THI >83 units (16.8 vs. 5.4%). The conception rate considering all services was affected (p<0.05) by AFC (42.7, 50.4 and 40.9% for AFC <2.0, 2.0-2.2 and >2.2 years, respectively). The interaction AFC × THI at calving was significant (p<0.05). The occurrence of metritis was higher (p<0.05) in heifers <2.0 years of age at calving than those calving after 2 years of age. The presence of ovarian cysts was less common (p<0.05) in heifers with greater AFC. In conclusion, increasing the AFC in Holstein heifers had no benefits in reproduction and health, compared with heifers calving at <2.0 years. These data in a hot climate suggest that heifers should be selected to begin their first lactation before 2 years of age.