Gestational diabetes in women with mental illness

To the Editor

Information on the safety of antipsychotic medication in pregnancy and breastfeeding is both limited and inconclusive and hence its use during pregnancy has brought about much debate. True prevention of mental illness begins with optimising maternal well-being during pregnancy and ensuring the best possible outcome for the baby.

The following case study presents Sally, a participant in the National Register of Antipsychotic Medication in Pregnancy (NRAMP) (Kulkarni et al., 2008). Sally is a 29-year-old woman with schizophrenia and morbid obesity (body mass index of 50). She has a family history of diabetes. Her medications during pregnancy included risperidone (Consta) 37.5 mg intramuscularly fortnightly. Quetiapine (Seroquel XR) 50 mg/day was added at 34 weeks’ gestation. Throughout pregnancy she gained 25 kg, well above the recommended weight gain in pregnancy (Cogswell et al., 1999) (Table 1). Gestational diabetes mellitus (GDM) was diagnosed during routine screening at 28 weeks’ gestation. Dietary management was trialled initially. However, at 32 weeks’ gestation her glycaemic control was suboptimal, requiring the institution of basal-bolus insulin therapy: aspart (NovoRapid) with meals and isophane (Protophane) before bed. Insulin therapy was ceased at the onset of labour. Her postpartum oral glucose tolerance test confirmed that her diabetes had resolved.

Table 1.

Maternal perinatal weight/BMI.

Weight pre-pregnancy	130 kg	BMI pre-pregnancy	50
Weight full term	155 kg	BMI full term	61
Weight 6 months postnatal	143 kg	BMI postnatal	56
Overall weight gain during pregnancy	25 kg	Height	159 cm

Sally’s son was born at 36 weeks’ gestation by elective caesarean section (due to maternal obesity, GDM and anxiety). At 4100 g he was large for gestational age (birth weight 99th percentile). He was admitted to the neonatal intensive care unit and then the special care nursery for a total of 8.5 weeks due to neonatal respiratory distress. The baby had neonatal abstinence syndrome and neonatal hypoglycaemia. He was breastfed at birth; however, his poor suckling reflex meant he required nasogastric feeding for 2 weeks. He was noted to be progressing well at 12 months of age.

Sally and her son highlight some of the difficulties encountered by women who require antipsychotics in pregnancy. GDM is associated with obesity and excess weight gain in pregnancy. Poorly controlled GDM is also associated with neonatal hypoglycaemia and high birth weight. GDM is noted in 22.1% of NRAMP mothers compared with the Australian population rate of 5.5% (Worsley et al., 2012). It is clear, therefore, that research in this area should be made a priority to achieve better health outcomes for mothers and babies.