Anorexia nervosa and pregnancy: having a baby when you are dying to be thin--case report and proposed treatment guidelines

Pregnancy and breastfeeding in mental health policy: a narrative review

OBJECTIVES

Mental health difficulties are often exacerbated during the perinatal period. Policy and guidelines are increasingly being used to enhance the quality of healthcare. We conducted a literature review of published research relating to pregnancy and breastfeeding in mental health policy.

METHODS

Relevant terms were searched in Medline, CINAHL, APA PsycINFO and EMBASE for articles published in English from 1970 until 2020. Only papers that referenced policy, guidance, legislation or standards were included. While a systematic approach was used, the nature of the results necessitated a narrative review.

RESULTS

Initially, 262 papers were identified, 44 met the inclusion criteria. Reproductive health is given sparse consideration in research relating to mental health policy. Despite this, some key areas emerged. These included: the need for proactive preconception psychoeducation, proactive screening of mothers of infants and young children for perinatal mental health issues, enhanced prescribing practice for women of child-bearing age, enhanced monitoring during pregnancy, development of safe modification of coercive practices should they need to be employed in emergency circumstances and targeted measures to reduce substance misuse. Themes that arose relating to breastfeeding and bonding are also described.

CONCLUSIONS

Female reproductive health is often ignored in research relating to mental health policy, guidelines and standards. These tools need to be harnessed to promote good healthcare. Reproductive health should be included in the care plan of all mental health patients. These topics need to be integrated into existing relevant policies and not isolated to a separate policy.

Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review

Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.

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.

Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline

COSPONSORING ASSOCIATIONS

The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.

OBJECTIVE

To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA).

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline.

CONCLUSIONS

FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.

Impact of maternal malnutrition during the periconceptional period on mammalian preimplantation embryo development

During episodes of undernutrition and overnutrition the mammalian preimplantation embryo undergoes molecular and metabolic adaptations to cope with nutrient deficits or excesses. Maternal adaptations also take place to keep a nutritional microenvironment favorable for oocyte development and embryo formation. This maternal-embryo communication takes place via several nutritional mediators. Although adaptive responses to malnutrition by both the mother and the embryo may ensure blastocyst formation, the resultant quality of the embryo can be compromised, leading to early pregnancy failure. Still, studies have shown that, although early embryonic mortality can be induced during malnutrition, the preimplantation embryo possesses an enormous plasticity that allows it to implant and achieve a full-term pregnancy under nutritional stress, even in extreme cases of malnutrition. This developmental strategy, however, may come with a price, as shown by the adverse developmental programming induced by even subtle nutritional challenges exerted exclusively during folliculogenesis and the preimplantation period, resulting in offspring with a higher risk of developing deleterious phenotypes in adulthood. Overall, current evidence indicates that malnutrition during the periconceptional period can induce cellular and molecular alterations in preimplantation embryos with repercussions for fertility and postnatal health.

Involuntary admission: the case of anorexia nervosa

Involuntary treatment of psychiatric disorders has always been controversial; this is especially true for eating disorders. Patients with anorexia nervosa of life threatening severity frequently refuse psychiatric hospitalization. Ambivalence toward treatment is characteristic of eating disorders and patients are often admitted to inpatient programs under pressure from family and doctors. In this article, we report research on the positive or negative impact of involuntary admission in the treatment of eating disorders, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders. A literature review was done. From a total of 134 publications which were retrieved from the literature search, 50 studies were directly relevant to the scope of this review and fulfilled all inclusion criteria. There are trends and arguments for both sides; for and against involuntary treatment in anorexia nervosa. The scientific literature so far is inconclusive, although in the short term, involuntary hospitalization has benefits. This review has also shown that involuntary hospitalization can have adverse long-term consequences for the patient-therapist allegiance. We conclude that in some cases, involuntary treatment can save lives of young patients with anorexia nervosa; however, in other cases, it can break the psychotherapeutic relationship and make the patient abandon treatment. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.

The experience of pregnancy in women with a history of anorexia nervosa: An interpretive phenomenological analysis

BACKGROUND AND AIMS

To explore the experience of pregnancy for women who have a history of anorexia nervosa (AN), in relation to the impact of AN on pregnancy, and pregnancy on AN.

METHODS

Semi-structured interviews were conducted with six women with a history of AN. Data were analysed using Interpretive Phenomenological Analysis.

RESULTS

Four super-ordinate themes emerged: 'Effortful resistance of AN'; 'The unvalued self, valued other dialectic'; 'In new territory'; and 'Feeling distanced'.

CONCLUSIONS

Various factors motivated the women to try and change their AN behaviours. This was achieved with varying degrees of success. Attempts to manage AN cognitions and emotions were less successful, and this aspect of their illness persisted. Whilst the baby was viewed as worthy of nurturance, the self was not. Pregnancy represented an unfamiliar experience, and was a time of relative isolation and lack of psychological support. Findings are discussed in the context of theory, research and practice.

Forced treatment of anorexic patients: part 2

PURPOSE OF REVIEW

The purpose of this review was to update and complement part 1 of this study. Clinical, ethical and legal approaches to forced treatment in patients with anorexia nervosa were considered in the light of recent literature.

RECENT FINDINGS

The first comparison of compulsorily detained adolescents and those treated under parental consent shows mainly advantages in the short and medium term of using the Mental Health Act. In a qualitative study, a pathway for advance decisions has been developed. Implications of the Human Rights Act for clinical practice have been elucidated. A case report of a pregnant anorexic woman shows the risk for her foetus. The ethical dilemma of treating a woman with cerebral palsy and chronic anorexia nervosa has been reported and an ethical re-evaluation of treatments for (especially chronic) anorexia nervosa recommended.

SUMMARY

The treatment of adolescents with severe anorexia nervosa may be improved by detention under the Mental Health Act. The Human Rights Act has implications for the treatment of anorexia nervosa. Guidelines for treating anorexia nervosa should include recommendations for pregnant sufferers as well as for those with severe physical comorbidity. A shift from cure to care for chronic anorexia nervosa might improve ethical conduct.