Birth outcomes in women with eating disorders in the Norwegian Mother and Child cohort study (MoBa)

Impact of Low Maternal Weight on Pregnancy and Neonatal Outcomes

Objective

To examine the effect of underweight maternal body mass index (BMI) on pregnancy complications and neonatal outcomes.

Design

Cohort study.

Setting

Tertiary academic center.

Patients

A total of 16 361 mothers who delivered a singleton between 2015-2021 with either a BMI <18.5 kg/m2 (n = 732) or normal BMI (18.5 ≥ BMI <23 or 25 kg/m2, n = 15 629) at the initial prenatal visit or within 6 months of the initial visit.

Main Outcome Measures

Birthweight, gestational age, neonatal intensive care unit admission, preterm birth, and fetal death; obstetrical complications including preeclampsia/eclampsia, premature rupture of membranes, preterm premature rupture of membranes, and postpartum hemorrhage.

Results

Underweight women were younger and less likely to have private insurance (P < .01 for both) than normal-weight women. Approximately 23% of infants born to underweight mothers were small for gestational age and 15% were low birth weight vs 13.5% and 9% of infants of normal-weight mothers, respectively (P < .01 for both). These differences remained significant after adjusting for potential confounders. In adjusted logistic regression models, underweight women had a decreased risk of premature rupture of membranes and postpartum hemorrhage compared to normal-weight women.

Conclusion

Underweight BMI during pregnancy is associated with an increased risk of small for gestational age and low birth weight infants and a decreased risk of premature rupture of membranes and postpartum hemorrhage. These findings suggest underweight BMI during pregnancy increases the risk of adverse neonatal outcomes, while maternal-related pregnancy outcomes are less affected.

Associations between maternal early pregnancy depression and longitudinal fetal growth

BACKGROUND

The impacts of maternal depression during mid-to-late pregnancy on fetal growth have been extensively investigated. However, the association between maternal depression during early pregnancy and fetal intrauterine growth are less clear.

METHODS

A prospective study comprised 23,465 eligible pregnant women and their offspring was conducted at a hospital-based center in Shanghai. Prenatal depression was assessed used using Patient Health Questionnaire (PHQ-9) before 14 gestational weeks. Differences in fetal growth trajectory of different maternal depressive statuses during three periods (16-23, 24-31, and 32-41 gestational weeks) were compared using a multilevel model with fractional polynomials.

RESULTS

Women with depressive symptoms during early pregnancy had higher longitudinal fetal trajectories, with an estimated increase in fetal weight (β = 0.33; 95 % CI, 0.06-0.61), compared to those without depressive symptoms. Increases in fetal abdominal circumference among women with depressive symptoms were observed before 23 gestational weeks. Offspring born to mothers with early pregnancy depression had a significantly higher birth weight of 14.13 g (95 % CI, 1.33-27.81 g) and an increased risk of severe large size for gestational age (adjusted odds ratio [aOR], 1.64; 95 % CI, 1.32-2.04) and macrosomia (aOR, 1.21; 95 % CI, 1.02-1.43).

LIMITATIONS

Self-rated scale was used to assess depressive symptoms rather than clinical diagnosis. And Long-term effects of early pregnancy depression on offspring were not explored.

CONCLUSIONS

The study revealed an association between maternal depression during early pregnancy and increased fetal biometrics, higher birth weight, and an elevated risk of severe large size for gestational age and macrosomia.

Adverse live-born pregnancy outcomes among pregnant people with anorexia nervosa

BACKGROUND

Previous findings related to the association of adverse pregnancy outcomes with anorexia nervosa are mixed.

OBJECTIVE

This study aimed to investigate the association of adverse live-born pregnancy outcomes with anorexia nervosa using adjustment modeling accounting for confounding factors, and a mediation analysis addressing the contribution of underweight prepregnancy body mass index and gestational weight gain to those outcomes.

STUDY DESIGN

The sample included California live-born singletons with births between 2007 and 2021. The administrative data set contained birth certificates linked to hospital discharge records. Anorexia nervosa diagnosis during pregnancy was obtained from International Classification of Diseases codes on hospital discharge records. Adverse pregnancy outcomes examined included gestational diabetes, gestational hypertension, preeclampsia, anemia, antepartum hemorrhage, premature rupture of membranes, premature labor, cesarean delivery, oligohydramnios, placenta previa, chorioamnionitis, placental abruption, severe maternal morbidity, small for gestational age, large for gestational age, low birthweight, and preterm birth (by timing and indication). Risk of each adverse outcome was calculated using Poisson regression models. Unadjusted risk of each adverse outcome was calculated, and then the risks were adjusted for demographic factors. The final adjusted model included demographic factors, anxiety, depression, substance use, and smoking. A mediation analysis was performed to estimate the excess risk of adverse outcomes mediated by underweight prepregnancy body mass index and gestational weight gain below the American College of Obstetricians and Gynecologists recommendation.

RESULTS

The sample included 241 pregnant people with a diagnosis of anorexia nervosa and 6,418,236 pregnant people without an eating disorder diagnosis. An anorexia nervosa diagnosis during pregnancy was associated with many adverse pregnancy outcomes in unadjusted models (relative risks ranged from 1.65 [preeclampsia] to 3.56 [antepartum hemorrhage]) in comparison with people without an eating disorder diagnosis. In the final adjusted models, birthing people with an anorexia nervosa diagnosis were more likely to have anemia, preterm labor, oligohydramnios, severe maternal morbidity, a small for gestational age or low-birthweight infant, and preterm birth between 32 and 36 weeks with spontaneous preterm labor (adjusted relative risks ranged from 1.43 to 2.55). Underweight prepregnancy body mass index mediated 7.78% of the excess in preterm births and 18.00% of the excess in small for gestational age infants. Gestational weight gain below the recommendation mediated 38.89% of the excess in preterm births and 40.44% of the excess in low-birthweight infants.

CONCLUSION

Anorexia nervosa diagnosis during pregnancy was associated with a number of clinically important adverse pregnancy outcomes in comparison with people without an eating disorder diagnosis. Adjusting for anxiety, depression, substance use, and smoking during pregnancy decreased this risk. A substantial percentage of the excess risk of adverse outcomes was mediated by an underweight prepregnancy body mass index, and an even larger proportion of excess risk was mediated by gestational weight gain below the recommendation. This information is important for clinicians to consider when caring for patients with anorexia nervosa. Considering and treating anorexia nervosa and comorbid conditions and counseling patients about mediating factors such as preconception weight and gestational weight gain may improve live-born pregnancy outcomes among people with anorexia nervosa.

Management of eating disorders during pregnancy: A survey of Australian dietitians in clinical practice

BACKGROUND

Eating disorders (EDs) are estimated to affect 5.2%-7.5% of pregnant women, equating to 15,800-23,000 births in Australia annually. In pregnancy, an ED increases the risk of complications for both mother and child. Heightened motivation and increased utilisation of healthcare services during pregnancy present an opportunity to identify and commence ED treatment. Dietetic management of EDs differs from nutrition guidelines for pregnancy. This study aimed to assess current practice, confidence and training needs of dietitians to manage EDs in pregnancy.

METHODS

A cross-sectional survey of Australian dietitians with past year exposure to ED and/or antenatal fields was completed using Microsoft Forms between November 2022 and January 2023.

RESULTS

One hundred and seventeen responses were analysed. Confidence was less for assessment of a woman with an active ED in pregnancy than a pregnant woman with a history of an ED, pregnancy or an ED alone (p < 0.001). Greater than 5 years of experience as a dietitian, but without recent exposure to the patient population, was associated with increased confidence (p < 0.01). Almost half provided descriptions of treatments and interventions used to treat a pregnant woman with an ED, some of which conflict with ED or antenatal guidelines. Dietitians were more likely to weigh a person with an ED in pregnancy. Most respondents indicated further training (93%) and guidelines (98%) would be helpful.

CONCLUSION

This is the first investigation into the dietetic management of EDs in pregnancy, and it highlights a need for guidelines and training for dietitians.

Assessment of eating disorders and depression in postpartum women

OBJECTIVE

To determine the prevalence of eating disorders and orthorexia in postpartum women and examine the relationship with postpartum depression.

STUDY DESIGN

Included in this study were 227 postpartum women. The Eating Attitude Test-26 (EAT-26) was used to determine the risk of eating disorders in the women, followed by the Orthorexia 11 Scale (ORTO-11) to identify orthorexia, and the Edinburgh Postpartum Depression Scale (EPDS) to identify postpartum depression.

RESULTS

63 of the women (27.8%) exhibited an orthorexic tendency, which was also related to eating disorders and postpartum depression. Each one-point increase in the EAT-26 score led to a decrease of 0.32 points in the ORTO-11 score. Similarly, each one-point increase in the EPDS score caused a reduction of 0.18 points in the ORTO-11 score. The ORTO-11 score increased by 0.26 points per each live birth.

CONCLUSION

An obsessive focus on healthful nutrition may result in the impairment of health and numerous adverse psychological and physiological outcomes in the future. Healthy eating habits should be maintained to improve the quality of life without causing an obsession with healthy eating.

Maternal Eating Disorders and Adverse Birth Outcomes: A Systematic Review and Meta-Analysis

Previous systematic reviews have reported on the relationship between eating disorders (EDs) and birth outcomes, but there are no existing meta-analyses on this topic. This systematic review and meta-analysis examines the association between lifetime maternal EDs, including anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) with low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA), large for gestational age (LGA), and miscarriage. Four databases were systematically searched for quantitative literature on maternal EDs that preceded birth outcomes. Eighteen studies met the inclusion criteria and were included in the review. The meta-analyses included 6 studies on miscarriage, 11 on PTB, 4 on LBW, 9 on SGA, and 4 on LGA. The Mantel-Haenszel random effects model was used to test the associations between EDs and birth outcomes. The results showed significant positive associations between AN and LBW (OR 1.74, 95% confidence interval (CI) 1.49, 2.03), AN and SGA (OR 1.39, 95% CI 1.17, 1.65), BN and PTB (OR 1.19, 95% CI 1.04, 1.36), and BED and LGA (OR 1.43 95% CI 1.18, 1.72). EDs were not significantly correlated with miscarriage. These findings reveal the importance of screening for and treating EDs in pregnant women.

Trajectories of severe eating disorders through pregnancy and early motherhood

Background

During pregnancy and early motherhood, risks of relapse and worsening are high for women with a history of eating disorders (EDs), as are adverse sequelae for their babies. However, systematic descriptions of the processes that these women undergo through pregnancy, birth, and early motherhood are lacking, as are good descriptions of the various trajectories these women follow through pregnancy and early motherhood. This study addresses both these knowledge gaps.

Methods

We used a longitudinal research interview design, recruiting a non-clinical sample of 24 women with a history of severe EDs from routine pregnancy controls in five public, local, family health care centers in Norway. The participants were interviewed twice, first during pregnancy and then 4-6 months after delivery. Data were analyzed according to grounded theory. The focus was on modeling the trajectories of EDs through pregnancy, birth, and early motherhood. All the participants were diagnosed (DSM-5) using the Eating Disorder Examination and then completed the Eating Disorder Examination Questionnaire.

Results

Five perceived trajectories through pregnancy and early motherhood were identified: "The mastering mother," in which an ED pathology seems to be absent through pregnancy and early motherhood; "The inadequate mother," in which the ED pathology worsens before pregnancy, through pregnancy, and early motherhood; "The overwhelmed mother," in which the ED worsens during pregnancy and early motherhood; "The depressed mother," in which the ED is put on hold during pregnancy, but worsens in early motherhood; and "The succeeding mother," in which the ED worsens during pregnancy, but reduces in early motherhood.

Discussion

ED trajectories through pregnancy and early motherhood vary greatly among women with a history of EDs. This may indicate different psychological dynamics through these phases. A model with five trajectories captures a large degree of the variation. The model may help clinicians' preparedness when dealing with these patients.

Pregnancy outcomes in women with anorexia nervosa: a population-based study and analysis of a matched cohort

RESEARCH QUESTION

What implications does anorexia nervosa have on pregnancy outcomes in a US population?

DESIGN

A retrospective, population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. A dataset of all deliveries between 2004 and 2014 inclusively was created. The population was divided into women with anorexia nervosa (n = 214) and women without anorexia nervosa (n = 9,096,574), and a cohort matched 1:4 with anorexia nervosa for age, race, medical insurance type and income quartile. Delivery and neonatal outcomes were compared between the two matched groups and with the control group of deliveries. A multivariable logistic regression analysis, controlling for statistically significant baseline characteristics, explored associations between anorexia nervosa and delivery, and neonatal outcomes.

RESULTS

Compared with the entire group, women diagnosed with anorexia nervosa were more likely to be white, smokers, of higher income or diagnosed with another psychiatric disorder. In the unmatched comparison, women with anorexia nervosa had a higher frequency of preterm delivery (adjusted odds ratio [aOR] 2.98 CI 1.86 to 4.76, P < 0.001), placental abruption (aOR 3.41 CI 1.38 to 8.40, P = 0.008) and small for gestational age (SGA) neonates (aOR 5.32 CI 3.12 to 9.09, P < 0.001). In the matched comparison, preterm delivery (aOR 5.31, CI 3.02 to 9.32, P < 0.001) and SGA neonates were significantly higher in the anorexia nervosa group (aOR 4.69 CI 2.6 to 8.41, P < 0.001), providing results similar to the unmatched comparison.

CONCLUSION

Healthcare providers, specifically fertility specialists, should be aware of the magnitude of adverse outcomes related to pregnancy in women with anorexia nervosa.

Comparison of the burden of anorexia nervosa in the Middle East and North Africa region between 1990 and 2019

BACKGROUND

Anorexia nervosa (AN) is a complex and heritable psychiatric disorder, which imposes significant mortality and morbidity on sufferers globally. We aimed to report the prevalence, incidence and disability-adjusted life-years (DALYs) attributable to AN in the Middle East and North Africa (MENA) region by age, sex and socio-demographic index (SDI), between 1990 and 2019.

METHODS

The disease burden attributable to AN was obtained for the 21 countries located in the MENA region between 1990 and 2019 using publicly available data from the Global Burden of Disease (GBD) 2019 study. All estimates were provided as counts and age-standardized rates per 100,000 population, along with 95% uncertainty intervals (UIs).

RESULTS

In 2019, the estimated age-standardised point prevalence and incidence rate of AN (per 100,000) in MENA were 49.3 (95% UI: 34.6-70.4) and 16.0 (11.3-22.0), which were 11.4% (7.3-15.4) and 5.9% (2.6-9.1) higher than in 1990, respectively. Furthermore, the regional age-standardised DALY rate was 10.6 (6.3-17.0) per 100,000 in 2019, which was 11.8% (5.2-19.1) higher than in 1990. In 2019, Kuwait [17.3 (10.3-27.9)] and Afghanistan [6.3 (3.7-10.3)] had the highest and lowest age-standardised DALY rates, respectively. In addition, Iran showed the largest increases in the age-standardised point prevalence [30.0% (24.1-36.2)], incidence [24.6% (18.6-30.4)] and DALY [30.5% (22.6-38.9)] rates between 1990 and 2019. In 2019, the number of prevalent cases and prevalence estimates peaked in the 15-19 age group for males and the 20-24 age group for females, with females having a higher number of cases and prevalence in all age groups. In 2019, the age-standardised DALY rates in MENA were higher than the global rates among males aged 10-34 years, but were lower than the global estimates among females in almost all age groups. In addition, the burden of AN was positively associated with the level of socio-economic development during the measurement period.

CONCLUSIONS

The burden of AN in the MENA region increased between 1990 and 2019, which indicates that it is likely to become a more serious public health issue in the future. Up-to-date information about the epidemiological trends in the region would allow health policymakers to make informed and appropriate decisions to help address this issue. The findings of the present study showed that the point prevalence and incidence rate of anorexia nervosa have increased in the Middle East and North Africa region between 1990 and 2019. The highest burden in 2019 was found in Kuwait, while Afghanistan had the lowest attributable burden. In addition, between 1990 and 2019 Iran had the largest increase in the point prevalence of anorexia nervosa. Also in 2019, anorexia nervosa was more prevalent in females and peaked in the 15-19 age group for males and the 20-24 age group for females. Furthermore, as the level of socioeconomic development increased, so did the burden attributable to anorexia nervosa.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Systematic review and meta-analysis of risk of gestational diabetes in women with preconception mental disorders

There is a well-established bidirectional association between Type 2 diabetes and mental disorder and emerging evidence for an increased risk of perinatal mental disorder in women with gestational diabetes (GDM). However, the relation between mental disorder prior to pregnancy and subsequent risk of GDM remains relatively unexplored. This is a systematic review and meta-analysis of the risk of GDM in women with a range of preconception mental disorders. Peer-reviewed literature measuring odds of GDM and preconception mood, anxiety, psychotic and eating disorders was systematically reviewed. Risk of bias was assessed using a checklist. Two independent reviewers were involved. 22 observational studies met inclusion criteria; most were retrospective cohorts from English speaking, high income countries. 14 studies were at high risk of bias. There was evidence for an increased risk of GDM in women with schizophrenia (pooled OR 2.44; 95% CI 1.17,5.1; 5 studies) and a reduced risk of GDM in women with anorexia nervosa (pooled OR 0.63; 95% CI 0.49,0.80; 5 studies). There was some limited evidence of an increased risk in women with bipolar disorder. There was no evidence for an association with preconception depression or bulimia nervosa on meta-analysis. There were insufficient studies on anxiety disorders for meta-analysis. This review indicates that there is not a significant risk of GDM associated with many preconception mental disorders but women with psychotic disorders represent a group uniquely vulnerable to GDM. Early detection and management of GDM could improve physical and mental health outcomes for these women and their children.

Reproductive health outcomes among eating disordered females: a register-based follow-up study among former adolescent psychiatric inpatients

OBJECTIVE

To analyze an association of eating disorders (EDs) to reproductive health outcomes among former adolescent psychiatric inpatients, hospitalized between the ages 13 and 17 years. The register-based follow-up information on psychiatric comorbidity and use of prescribed addictive psychotropic medication up to early adulthood were also explored.

METHODS

A total of 31 (10.3%) women with a diagnosed ED were identified from the initial sample of 300 female adolescents, treated in psychiatric inpatient care between 2001 and 2006. The K-SADS-PL and EuropASI research instruments were used to gather information during the adolescent psychiatric hospitalization. The follow-up data for reproductive health outcomes and psychiatric comorbidity up to early adulthood were obtained from the national health care registers. Information on prescribed addictive psychotropic medication was provided by the Social Insurance Institution of Finland. In analyses, EDs were categorized into anorexia nervosa (AN) and other EDs (OED). AN accounted for 58.1% of all EDs. Of OEDs, the majority (69.1%) were bulimia.

RESULTS

None of the women with AN, but 53.8% of those with OED had undergone medical abortions by early adulthood. Childbirths were emphasized in women with OED (61.5%) and a history of hospital-treated poisonings in women with AN (55.6%). High nicotine dependence in adolescence (30.8%) was a characteristic of women with OED.

CONCLUSION

Our study findings suggest that OED may expose affected women to various unfavorable reproductive health outcomes, particularly women with a history of psychiatric admissions. Recognizing the differences in young women with different subtypes of ED is important when discussing contraception and pregnancy.

Outcomes for infants whose mothers had an eating disorder in the perinatal period: A systematic review of the evidence

OBJECTIVE

To establish any health outcomes for infants to age one, associated with their mother having a diagnosis of an active eating disorder during pregnancy or the 12-month postnatal period.

METHOD

A qualitative systematic literature review of numerous databases (Medline, PsycINFO, CINAHL, Scopus, Cochrane Library, MedNar, PsycExtra, National Institute for Health and Care Excellence and Open Grey) was performed examining any infant health outcomes.

RESULTS

This resulted in 22 included studies (17 cohort, 3 cross-sectional, 1 case controlled and 1 mixed methods study). A range of adverse infant outcomes including poor birth, growth and interactional feeding outcomes were identified.

DISCUSSION

Antenatal identification and treatment for women with an eating disorder during the perinatal period and their infants are vital. Optimizing pregnancy nutrition, maternal eating disorder symptoms and feeding interactions appear particularly important.

Disordered Eating Behaviors Are Associated with Gestational Weight Gain in Adolescents

Disordered eating behaviors (DEBs) and adolescent pregnancy are public health problems. Among adolescents, there is little evidence concerning the relationship of DEB with gestational weight gain (GWG) and the birth weight and length of their offspring. We aimed to determine the association between DEB with GWG and the weight and length of adolescents’ offspring. We conducted a study with 379 participants. To evaluate DEB, we applied a validated scale. We identified three factors from DEB by factorial analysis: restrictive, compensatory, and binge–purge behaviors. The main events were GWG and offspring’s birth weight and length. We performed linear regression models. We found that 50% of adolescents have at least one DEB. Excessive and insufficient GWG were 37 and 34%, respectively. The median GWG was 13 kg; adolescents with restrictive behaviors had higher GWG (13 vs. 12 kg, p = 0.023). After adjusting for pregestational body mass index and other covariables, the restrictive (β = 0.67, p = 0.039), compensatory (β = 0.65, p = 0.044), and binge–purge behaviors (β = 0.54, p = 0.013) were associated with higher GWG. We did not find an association between the birth weight and length of newborns with DEB, and suggest that DEB is associated with GWG but not with the birth weight or length of the offspring.

Eating disorders are associated with adverse obstetric and perinatal outcomes: a systematic review

Objective:

To systematically review the literature focusing on obstetric and perinatal outcomes in women with previous or current eating disorders (EDs) and on the consequences of maternal EDs for the offspring.

Methods:

The study was performed following the systematic review and meta-analysis (PRISMA) statement. PubMed, SciELO, and Cochrane databases were searched for non-interventional studies published in English or Portuguese from January 1980 to December 2020. Risk of bias was assessed using the Methods guide for effectiveness and comparative effectiveness reviews (American Agency for Healthcare Research and Quality).

Results:

The search yielded 441 records, and 30 articles were included. The psychiatric outcome associated with EDs in women was mainly perinatal depression. The most prevalent obstetric outcomes observed in women with EDs were vomiting, hyperemesis, bleeding, and anemia. Most studies found maternal anorexia nervosa and bulimia nervosa to be associated with low birth weight and slow fetal growth. Women with binge EDs delivered children with increased birth weight. Of the 30 studies included, methodological quality was good in seven, fair in eight, and poor in 15 studies.

Conclusion:

A considerable body of evidence was reviewed to assess obstetric and perinatal outcomes in EDs. Acute and lifetime EDs, especially if severe, correlated with poor perinatal, obstetric, and neonatal outcomes. Obstetricians and general practitioners should be vigilant and screen for EDs during pregnancy.

Documenting the course of loss of control over eating prior to, during and after pregnancy among women with pre-pregnancy overweight and obesity

OBJECTIVE

Loss of control over eating (LOC) is common among women, particularly those with overweight and obesity (OV/OB), and predicts weight gain. Given the importance of understanding weight and eating behaviors during pregnancy, we sought to characterize LOC across pregnancy and the postpartum period among women with pre-pregnancy OV/OB.

METHODS

Pregnant women (N = 257; 28.44 ± 5.48 years old) with self-reported OV/OB prior to pregnancy were interviewed using a pregnancy-adapted version of the Eating Disorder Examination (EDE-PV). Pre-pregnancy LOC was retrospectively assessed during the first trimester and then prospectively assessed monthly throughout pregnancy and postpartum over the course of seven assessments.

RESULTS

Rates of LOC were significantly higher during pregnancy compared to prior to ( χ 1 2 =44.845, p < .01) and after ( χ 1 2 =36.379, p < .01) pregnancy, with 37% (n = 95) of women reporting ≥1 LOC episode during pregnancy. LOC during pregnancy was associated with higher likelihood of LOC postpartum. Higher age (OR = 1.084, p = .04) and identifying as a minority (OR = 0.344, p = .02) was associated with greater likelihood of experiencing LOC during pregnancy only.

DISCUSSION

LOC during pregnancy is common among women with pre-pregnancy OV/OB, suggesting that screening and intervention for LOC during pregnancy may be warranted. Future research is necessary to examine the relationship between LOC during pregnancy and maternal and infant health outcomes.

Eating Disorders in Pregnant and Breastfeeding Women: A Systematic Review

Background: Pregnancy is a stage associated with various biopsychosocial changes. These changes, along with concerns about keeping an adequate weight, can modulate an individual's risk for psychological disorders, especially eating disorders (EDs). The aim of this review was to investigate the prevalence, associated risks, and consequences of eating disorders in pregnancy and in breastfeeding mothers. Materials and Methods: A systematic review was carried out following the PRISMA guidelines in the scientific databases: PubMed, Web of Science, Scopus, and PsycINFO. Search terms related to EDs, pregnancy, and breastfeeding were used. The evaluation of the methodological quality of the studies was carried out using different scales; CASP (Checklist for Cohort Study), NICE (Methodology Checklist for Cohort Study), ARHQ (Methodology Checklist for Cross-Sectional), and NOS (Newcastle-Ottawa Scale for Cohort). Results: From 2920 studies, 16 were selected to study EDs in pregnant women and 2 studies in nursing mothers. Most of the studies used questionnaires and scales as tools for the diagnosis of EDs. Binge eating, anxiety, and depression were the most common comorbidities of EDs, accompanied in most cases by excessive concern about weight gain. The consequences of EDs are diverse. The prevalence of EDs in this population is estimated to be 1 out of 20. Conclusions: Eating disorders are related to anxiety and depression and have negative consequences for both mothers and fetuses (cesarean, miscarriages, premature births). More research on the field to determine the risk factors for EDs in the population of pregnant and lactating women is needed.

Pregnancy outcomes in women with anorexia nervosa

OBJECTIVE

Birth outcomes of women with anorexia nervosa are poorly understood. We hypothesized that hospitalization for anorexia nervosa before or during pregnancy is associated with an elevated risk of adverse maternal and infant birth outcomes.

METHOD

We performed a retrospective cohort study of 2,134,945 pregnancies in Quebec, Canada, from 1989 to 2016. The main exposure measure was anorexia nervosa requiring hospital treatment before or during pregnancy. Outcome measures included stillbirth, preterm birth, low birth weight, small-for-gestational age birth, preeclampsia, gestational diabetes, cesarean delivery, and other pregnancy disorders. We computed risk ratios and 95% confidence intervals (CI) for the association between anorexia nervosa and birth outcomes adjusted for maternal characteristics.

RESULTS

Compared with no hospitalization, anorexia nervosa hospitalization was associated with 1.99 times the risk of stillbirth (95% CI 1.20-3.30), 1.32 times the risk of preterm birth (95% CI 1.13-1.55), 1.69 times the risk of low birth weight (95% CI 1.44-1.99), and 1.52 times the risk of small-for-gestational age birth (95% CI 1.35-1.72). The associations with low birth weight and small-for-gestational age birth were more prominent in women hospitalized for anorexia nervosa during pregnancy or within 2 years of delivery. Hospitalization for anorexia nervosa was associated with certain maternal outcomes, including precipitate labor, acute liver failure, and admission to an intensive care unit.

DISCUSSION

Hospitalization for anorexia nervosa before or during pregnancy is associated with adverse infant and maternal outcomes. Infants are primarily at risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth.

Eating Disorders During Gestation: Implications for Mother's Health, Fetal Outcomes, and Epigenetic Changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period.

Associations between maternal dietary patterns and infant birth weight, small and large for gestational age in the Norwegian Mother and Child Cohort Study

BACKGROUND/OBJECTIVES

To assess whether quality of maternal diet affects birth weight and the risk of small for gestational age (SGA) and/or large for gestational age (LGA) babies.

SUBJECTS/METHODS

This study is based on the Norwegian Mother and Child Cohort Study (MoBa) and includes 65,904 pregnant women who answered a validated food frequency questionnaire at mid-pregnancy. Three maternal dietary patterns were extracted based on characteristics of food items in each pattern. From these we created four non-overlapping groups: "high prudent," "high Western," "high traditional," and "mixed". We obtained information about birth weight from the Norwegian Medical Birth Registry and calculated birth weight z-scores, SGA, and LGA according to an ultrasound-based, population-based, and a customized growth standards. Associations were studied by linear and multiple logistic regression.

RESULTS

Compared to the high Western group, the high prudent group was associated with lower birth weight (βultrasound z-scores -0.041 (95% confidence interval (CI): -0.068, -0.013)) and the high traditional group with higher birth weight (βultrasound 0.067 (95% CI: 0.040, 0.094)) for all three growth standards. The high prudent pattern was associated with increased SGA risk (SGAultrasound odds ratio (OR) 1.25 (95% CI: 1.02, 1.54)) and decreased LGA risk (LGApopulation OR 0.84 (95% CI: 0.75, 0.94)), while the high traditional group on the contrary was associated with decreased SGA (SGAcustomized OR 0.92 (95% CI: 0.84, 0.99)) and increased LGA risk (LGApopulation OR 1.12 (95% CI: 1.02, 1.24)).

CONCLUSIONS

Food quality was associated with birth weight in this well-nourished Norwegian population. Food quality may affect a woman's risk of giving birth to a SGA or LGA baby.

Adverse Birth Outcomes Associated with Types of Eating Disorders: A Review

At least 5% of women have an eating disorder (ED) during pregnancy. These EDs affect prepregnancy body mass index (BMI) and weight gain during pregnancy, factors associated with birth complications and adverse neonatal outcomes. This review contributes to the literature by examining several adverse birth outcomes associated with EDs and differentiates between past and present EDs. Of the 18 articles reviewed, EDs were associated with preterm birth in 5/14 (36%) and small-for-gestational-age in 5/8 (63%) studies. Anorexia Nervosa increases the odds of a low birth weight baby, particularly when women enter pregnancy with a low BMI. Binge Eating Disorder is positively associated with having a large-for-gestational-age infant, and Bulimia Nervosa is associated with miscarriage when symptomatic during pregnancy. Having a current ED increases the risk for adverse birth outcomes more than a past ED. Since the aetiology of adverse birth outcomes is multi-factorial, drawing conclusions about causal relationships between EDs and birth outcomes is problematic given the small number of studies reporting these outcomes. Resources should target preconception interventions that put EDs into remission and help women achieve a healthier BMI prior to pregnancy, as these have been consistently shown to improve birth outcomes.

Medical Complications of Binge Eating Disorder

Binge eating disorder (BED) is the most common eating disorder and is accompanied by multiple medical comorbidities, many of which are associated with obesity-related diseases. However, the BED itself is likely to confer additional risk factors. BED presents with medical symptoms in virtually every body system and can have devastating consequences on both quality and length of life. This review covers the major comorbidities of BED and highlights areas of ongoing research in this disorder.

The Impact of Maternal Eating Disorders on Dietary Intake and Eating Patterns during Pregnancy: A Systematic Review

Maternal nutrition in pregnancy has a key influence on optimum fetal health. Eating disorders (EDs) during pregnancy may have detrimental effects on fetal growth and the child’s early development. There is limited knowledge concerning the eating behavior, dietary intake and derived nutritional biomarkers as well as the nutrient supplementation in women with EDs during pregnancy. We performed a systematic review according to the PRISMA statement to synthesize current evidence in this field. Of N = 1203 hits, 13 full-texts were included in the qualitative synthesis. While women with current Binge Eating Disorder (BED) showed higher energy and fat intakes during pregnancy, women with a lifetime Anorexia Nervosa (AN), Bulimia Nervosa (BN) or both (AN + BN) had similar patterns of nutrient intake and dietary supplement use as healthy women. There is evidence, that women with a history of EDs have a sufficient diet quality and are more likely to be vegetarian. Dieting and bingeing improved substantially with pregnancy. The highlighted differences in the consumption of coffee/caffeine and artificially sweetened beverages as well as the elevated prevalence of iron deficiency anemia in women with a past or active ED during pregnancy might have an important impact on fetal development.

Waking up every day in a body that is not yours: a qualitative research inquiry into the intersection between eating disorders and pregnancy

BACKGROUND

Women with eating disorders are more likely to negatively react to finding out they are pregnant, although this difference in attitudes between women with eating disorders and controls disappears at 18-weeks' gestation. Those with anorexia also are twice as likely to have an unplanned pregnancy and those with bulimia have a 30-fold increased chance compared with healthy controls. Therefore, due to these considerations, pregnancy and the transition to motherhood can be an extremely challenging time for these women both psychologically and physically. The purpose of this qualitative descriptive study was to understand the intersection between eating disorders and pregnancy from the lived experience of women who have been pregnant or want to or do not want to become pregnant.

METHODS

A total of 15 women with a current or past history of an eating disorder were recruited, including nine women who have had previous pregnancies as well as six nonparous women. Interviews were the primary unit of data collection, in addition to document analysis of diaries or blogs. Data analysis was based on verbatim transcripts from audio recordings. NVIVO 11© was used to manage the data from these interviews and thematic analysis was then conducted for emergence of major and sub themes.

RESULTS

A total of six themes emerged from the iterative process of coding and categorizing. They were: Control, Disclosure to Others, Battle between Mothering & Eating Disorder, Fear of Intergenerational Transmission, Weight and Body Image Concerns, and Coping Strategies. One theme, Battle between Mothering & Eating Disorder also had three sub-themes: Decision to Have Child, Emotions Towards Pregnancy, and Focus on Child/Greater Good.

CONCLUSIONS

It is hoped that quotes and themes derived from this study will help inform both prenatal and postnatal care and interventions, as well as addressing intergenerational transmission concerns among mothers with eating disorders.

Intake of supplementary food during pregnancy and lactation and its association with child nutrition in Timor Leste

Abstract

There is little evidence on maternal consumption of supplementary food on nutritional status of children. The objectives of this study were to measure the prevalence and determinants of supplementary food intake during pregnancy and lactation, and their association with nutritional status of under-five children in Timor Leste.

Methods

Cross-sectional data from Timor Leste Demographic and Health Survey on 5,993 mother (15-49 years) child dyads (<5 years) were included in the analysis. Self-reported intake of supplementary food intake was the explanatory variable. Child's nutritional status was assessed by stunting, wasting, and underweight and categorized according to WHO recommendations.

Results

The prevalence of taking supplementary food during pregnancy and lactation was, respectively, 29.1% (95% CI [27.2-31.0]) 31.0% (95% CI [29.1-33.0]), and that of taking iron supplement during pregnancy was close to three-fifths (63.1%, 95% CI [60.9-65.3]). The odds of taking supplementary food during pregnancy and lactation were lower among those in the younger age groups and higher among urban residents. Compared with mothers who had supplementary food during pregnancy and lactation, those did not have had respectively 1.36 (OR = 1.360, 95% CI [1.191-2.072]) and 1.15 times (OR = 1.152, 95% CI [1.019-1.754]) higher odds of having stunted, and 1.30 (OR = 1.307, 95% CI [1.108-1.853]) and 1.43 (OR = 1.426, 95% CI [1.140-1.863]) times higher odds of having underweight children. Those who had none of the supplements had respectively 1.67 (OR = 1.674, 95% CI [1.118-2.087]) and 1.63 (OR = 1.631, 95% CI [1.130-2.144]) times higher odds of having stunted and underweight children.

Conclusion

A great majority of the mothers in Timor Leste are not taking supplementary food during pregnancy and lactation. We found a positive relationship between supplementary food intake during pregnancy and lactation with stunting and wasting among under-five children.

Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with the HUNT study

OBJECTIVE

Current evidence from clinical studies suggests that having an active eating disorder (ED) during pregnancy is associated with unfavorable obstetric outcomes. However, the role of a lifetime diagnosis of ED is not fully understood. Variations in findings suggest a need for additional studies of maternal ED. This study aims to identify associations between a lifetime ED and obstetric outcomes.

METHOD

Data from a hospital patient register and a population-based study (The HUNT Study) were linked to the Medical Birth Registry in Norway. Register based information of obstetric complications (preeclampsia, preterm birth, perinatal deaths, small for gestational age (SGA), large for gestational age (LGA), Caesarean sections, and 5-min Apgar score) were acquired for 532 births of women with ED and 43,657 births of non-ED women. Multivariable regression in generalized estimating equations was used to account for clusters within women as they contributed multiple births to the dataset.

RESULTS

After adjusting for parity, maternal age, marital status, and year of delivery, lifetime history of anorexia nervosa was associated with increased odds of having offspring who were SGA (Odds ratio (OR) 2.7, 95% Confidence Interval (CI) 1.4-5.2). Women with a lifetime history of bulimia nervosa had higher odds of having a Caesarian section (OR 1.7 95% CI 1.1-2.5). Women with EDNOS/sub-threshold ED had a higher likelihood of having a low Apgar score at 5 min (OR 3.1, 95% CI 1.1-8.8).

CONCLUSION

Our study corroborates available evidence on the associations between maternal ED and adverse obstetric outcomes.

The role of maternal anorexia nervosa and bulimia nervosa before and during pregnancy in early childhood wheezing: Findings from the NINFEA birth cohort study

OBJECTIVE

This study evaluates associations of maternal eating disorders (bulimia nervosa, anorexia nervosa, and purging behaviors) with infant wheezing and examines the effects of eating disorders on several wheezing determinants.

METHOD

We studied 5,150 singletons from the NINFEA birth cohort. Maternal bulimia nervosa and anorexia nervosa diagnoses were ascertained from the questionnaires completed in pregnancy and 6 months after delivery, and were analyzed as: ever diagnosis, only before pregnancy, and during pregnancy. Purging behaviors were assessed for 12 months before or during pregnancy. The associations with wheezing between 6 and 18 months of age were assessed in models adjusted for a priori selected confounders.

RESULTS

Children born to mothers with lifetime eating disorders were at an increased risk of developing wheezing (adjusted OR 1.68; [95% CI: 1.08, 2.60]), and this risk further increased when the disorders were active during pregnancy (2.52 [1.23, 5.19]). Increased risk of offspring wheezing was observed also for purging behaviors without history of eating disorder diagnosis (1.50 [1.10, 2.04]). The observed associations were not explained by comorbid depression and/or anxiety. Bulimia nervosa and/or anorexia nervosa during pregnancy were also associated with several risk factors for wheezing, including maternal smoking, adverse pregnancy outcomes, shorter breastfeeding duration, and day-care attendance.

DISCUSSION

The associations of maternal eating disorders with offspring wheezing suggest long-term adverse respiratory outcomes in children of mothers with eating disorders. A better understanding of mechanisms implicated is necessary to help reduce the respiratory disease burden in these children.

Pregnancy loss of control over eating: a longitudinal study of maternal and child outcomes

Background

To our knowledge, no previous studies have investigated longitudinal outcomes of maternal loss of control over eating (LOC) in pregnancy in a general population sample.

Objective

We aimed to determine whether pregnancy LOC is associated with dietary, gestational weight gain, and offspring birth-weight outcomes in a large population-based prospective study of pregnant women and their children. We also explored the association with offspring weight at age 15.5 y.

Design

Women (n = 11,132) from the Avon Longitudinal Study of Parents and Children (ALSPAC) were included. Crude and adjusted logistic and multinomial regression models were used. LOC in pregnancy and diet at 32 wk of gestation were assessed by self-report. Pregnancy weight gain and birth weight were obtained from obstetric records. Child weight and height were objectively measured at age 15.5 y.

Results

LOC in pregnancy was common (36.3%). Women with pregnancy LOC reported higher total energy intake, consumed more snacks, and had lower vitamin B-6, A, and C intake compared with women without LOC. Women with frequent LOC had lower vitamin B-1 and folate intake [respectively: b = -0.05 (95% CI: -0.07, -0.02) and b = -7.1 (95% CI: -11.8, -2.3) in adjusted analyses], and gained on average 3.74 kg (95% CI: 3.33, 4.13 kg) more than women without LOC. Frequent and occasional LOC were associated with higher birth weight [respectively: b = 0.07 (95% CI: 0.03, 0.1), b = 0.04 (95% CI: 0.02, 0.06)]. Offspring of mothers with frequent pregnancy LOC had 2-fold increased odds of being overweight/obese at 15.5 y [OR = 2.02 (95% CI: 1.37, 3.01)].

Conclusions

Pregnancy LOC eating is common and has an adverse short- and long-term impact on mother and offspring, but has received very limited attention. Our findings further the understanding of risk factors for obesity and highlight a need for improved identification of maternal pregnancy loss of control eating. This trial was registered at clinicaltrials.gov as NCT03269253.

Barriers to identifying eating disorders in pregnancy and in the postnatal period: a qualitative approach

Background

Eating Disorders (ED) are mental health disorders that typically effect women of childbearing age and are associated with adverse maternal and infant outcomes. UK healthcare guidance recommends routine enquiry for current and past mental illness in antenatal and postnatal care for all women, and that pregnant women with a known ED are offered enhanced monitoring and support. Midwives and health visitors are ideally placed to identify and support women with ED as they are often the primary point of contact during the antenatal and postnatal periods. However, research on the barriers to identifying ED in the perinatal period is limited. This study aimed to understand the barriers to disclosure and identification of ED in pregnancy and postnatally as perceived by women with past or current ED, and midwives and health visitors working in the UK National Health Service.

Methods

Two studies were undertaken: mixed-measures survey of pregnant and postnatal women with current or past ED; focus groups with student and qualified midwives and health visitors.

Results

Five themes emerged on the barriers to disclosure in pregnancy as perceived by women: stigma, lack of opportunity, preference for self-management, current ED symptomatology and illness awareness. Four themes were identified on the barriers to identification of ED in pregnancy and in the postnatal period as perceived by health professionals: system constraints, recognition of role, personal attitudes, and stigma and taboo.

Conclusions

Several barriers to the identification of ED during and after pregnancy were described, the main factors were stigma and poor professional training. Perinatal mental health is becoming increasingly prioritised within national policy initiatives; however, ED continue to be neglected and increased awareness is needed. Similarly, clinical guidance aimed at responding to the rising prevalence of obesity focus on changing nutrition but not on assessing for the presence of ED behaviours that might be affecting nutrition. Improving education and training for health professionals may contribute to reducing stigma and increase confidence in identifying ED. The barriers identified in this research need to be addressed if recognition and response to women with ED during the perinatal period is to improve.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1745-x) contains supplementary material, which is available to authorized users.

Maternal eating disorders and perinatal outcomes: A three-generation study in the Norwegian Mother and Child Cohort Study

Previous studies of the relationship between maternal eating disorders and adverse perinatal outcomes have failed to control for familial transmission of perinatal phenotypes, which may confound the reported association. In a unique design afforded by the Norwegian Mother and Child Cohort Study and Medical Birth Registry of Norway, we linked three generations through birth register records and maternal-reported survey data to investigate whether maternal eating disorders increase risk after parsing out the contribution of familial transmission of perinatal phenotypes. The samples were 70,881 pregnancies in grandmother-mother-child triads for analyses concerning eating disorder exposure during pregnancy and 52,348 for analyses concerning lifetime maternal eating disorder exposure. As hypothesized, eating disorders predicted a higher incidence of perinatal complications even after adjusting for grandmaternal perinatal phenotypes. For example, anorexia nervosa immediately prior to pregnancy was associated with smaller birth length (relative risk = 1.62; 95% CI [1.20, 2.14]), bulimia nervosa with induced labor (relative risk = 1.21; 95% CI [1.07, 1.36]), and binge-eating disorder with several delivery complications, larger birth length (relative risk = 1.25; 95% CI [1.17, 1.34]), and large-for-gestational-age (relative risk = 1.04; 95% CI [1.01, 1.06]). Maternal pregravid body mass index and gestational weight mediated most associations. Our results support that exposure to eating disorders increases the risk for negative health outcomes in pregnant women and their babies. (PsycINFO Database Record

Obstetric and gynecologic problems associated with eating disorders

OBJECTIVE

This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders.

METHOD

We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers.

RESULTS

Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder.

DISCUSSION

We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.

Preconception Nutrition, Physical Activity, and Birth Outcomes in Adolescent Girls

STUDY OBJECTIVE

Recommendations for preconception care usually include optimal nutrition and physical activity, but these have not been tested extensively for their relationship with birth outcomes such as low birth weight and preterm birth.

DESIGN

Data from Waves I, II, and IV of the National Longitudinal Study of Adolescent Health (Add Health) contractual dataset were used.

METHODS

In Wave I in-home interview, participants were asked to recall their frequency of having 5 types of food on the previous day, including milk, fruit, vegetables, grains, and sweets. At Wave II, participants reported the previous day's intake of 55 items, and results were categorized into high-calorie sweet, high-calorie nonsweet, and low-calorie food. At Wave I in-home interview, participants were also asked how many times in a week or during the past week they were involved in types of physical activity. At Wave IV, female participants reported pregnancies and birth outcomes. Multivariable linear regression analysis with survey weighting was used to predict birth weight and gestational age.

RESULTS

There were no associations between reported food intake and birth outcomes. Girls who engaged in more episodes of active behavior had higher birth weights (P < .01), but hours of sedentary behavior was not associated with birth weight. Multivariable analysis also indicated a U-shaped association between BMI and birth weight (P for quadratic term = .01).

CONCLUSION

Adolescents who are more physically active before pregnancy have more positive birth outcomes as represented by birth weight.

Perinatal mental health: What every neonatologist should know

Perinatal mental disorders are common and can impact adversely both on maternal functioning and on foetal and neonatal outcomes. For the more severe disorders, such as schizophrenia, bipolar disorder and severe depression, medication may be needed during pregnancy and breastfeeding, and there is a growing but complex evidence based on the effects of psychotropic medication on the foetus and neonate. In addition, the neonatologist needs to be aware of the co-morbid problems that women with mental disorders are more likely to have as these may also impact on the neonate. Close liaison with family physicians and primary care where there are concerns about mental health is important to ensure maternal mental health is optimal for the mother and her infant.

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.

Psychiatric disorders and gestational weight gain among women who quit smoking during pregnancy

OBJECTIVE

Pregnancy is a common time for women to quit using cigarettes and other substances. Such changes in substance use as well as other psychiatric and psychosocial changes during pregnancy can affect gestational weight gain (GWG). Thus, we evaluated the relationship between psychiatric disorders and GWG among pregnant women who had quit smoking.

METHODS

Pregnant former smokers (n = 281) enrolled in a larger trial for postpartum relapse prevention completed semi-structured psychiatric interviews and measures of prepregnancy nicotine dependence and smoking behavior, and were weighed to estimate gestational weight gain. Using linear regression and mixed-effect models, the relationship between a lifetime prevalence of each psychiatric disorder and total GWG was evaluated, controlling for variables previously related to GWG.

RESULTS

Average GWG was 15.6 (± 8.5) kg, and 56% (n = 157) of women exceeded the GWG recommended by the Institute of Medicine (IOM) according to prepregnancy BMI. Over one-third (34.3%) of pregnant former smokers had a history of at least one diagnosable psychiatric disorder. History of psychiatric disorder was unrelated to GWG, with one exception; lifetime history of alcohol use disorder was associated with significantly larger GWG.

CONCLUSION

Women who quit smoking during pregnancy gain a considerable amount of gestational weight, and a previous history of alcohol use disorder is related to GWG. However, the benefits of smoking cessation to maternal and fetal health likely outweigh the disadvantage of weight gain, and other psychiatric disorders are not linked to GWG.

Weight-for-length trajectories in the first year of life in children of mothers with eating disorders in a large Norwegian Cohort

OBJECTIVE

To describe weight-for-length (WFL) trajectories in the children (birth-12 months) of mothers with and without eating disorders.

METHOD

This study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. We categorized women (N = 57,185) based on diagnosis prior to and during pregnancy: anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified-purging subtype, binge eating disorder, or no eating disorder. The primary analysis included a shape invariant model fitted with nonlinear mixed effects to compare growth rates across eating disorder subtypes.

RESULTS

The children of mothers reporting any eating disorder had a lower WFL growth rate from birth to 12 months than the children of mothers without eating disorders, even after adjusting for relative birth weight and some confounders known to affect growth.

DISCUSSION

In this cohort, child WFL was related to maternal eating disorder status before and/or during pregnancy. These differences in growth trajectories warrant further study of long-term health outcomes and, if replicated, tailoring counseling to mothers with eating disorders during pregnancy.

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.

Disordered eating attitudes during pregnancy in mothers of newborns requiring Neonatal Intensive Care Unit admission: a case control study

OBJECTIVE

The aim of the study was to assess disordered eating attitudes and other related factors in mothers of newborns requiring Neonatal Intensive Care Unit (NICU) admission compared to those of mothers who delivered healthy infants.

METHODS

An anonymous self-report study conducted among 199 mothers of newborns hospitalized in NICU, and a control group of 127 mothers of healthy newborns. Eating Attitudes Test-26 (EAT-26) and a survey regarding other perinatal health issues were used.

RESULTS

Women in the study group (SG) gained significantly less weight during pregnancy when compared to control group (CG; p = 0.001). There were fewer women with appropriate pre-gestational BMI in the SG (p = 0.052). Women who feared weight-gain during pregnancy were younger (p < 0.001) and had higher EAT-26 scores (p < 0.001). Women with EAT-26 scores >20 smoked significantly more often during their last pregnancy in the SG (p = 0.010). Cesarean section was more frequent in the SG (p = 0.017).

CONCLUSIONS

Disordered eating attitudes in gestation may significantly influence the pregnancy outcomes and newborns' health. Hence, it is vital for perinatal counseling and obstetrical care to focus on these issues to facilitate early diagnosis and intervention.

Epilepsy and eating disorders during pregnancy: Prevalence, complications and birth outcome

PURPOSE

The aim was to investigate the prevalence of eating disorders and its relation to pregnancy and delivery complications in childbearing women with epilepsy (WWE).

METHOD

This study is based on The Norwegian Mother and Child Cohort Study (MoBa) linked to the Medical Birth Registry of Norway. Epilepsy was reported in 706 pregnancies. The remaining cohort (n=106,511) served as the reference group. Eating disorders were diagnosed using DSM-IV criteria adjusted for pregnancy. The risk of preeclampsia, gestational hypertension, diabetes and weight gain during pregnancy as well as delivery outcome (small for gestational age, large for gestational age, ponderal index, low APGAR score, small head circumference) were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for maternal age, smoking, parity and socioeconomic factors.

RESULTS

Pregnant WWE were significantly more likely to have binge eating disorder (6.5% vs. 4.7%, p<0.05). WWE and comorbid eating disorders had significantly more preeclampsia (7.9% vs. 3.7%, p<0.05), peripartum depression and/or anxiety (40.4% vs. 17.8%, p<0.001) and operative delivery (38.2% vs. 23.5%, p<0.001) than the reference group without epilepsy or eating disorders. After adjustment for confounders, a significantly increased risk of operative delivery (OR 1.96, CI 1.26-3.05) and peripartum depression and/or anxiety (OR 2.17, CI 1.40-3.36) was demonstrated.

CONCLUSION

Eating disorders in WWE contribute to the increased risk of pregnancy and delivery complications. Health personnel should be aware of eating disorders in WWE and refer them for treatment before pregnancy.

Adverse obstetric and neonatal outcomes in women with mental disorders

The brain and the placenta synthesize identical peptides and proteins, such as brain-derived neurotrophic factor, oxytocin, vascular endothelial growth factor, cortisol, and matrix metalloproteinases. Given the promiscuity between neurochemistry and the mechanism of placentation, it would be expected that mental disorders occurring during pregnancy would increase the risk of adverse obstetric and neonatal outcomes. Indeed, expectant mothers with anxiety disorders, post-traumatic stress disorder, schizophrenia, or depressive disorders are at higher risk of preterm birth, low-birth-weight and small-for-gestational-age infants than controls. These mental illnesses are accompanied by a procoagulant phenotype and low activity of tissue plasminogen activator, which may contribute to placental insufficiency. Another risk factor for pregnancy complications is hyperemesis gravidarum, more common among women with eating disorders or anxiety disorders than in controls. Severe hyperemesis gravidarum is associated with dehydration, electrolyte imbalance and malnutrition, all of which may increase the risk of miscarriages, of low-birth-weight babies and preterm birth. This paper reviews some aspects of mental disorders that may influence pregnancy and neonatal outcomes.

Eating Disorders, Pregnancy, and the Postpartum Period: Findings from the Norwegian Mother and Child Cohort Study (MoBa)

This review summarizes studies on eating disorders in pregnancy and the postpartum period that have been conducted as part of the broader Norwegian Mother and Child Cohort Study (MoBa). Prior to the 2000s, empirical literature on eating disorders in pregnancy was sparse and consisted mostly of studies in small clinical samples. MoBa has contributed to a new era of research by making population-based and large-sample research possible. To date, MoBa has led to 19 studies on diverse questions including the prevalence, course, and risk correlates of eating disorders during pregnancy and the postpartum. The associations between eating disorder exposure and pregnancy, birth and obstetric outcomes, and maternal and offspring health and well-being, have also been areas of focus. The findings indicate that eating disorders in pregnancy are relatively common and appear to confer health risks to mother and her child related to sleep, birth outcomes, maternal nutrition, and child feeding and eating.

Pregnancy, obstetric, and perinatal health outcomes in eating disorders

OBJECTIVE

The purpose of this study was to assess pregnancy, obstetric, and perinatal health outcomes and complications in women with lifetime eating disorders.

STUDY DESIGN

Female patients (n = 2257) who were treated at the Eating Disorder Clinic of Helsinki University Central Hospital from 1995-2010 were compared with unexposed women from the population (n = 9028). Register-based information on pregnancy, obstetric, and perinatal health outcomes and complications were acquired for all singleton births during the follow-up period among women with broad anorexia nervosa (AN; n = 302 births), broad bulimia nervosa (BN; n = 724), binge eating disorder (BED; n = 52), and unexposed women (n = 6319).

RESULTS

Women with AN and BN gave birth to babies with lower birthweight compared with unexposed women, but the opposite was observed in women with BED. Maternal AN was related to anemia, slow fetal growth, premature contractions, short duration of the first stage of labor, very premature birth, small for gestational age, low birthweight, and perinatal death. Increased odds of premature contractions, resuscitation of the neonate, and very low Apgar score at 1 minute were observed in mothers with BN. BED was associated positively with maternal hypertension, long duration of the first and second stage of labor, and birth of large-for-gestational-age infants.

CONCLUSION

Eating disorders appear to be associated with several adverse perinatal outcomes, particularly in offspring. We recommend close monitoring of pregnant women with either a past or current eating disorder. Attention should be paid to children who are born to these mothers.

Gestational and postpartum weight change patterns in mothers with eating disorders

BACKGROUND

Although pregnancy can be associated with adaptive changes in weight and eating behaviour for women with eating disorders, less is known about whether these changes are maintained in the postpartum period. We used a longitudinal design to examine gestational and postpartum weight trajectories in mothers with and without eating disorders in the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health.

METHODS

Fifty-six women reported anorexia nervosa (AN), 636 bulimia nervosa, 3327 binge eating disorder and 69 eating disorder not otherwise specified, purging type. The referent group included 61,233 mothers with no eating disorder. We used a mixed effects model to predict weight change over time by eating disorder subtype.

RESULTS

Mothers with AN, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified had greater increases in body mass index (BMI) during pregnancy and greater decreases in BMI over the first 6 months postpartum. Women with AN shifted from the underweight BMI range before pregnancy to the normal weight range at 36 months postpartum

CONCLUSIONS

Patterns of maternal weight gain and retention during the perinatal period vary across eating disorder subtype and warrant clinical attention.

Associations between birth characteristics and eating disorders across the life course: findings from 2 million males and females born in Sweden, 1975-1998

Birth characteristics predict a range of major physical and mental disorders, but findings regarding eating disorders are inconsistent and inconclusive. This total-population Swedish cohort study identified 2,015,862 individuals born in 1975-1998 and followed them for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified until the end of 2010. We examined associations with multiple family and birth characteristics and conducted within-family analyses to test for maternal-level confounding. In total, 1,019 males and 15,395 females received an eating disorder diagnosis. Anorexia nervosa was independently predicted by multiple birth (adjusted hazard ratio = 1.33, 95% confidence interval: 1.15, 1.53) for twins or triplets vs. singletons) and lower gestational age (adjusted hazard ratio = 0.96, 95% confidence interval: 0.95, 0.98) per extra week of gestation, with a clear dose-response pattern. Within-family analyses provided no evidence of residual maternal-level confounding. Higher birth weight for gestational age showed a strong, positive dose-response association with bulimia nervosa (adjusted hazard ratio = 1.15, 95% confidence interval: 1.09, 1.22, per each standard-deviation increase), again with no evidence of residual maternal-level confounding. We conclude that some perinatal characteristics may play causal, disease-specific roles in the development of eating disorders, including via perinatal variation within the normal range. Further research into the underlying mechanisms is warranted. Finally, several large population-based studies of anorexia nervosa have been conducted in twins; it is possible that these studies considerably overestimate prevalence.