Obstetrics

CHICAGO — A preview of much-anticipated updates to guidelines on managing thyroid disease in pregnancy shows key changes to recommendations in the evolving field, ranging from consideration of the chance of spontaneous normalization of thyroid levels during pregnancy to a heightened emphasis on shared decision-making and the nuances can factor into personalized treatment.

The guidelines, expected to be published in early 2025, have not been updated since 2017, and with substantial advances and evidence from countless studies since then, the new guidelines were developed with a goal to start afresh, said ATA Thyroid and Pregnancy Guidelines Task Force cochair Tim IM Korevaar, MD, PhD, in presenting the final draft guidelines at the American Thyroid Association (ATA) 2024 Meeting.

“Obviously, we’re not going to ignore the 2017 guidelines, which have been a very good resource for us so far, but we really wanted to start from scratch and follow a ‘blank canvas’ approach in optimizing the evidence,” said Korevaar, an endocrinologist and obstetric internist with the Division of Pharmacology and Vascular Medicine & Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.

The guidelines, developed through a collaborative effort involving a wide variety of related medical societies, involved 14 systematic literature reviews. While the pregnancy issues covered by the guidelines is extensive, key highlights include:
 

Management in Preconception

Beginning with preconception, a key change in the guidelines will be that patients with euthyroid thyroid peroxidase (TPO) antibodies, which can be indicative of thyroid dysfunction, routine treatment with levothyroxine is not recommended, based on new evidence from randomized trials of high-risk patients showing no clear benefit from the treatment. 

“In these trials, and across analyses, there was absolutely no beneficial effect of levothyroxine in these patients [with euthyroid TPO antibody positivity],” he said.

With evidence showing, however, that TPO antibody positivity can lead to subclinical or overt hypothyroidism within 1 or 2 years, the guidelines will recommend that TPO antibody–positive patients do have thyroid stimulating hormone (TSH) levels tested every 3-6 months until pregnancy, and existing recommendations to test during pregnancy among those patients remain in place, Korevaar reported.

In terms of preconception subclinical hypothyroidism, the guidelines will emphasize the existing recommendation “to always strive to reassess” thyroid levels, and if subclinical hypothyroidism does persist, to treat with low-dose levothyroxine.
 

During Pregnancy

During pregnancy, the new proposed recommendations will reflect the important change that three key risk factors, including age over 30 years, having at least two prior pregnancies, and morbid obesity (body mass index [BMI] at least 40 kg/m²), previously considered a risk for thyroid dysfunction in pregnancy, should not, on their own, suggest the need for thyroid testing, based on low evidence of an increased risk in pregnancy.

Research on the issue includes a recent study from Korevaar’s team showing these factors to in fact have low predictability of thyroid dysfunction.

“We deemed that these risk differences weren’t really clinically meaningful (in predicting risk), and so we have removed to maternal age, BMI, and parity as risk factors for thyroid testing indications in pregnancy,” Korevaar said.

Factors considered a risk, resulting in recommended testing at presentation include a history of subclinical or clinical hypo- or hyperthyroidism, postpartum thyroiditis, known thyroid antibody positivity, symptoms of thyroid dysfunction or goiter, and other factors. 
 

Treatment for Subclinical Hypothyroidism in Pregnancy

Whereas current guidelines recommend TPO antibody status in determining when to consider treatment for subclinical hypothyroidism, the new proposed guideline will instead recommend treatment based on the timing of the diagnosis of the subclinical hypothyroidism, with consideration of treatment during the first trimester, but not in the second or third trimester, based on newer evidence of the absolute risk for pregnancy complications and randomized trial data.

“The recommendations are now to no longer based on TPO antibody status, but instead according to the timing of the diagnosis of subclinical hypothyroidism,” Korevaar said.

Based on the collective data, “due to the low risk, we do not recommend for routine levothyroxine treatment in the second or third trimester groups with TSH levels under 10 mU/L now.”

“However, for subclinical hypothyroidism diagnosed in the first trimester, the recommendation would be that you can consider levothyroxine treatment,” he said.

While a clear indication for treatment in any trimester is the presence of overt hypothyroidism, or TSH levels over 10 mU/L, Korevaar underscored the importance of considering nuances of the recommendations that may warrant flexibility, for instance among patients with borderline TSH levels.
 

Spontaneous Normalization of Thyroid Levels in Pregnancy

Another new recommendation addresses the issue of spontaneous normalization of abnormal thyroid function during pregnancy, with several large studies showing a large proportion of subclinical hypothyroidism cases spontaneously revert to euthyroidism by the third trimester — despite no treatment having been provided.

Under the important proposed recommendation, retesting of subclinical hypothyroidism is suggested within 3 weeks.

“The data shows that a large proportion of patients spontaneously revert to euthyroidism,” Korevaar said.

“Upon identifying subclinical hypothyroidism in the first trimester, there will be essentially two options that clinicians can discuss with their patient — one would be to consider confirmatory tests in 3 weeks or to discuss the starting the lower dose levothyroxine in the first trimester,” he said.

In terms of overt hypothyroidism, likewise, if patients have a TSH levels below 6 mU/L in pregnancy, “you can either consider doing confirmatory testing within 3 weeks, or discussing with the patient starting levothyroxine treatment,” Korevaar added.
 

Overt Hyperthyroidism

For overt hyperthyroidism, no significant changes from current guidelines are being proposed, with the key exception of a heightened emphasis on the need for shared decision-making with patients, Korevaar said.

“We want to emphasize shared decision-making especially for women who have Graves’ disease prior to pregnancy, because the antithyroid treatment modalities, primarily methimazole (MMI) and propylthiouracil (PTU), have different advantages and disadvantages for an upcoming pregnancy,” he said.

“If you help a patient become involved in the decision-making process, that can also be very helpful in managing the disease and following-up on the pregnancy.”

Under the recommendations, PTU remains the preferred drug in overt hyperthyroidism, due to a more favorable profile in terms of potential birth defects vs MMI, with research showing a higher absolute risk of 3% vs 5%.

The guidelines further suggest the option of stopping the antithyroid medications upon a positive pregnancy test, with the exception of high-risk patients.

Korevaar noted that, if the treatment is stopped early in pregnancy, relapse is not likely to occur until after approximately 3 months, or 12 weeks, at which time, the high-risk teratogenic period, which is between week 5 and week 15, will have passed.

Current guidelines regarding whether to stop treatment in higher-risk hyperthyroid patients are recommended to remain unchanged.
 

Thyroid Nodules and Cancer

Recommendations regarding thyroid nodules and cancer during pregnancy are also expected to remain largely similar to those in the 2017 guidelines, with the exception of an emphasis on simply considering how the patient would normally be managed outside of pregnancy. 

For instance, regarding the question of whether treatment can be withheld for 9 months during pregnancy. “A lot of times, the answer is yes,” Korevaar said.

Other topics that will be largely unchanged include issues of universal screening, definitions of normal and abnormal TSH and free T4 reference ranges and isolated hypothyroxinemia.
 

Steps Forward in Improving Updates, Readability

In addition to recommendation updates, the new guidelines are being revised to better reflect more recent evidence-based developments and user-friendliness.

“We have now made the step to a more systematic and replicable methodology to ensure for easier updates with a shorter interval,” Korevaar told this news organization.

“Furthermore, since 2006, the ATA guideline documents have followed a question-and-answer format, lacked recommendation tables and had none or only a few graphic illustrations,” he added. 

“We are now further developing the typical outline of the guidelines to improve the readability and dissemination of the guideline document.”

Korevaar’s disclosures include lectureship fees from IBSA, Merck, and Berlin Chemie.

A version of this article first appeared on Medscape.com.

CHICAGO — A preview of much-anticipated updates to guidelines on managing thyroid disease in pregnancy shows key changes to recommendations in the evolving field, ranging from consideration of the chance of spontaneous normalization of thyroid levels during pregnancy to a heightened emphasis on shared decision-making and the nuances can factor into personalized treatment.

The guidelines, expected to be published in early 2025, have not been updated since 2017, and with substantial advances and evidence from countless studies since then, the new guidelines were developed with a goal to start afresh, said ATA Thyroid and Pregnancy Guidelines Task Force cochair Tim IM Korevaar, MD, PhD, in presenting the final draft guidelines at the American Thyroid Association (ATA) 2024 Meeting.

“Obviously, we’re not going to ignore the 2017 guidelines, which have been a very good resource for us so far, but we really wanted to start from scratch and follow a ‘blank canvas’ approach in optimizing the evidence,” said Korevaar, an endocrinologist and obstetric internist with the Division of Pharmacology and Vascular Medicine & Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.

The guidelines, developed through a collaborative effort involving a wide variety of related medical societies, involved 14 systematic literature reviews. While the pregnancy issues covered by the guidelines is extensive, key highlights include:
 

Management in Preconception

Beginning with preconception, a key change in the guidelines will be that patients with euthyroid thyroid peroxidase (TPO) antibodies, which can be indicative of thyroid dysfunction, routine treatment with levothyroxine is not recommended, based on new evidence from randomized trials of high-risk patients showing no clear benefit from the treatment. 

“In these trials, and across analyses, there was absolutely no beneficial effect of levothyroxine in these patients [with euthyroid TPO antibody positivity],” he said.

With evidence showing, however, that TPO antibody positivity can lead to subclinical or overt hypothyroidism within 1 or 2 years, the guidelines will recommend that TPO antibody–positive patients do have thyroid stimulating hormone (TSH) levels tested every 3-6 months until pregnancy, and existing recommendations to test during pregnancy among those patients remain in place, Korevaar reported.

In terms of preconception subclinical hypothyroidism, the guidelines will emphasize the existing recommendation “to always strive to reassess” thyroid levels, and if subclinical hypothyroidism does persist, to treat with low-dose levothyroxine.
 

During Pregnancy

During pregnancy, the new proposed recommendations will reflect the important change that three key risk factors, including age over 30 years, having at least two prior pregnancies, and morbid obesity (body mass index [BMI] at least 40 kg/m²), previously considered a risk for thyroid dysfunction in pregnancy, should not, on their own, suggest the need for thyroid testing, based on low evidence of an increased risk in pregnancy.

Research on the issue includes a recent study from Korevaar’s team showing these factors to in fact have low predictability of thyroid dysfunction.

“We deemed that these risk differences weren’t really clinically meaningful (in predicting risk), and so we have removed to maternal age, BMI, and parity as risk factors for thyroid testing indications in pregnancy,” Korevaar said.

Factors considered a risk, resulting in recommended testing at presentation include a history of subclinical or clinical hypo- or hyperthyroidism, postpartum thyroiditis, known thyroid antibody positivity, symptoms of thyroid dysfunction or goiter, and other factors. 
 

Treatment for Subclinical Hypothyroidism in Pregnancy

Whereas current guidelines recommend TPO antibody status in determining when to consider treatment for subclinical hypothyroidism, the new proposed guideline will instead recommend treatment based on the timing of the diagnosis of the subclinical hypothyroidism, with consideration of treatment during the first trimester, but not in the second or third trimester, based on newer evidence of the absolute risk for pregnancy complications and randomized trial data.

“The recommendations are now to no longer based on TPO antibody status, but instead according to the timing of the diagnosis of subclinical hypothyroidism,” Korevaar said.

Based on the collective data, “due to the low risk, we do not recommend for routine levothyroxine treatment in the second or third trimester groups with TSH levels under 10 mU/L now.”

“However, for subclinical hypothyroidism diagnosed in the first trimester, the recommendation would be that you can consider levothyroxine treatment,” he said.

While a clear indication for treatment in any trimester is the presence of overt hypothyroidism, or TSH levels over 10 mU/L, Korevaar underscored the importance of considering nuances of the recommendations that may warrant flexibility, for instance among patients with borderline TSH levels.
 

Spontaneous Normalization of Thyroid Levels in Pregnancy

Another new recommendation addresses the issue of spontaneous normalization of abnormal thyroid function during pregnancy, with several large studies showing a large proportion of subclinical hypothyroidism cases spontaneously revert to euthyroidism by the third trimester — despite no treatment having been provided.

Under the important proposed recommendation, retesting of subclinical hypothyroidism is suggested within 3 weeks.

“The data shows that a large proportion of patients spontaneously revert to euthyroidism,” Korevaar said.

“Upon identifying subclinical hypothyroidism in the first trimester, there will be essentially two options that clinicians can discuss with their patient — one would be to consider confirmatory tests in 3 weeks or to discuss the starting the lower dose levothyroxine in the first trimester,” he said.

In terms of overt hypothyroidism, likewise, if patients have a TSH levels below 6 mU/L in pregnancy, “you can either consider doing confirmatory testing within 3 weeks, or discussing with the patient starting levothyroxine treatment,” Korevaar added.
 

Overt Hyperthyroidism

For overt hyperthyroidism, no significant changes from current guidelines are being proposed, with the key exception of a heightened emphasis on the need for shared decision-making with patients, Korevaar said.

“We want to emphasize shared decision-making especially for women who have Graves’ disease prior to pregnancy, because the antithyroid treatment modalities, primarily methimazole (MMI) and propylthiouracil (PTU), have different advantages and disadvantages for an upcoming pregnancy,” he said.

“If you help a patient become involved in the decision-making process, that can also be very helpful in managing the disease and following-up on the pregnancy.”

Under the recommendations, PTU remains the preferred drug in overt hyperthyroidism, due to a more favorable profile in terms of potential birth defects vs MMI, with research showing a higher absolute risk of 3% vs 5%.

The guidelines further suggest the option of stopping the antithyroid medications upon a positive pregnancy test, with the exception of high-risk patients.

Korevaar noted that, if the treatment is stopped early in pregnancy, relapse is not likely to occur until after approximately 3 months, or 12 weeks, at which time, the high-risk teratogenic period, which is between week 5 and week 15, will have passed.

Current guidelines regarding whether to stop treatment in higher-risk hyperthyroid patients are recommended to remain unchanged.
 

Thyroid Nodules and Cancer

Recommendations regarding thyroid nodules and cancer during pregnancy are also expected to remain largely similar to those in the 2017 guidelines, with the exception of an emphasis on simply considering how the patient would normally be managed outside of pregnancy. 

For instance, regarding the question of whether treatment can be withheld for 9 months during pregnancy. “A lot of times, the answer is yes,” Korevaar said.

Other topics that will be largely unchanged include issues of universal screening, definitions of normal and abnormal TSH and free T4 reference ranges and isolated hypothyroxinemia.
 

Steps Forward in Improving Updates, Readability

In addition to recommendation updates, the new guidelines are being revised to better reflect more recent evidence-based developments and user-friendliness.

“We have now made the step to a more systematic and replicable methodology to ensure for easier updates with a shorter interval,” Korevaar told this news organization.

“Furthermore, since 2006, the ATA guideline documents have followed a question-and-answer format, lacked recommendation tables and had none or only a few graphic illustrations,” he added. 

“We are now further developing the typical outline of the guidelines to improve the readability and dissemination of the guideline document.”

Korevaar’s disclosures include lectureship fees from IBSA, Merck, and Berlin Chemie.

A version of this article first appeared on Medscape.com.

CHICAGO — A preview of much-anticipated updates to guidelines on managing thyroid disease in pregnancy shows key changes to recommendations in the evolving field, ranging from consideration of the chance of spontaneous normalization of thyroid levels during pregnancy to a heightened emphasis on shared decision-making and the nuances can factor into personalized treatment.

The guidelines, expected to be published in early 2025, have not been updated since 2017, and with substantial advances and evidence from countless studies since then, the new guidelines were developed with a goal to start afresh, said ATA Thyroid and Pregnancy Guidelines Task Force cochair Tim IM Korevaar, MD, PhD, in presenting the final draft guidelines at the American Thyroid Association (ATA) 2024 Meeting.

“Obviously, we’re not going to ignore the 2017 guidelines, which have been a very good resource for us so far, but we really wanted to start from scratch and follow a ‘blank canvas’ approach in optimizing the evidence,” said Korevaar, an endocrinologist and obstetric internist with the Division of Pharmacology and Vascular Medicine & Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.

The guidelines, developed through a collaborative effort involving a wide variety of related medical societies, involved 14 systematic literature reviews. While the pregnancy issues covered by the guidelines is extensive, key highlights include:
 

Management in Preconception

Beginning with preconception, a key change in the guidelines will be that patients with euthyroid thyroid peroxidase (TPO) antibodies, which can be indicative of thyroid dysfunction, routine treatment with levothyroxine is not recommended, based on new evidence from randomized trials of high-risk patients showing no clear benefit from the treatment. 

“In these trials, and across analyses, there was absolutely no beneficial effect of levothyroxine in these patients [with euthyroid TPO antibody positivity],” he said.

With evidence showing, however, that TPO antibody positivity can lead to subclinical or overt hypothyroidism within 1 or 2 years, the guidelines will recommend that TPO antibody–positive patients do have thyroid stimulating hormone (TSH) levels tested every 3-6 months until pregnancy, and existing recommendations to test during pregnancy among those patients remain in place, Korevaar reported.

In terms of preconception subclinical hypothyroidism, the guidelines will emphasize the existing recommendation “to always strive to reassess” thyroid levels, and if subclinical hypothyroidism does persist, to treat with low-dose levothyroxine.
 

During Pregnancy

During pregnancy, the new proposed recommendations will reflect the important change that three key risk factors, including age over 30 years, having at least two prior pregnancies, and morbid obesity (body mass index [BMI] at least 40 kg/m²), previously considered a risk for thyroid dysfunction in pregnancy, should not, on their own, suggest the need for thyroid testing, based on low evidence of an increased risk in pregnancy.

Research on the issue includes a recent study from Korevaar’s team showing these factors to in fact have low predictability of thyroid dysfunction.

“We deemed that these risk differences weren’t really clinically meaningful (in predicting risk), and so we have removed to maternal age, BMI, and parity as risk factors for thyroid testing indications in pregnancy,” Korevaar said.

Factors considered a risk, resulting in recommended testing at presentation include a history of subclinical or clinical hypo- or hyperthyroidism, postpartum thyroiditis, known thyroid antibody positivity, symptoms of thyroid dysfunction or goiter, and other factors. 
 

Treatment for Subclinical Hypothyroidism in Pregnancy

Whereas current guidelines recommend TPO antibody status in determining when to consider treatment for subclinical hypothyroidism, the new proposed guideline will instead recommend treatment based on the timing of the diagnosis of the subclinical hypothyroidism, with consideration of treatment during the first trimester, but not in the second or third trimester, based on newer evidence of the absolute risk for pregnancy complications and randomized trial data.

“The recommendations are now to no longer based on TPO antibody status, but instead according to the timing of the diagnosis of subclinical hypothyroidism,” Korevaar said.

Based on the collective data, “due to the low risk, we do not recommend for routine levothyroxine treatment in the second or third trimester groups with TSH levels under 10 mU/L now.”

“However, for subclinical hypothyroidism diagnosed in the first trimester, the recommendation would be that you can consider levothyroxine treatment,” he said.

While a clear indication for treatment in any trimester is the presence of overt hypothyroidism, or TSH levels over 10 mU/L, Korevaar underscored the importance of considering nuances of the recommendations that may warrant flexibility, for instance among patients with borderline TSH levels.
 

Spontaneous Normalization of Thyroid Levels in Pregnancy

Another new recommendation addresses the issue of spontaneous normalization of abnormal thyroid function during pregnancy, with several large studies showing a large proportion of subclinical hypothyroidism cases spontaneously revert to euthyroidism by the third trimester — despite no treatment having been provided.

Under the important proposed recommendation, retesting of subclinical hypothyroidism is suggested within 3 weeks.

“The data shows that a large proportion of patients spontaneously revert to euthyroidism,” Korevaar said.

“Upon identifying subclinical hypothyroidism in the first trimester, there will be essentially two options that clinicians can discuss with their patient — one would be to consider confirmatory tests in 3 weeks or to discuss the starting the lower dose levothyroxine in the first trimester,” he said.

In terms of overt hypothyroidism, likewise, if patients have a TSH levels below 6 mU/L in pregnancy, “you can either consider doing confirmatory testing within 3 weeks, or discussing with the patient starting levothyroxine treatment,” Korevaar added.
 

Overt Hyperthyroidism

For overt hyperthyroidism, no significant changes from current guidelines are being proposed, with the key exception of a heightened emphasis on the need for shared decision-making with patients, Korevaar said.

“We want to emphasize shared decision-making especially for women who have Graves’ disease prior to pregnancy, because the antithyroid treatment modalities, primarily methimazole (MMI) and propylthiouracil (PTU), have different advantages and disadvantages for an upcoming pregnancy,” he said.

“If you help a patient become involved in the decision-making process, that can also be very helpful in managing the disease and following-up on the pregnancy.”

Under the recommendations, PTU remains the preferred drug in overt hyperthyroidism, due to a more favorable profile in terms of potential birth defects vs MMI, with research showing a higher absolute risk of 3% vs 5%.

The guidelines further suggest the option of stopping the antithyroid medications upon a positive pregnancy test, with the exception of high-risk patients.

Korevaar noted that, if the treatment is stopped early in pregnancy, relapse is not likely to occur until after approximately 3 months, or 12 weeks, at which time, the high-risk teratogenic period, which is between week 5 and week 15, will have passed.

Current guidelines regarding whether to stop treatment in higher-risk hyperthyroid patients are recommended to remain unchanged.
 

Thyroid Nodules and Cancer

Recommendations regarding thyroid nodules and cancer during pregnancy are also expected to remain largely similar to those in the 2017 guidelines, with the exception of an emphasis on simply considering how the patient would normally be managed outside of pregnancy. 

For instance, regarding the question of whether treatment can be withheld for 9 months during pregnancy. “A lot of times, the answer is yes,” Korevaar said.

Other topics that will be largely unchanged include issues of universal screening, definitions of normal and abnormal TSH and free T4 reference ranges and isolated hypothyroxinemia.
 

Steps Forward in Improving Updates, Readability

In addition to recommendation updates, the new guidelines are being revised to better reflect more recent evidence-based developments and user-friendliness.

“We have now made the step to a more systematic and replicable methodology to ensure for easier updates with a shorter interval,” Korevaar told this news organization.

“Furthermore, since 2006, the ATA guideline documents have followed a question-and-answer format, lacked recommendation tables and had none or only a few graphic illustrations,” he added. 

“We are now further developing the typical outline of the guidelines to improve the readability and dissemination of the guideline document.”

Korevaar’s disclosures include lectureship fees from IBSA, Merck, and Berlin Chemie.

A version of this article first appeared on Medscape.com.

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

TOPLINE:

About one in six women experience symptoms of postpartum depression (PPD) 2 months after cesarean delivery, with certain obstetric factors such as emergency cesarean delivery before labor, cesarean delivery after labor induction, lack of social support in the operating room, and severe postoperative pain influencing the risk.

METHODOLOGY:

• Researchers conducted a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial to examine the prevalence of PPD 2 months after cesarean delivery and associated risk factors.
• A total of 2793 women (median age, 33.5 years) were included who had a cesarean delivery at 34 or more weeks of gestation; they completed the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire, at 2 months after delivery.
• Information about the cesarean delivery, postpartum blood loss, immediate postpartum period, psychiatric history, and memories of delivery and postoperative pain were prospectively collected.
• Medical records were used to obtain details about characteristics of patients; 5.0% had a psychiatric history (2.4% composed of depression).
• The main endpoint was a positive screening for symptoms consistent with this depression — defined as a PPD diagnosis — 2 months after caesarian delivery, with an EPDS score of 13 or higher.

TAKEAWAY:

• The prevalence of a provisional PPD diagnosis at 2 months after cesarean delivery was 16.4% (95% CI, 14.9-18.0) with an EPDS score of 13 or higher and was 23.1% (95% CI, 21.4-24.9%) with a cutoff value of 11 or higher.
• Women who had an emergency cesarean delivery before labor had a higher risk for PPD than those who had a normal cesarean delivery before labor started (adjusted odds ratio [aOR], 1.70; 95% CI, 1.15-2.50); women who had started labor after induction but then had a cesarean delivery also had a higher risk for PPD than those who had a cesarean delivery before going into labor (aOR, 1.36; 95% CI, 1.03-1.84).
• Severe pain during the postpartum stay (aOR, 1.73; 95% CI, 1.32-2.26) and bad memories of delivery (aOR, 1.67; 95% CI, 1.14-2.45) were also risk factors for PPD.
• However, women who had social support in the operating room showed a 27% lower risk for PPD (P = .02).

IN PRACTICE:

“Identifying subgroups of women at risk for PPD based on aspects of their obstetric experience could help to screen for women who might benefit from early screening and interventions,” the authors wrote.

SOURCE:

This study was led by Alizée Froeliger, MD, MPH, of the Department of Obstetrics and Gynecology at Bordeaux University Hospital in France, and was published online in American Journal of Obstetrics & Gynecology.

LIMITATIONS:

The study population was derived from a randomized controlled trial, which may have underestimated the prevalence of PPD. The use of a self-administered questionnaire for PPD screening may not have provided a definitive diagnosis. Moreover, this study did not assess the prevalence of depressive symptoms during pregnancy.

DISCLOSURES:

The TRAAP2 trial was supported by a grant from the French Ministry of Health under its Clinical Research Hospital Program. One author reported carrying out consultancy work and lecturing for Ferring Laboratories, GlaxoSmithKline, and other pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

About one in six women experience symptoms of postpartum depression (PPD) 2 months after cesarean delivery, with certain obstetric factors such as emergency cesarean delivery before labor, cesarean delivery after labor induction, lack of social support in the operating room, and severe postoperative pain influencing the risk.

METHODOLOGY:

• Researchers conducted a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial to examine the prevalence of PPD 2 months after cesarean delivery and associated risk factors.
• A total of 2793 women (median age, 33.5 years) were included who had a cesarean delivery at 34 or more weeks of gestation; they completed the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire, at 2 months after delivery.
• Information about the cesarean delivery, postpartum blood loss, immediate postpartum period, psychiatric history, and memories of delivery and postoperative pain were prospectively collected.
• Medical records were used to obtain details about characteristics of patients; 5.0% had a psychiatric history (2.4% composed of depression).
• The main endpoint was a positive screening for symptoms consistent with this depression — defined as a PPD diagnosis — 2 months after caesarian delivery, with an EPDS score of 13 or higher.

TAKEAWAY:

• The prevalence of a provisional PPD diagnosis at 2 months after cesarean delivery was 16.4% (95% CI, 14.9-18.0) with an EPDS score of 13 or higher and was 23.1% (95% CI, 21.4-24.9%) with a cutoff value of 11 or higher.
• Women who had an emergency cesarean delivery before labor had a higher risk for PPD than those who had a normal cesarean delivery before labor started (adjusted odds ratio [aOR], 1.70; 95% CI, 1.15-2.50); women who had started labor after induction but then had a cesarean delivery also had a higher risk for PPD than those who had a cesarean delivery before going into labor (aOR, 1.36; 95% CI, 1.03-1.84).
• Severe pain during the postpartum stay (aOR, 1.73; 95% CI, 1.32-2.26) and bad memories of delivery (aOR, 1.67; 95% CI, 1.14-2.45) were also risk factors for PPD.
• However, women who had social support in the operating room showed a 27% lower risk for PPD (P = .02).

IN PRACTICE:

“Identifying subgroups of women at risk for PPD based on aspects of their obstetric experience could help to screen for women who might benefit from early screening and interventions,” the authors wrote.

SOURCE:

This study was led by Alizée Froeliger, MD, MPH, of the Department of Obstetrics and Gynecology at Bordeaux University Hospital in France, and was published online in American Journal of Obstetrics & Gynecology.

LIMITATIONS:

The study population was derived from a randomized controlled trial, which may have underestimated the prevalence of PPD. The use of a self-administered questionnaire for PPD screening may not have provided a definitive diagnosis. Moreover, this study did not assess the prevalence of depressive symptoms during pregnancy.

DISCLOSURES:

The TRAAP2 trial was supported by a grant from the French Ministry of Health under its Clinical Research Hospital Program. One author reported carrying out consultancy work and lecturing for Ferring Laboratories, GlaxoSmithKline, and other pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

About one in six women experience symptoms of postpartum depression (PPD) 2 months after cesarean delivery, with certain obstetric factors such as emergency cesarean delivery before labor, cesarean delivery after labor induction, lack of social support in the operating room, and severe postoperative pain influencing the risk.

METHODOLOGY:

• Researchers conducted a prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery (TRAAP2) trial to examine the prevalence of PPD 2 months after cesarean delivery and associated risk factors.
• A total of 2793 women (median age, 33.5 years) were included who had a cesarean delivery at 34 or more weeks of gestation; they completed the Edinburgh Postnatal Depression Scale (EPDS), a self-administered questionnaire, at 2 months after delivery.
• Information about the cesarean delivery, postpartum blood loss, immediate postpartum period, psychiatric history, and memories of delivery and postoperative pain were prospectively collected.
• Medical records were used to obtain details about characteristics of patients; 5.0% had a psychiatric history (2.4% composed of depression).
• The main endpoint was a positive screening for symptoms consistent with this depression — defined as a PPD diagnosis — 2 months after caesarian delivery, with an EPDS score of 13 or higher.

TAKEAWAY:

• The prevalence of a provisional PPD diagnosis at 2 months after cesarean delivery was 16.4% (95% CI, 14.9-18.0) with an EPDS score of 13 or higher and was 23.1% (95% CI, 21.4-24.9%) with a cutoff value of 11 or higher.
• Women who had an emergency cesarean delivery before labor had a higher risk for PPD than those who had a normal cesarean delivery before labor started (adjusted odds ratio [aOR], 1.70; 95% CI, 1.15-2.50); women who had started labor after induction but then had a cesarean delivery also had a higher risk for PPD than those who had a cesarean delivery before going into labor (aOR, 1.36; 95% CI, 1.03-1.84).
• Severe pain during the postpartum stay (aOR, 1.73; 95% CI, 1.32-2.26) and bad memories of delivery (aOR, 1.67; 95% CI, 1.14-2.45) were also risk factors for PPD.
• However, women who had social support in the operating room showed a 27% lower risk for PPD (P = .02).

IN PRACTICE:

“Identifying subgroups of women at risk for PPD based on aspects of their obstetric experience could help to screen for women who might benefit from early screening and interventions,” the authors wrote.

SOURCE:

This study was led by Alizée Froeliger, MD, MPH, of the Department of Obstetrics and Gynecology at Bordeaux University Hospital in France, and was published online in American Journal of Obstetrics & Gynecology.

LIMITATIONS:

The study population was derived from a randomized controlled trial, which may have underestimated the prevalence of PPD. The use of a self-administered questionnaire for PPD screening may not have provided a definitive diagnosis. Moreover, this study did not assess the prevalence of depressive symptoms during pregnancy.

DISCLOSURES:

The TRAAP2 trial was supported by a grant from the French Ministry of Health under its Clinical Research Hospital Program. One author reported carrying out consultancy work and lecturing for Ferring Laboratories, GlaxoSmithKline, and other pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.

Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.

The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.

“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.

The data were published on November 4 in The Journal of Clinical Psychiatry.
 

Implications for Prevention

“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.

The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.

The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.

Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).

The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).

“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”

Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.

“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
 

Area of Concern

“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.

“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.

“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.

“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.

“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.

The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.

Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.

The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.

“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.

The data were published on November 4 in The Journal of Clinical Psychiatry.
 

Implications for Prevention

“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.

The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.

The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.

Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).

The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).

“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”

Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.

“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
 

Area of Concern

“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.

“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.

“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.

“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.

“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.

The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.

Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.

The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.

“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.

The data were published on November 4 in The Journal of Clinical Psychiatry.
 

Implications for Prevention

“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.

The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.

The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.

Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).

The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).

“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”

Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.

“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
 

Area of Concern

“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.

“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.

“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.

“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.

“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.

The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.