Fertility and prenatal attitudes towards pregnancy in women with eating disorders: results from the Avon Longitudinal Study of Parents and Children

Medication Use before, during, and after Pregnancy among Women with Eating Disorders: A Study from the Norwegian Mother and Child Cohort Study

INTRODUCTION

Little is known about medication use among women with eating disorders in relation to pregnancy.

AIMS

To explore patterns of and associations between use of psychotropic, gastrointestinal and analgesic medications and eating disorders in the period before, during and after pregnancy.

METHOD

This study is based on the Norwegian Mother and Child Cohort Study (MoBa). A total of 62,019 women, enrolled at approximately 17 weeks' gestation, had valid data from the Norwegian Medical Birth Registry and completed three MoBa questionnaires. The questionnaires provided diagnostic information on broadly defined anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and recurrent self-induced purging in the absence of binge eating (EDNOS-P), along with self-reported use of medication six months before, during, and 0-6 months after pregnancy.

RESULTS

The prevalence of eating disorder subtypes before and/or during pregnancy was: 0.09% AN (n = 54), 0.94% BN (n = 585), 0.10% EDNOS-P (n = 61) and 5.00% BED (n = 3104). The highest over-time prevalence of psychotropic use was within the AN (3.7-22.2%) and EDNOS-P (3.3-9.8%) groups. Compared to controls, BN was directly associated with incident use of psychotropics in pregnancy (adjusted RR: 2.25, 99% CI: 1.17-4.32). Having AN (adjusted RR: 5.11, 99% CI: 1.53-17.01) or EDNOS-P (adjusted RR: 6.77, 99% CI: 1.41-32.53) was directly associated with use of anxiolytics/sedatives postpartum. The estimates of use of analgesics (BED) and laxatives (all eating disorders subtypes) were high at all time periods investigated.

CONCLUSIONS

Use of psychotropic, gastrointestinal, and analgesic medications is extensive among women with eating disorders in the period around pregnancy. Female patients with eating disorders should receive evidence-based counseling about the risk of medication exposure versus the risk of untreated psychiatric illness during pregnancy and postpartum.

Dysfunctional eating behaviour, psychological well-being and adaptation to pregnancy: A study with women in the third trimester of pregnancy

This study evaluated the prevalence and predictors of dysfunctional eating. Women in the third trimester of pregnancy participated in this study ( N = 105). Dysfunctional eating was associated with a higher body mass index, enhanced negative body image, more somatic symptoms, poorer marital relationships, more negative attitudes regarding pregnancy and the baby and more emotional problems. A higher body mass index prior to the pregnancy, higher weight gain during pregnancy and a more negative perception of body image predicted dysfunctional eating. Clinicians must be aware of the presence of dysfunctional eating during pregnancy to prevent relevant physiological and psychosocial consequences during this stage.

Non-psychotic mental disorders in the perinatal period

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

Functional hypothalamic amenorrhea and its influence on women's health

INTRODUCTION

Functional hypothalamic amenorrhea (FHA) is one of the most common causes of secondary amenorrhea. There are three types of FHA: weight loss-related, stress-related, and exercise-related amenorrhea. FHA results from the aberrations in pulsatile gonadotropin-releasing hormone (GnRH) secretion, which in turn causes impairment of the gonadotropins (follicle-stimulating hormone and luteinizing hormone). The final consequences are complex hormonal changes manifested by profound hypoestrogenism. Additionally, these patients present mild hypercortisolemia, low serum insulin levels, low insulin-like growth factor 1 (IGF-1) and low total triiodothyronine.

AIM

The aim of this work is to review the available data concerning the effects of FHA on different aspects of women's health.

RESULTS

Functional hypothalamic amenorrhea is related to profound impairment of reproductive functions including anovulation and infertility. Women's health in this disorder is disturbed in several aspects including the skeletal system, cardiovascular system, and mental problems. Patients manifest a decrease in bone mass density, which is related to an increase in fracture risk. Therefore, osteopenia and osteoporosis are the main long-term complications of FHA. Cardiovascular complications include endothelial dysfunction and abnormal changes in the lipid profile. FHA patients present significantly higher depression and anxiety and also sexual problems compared to healthy subjects.

CONCLUSIONS

FHA patients should be carefully diagnosed and properly managed to prevent both short- and long-term medical consequences.

Endocrine consequences of anorexia nervosa

Anorexia nervosa is prevalent in adolescents and young adults, and endocrine changes include hypothalamic amenorrhoea; a nutritionally acquired growth-hormone resistance leading to low concentrations of insulin-like growth factor-1 (IGF-1); relative hypercortisolaemia; decreases in leptin, insulin, amylin, and incretins; and increases in ghrelin, peptide YY, and adiponectin. These changes in turn have harmful effects on bone and might affect neurocognition, anxiety, depression, and the psychopathology of anorexia nervosa. Low bone-mineral density (BMD) is particularly concerning, because it is associated with changes in bone microarchitecture, strength, and clinical fractures. Recovery leads to improvements in many--but not all--hormonal changes, and deficits in bone accrual can persist. Oestrogen-replacement therapy, primarily via the transdermal route, increases BMD in adolescents, although catch-up is incomplete. In adults, oral oestrogen--combined with recombinant human IGF-1 in one study and bisphosphonates in another--increased BMD, but not to the normal range. More studies are necessary to investigate the optimum therapeutic approach in patients with, or recovering from, anorexia nervosa.

NURTURE: development and pilot testing of a novel parenting intervention for mothers with histories of an eating disorder

OBJECTIVE

To describe the treatment development and pilot testing of a group parenting intervention, NURTURE (Networking, Uniting, and Reaching out To Upgrade Relationships and Eating), for mothers with histories of eating disorders.

METHOD

Based on focus group findings, extant research, and expert opinion, NURTURE was designed to be delivered weekly over 16 (1.5 h) sessions via an interactive web conferencing forum. It comprises four modules: (1) laying the foundation, (2) general parenting skills, (3) eating and feeding, and (4) breaking the cycle of risk. Pilot testing was conducted with three groups of 3-6 mothers (N = 13) who had children ages 0-3 years to determine feasibility (e.g., retention), acceptability (e.g., feedback questionnaire responses), and preliminary efficacy. Maternal satisfaction with NURTURE and changes in mother-child feeding relationship measures, maternal feeding style, maternal self-efficacy, and maternal psychopathology (eating disorder, depression, and anxiety symptoms) across three time points (baseline, post-treatment, 6-month follow-up) were examined. All outcomes were exploratory.

RESULTS

The intervention was well tolerated with a 100% retention rate. Feedback from mothers was generally positive and indicated that the groups provided an engaging, supportive experience to participants. We observed changes suggestive of improvement in self-reported maternal self-efficacy and competence with parenting. There were no notable changes in measures of maternal feeding style or psychopathology.

DISCUSSION

NURTURE is a feasible, acceptable, and potentially valuable intervention for mothers with eating disorder histories. Results of this pilot will inform a larger randomized-controlled intervention to determine efficacy and impact on child outcomes.

Reproductive health outcomes in eating disorders

OBJECTIVE

Eating disorders are common psychiatric disorders in women at childbearing age. Previous research suggests that eating disorders are associated with fertility problems, unplanned pregnancies, and increased risk of induced abortions and miscarriages. The purpose of this study was to assess how eating disorders are related to reproductive health outcomes in a representative patient population.

METHOD

Female patients (N = 2,257) treated at the eating disorder clinic of Helsinki University Central Hospital during 1995-2010 were compared with matched controls identified from the Central Population Register (N = 9,028). Patients had been diagnosed (ICD-10) with anorexia nervosa (AN), atypical AN, bulimia nervosa (BN), atypical BN, or binge eating disorder (BED, according to DSM-IV research criteria). Register-based data on number of children, pregnancies, childbirths, induced abortions, miscarriages, and infertility treatments were used to measure reproductive health outcomes.

RESULTS

Patients were more likely to be childless than controls [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.62-2.13, p < .001]. Pregnancy and childbirth rates were lower among patients than among controls. BN was associated with increased risk of induced abortion compared to controls (OR 1.85; 95% CI 1.43-2.38, p < .001), whereas BED was associated with elevated risk of miscarriage (OR 3.18; 95% CI 1.52-6.66, p = .002).

DISCUSSION

Reproductive health outcomes are compromised in women with a history of eating disorders across all eating disorder types. Our findings emphasize the importance of reproductive health counseling and monitoring among women with eating disorders.

Fertility treatment, twin births, and unplanned pregnancies in women with eating disorders: findings from a population-based birth cohort

Objective

To investigate fertility treatment, twin births, and unplanned pregnancies in pregnant women with eating disorders in a population-based sample.

Design

A longitudinal population-based birth cohort (Generation R).

Setting

Rotterdam, the Netherlands.

Sample

Women from the Generation R study who reported a history of (recent or past) anorexia nervosa (n = 160), bulimia nervosa (n = 265), or both (n = 130), and a history of psychiatric disorders other than eating disorders (n = 1396) were compared with women without psychiatric disorders (n = 4367).

Methods

Women were compared on the studied outcomes using logistic regression. We performed crude and adjusted analyses (adjusting for relevant confounding factors).

Main outcome measures

Fertility treatment, twin births, unplanned pregnancies, and women's feelings towards unplanned pregnancies.

Results

Relative to women without psychiatric disorders, women with bulimia nervosa had increased odds (odds ratio, OR, 2.3; 95% confidence interval, 95% CI, 1.1–5.2) of having undergone fertility treatment. Women with all eating disorders had increased odds of twin births (anorexia nervosa, OR 2.7, 95% CI 1.0–7.7; bulimia nervosa, OR 2.7, 95% CI 1.1–6.6; anorexia and bulimia nervosa, OR 3.795% CI 1.3–10.7). Anorexia nervosa was associated with increased odds of unplanned pregnancies (OR 1.8, 95% CI 1.2–2.6) and mixed feelings about these pregnancies (adjusted OR 5.0, 95% CI 1.7–14.4). Pre-pregnancy body mass index did not explain the observed associations.

Conclusions

Eating disorders are associated with increased odds of receiving fertility treatment and twin births. Women with anorexia nervosa were more likely to have an unplanned pregnancy and have mixed feelings about the unplanned pregnancy. Fertility treatment specialists should be aware that both active and past eating disorders (both anorexia nervosa and bulimia nervosa) might underlie fertility problems.

Long-term consequences of anorexia nervosa

Anorexia nervosa (AN) is a psychiatric disorder that occurs mainly in female adolescents and young women. The obsessive fear of weight gain, critically limited food intake and neuroendocrine aberrations characteristic of AN have both short- and long-term consequences for the reproductive, cardiovascular, gastrointestinal and skeletal systems. Neuroendocrine changes include impairment of gonadotropin releasing-hormone (GnRH) pulsatile secretion and changes in neuropeptide activity at the hypothalamic level, which cause profound hypoestrogenism. AN is related to a decrease in bone mass density, which can lead to osteopenia and osteoporosis and a significant increase in fracture risk in later life. Rates of birth complications and low birth weight may be higher in women with previous AN. The condition is associated with fertility problems, unplanned pregnancies and generally negative attitudes to pregnancy. During pregnancy, women with the condition have higher rates of hyperemesis gravidarum, anaemia and obstetric complications, as well as impaired weight gain and compromised intrauterine foetal growth. It is reported that 80% of AN patients are affected by a cardiac complications such as sinus bradycardia, a prolonged QT interval on electrocardiography, arrythmias, myocardial mass modification and hypotension. A decrease in bone mineral density (BMD) is one of the most important medical consequences of AN. Reduced BMD may subsequently lead to a three- to seven-fold increased risk of spontaneous fractures. Untreated AN is associated with a significant increase in the risk of death. Better detection and sophisticated therapy should prevent the long-term consequences of this disorder. The aims of treatment are not only recovery but also prophylaxis and relief of the long-term effects of this disorder. Further investigations of the long-term disease risk are needed.

Psychiatric disorders among women and men in assisted reproductive technology (ART) treatment. The Danish National ART-Couple (DANAC) cohort: protocol for a longitudinal, national register-based cohort study

INTRODUCTION

There are complex causal associations between mental disorders, fertility treatment, fertility treatment outcome and infertility per se. Eating disorders cause endocrine disturbances, anovulation and thereby infertility, and research has shown that infertility as well as unsuccessful assisted reproductive technology (ART) treatment are potential risk factors for developing a depression on a long-term basis. Despite the fact that worldwide more than 400 000 ART treatment cycles are performed every year, the causal associations between mental disorders, use of medication for mental disorders and ART treatment in both sexes have only been sparsely explored.

METHOD AND ANALYSIS

The main objective of this national register-based cohort study is to assess women's and men's mental health before, during, and after ART treatment in comparison with the mental health in an age-matched population-based cohort of couples with no history of ART treatment. Furthermore, the objective is to study the reproductive outcome of ART treatment among women who have a registered diagnosis of a mental disorder or have used medication for mental disorders prior to ART treatment compared with women in ART treatment without a mental disorder. We will establish the Danish National ART-Couple (DANAC) cohort including all women registered with ART treatment in the Danish in vitro fertilisation Register during 1994-2009 (N=42 915) and their partners. An age-matched population-based comparison cohort of women without ART treatment (n=215 290) and their partners will be established. Data will be cross-linked with data from national registers on psychiatric disorders, medical prescriptions for mental disorders, births, causes of deaths and sociodemographic data. Survival analyses and other statistical analyses will be conducted on the development of mental disorders and use of medication for mental disorders for women and men both prior to and after ART treatment.

Recognising the symptoms: how common are eating disorders in pregnancy?

OBJECTIVES

This study aimed to investigate eating disorder diagnostic status and related symptoms in early pregnancy.

METHODS

Pregnant women (n=739), attending their first routine antenatal scan, were assessed using an adapted version of the Eating Disorder Diagnostic Scale (EDDS). Prevalence estimates and eating disorder symptoms were assessed during the first 3 months of pregnancy and, retrospectively, in the 6 to 12 months prior to pregnancy.

RESULTS

During pregnancy 7.5% of women met diagnostic criteria for an eating disorder, compared to prepregnancy prevalence of 9.2%. Approximately one quarter (23.4%) of women reported high weight and shape concern during pregnancy; binge eating was endorsed by 8.8%, and 2.3% of women engaged in regular compensatory behaviours.

CONCLUSIONS

Eating disorders are more common than previously thought in pregnancy. There is a clinical need for increased understanding of eating disorder symptomatology during pregnancy and for appropriate screening tools to be incorporated into antenatal care.

Childbearing and mortality among women with anorexia nervosa

OBJECTIVE

To assess the association between childbearing and mortality from anorexia nervosa (AN).

METHOD

A total of 5,251 females, from a population-based Swedish registry, admitted with an AN diagnosis during the period 1973-2003 were included. Standardized mortality ratios (SMR) were estimated and hazard ratios (HR) were calculated using Cox regression.

RESULTS

Nulliparous women had a sixfold higher mortality due to natural causes and ninefold higher mortality due to unnatural causes compared to the general population. Parous women had higher mortality compared to the general population only due to unnatural causes. Suicide was the most common cause of death. Childbearing was associated with a 65% lower mortality. One hundred forty four women out of 1,941 parous women were hospitalized perinatally for any psychiatric disorder (7.4%).

DISCUSSION

Childbearing is associated with lower mortality among women with AN.

Pregnancy outcomes of women with and without a history of anorexia nervosa

BACKGROUND

When women have a history of anorexia nervosa (AN), the advice given about becoming pregnant, and about the management of pregnancies, has usually been cautious. This study compared the pregnancy outcomes of women with and without a history of AN.

METHOD

Women with a confirmed diagnosis of AN who had presented to psychiatric services in North East Scotland from 1965 to 2007 were identified. Those women with a pregnancy recorded in the Aberdeen Maternal and Neonatal Databank (AMND) were each matched by age, parity and year of delivery of their first baby with five women with no history of AN. Maternal and foetal outcomes were compared between these two groups of women. Comparisons were also made between the mothers with a history of AN and all other women in the AMND.

RESULTS

A total of 134 women with a history of AN delivered 230 babies and the 670 matched women delivered 1144 babies. Mothers with AN delivered lighter babies but this difference did not persist after adjusting for maternal body mass index (BMI) in early pregnancy. Standardized birthweight (SBW) scores suggested that the AN mothers were more likely to produce babies with intrauterine growth restriction (IUGR) [relative risk (RR) 1.54, 95% confidence interval (CI) 1.11-2.13]. AN mothers were more likely to experience antepartum haemorrhage (RR 1.70, 95% CI 1.09-2.65).

CONCLUSIONS

Mothers with a history of AN are at increased risk of adverse pregnancy outcomes. The magnitude of these risks is relatively small and should be appraised holistically by psychiatric and obstetric services.

A systematic review of obstetric complications as risk factors for eating disorder and a meta-analysis of delivery method and prematurity

OBJECTIVE

The aim of this study was to systematically review the literature on obstetric factors at birth and their role as risk factors for a subsequent eating disorder (ED) and where possible to perform a meta-analysis of case-control studies of EDs and obstetric complications (OCs).

METHOD

Studies were ascertained by computer searches of electronic databases (Medline, PsycINFO, Web of Science and CINAHL), searches of reference lists and from raw data obtained upon request from the authors. A total of 14 studies were identified for the systematic review, of which 6 were eligible for the subsequent meta-analysis. Of the selected 6 studies, 5 reported on the same OCs, namely vaginal instrumental delivery and prematurity. Accordingly, meta-analyses were run on these two variables. Both analyses were conducted on anorexia nervosa (AN) patients.

RESULTS

Findings from the systematic review were conflicting, with some studies reporting a significant relationship between OCs and ED diagnoses and/or ED symptomatology and others refuting it. A non-significant association of instrumental delivery [pooled odds ratio (OR) 1.06, 95%CI: 0.69, 1.65] and prematurity [pooled OR 1.17, 95%CI: 0.91, 1.52] with AN was revealed in our meta-analysis.

CONCLUSION

The current literature on OCs as risk factors for a later ED is contradictory. The range of different occurrences considered as OCs and methodological limitations hinder ultimate conclusions. Upcoming studies should pool datasets together to obtain sufficient power to assess OCs and EDs in combination.