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VA Research Currents archive
April 26, 2017
By Tristan Horrom
VA Research Communications
Gestational diabetes and Preeclampsia
Posttraumatic stress disorder (PTSD) may be a risk factor for two common pregnancy complications, according to a recent VA study. Women Veterans with PTSD receiving care in the VA health care system had higher rates of gestational diabetes and preeclampsia than those without PTSD.
Health care systems should manage pregnancies in women with PTSD as high risk because of the rise in prevalence of these two conditions, say the researchers. According to Dr. Jonathan G. Shaw, lead author on the study, "this means not only increased vigilance for these conditions when treating pregnant Veterans with PTSD, but also begins with preconception counseling, which can include review of potential increased risk for these common antepartum [pre-birth] complications as an opportunity to encourage and ensure women are tied into appropriate mental health care and early prenatal care."
The results were published in a March 2017 issue of Paediatric and Perinatal Epidemiology.
"We hope that future research in the VA might include evaluating stress biomarkers in this unique population."
Increasing evidence suggests that stress and poor mental health have negative effects on pregnancy. Prior research shows that women with PTSD have an increased risk of preterm birth, and PTSD affects an estimated one in 20 reproductive-aged women. This number is even higher for Veterans: Between 13 and 21 percent of pregnant Veterans in the VA system have PTSD. "Greater focus is needed on addressing mental health in pregnancy. This is particularly salient for women VA patients, for whom the prevalence of PTSD is high," says Shaw. To address these concerns, the researchers sought to examine the link between PTSD and several common pregnancy problems.
To that end, they analyzed VHA data of deliveries from 2000 to 2012, which encompassed 15,986 individual births. VA covers outsourced maternity care, with the births occurring at non-VA facilities. Of these births, 2,977 mothers had a PTSD diagnosis, and 1,880 had a diagnosis of current PTSD.
Gestational diabetes was present in 4.9 percent of all mothers examined, while 4.6 percent had preeclampsia. The rate of both conditions was 30 to 40 percent higher in women with current PTSD than in other women. The researchers also checked for gestational hypertension, placental abruption, and intrauterine growth restriction, but did not find a correlation between these conditions and PTSD.
Gestational diabetes is the development of diabetes in the mother during pregnancy. Hormones created by the placenta block the action of insulin in the mother's blood, which can lead to high blood sugar. It usually develops in the second half of pregnancy. Gestational diabetes affects four to nine percent of all U.S. births. While most women with gestational diabetes give birth to healthy babies, it can have consequences for both the child and the mother. Extra glucose in the system can lead to excessive birth weight in the child. This makes it more likely that a C-section will be required. After birth, the baby may develop hypoglycemia (low blood sugar) as a reaction to the change in glucose levels. When the mother develops gestational diabetes, the baby is also at higher risk for type 2 diabetes later in life.
Women who have had gestational diabetes are also at higher risk of developing type 2 diabetes after pregnancy. Gestational diabetes also increases the risk of preeclampsia and several other pregnancy complications.
Preeclampsia is the leading cause of maternal mortality, and also the number-one cause of medically induced preterm delivery. The condition is characterized by increased blood pressure and proteinuria, or protein in the urine, which is a sign of kidney problems. Preeclampsia can cause damage to the mother's kidney, liver, and brain. It can also affect the placenta, causing problems for the baby. If left untreated, preeclampsia may result in seizures (eclampsia) in the mother. It generally develops after the 20th week of pregnancy.
According to Shaw, appropriate prenatal and perinatal care can lower the likelihood of developing gestational diabetes and preeclampsia, as well as the progression and complications of the conditions.
The link between PTSD and gestational diabetes and preeclampsia could be chemical, say the researchers. Evidence is growing that PTSD disrupts both neuroendocrine and cardiovascular health. PTSD is widely believed to cause dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is responsible for many of the hormones the body produces, and is central to the stress response. Stress hormones are known to impair glucose tolerance, which could lead to gestational diabetes. Increased stress has also been linked to preeclampsia in other studies, but results are mixed.
However, proving a direct chemical link is difficult. PTSD is a known risk factor for reduced physical fitness and maladaptive behaviors such as substance abuse. These behavioral changes could lead to cardiovascular problems, and thus pregnancy complications. More research is needed to determine whether PTSD is a direct biological cause of gestational diabetes and preeclampsia or if indirect PTSD symptoms lead to the complications, say the study authors. As Shaw explains, "We hope that future research in the VA might include evaluating stress biomarkers in this unique population and examining if mental health interventions focused on tempering stress response can modify these biomarkers and, most importantly, the risk of developing these complications."
The study was funded by the VA Office of Academic Affairs, Health Services Research and Development Service, and Women's Health Evaluation Initiative.
Women Veterans' health, including their reproductive health, is a priority area for VA's nationwide research program. To learn more, visit www.research.va.gov/topics/womens_health.