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 often restrict US adults,1 and disordered eating, food intake and have compulsive rituals E or unspecified , 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 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 , 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

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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 .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

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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- , 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 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 care of pregnant food restrictions in pregnancy, such as avoid- patients with eating disorders is necessary to ance of unpasteurized cheese or deli meats,

24 OBG Management | January 2020 | Vol. 32 No. 1 mdedge.com/obgyn may be triggering for many patients with a his- tory of restrictive eating. A case of bulimia prepregnancy One of the greatest difficulties for women with disordered eating in pregnancy revolves A 38-year-old woman (G1) at 32 weeks’ gestation presents for a around weight gain. Many patients find the routine visit. Her bulimia had been in relatively good control until various measurements of pregnancy (mater- the nausea of pregnancy triggered a return to purging behaviors. nal weight gain, fetal weight, fetal heart rate, She reports searching her online medical record for any recording of weights, and has now started restrictive eating because a routine and fundal height) triggering, which can recent growth scan revealed the baby to be in the 80th percentile make appropriate maternal and fetal weight for growth. She is concerned about her mood, and thinks she may gain in pregnancy very challenging. One be depressed. Because her bulimia was present before pregnancy, strategy for managing this includes using fetal during her pregnancy she is followed by a multidisciplinary team, weight and growth as a surrogate for appro- including maternal-fetal medicine, perinatal psychiatry, and nutrition. priate maternal gestational weight gain. One At pregnancy, she elected for outpatient day program management other strategy involves blind weights, where during her pregnancy. the woman is turned away from the scale so her weight is not disclosed to her. Patients often will not be able to achieve the expected women with eating disorders along with 28 to 40 lb of pregnancy weight gain. It is best common misconceptions regarding fertility to have an open, honest conversation in early in the postpartum period increase the risk of pregnancy to discuss how she would like to unplanned pregnancy. address weight in her pregnancy.

Postpregnancy concerns Remain cognizant of eating Patients with eating disorders are at high risk disorders FAST of relapse in the postpartum period, even A clear surveillance plan early in the preg- TRACK if they are able to achieve full remission in nancy that is developed in conjunction with pregnancy. Rapid postpartum weight loss the patient and her care team is crucial in Women with a may be a sign of disordered eating. Postpar- improving maternal and fetal outcomes history of eating tum depression also is a concern, and women among women with an eating disorder. disorders should should be followed closely for surveillance Clinician knowledge of complications and be followed of symptoms. Finally, postpartum contra- risks specific to disordered eating and preg- postpartum for ception is extremely important. The men- nancy can affect outcomes for both mother rapid weight strual irregularities that are common among and baby. loss and signs of depression References 1. Udo T, Grilo CM. Prevalence and correlates of DSM-5-defined 9. Carmichael SL, Shaw GM, Schaffer DM, et al. Dieting eating disorders in a nationally representative sample of U.S. behaviors and risk of neural tube defects. Am J Epidemiol. adults. Biol Psychiatry. 2018;84:345-354. 2003;158:1127-1131. 2. Easter A, Bye A, Taborelli E, et al. Recognising the symptoms: 10. Micali N, Simonoff E, Treasure J. Risk of major adverse how common are eating disorders in pregnancy? Eur Eat perinatal outcomes in women with eating disorders. Br J Disord Rev. 2013;21:340-344. Psychiatry. 2007;190-255. 3. Hudson JI, Hiripi E, Pope HG Jr, et al. The prevalence and 11. Linna MS, Raevuori A, Haukka J. Pregnancy, obstetrics, and correlates of eating disorders in the National Comorbidity perinatal health outcomes in eating disorders. Am J Obstet Survey Replication. Biol Psychiatry. 2007;61:348-358. Gynecol. 2014;211:392.e1-e8. 4. American Psychiatric Association. Diagnostic and Statistical 12. Barona M, Nybo Andersen AM, Micali N. Childhood Manual of Mental Disorders, Fifth Edition (DSM-5). American psychopathology in children of women with eating disorders. Psychiatry Association: Arlington, VA; 2013. Acta Psychiatr Scand. 2016;134:295-304. 5. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on 13. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: bulimia nervosa. Br J Psychiatry. 1999;174:135-140. assessment of a new screening tool for eating disorders. BMJ. 6. Franko DL, Spirrell EB. Detection and management of eating 1999;319:1467. disorders during pregnancy. Obstet Gynecol. 2000;95:942-946. 14. Andersen AE, Ryan GL. Eating disorders in the obstetric 7. Bulik CM, Von Holle A, Siega-Riz AM, et al. Birth outcomes in and gynecologic patient population. Obstet Gynecol. women with eating disorders in the Norwegian Mother and 2009;114:1353-1367. Child Cohort Study. Int J Eat Disord. 2009;42:9-18. 15. Weisskopf E, Fischer CJ, Bickle Graz M, et al. Risk-benefit 8. Mitchell-Gieleghem A, Mittelstaedt ME, Bulik CM. Eating balance assessment of SSRI antidepressant use during disorders and childbearing: concealment and consequences. pregnancy and lactation based on best available evidence. Birth. 2002;29:182. Expert Opin Drug Saf. 2015;14:413-427.

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