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Pregnancy and Eating Disorders

Reprinted from Eating Disorders Today
By Diane Mickley, MD
Summer 2005 Volume 3, Number 3
©2005 Gürze Books

Eating disorders are common in women of childbearing age. A recent Swedish study of women who had given birth recently found that 11.5 percent had a past or current eating disorder. Anorexia and bulimia can have a powerful impact on fertility, as well as the health of both mother and baby during pregnancy and thereafter. Current research on these topics is limited, and many studies reach conflicting conclusions. Nonetheless, information and guidelines are emerging.

Likelihood of Pregnancy
Fertility is generally compromised in the low weight phase of anorexia nervosa and for some women with bulimia. However, fertility often returns rapidly with recovery, and some women conceive before their first returning menstrual period. In unpublished data from the first thousand patients treated at the Wilkins Center, a majority of sexually active patients with eating disorders had had an unintended pregnancy. The caveat is that women with eating disorders should assume that they are fertile, despite absent or inconsistent menses, and use reliable contraception if they do not wish to become pregnant.

Women who are fully recovered from their eating disorders appear to have the same age at onset of first pregnancy, frequency of pregnancy, and total number of pregnancies. However, a group of patients with mild or ongoing eating disorders experienced fertility problems.

One study at an infertility clinic found that more than half their patients with irregular or absent periods had an eating disorder, often either unrecognized or untreated. It is generally possible (though unwise) to induce pregnancy in these women, and many would prefer fertility treatment to eating disorder treatment. However, most of these women will conceive on their own with normalization of their weight and eating behaviors, and the resulting pregnancies and babies will be safer and healthier this way.

Pregnancy Outcome
The outcome of pregnancy may be compromised in women with active eating disorders, those with subtle eating disorders, and even those who are fully recovered. Risks are minimized by 1) complete absence of disordered eating, including restricting intake or binging and purging, 2) healthy weight before conception, and 3) prompt and desirable weight gain during pregnancy.

Complications commonly reported in studies of pregnancy in women with past or active eating disorders include higher rates of miscarriage, morning sickness, preterm delivery, and cesarean section. Fetal complications include intrauterine growth retardation, babies who are premature or small for gestational age, and newborns with low birth weights, smaller head circumferences, and /or low Apgar scores.

Pregnancy may have a positive or negative impact on a womanÕs eating disorder. Some studies demonstrate increased body satisfaction, while others describe greater discomfort. One study reported a subset of women who relapsed in their disordered eating, while another concluded that both anorexic and especially bulimic symptoms often lessen during pregnancy.

Despite the profound implications of an eating disorder on pregnancy outcome, research shows that few women disclose this information to their obstetrician. In addition, most health care providers do not screen for eating disorder symptoms or history during routine prenatal care.

Postpartum
The most common risk following childbirth is a very high incidence of postpartum depression, which may occur in up to 30 percent of women with a history of an eating disorder. For those with active eating disorders, some women whose bulimia improved during pregnancy may continue to be less symptomatic but many tend to relapse. Anorexics whose symptoms improved during pregnancy are generally back to their baseline difficulties in less than a year.

Parenting may present special challenges, especially regarding feeding. New moms with a past eating disorder are less likely to breast-feed their newborns, and may do so for a shorter length of time. Fewer positive maternal responses during mealtimes have been observed once babies are older.

Medication
Many women with active or past eating disorders take psychotropic medication. Ideally, medication can be discontinued during pregnancy, at least for the first trimester. However, it is crucial to protect the mother's emotional health. Depression, unmanageable anxiety, or other psychiatric difficulties in pregnancy can have a negative impact on the fetus, perhaps because of associated high cortisol levels.

Medication during pregnancy can be looked at in phases. During the 6 to 12 months before a planned pregnancy, medication can be tapered or changed to drugs that are safer during pregnancy. Fluoxetine (Prozac) is widely used during pregnancy and studies have been done on babies with in utero exposure showing normal physical, intellectual, and emotional well-being up to 6 years of age. An unintended pregnancy may require immediate discontinuation of medication that may be harmful to the baby, as well as a decision on whether to substitute a safer alternative. While the hormone surge of early pregnancy lifts the mood of some women, others will experience psychological symptoms that require ongoing management.

As delivery approaches, additional decisions arise. Women on medication during pregnancy will have to consider whether an adjustment is needed to minimize discontinuation of symptoms after delivery.

In addition, because of the high rate of postpartum depression, all women with a history of anorexia or bulimia should discuss the possibility of taking antidepressant medication immediately upon delivery with a physician experienced in managing eating disorders. Medications (such as paroxetine) are available that are not excreted in breast milk and can be used even during nursing. When no longer breast-feeding, a woman may reassess her options from a wider range of choices.

5 Tips for a Healthy Pregnancy
1. Get well first. Strive for complete resolution of symptoms before conception: a fully adequate weight, including a BMI over 19, spontaneous menstrual periods, and total absence of binges or any form of purging.
2. Discuss your intentions of pregnancy with your physician and develop a plan for your medication.
3 . Choose aknowledgeable obstetrician. Notify him or her of your eating disorder status and your eagerness to have special care for the added risks involved.
4. Work with an experienced nutritionist to ensure ideal weight gain throughout the pregnancy.
5. Collaborate with an eating disorder specialist to anticipate and manage the special challenges of pregnancy and parenting.

Additional Resources:
Basic Facts About Eating Disorders
Betwixt and Be'Tween: Puberty and Body Image
Big Fat Lies
Binge Eating and Substance Abuse
Black-and-White vs. Rainbow Thinking