Pregnancy in Women with Severe Eating Disorders

Pregnancy & Eating Disorders

At least 5% of women have an eating disorder during pregnancy, which can affect pre-pregnancy body mass index (BMI) and weight gain during pregnancy. Small studies have suggested that pregnancy is a high-risk period for eating disorder relapse, while others have suggested disordered eating behaviors stop but continue postpartum.

Weight gain and the natural changes in body shape that occur during pregnancy can be very triggering for patients and exacerbate disordered eating behaviors. Trying to become pregnant or difficulty carrying to term are also two situations where women may come to terms with the severity and impact of their eating disorder.

Eating Disorders & Fertility

Malnutrition can cause hormonal changes that impact reproductive health and sex hormones. Women may lose their menses, experience irregular menstruation or not ovulate.

Amenorrhea

Amenorrhea is a common occurrence in patients with a history of anorexia nervosa, affecting between 66-84% of women with anorexia nervosa and 7-40% of women with bulimia nervosa.

Many patients become concerned about their fertility because they experienced amenorrhea (loss of menses). However, in patients with eating disorders, amenorrhea primarily occurs due to low body weight and the resulting hormonal changes, rather than primary dysfunction of the ovaries or uterus. Patients can expect to regain their menses with adequate weight gain and refeeding.

Long-Term Fertility

Malnutrition, loss of menstrual cycle and/or irregular menses can make family planning more difficult. Fortunately, research suggests that anorexia nervosa does not permanently affect fertility, given patients undergo appropriate eating disorder treatment and weight restoration. Recovered patients do not significantly differ from their peers in regard to fertility.

Additionally, unplanned pregnancies and delays in the diagnosis of pregnancies are more common in women with anorexia nervosa, which may be explained by patient misunderstandings about fertility and eating disorders, given that ovulation (egg release from the ovary) can still occur without menstruation.

Eating Disorders & Pregnancy Complications

Malnutrition or poor or inadequate nutrition during the perinatal period can contribute to complications with fertility, conception, placenta development, embryonic and fetal development and fetal size, as well as miscellaneous perinatal complications.

Delivery Complications

Women with a history of hospitalization due to anorexia nervosa are more likely to experience delivery complications, including an increased likelihood of premature birth and cesarean section.Those with the highest risk of premature birth are women with anorexia nervosa (60%), followed by unspecified ED (40%) and bulimia (40%). Mothers with bulimia were at the greatest risk for very premature birth, at 70%.

Maternal eating disorders are also associated with premature contractions, short duration of first stage of labor and labor induction.

Maternal Medical Complications

While medical complications from an active eating disorder will continue during pregnancy, there are a select few medical complications that occur or worsen during pregnancy.

Hyperemesis Gravidarum

Hyperemesis gravidarum consists of excessive vomiting and nausea in pregnancy. Research suggests that a bidirectional relationship exists eating disorders and hyperemesis gravidarum--an active eating disorder predisposes to an increased risk of developing hyperemesis gravidarum, and women who experience hyperemesis gravidarum are more likely to develop an eating disorder after pregnancy. However, another study found that all eating disorder subtypes were twice as likely to suffer from hyperemesis gravidarum, but when controlled for anxiety or depression, this increased risk was no longer significant.

Anemia

Women with eating disorders are also more likely to experience anemia during pregnancy. Anemia during pregnancy occurs because blood volume increases and the body uses iron to produce more blood to deliver oxygen to the fetus, necessitating a higher iron intake. An existing lack of dietary intake of iron may exacerbate anemia during pregnancy.

Severe iron deficiency during pregnancy increases the risk of:

• Placental abruption
• Preterm birth
• Severe postpartum hemorrhage
• Fetal malformation
• Maternal shock
• ICU admission
• Maternal death
• Fetal growth restriction
• Stillbirth

Antepartum Hemorrhaging

Women with an active anorexia disorder were at a 60% increased risk for antepartum hemorrhage (bleeding during pregnancy), mostly caused by a low-lying placenta, abruptio placentae (separation of the placenta before birth) and unspecified bleeding. Risk was highest among patients with active eating disorders, but women who hadn’t been treated for an eating disorder in over a year before conception also showed greater risk of complications than those without a history of an eating disorder diagnosis.

Fetal Growth Restriction

Features of eating disorders, such as chronic malnutrition and maternal low body weight, can cause fetal malnutrition and impact development. Maternal body size, diet and nutrition state before and during pregnancy have been found to consistently impact fetal health.

Chronic malnourishment can cause the fetus to develop chronic fetal growth restriction (FGR), formally known as intrauterine growth restriction (IUGR), which is when a fetus is smaller than expected its gestational age. The fetus adapts to low nutrition intake by increasing peripheral insulin sensitivity for glucose utilization, decreasing insulin sensitivity for protein synthesis in muscle, decreasing pancreatic development, and increasing hepatic glucose production.

Growth restriction occurs as an adaptation to a low nutrient intake. The fetus prioritizes survival over growth, expending more energy to maintain the brain and energy-dependent basal metabolic functions than for growth of subcutaneous tissue, muscle and bone.

FGR can cause low birth weight, stunting, wasting, low blood sugar, low body temperature, high red blood cell count, micronutrient deficiencies and difficulty fighting infections. Inadequate nutrition is also associated with smaller brain size, reduced neuronal development and impairments in cognition, behavior and motor capacity in childhood. Fortunately, targeted nutrition intervention during key periods of early development can improve these outcomes.

There are no treatments or nutritional interventions for FGR, therefore the focus should be on nutrition support prior to pregnancy. It’s also important to look at history of eating disorder within the last two years, as low birth weight and small-for-gestational age weights were also higher in infants of women who have been hospitalized for anorexia nervosa within two years of delivery.

Neonatal Medical Complications

Maternal eating disorders can impact an infant postpartum, increasing their risk of being low weight, premature and medically fragile.

Low Weight & Medical Fragility

Maternal eating disorders are associated with lower birth weights, likely caused by low pre-pregnancy BMI. Lower birth weights are associated with difficulty eating, gaining weight, fighting infections and regulating temperature. If infants are premature, it also puts them at risk for a host of complications due to their prematurity. Maternal eating disorders can also cause very low Apgar scores at 1 minute, resuscitation of the infant and perinatal death.

Microcephaly

Additionally, anorexia nervosa, bulimia nervosa and OSFED all increase the likelihood of microcephaly (smaller head than expected), likely caused by limited fetal growth due to maternal malnutrition.¹³ Infants with microcephaly are like to suffer from other complications, which are often dependent on the severity of the microcephaly, such as:

• Seizures
• Developmental delay
• Intellectual disability
• Problems with movement and balance
• Feeding problems, such as difficulty swallowing
• Hearing loss
• Vision problems

Eating Disorders Postpartum

Studies show that many women with eating disorders experience a decrease in disordered eating symptomology during pregnancy, but symptoms often become worse during the postpartum period. Additionally, while some women maintain remittance at 18 and 36 months postpartum, a significant portion do not.

Changes in body shape or weight after pregnancy can be triggering and patients may experience more anxiety or body image disturbance related to their postpartum body. Stress from caring for an infant, routine disruption and little time for self-care may also exacerbate disordered eating behaviors.

Women with eating disorders are also more likely to report difficulty to adjusting to postpartum life, with 50% of them seeking out psychiatric care during this time.

Peripartum Depression & Eating Disorders

Eating disorder symptoms during pregnancy put patients at a higher risk of developing peripartum (formerly postpartum) depression (PPD). More severe than postpartum blues, women who struggle with PPD often experience sadness, hopelessness and emptiness. Peripartum depression typically occurs up to a year after birth and between 10-15% of mothers experience PPD every year. PPD may manifest in a number of ways, ranging from:

• Sleep disorders
• Mood swings
• Changes in appetite
• Fear of injury
• Serious concerns about the baby
• Frequent sadness and crying
• Sense of doubt
• Difficulty concentrating
• Lack of interest in daily activities
• Thoughts of death or suicide

PPD occurs within one month before or after delivery. Risk factors for PPD include:

• Major depression disorder during pregnancy
• Anxiety during pregnancy
• History of major depressive disorder (MDD)
• History of moderate to severe premenstrual syndrome (PMS)
• History of PMDD
• High risk pregnancy or postpartum complications
• Stressful life events during pregnancy or soon afterwards
• Poor social support
• Young maternal age

Up to 34% of women with eating disorder may experience peripartum depression and up to 37% of women who experience PPD have a history of an eating disorder. Patients with bulimia nervosa and binge-eating disorder (BED) have been found to have an elevated risk of experiencing peripartum depression, accounting for one third of admissions to perinatal psychiatric clinics. Another study found that a third of patients with bulimia nervosa developed PPD compared to 3-12% in the general population.

The chronic malnutrition and low weight seen in many patients with eating disorders may result in low birth weight infants, which may also increase peripartum depression risk as mothers of infants with very low birth weights have also been shown to be at a higher risk of peripartum depression. Eating disorders also often co-occur with MDD and pregnancy may trigger anxiety in patients, increasing a patient’s risk for PPD.

Management of Eating Disorders in Pregnancy

Pregnancy is associated with a variety of physiological changes, however many of the usual recommendations and guidance for managing care in pregnant patients may not apply to patients with eating disorders. There exists little guidance on the management of pregnancy in active eating disorder patients, with the existing literature primarily focusing on patients with anorexia nervosa. In 2022, the first comprehensive guidelines were released to help providers manage pregnancy for women with anorexia nervosa. Comprehensive guidelines do not exist for the management of pregnancy with other eating disorders.

Preconception Care for Women with Anorexia

Ideally, care for anorexia nervosa should begin prior to pregnancy. Women identified with anorexia nervosa should be offered treatment as soon as possible. In addition to medical treatment, mental health treatment and psychoeducation, all women of childbearing age should receive contraception and pregnancy planning guidance with the intent to optimize physical and mental health status before conception.

Pregnancy Care for Women with Anorexia

Pregnancy can complicate eating disorder treatment, impacting patient monitoring, nutritional rehabilitation and refeeding during pregnancy as well as nutrition and psychiatric care postpartum.

BMI & Weight Gain

During pregnancy, fluid volume increases and placental and fetal weight can vary, making monitoring weight gain increasingly difficult. Weight gain varies greatly amongst individuals during pregnancy and it is difficult to account for weight from fluid, the uterus, placenta and fetus.

While professional organizations have outlined expected weight gain across BMIs during pregnancy, there is no available pregnancy guidance available for individuals with an extremely low weight (BMI ≤15 kg/m²) before or during pregnancy.

Patient Monitoring

Many of the blood markers used to monitor the severity of weight loss are altered by the physiological changes of pregnancy, which needs to be considered when analyzing test results. Aspects of chronic malnutrition also require specific consideration, such as the implications of muscle wasting on labor.

Other factors should be monitored throughout pregnancy include:

• Sodium, potassium, magnesium, phosphate and chloride concentrations
• Iron studies
• Vitamin D and bone mineral density
• Blood sugar concentration (fasting or random) and HbA1c
• Liver function (including bilirubin, aspartate transaminase, alanine aminotransferase and gamma-glutamyl transferase)
• Bone marrow function (including full blood examination, white cell count, neutrophil count, platelets and hemoglobin)
• Inflammatory markers
• Cardiac function (electrocardiogram and echocardiogram)
• Blood pressure and heart rate (lying and standing)
• Body temperature

Nutritional Rehabilitation

During pregnancy, admission should be considered in the context of lack of weight gain or low weight for pregnancy, not only weight loss. A maternal BMI in pregnancy of less than 18 kg/m² with a pre-pregnancy BMI of 18 kg/m² or less should be a consideration for nutritional support.

Nutritional support should also be considered if there is:

• Suboptimal fetal growth
• Clinically significant changes in blood parameters
• Clinically significant changes in physiological markers
• Changes on ECG
• Hypoglycemia

Inpatient medical stabilization may be necessary to facilitate treatment for the effects of starvation, including nutrition rehabilitation, weight restoration, and monitoring for development of refeeding syndrome.

When deciding on the level of care, various factors should be considered, including:

• BMI
• Rate of weight lost or lack of weight gain during pregnancy
• Concerns with fetal growth
• The need to actively monitor medical risk parameters
• Patient’s current overall physical health
• Patient’s specific mental and physical comorbidities
• Frequency of laxative use or other purging behaviors
• Whether family, caregivers or a partner can support a patient and keep them from serious harm

Postpartum Care for Patients with Anorexia Nervosa

Because patients with anorexia are at risk of relapse and PPD, a comprehensive treatment in the postpartum period is necessary to support the healthy development of mother and infant. Treatment should include ongoing eating disorder support and management, breast feeding counseling (if applicable), meal planning, as well as screening and monitoring for depression, anxiety and difficulty parenting.

Parts of postpartum care can be managed by a general practitioner (GP). A GP can monitor weekly blood tests, blood pressure, pulse and temperature for the first 4-6 weeks for signs of nutritional improvement or decline. Frequency can then be reduced as the patient improves.

If a higher level of care is required, given that it is safe and appropriate for the baby to stay with their mother, it is recommended that the mother be admitted to a mother and baby unit. While mother and baby unit services are not accessible to all patients, it is preferable when available to avoid prolonged separation between mother and infant.

Breastfeeding & Nutrition

Breastfeeding can impact nutritional needs postpartum. Patients considering breastfeeding should be referred to a dietitian for ongoing nutritional support postpartum.

Peripartum Depression Treatment

PPD should be addressed in conjunction with an eating disorder. Firstline treatment for peripartum depression includes psychotherapy and antidepressant medication. For patients with mild to moderate peripartum depression, who are breastfeeding or are hesitant about starting psychiatric medication, psychosocial and psychological psychotherapy may be adequate.

For women with moderate to severe PPD, antidepressant drugs are recommended. Selective serotonin reuptake inhibitors (SSRIs) are the most common choice, but serotonin-norepinephrine reuptake inhibitors (SSNRIs) and mirtazapine can be used if SSRIs are ineffective. It is important to discuss the benefits of breastfeeding against the risks of antidepressant use during breastfeeding and the risks of untreated illness with patients who are hesitant about taking antidepressants.

For patients who do not see improvement with psychotherapy or antidepressants, transcranial magnetic stimulation (TMS) or electroconvulsion therapy (ECT) are additional non-pharmacologic treatment options. ECT has been shown to be particularly useful in patients with intent or plans of suicide, infanticide and refusal to eat. For patients with particularly resistant PPD, the intravenous drug brexanolone may be considered.

Pregnancy can be a very anxious time for patients. While preventative care and treatment prior to pregnancy is ideal, many women with eating disorders may experience unplanned pregnancies which necessitate parallel eating disorder and obstetric care.

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