Clinical Review

Eating for 2: Managing eating disorders in pregnancy

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Fetal risks and complications. Excessive caloric restriction and dieting can lead to folate deficiency, which in turn increases the risk of neural tube defects. Such defects are more common among women with eating disorders.9 Intrauterine growth restriction also can be a concern, most likely because of maternal malnutrition and poor maternal weight gain.10 In addition, women with eating disorders are more likely to have a preterm delivery or experience perinatal mortality or stillbirth.10

Bulimia nervosa is associated with low birthweight, while anorexia nervosa is associated with the very premature birth, low birthweight, and perinatal death.11 Eating disorders during pregnancy can have long-term psychological impacts on children, including increased likelihood of childhood hyperactivity, conduct, and adjustment disorder.12

How to start a conversation with a patient once you suspect an eating disorder
When a patient presents showing concerning signs or symptoms of an eating disorder, it is best to start by giving her a validated assessment tool. Normalize this questioning as routine amongst populations of obstetric patients. If concerning behaviors are identified, it is best to have an open and honest conversation with the patient about her history and current disordered eating behaviors, including restrictive, binging, or purging. It is also important to address concerns and fears about pregnancy and its associated 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.

Assessing patients for an eating disorder

Diagnosis of eating disorders is an interview-guided process using clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.4 The Eating Disorder Examination is a semi-structured interview composed of 4 subsections (restraint, eating concern, shape concern, and weight concern). The interview’s aim is to assess the psychopathology associated with eating disorders, and it is used in research settings rather than clinically.

Clinical diagnosis. The SCOFF questionnaire is a quick, validated tool that can be used to clinically assess for an eating disorder.13 It is composed of 5 questions, with a positive test resulting from 2 yes answers:

  1. Do you make yourself sick because you feel uncomfortably full?
  2. Do you worry that you have lost control over how much you eat?
  3. Have you recently lost more than one stone (14 lb) in a 3-month period?
  4. Do you believe yourself to be fat when others say you are too thin?
  5. Would you say that food dominates your life?

Referral. Patients for whom you have a concern for any eating disorder should be referred to a psychiatrist for formal diagnosis. Integrated multidisciplinary care of pregnant patients with eating disorders is necessary to improve maternal and fetal outcomes. Care teams should include obstetricians or maternal-fetal medicine clinicians experienced in caring for patients with eating disorders, psychiatrists, psychologists, nutritionists, and social workers. General treatment principles require an assessment for appropriate setting of intervention, which depends on presentation severity, assessment of nutritional status, treatment of psychiatric comorbidity, and psychotherapeutic intervention.

Overall management strategy

The initial treatment strategy for pregnant women with eating disorders should involve evaluating for severe illness and life-threatening complications of the specific disorder. All patients should be screened for suicidal ideation, severe malnutrition, electrolyte abnormalities, dehydration, hemodynamic instability, and cardiac arrhythmia. Patients with any of these severe features should be admitted for medical hospitalization and psychiatric evaluation.14 Patients that are hospitalized should be watched closely for refeeding syndrome—potentially life threatening metabolic disturbances that occur when nutrition is reinstituted to patients who are severely malnourished.

Patients without severe features or acute life-threatening complications can be managed safely on an outpatient basis with close medical monitoring. Psychiatric providers should be involved to assess for treatment needs including psychotherapy and psychotropic medications. There are numerous pharmacologic options available for patients, with the use of selective serotonin reuptake inhibitors (SSRIs) most common. While SSRI use has been controversial in pregnancy in the past, the risks of untreated illness carry risk to the mother and unborn child that outweigh the small risks associated with SSRI exposure in pregnancy.15

Women should have established care with a nutritionist or dietician who can ensure adequate counseling regarding meal planning and multivitamin supplementation. The numerous food restrictions in pregnancy, such as avoidance of unpasteurized cheese or deli meats, may be triggering for many patients with a history of restrictive eating.

One of the greatest difficulties for women with disordered eating in pregnancy revolves around weight gain. Many patients find the various measurements of pregnancy (maternal weight gain, fetal weight, fetal heart rate, and fundal height) triggering, which can make appropriate maternal and fetal weight gain in pregnancy very challenging. One strategy for managing this includes using fetal weight and growth as a surrogate for appropriate maternal gestational weight gain. One other strategy involves blind weights, where 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 28 to 40 lb of pregnancy weight gain. It is best to have an open, honest conversation in early pregnancy to discuss how she would like to address weight in her pregnancy.

A case of bulimia prepregnancy
A 38-year-old woman (G1) at 32 weeks' gestation presents for a routine visit. Her bulimia had been in relatively good control until the nausea of pregnancy triggered a return to purging behaviors. She reports searching her online medical record for any recording of weights, and has now started restrictive eating because a routine recent growth scan revealed the baby to be in the 80th percentile for growth. She is concerned about her mood, and thinks she may be depressed. Because her bulimia was present before pregnancy, during her pregnancy she is followed by a multidisciplinary team, including maternal-fetal medicine, perinatal psychiatry, and nutrition. At pregnancy, she elected for outpatient day program management during her pregnancy.

Continue to: Postpregnancy concerns...

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