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Managing Eating Disorders in Pregnancy

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Managing Eating Disorders in Pregnancy Eating for 2: Managing eating disorders in pregnancy Clinician knowledge of complications and risks specific to disordered eating and pregnancy can affect outcomes for both mother and baby Gianna Wilkie, MD; Leena Mittal, MD; and Nicole Smith, MD, MPH ating disorders affect nearly 1% of Patients with anorexia nervosa often restrict US adults,1 and disordered eating, food intake and have compulsive rituals E or unspecified eating disorder, affects around eating and exercise, leading to weight at least 1% of all pregnancies.2 Among loss and starvation.4 739 pregnant women assessed with the Bulimia nervosa is marked by intensive Eating Disorder Diagnostic scale, 7.5% of dieting, uncontrolled episodes of overeating, patients met criteria for an eating disorder, and compensatory behaviors.4 Compensa- with 8.8% of women reporting binge eat- tory behaviors include self-induced vomiting; ing and 2.3% of pregnant women engaging excessive exercise; and misuse of laxatives, IN THIS in regular compensatory behaviors. In fact, diuretics, or other medications. ARTICLE 23.4% of the study population expressed Binge eating disorder is classified as recur- concerns about pregnancy-related weight rent episodes of uncontrolled overeating Maternal and fetal gain and body shape.3 Eating disorders dur- without compensatory purging behaviors, 4 complications ing pregnancy are more common than previ- leading to excessive weight gain. ously thought, and they create unique clinical page 23 challenges for obstetric providers. Eating disorders and pregnancy Overall Types of eating disorders Pregnancy can impact the course of pre- management There are 3 major types of eating disorders: existing eating disorders, and women also strategy anorexia nervosa, bulimia nervosa, and binge can develop symptoms of eating disorders for page 24 eating disorder, with significant fluidity exist- the first time during pregnancy. This is clini- ing between all 3 conditions. cally significant as there are both maternal Postpregnancy Anorexia nervosa is a condition in which an and fetal consequences to a mother’s disor- concerns individual believes he or she is significantly dered eating. page 25 overweight despite being underweight. The risks of anorexia nervosa include vitamin deficiencies (vitamin B12/folate), dehydration leading to renal injury and elec- Dr. Wilkie is Clinical Fellow, Department of Obstetrics, trolyte imbalances, hypoglycemia, abnormal Gynecology and Reproductive Biology, Brigham lipid profiles, cardiac arrhythmia, and even and Women’s Hospital, Boston, Massachusetts death. The mortality rate of patients with Dr. Mittal is from the Department of Psychiatry, Brigham and Women’s Hospital anorexia nervosa may approach 10%; how- ever, death during pregnancy is quite rare.2 Dr. Smith is from the Division of Maternal Fetal Medicine, Department of Obstetrics and Bulimia nervosa also carries the risks of pro- Gynecology, Brigham and Women’s Hospital tein and vitamin deficiencies, hypoglycemia The authors report no financial relationships relevant to this and hyperglycemia, and death, with mortality article. estimated at 7% for those with a 5-year history 22 OBG Management | January 2020 | Vol. 32 No. 1 mdedge.com/obgyn FAST TRACK The nausea of pregnancy can of the illness. However, death in pregnancy psychiatric conditions. In fact, 30% to 40% serve as a trigger due to the condition is again quite rare.5 of women with an eating disorder develop for women with a Eating disorders can cause significant symptoms of postpartum depression.8 history of purging maternal and fetal complications during Fetal risks and complications. Excessive behaviors pregnancy and postpartum. caloric restriction and dieting can lead to folate Maternal complications. When women deficiency, which in turn increases the risk with eating disorders become pregnant, they of neural tube defects. Such defects are more have increased risks of some pregnancy com- common among women with eating disor- plications. Approximately 10% to 25% of preg- ders.9 Intrauterine growth restriction also can nant women with eating disorders develop be a concern, most likely because of maternal hyperemesis gravidarum.6 The nausea can malnutrition and poor maternal weight gain.10 serve as a trigger for a woman with an eating In addition, women with eating disorders are disorder, particularly among women with a more likely to have a preterm delivery or expe- history of purging behaviors. rience perinatal mortality or stillbirth.10 Cesarean delivery is more common Bulimia nervosa is associated with low among women with eating disorders, which birthweight, while anorexia nervosa is asso- may be due to preexisting fetal compromise, ciated with the very premature birth, low leading to poor tolerance of labor, or to clini- birthweight, and perinatal death.11 Eating dis- cians perceiving these pregnancies as higher orders during pregnancy can have long-term risk.7 psychological impacts on children, including It is well known that eating disorders are increased likelihood of childhood hyperac- 12 ILLUSTRATION: JOHN J. DENAPOLI / IMAGE: SPEEDKINGZ/SHUTTERSTOCK ILLUSTRATION: highly comorbid with depression and other tivity, conduct, and adjustment disorder. CONTINUED ON PAGE 24 mdedge.com/obgyn Vol. 32 No. 1 | January 2020 | OBG Management 23 Eating for 2: Managing eating disorders in pregnancy CONTINUED FROM PAGE 23 improve maternal and fetal outcomes. Care How to start a conversation with a patient once teams should include obstetricians or mater- you suspect an eating disorder nal-fetal medicine clinicians experienced in caring for patients with eating disorders, psy- When a patient presents showing concerning signs or symptoms chiatrists, psychologists, nutritionists, and of an eating disorder, it is best to start by giving her a validated social workers. General treatment principles assessment tool. Normalize this questioning as routine amongst require an assessment for appropriate setting populations of obstetric patients. If concerning behaviors are of intervention, which depends on presenta- identified, it is best to have an open and honest conversation with tion severity, assessment of nutritional status, the patient about her history and current disordered eating behaviors, treatment of psychiatric comorbidity, and including restrictive, binging, or purging. It is also important to address concerns and fears about pregnancy and its associated psychotherapeutic intervention. triggers. If patients are willing to accept care, it is best to connect them with a multidisciplinary treatment team, including psychiatry, nutrition, obstetrics, and social work. Overall management strategy The initial treatment strategy for preg- nant women with eating disorders should involve evaluating for severe illness and life- Assessing patients for an threatening complications of the specific eating disorder disorder. All patients should be screened for Diagnosis of eating disorders is an interview- suicidal ideation, severe malnutrition, elec- guided process using clinical criteria of the trolyte abnormalities, dehydration, hemo- Diagnostic and Statistical Manual of Mental dynamic instability, and cardiac arrhythmia. Disorders, 5th edition.4 The Eating Disorder Patients with any of these severe features FAST Examination is a semi-structured interview should be admitted for medical hospitaliza- TRACK composed of 4 subsections (restraint, eat- tion and psychiatric evaluation.14 Patients that ing concern, shape concern, and weight are hospitalized should be watched closely for If you suspect an concern). The interview’s aim is to assess refeeding syndrome—potentially life threat- eating disorder, the psychopathology associated with eating ening metabolic disturbances that occur when normalize the disorders, and it is used in research settings nutrition is reinstituted to patients who are questions of rather than clinically. severely malnourished. a validated Clinical diagnosis. The SCOFF questionnaire Patients without severe features or acute assessment is a quick, validated tool that can be used to life-threatening complications can be managed tool (such as clinically assess for an eating disorder.13 It is safely on an outpatient basis with close medi- the SCOFF composed of 5 questions, with a positive test cal monitoring. Psychiatric providers should be questionnaire) as resulting from 2 yes answers: involved to assess for treatment needs includ- routine amongst 1. Do you make yourself sick because you feel ing psychotherapy and psychotropic medi- obstetric patients uncomfortably full? cations. There are numerous pharmacologic 2. Do you worry that you have lost control options available for patients, with the use of over how much you eat? selective serotonin reuptake inhibitors (SSRIs) 3. Have you recently lost more than one stone most common. While SSRI use has been con- (14 lb) in a 3-month period? troversial in pregnancy in the past, the risks of 4. Do you believe yourself to be fat when oth- untreated illness carry risk to the mother and ers say you are too thin? unborn child that outweigh the small risks 5. Would you say that food dominates your associated with SSRI exposure in pregnancy.15 life? Women should have established care with Referral. Patients for whom you have a a nutritionist or dietician who can ensure ade- concern for any eating disorder should be quate counseling regarding meal planning and referred to a psychiatrist for formal diagnosis. multivitamin supplementation. The numerous Integrated multidisciplinary
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