Clinical and Case Study Article

Postpartum problems in primary care: Focus on postpartum

depression and diabetes
Jacqueline P. Cabrera, BSN (Graduate Nursing)

ABSTRACT
Postpartum depression and diabetes are common diagnoses affecting many childbearing women annually. Neverthe-
less, disease management by the primary care provider can be complicated by late entry to care or insufficient care.
Pharmacotherapeutic interventions must be initiated appropriately to address the disease progression while supporting
breastfeeding. This study explores the course of postpartum depression and diabetes in a postpartum woman using the
case study application and analysis along with interventions and education that can help primary care providers in
reducing the complications that come from undiagnosed depression and diabetes in the postpartum period.
Keywords: Diabetes; lactation; pharmacology; postpartum depression.

Journal of the American Association of Nurse Practitioners 32 (2020) 277–283, © 2019 American Association of Nurse Practitioners

DOI# 10.1097/JXX.0000000000000216

Postpartum problems in primary care: focus on
postpartum depression and diabetes
Women go through significant changes after childbirth.
Differentiating between chronic and acute conditions in
the postpartum period can be difficult, and medical in-
tervention can also be complicated when mothers are
breastfeeding. The diagnoses and relationship of post-
partum depression (PPD) and diabetes are explored, and
the corresponding pharmacotherapy is discussed. An
exemplar of a patient with complex postpartum needs
illustrates these dynamic conditions.
Postpartum depression and diabetes
Postpartum depression is a mood disorder that usually
develops within the first 6 weeks postpartum, with
symptoms lasting anywhere from 3 to 14 months (Arcan-
gelo, Peterson, Wilbur, & Reinhold, 2017). It affects
mothers around the world. On average, 100–150 mothers
will develop PPD of every 1,000 births globally (Upadhyay
et al., 2017). Postpartum depression is a result of emo-
tional factors, such as stress, life changes, self-esteem,
body changes, and physical factors, such as hormonal
fluctuations and sleep deprivation. After delivery, wom-
en’s estrogen and progesterone drastically drop, which
triggers chemical changes in their brain, causing mood
Saint Anthony College of Nursing, Rockford, Illinois
Correspondence: Jacqueline P. Cabrera, BSN, Department of Graduate
Nursing, Saint Anthony College of Nursing, Rockford, IL 61114. Tel:
815-742-0559; E-mail: JacquelineEngstrom@live.com
Received: 19 December 2018; revised: 7 February 2019; accepted
13 February 2019
swings ranging from mild to severe. These changes can
interfere with spousal relationships and maternal-
newborn bonding. Furthermore, researchers have noted
that women affected by PPD more likely present to the
health care provider with features of anxiety and take
longer to respond to antidepressant medications
(Brummelte & Galea, 2016).
Women with PPD have a lower chance of seeking
treatment from their providers and are less likely to
breastfeed their infants (Upadhyay et al., 2017). Un-
fortunately, PPD is commonly mistaken for “baby blues,”
which is a transient mood disturbance that affects up to
75% of new mothers in the 10 days after delivery, with
symptoms that are generally mild and self-limited
(Fitelson, Kim, Baker, & Leight, 2011). True PPD is different
because symptoms are more intense and have a longer
duration, potentially interfering with the mother’s ability
to care for her infant and complete activities of daily living
(Fitelson et al., 2011). Postpartum depression symptoms
can include any of the following: excessive crying, in-
somnia, depressed mood, severe mood swings, feeling
detached from the infant, intense irritability, anxiety and
panic attacks, reduced pleasure and interest in daily ac-
tivities, feelings of guilt, worthlessness, and shame, and
thoughts of suicide or harming the infant (Fitelson et al.,
2011).
Postpartum depression can be further complicated in
diabetic women. Researchers have found that depression
is associated with poorer diet, decreased medication
adherence, and higher primary health care costs among
diabetic patients (Ciechanowski, Katon, & Russo, 2000).
Women diagnosed with diabetes during pregnancy have a

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 Clinical and Case Study Article
four-fold risk (95% confidence interval 1.17, 13.65) of de-
veloping PPD and require subsequent antidepressant
medication within the first year postpartum, with the
greatest relationship between gestational diabetes and
PPD noted among nonobese women (Hinkle et al., 2016).
Although many women are diagnosed with gestational
diabetes during pregnancy, the diagnosis of type 2 di-
abetes usually does not occur until the postpartum
phase. About 16.8% of women have some form of hyper-
glycemia during pregnancy, and 84% of them have ges-
tational diabetes (Hod et al., 2015). Typically, symptoms of
diabetes gradually develop, including extreme thirst,
urination, hunger, fatigue, unexplained weight loss,
delayed wound healing, and blurred vision (NIH, 2016).
Complications that can be expected from uncontrolled
diabetes over time can include heart disease and stroke,
kidney disease, eye and dental problems, nerve damage,
and foot problems (NIH, 2016). Furthermore, development
of diabetes is most common among people who are
overweight, especially in the abdominal region, have a
sedentary lifestyle, have hypertension, and have a history
of heart disease, stroke, or depression (NIH, 2016). Type 2
diabetes involves insulin secretion impairment, insulin
resistance, and/or excess production of glucose by the
liver (Arcangelo et al., 2017). When a patient is insulin
resistant, the body increases circulating insulin levels
as a compensatory mechanism, but insulin is unable to
impede hepatic glucose production or stimulate adipose
and muscle tissue insulin uptake (Arcangelo et al., 2017).
For a patient to develop type 2 diabetes, insulin re-
sistance with diminished insulin secretion must exist.
Case study
J.L.C., a 39-year-old postpartum patient, returned to the
clinic to establish care with a new nurse practitioner (NP).
She requested a new NP for the ongoing care as
instructed during her hospitalization. This is a prior visit
to her actual six-week postpartum visit because she had
been experiencing depression—she was not sure whether
it was “baby blues” or depression. She also reported that
in the past week, she had experienced fatigue, thirst,
blurred vision, and headache. She was not sure whether
she had noticed any additional edema, epigastric dis-
comfort, or what her baseline laboratory results were, but
she was certain that her vital signs were always “normal”
at her prenatal visits.
Medical history
J.L.C. delivered her baby 2 weeks ago at 39 + 5 weeks of
estimated gestation at a local hospital. She had limited
prenatal care, with only two visits at 32 weeks and
38 weeks, because she did not realize that she was
pregnant. This was her first pregnancy, and she had an
uncomplicated vaginal delivery. She had one ultrasound
at 32 weeks, which showed normal fetal anatomy, but the
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Postpartum problems in primary care
fetus was large for gestational age. At this visit, she was
also diagnosed with gestational diabetes following an
impaired fasting glucose (with 102 mg/dL, after a 75-gram
oral glucose administration), and so she was referred to a
dietician for maintaining her diet to control hyperglyce-
mia (Garrison, 2015). She did not comply with the die-
tician’s suggestions and did not return to her certified
nurse midwife until she was 38 weeks pregnant, and later
she delivered her baby. She had no health care visits in
over 5 years before her first prenatal visit at 32 weeks.
Previous medical diagnoses include the following:
spontaneous vaginal delivery, gestational diabetes, and
obesity complicating pregnancy, as well as polycystic
ovarian syndrome (diagnosed in 2004).
Social history
She works as a certified nursing assistant at a long-term
care facility. She was concerned about returning to work
in 4 weeks, but she “needs the job for health insurance.”
Her request for 12 weeks of work leave through the Family
and Medical Leave Act was denied by her employer be-
cause she had not worked enough hours to avail the
extended period of leave. Since delivery, her sleeping
pattern has been changed because she has to wake up
every 2 hours to breastfeed her newborn. J.L.C. reported a
sedentary lifestyle, especially since delivery, with a diet
consisting mostly of fast food or prepackaged food—
frozen dinners, pastries, and macaroni and cheese. She
received strong support from her mother and spouse in
household activities, grocery shopping, and infant care.
Physical examination
The patient’s vital signs during this visit were oral tem-
perature 98.0, blood pressure 145/91, heart rate 95, re-
spiratory rate 18, height 5’5”, weight 220 lbs, and body
mass index (BMI) 36.6. After obtaining a thorough history,
the patient was asked to complete an Edinburgh PPD
screen (Figure 1). The score on the screen was 17, which
indicated the high likelihood of PPD development (Cox,
Holden, & Sagovsky, 1987). Physical examination findings
were abnormal: elevated blood pressure 145/91, BMI 36.6,
flat affect, acanthosis nigricans of the neck, and bilateral
lower extremity edema.
Differential diagnosis
The NP has considered possible diagnoses of obesity,
preeclampsia, hypertension, diabetes mellitus, and PPD.
A complete metabolic panel (CMP), complete blood count,
and hemoglobin A1c (HbA1c) was performed to analyze
the glucose level, blood urea nitrogen, aspartate amino-
transferase, alanine aminotransferase, total protein, and
platelets to find out if she has preeclampsia and diabetes.
After analyzing the laboratory results, the NP concluded
that the patient has type 2 diabetes, as indicated by the
elevated random glucose of 225 mmol/L and HbA1c of
www.jaanp.com

Figure 1. Edinburgh Postnatal Depression Scale completed by
the patient portrayed in this case study at her initial visit. The
patient’s answers are indicated by red font and are pertinent
to the past 7 days.
7.4%. Although gestational diabetes could have been a
reason for the elevated HbA1c, the random glucose level
indicated poor control of blood sugar, which did not
correlate with that of the last 10 weeks of pregnancy.
Fortunately, the patient’s laboratory results did not in-
dicate preeclampsia, but the patient was asked for repeat
CMP and blood pressure evaluation in 1 week to check
whether liver enzymes have increased.
Treatment plan
Because the patient experienced PPD symptoms and
scored high on the Edinburgh PPD screen, drug therapy
was appropriate. Both PPD and diabetes can be effec-
tively managed by the patient’s primary care NP. Common
antidepressants prescribed for PPD are selective sero-
tonin reuptake inhibitors (SSRIs) such as sertraline, se-
rotonin and norepinephrine reuptake inhibitors such as
venlafaxine, and bupropion (Table 1) (Fitelson et al., 2011).
First, the preferred drug therapies must be evaluated for
compatibility with breastfeeding. Sertraline, a SSRI, is
Journal of the American Association of Nurse Practitioners
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J. P. Cabrera
considered a first-line drug for the treatment of PPD and
would be safe for J.L.C. to take while breastfeeding
(Arcangelo et al., 2017). Sertraline binds to serotonin
transporters, inhibiting the serotonin reuptake in the
presynaptic neurons, which results in increased con-
centrations of serotonin in the postsynaptic site (Arcan-
gelo et al., 2017). The increased concentration of serotonin
reduces the 5HT1 inhibition receptors and 5HT2 receptors,
which results in more active serotonin or decreased af-
finity to serotonin (Hantsoo et al., 2013).
Researchers have found that women who experience
PPD within 3 months of delivery have significantly better
outcomes with 50 mg–200 mg of sertraline daily (59%
reduction in PPD) compared with placebo (26% reduction
in PPD), with the best outcomes noticeable with a com-
bination of sertraline and psychotherapy (Hantsoo et al.,
2013). Therefore, J.L.C. was prescribed 50 mg of sertraline
daily with an increase in dosage as needed (Arcangelo
et al., 2017). The patient should be able to see improve-
ment in depressive symptoms in about 4–6 weeks
(Arcangelo et al., 2017). Because sertraline can cause
anxiety and insomnia, it should be taken in the morning
to avoid these side effects (Arcangelo et al., 2017). In ad-
dition, abrupt discontinuation of sertraline can lead to
depression, flu-like symptoms, insomnia, anxiety, and
gastrointestinal disturbances; therefore, guidance from
the NP is required to gradually decrease the dosage
(Arcangelo et al., 2017). When sertraline is ineffective in
treating her PPD, other options include bupropion SR
150–300 mg daily (p = .015) or intravenous brexanolone
infusion (p < .001), and when PPD becomes severe, hos-
pitalization is required (Kanes et al., 2017a, 2017b). Alter-
native therapies such as fish oil did not show significant
improvement in preventing or decreasing PPD symptoms
(Vaz, Farias, Adegbove, Nardi, & Kac, 2017). Although
bupropion is undetectable in breast milk, sertraline can
be usually found in unquantifiable serum concentration;
thus, it is still compatible with breastfeeding (Pinheiro,
Bogen, Hoxha, Ciolino, & Wisner, 2016).
Next, according to the American Association of Clinical
Endocrinologists (2015), because the patient’s entry
HbA1c was less than 7.5%, she should be counseled on
lifestyle modifications and started on monotherapy with
one of the following antidiabetic agents: metformin,
glucagon-like peptide-1 receptor agonist, sodium-
glucose cotransporter-2 inhibitor, dipeptidyl peptidase-4
inhibitor, or alpha-glucosidase inhibitor (Table 2). The
patient was prescribed metformin (Glucophage), a
biguanide, for type 2 diabetes, which is a first-line treat-
ment as recommended by the American Association of
Clinical Endocrinologists (Garber et al., 2013). Metformin
inhibits the production of glucose by the liver and
improves insulin sensitivity in the peripheral tissues,
especially through hepatic inhibition of glycogenolysis
(conversion of glycogen to glucose) and gluconeogenesis
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 Clinical and Case Study Article Postpartum problems in primary care

Table 1. Common antidepressants used for postpartum depression: Safety in lactation

Most Commonly
Drug Class Prescribed Breastfeeding Safety and Indications

SSRI Sertraline (Zoloft) Found in small amounts in breast milk, usually undetectable in infants,
often considered the preferred antidepressant while breastfeeding

Fluoxetine (Prozac) Typically, higher concentration of drug found in breast milk and infants than
that of other SSRIs; monitor infants for colic, fussiness, drowsiness, and poor
weight gain

Paroxetine (Paxil) Usually, drug is not detectable in infants, one of the preferred
antidepressants during breastfeeding; monitor infants for insomnia,
increased crying, and restlessness

Citalopram (Celexa) Sometimes detectable levels of drug in infants; monitor infants for sedation
and fussiness

Fluvoxamine (Luvox) Limited research, but usually undetected drug levels in infants; monitor
infants for diarrhea and vomiting

SNRI Venlafaxine (Effexor) Active metabolites are found in most breastfed infants, but side effects are
rarely reported; monitor infants for excessive sedation and poor weight gain

Phenylpiperazine Nefazodone (Serzone) Limited research; should not cause adverse effects in term infants greater
than 2 months, yet some side effects in preterm infants have been reported

Aminoketone Bupropion SR (Wellbutrin) Undetectable in breast milk

Tricyclic Nortriptyline (Aventyl) Often undetectable in infants, a preferred antidepressant while

antidepressant breastfeeding; no effects reported on infant growth or development

Note: From U.S. National Library of Medicine. (2018). TOXNET: Toxicology Data Network. Retrieved from https://toxnet.nlm.nih.gov/). This table displays common
antidepressants and generic and brand names that are used to treat postpartum depression. Corresponding antidepressant class and lactation safety are included.
SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin and norepinephrine reuptake inhibitor.

(generation of glucose from proteins) (Arcangelo et al., Treatment goals

2017). Metformin also decreases the absorption of glu-
cose in the intestines and improves skeletal muscle
sensitivity to insulin (Arcangelo et al., 2017). Because in-
sulin secretion is not stimulated, patients will not expe-
rience hypoglycemic side effects but may experience
gastrointestinal symptoms, especially nausea and di-
arrhea. Metformin is safe for breastfeeding mothers. The
patient will be started on metformin 500 mg twice daily,
and the dosage will be increased based on her 1-week
laboratory/blood pressure check, if needed (Arcangelo
et al., 2017).
It is imperative that the patient is educated on lifestyle
modification with the prescription for metformin.
Researchers have found that weight loss of more than 2
kilograms had the most significant effect on lowering
fasting glucose, p < .01 (Ehrlich et al., 2014). However,
metformin has not been demonstrated to be effective in
helping mothers to decrease body weight during the
initial 6 weeks postpartum (Refuerzo et al., 2015). She
should avoid alcohol because it can also interfere with
metformin, causing weakness, shortness of breath,
stomach pain, and decreased heart rate due to lactic
acidosis (Arcangelo et al., 2017).
A decrease in body weight can result in decreased blood
sugar and enhanced sensitivity of peripheral glucose
receptors, which is more effective in treating type 2 diabetes
than taking metformin alone (Arcangelo et al., 2017). Lifestyle
interventions such as a healthier diet and more exercise can
decrease the incidence of type 2 diabetes by 58 percent,
whereas metformin can decrease the incidence of type 2
diabetes by 31 percent (Arcangelo et al., 2017). Exercise can
help improve depressive symptoms by releasing endor-
phins, allowing the patient to have time for herself and
improving body image. Furthermore, exercise can help the
patient manage her stress, decrease her anxiety, and aid her
in any difficulty in sleeping. Other possible goals for treat-
ment include reduction in blood pressure down to 120/80,
which will take time, and reduction of HbA1c to 6.5 percent
(Arcangelo et al., 2017). Ideally, the patient can have re-
mission of her symptoms within 8 weeks, with a great im-
provement noted within 4–6 weeks. Slight improvement in
depressive symptoms may be realized in the first 1–2 weeks
after beginning therapy (Arcangelo et al., 2017). Alcohol
consumption should be avoided while taking sertraline
because alcohol may cause dizziness, drowsiness, and im-
paired judgment (Arcangelo et al., 2017).

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 J. P. Cabrera

Table 2. Common antidiabetic agents: Safety during lactation

Drug Class Most Commonly Prescribed Breastfeeding Safety and Indications

Biguanide Metformin (Glucophage) Well studied, sometimes detectable in infants, but no adverse effects on infants
have been reported; use with caution if nursing newborn or premature infants;
monitor infants for hypoglycemia

GLP-1 RA Byetta (Exenatide) Not studied in lactating mothers, likely safe for breastfeeding

Victoza (Liraglutide) Not studied in lactating mothers, but probably safe. Absorption in infant gut is
very unlikely.

Trulicity (Dulaglutide) Not studied in lactating mothers, but probably safe. Absorption in infant gut is
very unlikely.

Sodium-glucose Invokana (Canagliflozin) Not studied in lactating mothers, not recommended because of the risk to
cotransporter 2 developing kidneys
inhibitors

Farxiga (Dapagliflozin) Not studied in lactating mothers and not likely to transfer into breast milk at
significant concentration. Alternative treatment is preferred because of risk to
infant's developing kidneys.

Jardiance (Empagliflozin) Not studied in lactating mothers and not likely to transfer into breast milk at
significant concentration. Alternative treatment is preferred because of risk to
infant's developing kidneys.

DPP-4i Januvia (Sitagliptin) Not studied in lactating mothers and not likely to transfer into breast milk at
significant concentration. Alternative treatment is preferred because of risk to
infant's developing kidneys.

Onglyza (Saxagliptin) Not studied in lactating mothers; shorter half life than other DPP-4i, so may be
better choice. However, not preferred while breastfeeding newborn or preterm
infant. It is recommended to monitor infant's blood glucose.

Tradjenta (Linagliptin) Not studied during lactation but unlikely to pass into breast milk. Monitor infant
for signs of hypoglycemia (poor feeding, excessive sleep, jitteriness, cyanosis,
seizures, apnea, or hypothermia). Alternate drug is preferred in newborns and
preterm infants.

AGi Precose (Acarbose) Limited data show that it is unlikely to be detectable in infants and unlikely to
affect breastfed infants

Glyset (Miglitol) Limited data on breastfeeding safety, yet unlikely to cause adverse effects in
newborn because it is poorly absorbed orally.

Note: From U.S. National Library of Medicine. (2018). TOXNET: Toxicology Data Network. Retrieved from https://toxnet.nlm.nih.gov/). This table displays common
antidiabetic agents and generic and brand names that are used to treat diabetes. The corresponding antidiabetic class and lactation safety are included.
AGi = alpha-glucosidase inhibitor; DPP-4 = dipeptidyl peptidase 4 inhibitor; GLP-1 = glucagon-like peptide-1 receptor agonist.

Case findings retinopathy, neuropathy, renal failure, and insulin de-

J.L.C. was educated on the risk factors for developing PPD,
which include life changes, hormonal fluctuations, sleep
deprivation, pain, low self-esteem toward motherhood or
body image, and relationship strain. She was also edu-
cated on the importance of seeking immediate medical
help when feeling suicidal, homicidal, or an urge to harm
her baby. She understood that some symptoms may im-
prove within 1 or 2 weeks after starting sertraline, but
most symptoms do not subside until she continues the
medication for 4–6 weeks. She also understood that the
lack of glycemic control over time can lead to complica-
tions such as hypertension, abnormal lipid profiles,
pendence. The possible benefits of adding cinnamon to
her meal plan were explained to her because cinnamon
could create greater insulin sensitivity, lower blood glu-
cose levels 2 hours after meals, and improve HbA1c and
fasting insulin (Arcangelo et al., 2017; Zare, Nadjarzadeh,
Zarshenas, Shams, & Heydari, 2018). Research outcomes
have been inconclusive, but cinnamon supplementation
could result in a reduction of 18–30 percent in fasting
glucose, with a decrease in triglycerides and low-density
lipoproteins, too (Arcangelo et al., 2017). Zare et al. (2018)
noted that cinnamon’s most significant effect on glycemic
outcomes is in people with a BMI of 27 or greater.

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 Clinical and Case Study Article
Figure 2. Edinburgh Postnatal Depression Scale completed by
the patient portrayed in this case study at the follow-up visit.
The patient’s answers are indicated by red font and are pertinent
to the past 7 days.
The patient was asked to return after 1 week for a
blood pressure recheck and reevaluation of preeclamptic
laboratory workup. Vital signs were oral temperature 97.8,
blood pressure 129/86, heart rate 75, respiratory rate 16,
height 5’5”, and weight 218 lbs. Her laboratory results were
getting closer to the reference range. However, the pa-
tient reported the same depressive symptoms that exis-
ted before treatment. Fortunately, breastfeeding has
been still going well, and she reported compliance with
the medication regimen. Her blood sugar levels were
recorded and were submitted in her next visit three weeks
later.
Three weeks later, her vital signs were oral tempera-
ture 97.8, blood pressure 119/79, heart rate 72, respiratory
rate 16, height 5’5”, and weight 210 lbs. She reported a
lower frequency of crying and felt more useful now, but
she still felt the depression compared with her baseline.
Her Edinburgh PPD screen was 12 (Figure 2). She was taking
sertraline every morning and had no diabetic symptoms.
It is observed that she felt optimistic, less thirsty at nights,
no headaches, less frequent urination, and no edema.
282 March 2020 · Volume 32 · Number 3
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Postpartum problems in primary care
She reported that she had been enjoying cooking healthy
meals at home with her husband and having leftovers
available for lunch during the day. She was recom-
mended for a follow-up after 1 month and was encour-
aged to reach the NP with any questions or concerns.
Conclusion
Women who are hyperglycemic during pregnancy have a
greater chance of developing PPD. It is important to
frequently monitor postpartum diabetic patients who
have a limited medical and prenatal history, set appro-
priate patient-centered goals, and initiate pharmaco-
therapy when needed. Previous studies have
demonstrated that most SSRIs are effective in treating
PPD and safe for use while breastfeeding. In patients
with a history of gestational diabetes and continued
hyperglycemia with symptoms, initiation of metformin is
considered a first-line treatment with the education on
lifestyle modification. With time, increased activity, and
diet modification, patients with postpartum with hy-
perglycemia and depression can achieve optimal health
outcomes and a healthy close maternal-infant
relationship.
Authors’ contributions: J. P. Cabrera is responsible for
manuscript conception, intellectual content, and final
draft approval and is accountable for all aspects of
manuscript development.
Competing interests: The author reports no conflicts of
interest.
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