Perinatal outcomes and gestational weight gain in women with eating disorders: a population-based cohort study

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.

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.

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.

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.

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy

OBJECTIVE

To determine the association between continued antidepressant use in pregnancy and postpartum psychiatric visits for eating (ED) or mood/anxiety disorders in women with preexisting ED.

METHOD

Using Danish health registry data (1998-2015), we identified 3529 pregnancies in women with ED prepregnancy: (i) 564 with continued antidepressant use before and during pregnancy; (ii) 778 with discontinued antidepressants before pregnancy; (iii) 2137 unexposed. Outpatient and inpatient postpartum visits for an ED or a mood/anxiety disorder constituted the outcome measures. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox regression with inverse probability of treatment weighting, and performed stratified analyses by antidepressant prescription filling in the first 3 months postpartum.

RESULTS

The weighted cumulative incidence for an ED visit at end of follow-up was 4.5% (continued) and 4.8% (discontinued). We found no association between continued antidepressant and postpartum ED visit, relative to discontinued (HR: 0.89, 95% CI: 0.52-1.52). The HR for postpartum mood/anxiety disorder visit was 1.27 (95% CI: 0.68-2.36) with continued antidepressants versus discontinued but decreased if more than two antidepressant prescriptions were refilled. Continued antidepressant use was associated with a 57% reduced likelihood of a postpartum ED visit versus discontinued use in pregnancies with antidepressant prescription refills in the early postpartum.

CONCLUSION

Among women with preexisting ED, there was no association between continued antidepressant use during pregnancy and the likelihood of postpartum psychiatric visits, relative to discontinued antidepressants before pregnancy. Continuation of treatment into the early postpartum is associated with reduced likelihood of postpartum ED visit.

PUBLIC SIGNIFICANCE

Based on data from the Danish registries, we identified 3529 pregnancies among women with preexisting eating disorders before pregnancy. Women with continued antidepressant treatment both before and during pregnancy did not have a lower probability of having postpartum psychiatric visits for an eating disorder or for mood/anxiety disorders (often coexisting with eating disorders), relative to those who discontinued antidepressants before pregnancy. Further continuation of antidepressant treatment into the early postpartum is associated with improved maternal postpartum outcomes. However, residual confounding by disease severity limits confidence in this conclusion.

Association of Eating Disorders in Prenatal and Perinatal Women and Its Complications in Their Offspring

Numerous studies revealed that women in the first trimester of pregnancy (prenatal) and 6-12 months after delivery of a newborn (postnatal) suffer from eating disorders like anorexia nervosa, bulimia nervosa, and binge eating disorder. Pregnancy may increase or decrease the symptoms of eating disorders. It varies from person to person. The mother faces many complications during this period which may also affect the newborn child. Weight loss is an essential symptom of eating disorders, which may cause extreme anxiety and depression during and after pregnancy. Stress is another symptom that is associated with binge eating disorders. The main aim of this narrative review article is to critically analyze and discuss the association of prenatal and postnatal factors that lead to different eating disorders in the mother and child. A total of 38 published and standard articles were selected for this review. The studies under consideration showed numerous methodological shortcomings, necessitating additional investigation to explain these discrepancies. The evidence points to a connection between prenatal and perinatal variables, and the children of these women also develop eating disorders. Earlier research focused on linking pregnancy and eating disorders, mainly emphasizing anorexia nervosa and bulimia nervosa. However, any significant correlation between binge eating disorder and pregnancy is yet to be found. In the first half of pregnancy, about 33%-35% of women who had binge eating disorder before becoming pregnant no longer met the diagnostic criteria, their illness improved, and they seemed to recover. These patients with eating disorders are more likely to have pregnancy-related complications and births. Therefore, creating a multidisciplinary screening strategy and guidelines for managing and supervising this particular patient population makes sense.

History of pre-pregnancy maternal symptoms of binge eating and childhood behavioral problems in girls and boys

OBJECTIVE

To explore whether children of mothers with pre-pregnancy binge eating (BE) symptoms have more behavioral difficulties compared with those without and whether associations are moderated by ED symptoms and other maternal health and social factors measured during childhood.

METHOD

Pre-pregnancy BE symptoms were collected by the Australian Longitudinal Study on Women's Health at Survey 1 (in 1996) and/or at Survey 2 (in 2000) using questions mapped to DSM BE criterion 1. In 2016/7, 2180 women from the 1973-78 cohort provided data on externalizing and internalizing behavior, measured by Strengths and Difficulties Questionnaire, on 4054 of their children (2-12 years) in the Mothers and their Children's Health study. Covariates were markers of other ED symptoms, sociodemographic, social support, and mental health factors collected proximally to the child outcomes. Hierarchical multivariable regression models, using generalized estimating equations accounting for clustering of children within mothers, were used.

RESULTS

Pre-pregnancy BE symptoms were associated with child behavior, with associations only moderated after adjustment for proximal markers of ED (girls internalizing behavior, b (95%CI) .30 (-.02, .61); boys externalizing behavior .34 (-.04, .73)) or social support (girls externalizing behavior 0.26 (-.08, .61)). Pre-pregnancy BE symptoms were not associated with boys internalizing behavior (-.27 (-.02, 0.57)).

DISCUSSION

Studies with repeated ED measures should test hypotheses that these associations vary by timing of ED measurement. Identification of young women at risk of BE symptoms pre-pregnancy, as well as when children are older, may enable health services, treatment programs, and supports to minimize longer term effects on children.

PUBLIC SIGNIFICANCE STATEMENT

A history of binge eating symptoms up to 10 years pre-pregnancy in mothers is associated with behavior problems in their girls and boys at average age of 7. However, the association is moderated by behaviors of eating disorders and social support in the mothers during childhood. Identification of ED symptoms prior to pregnancy, and then after childbirth, might enable health services to intervene to maximize child and mother 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.

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.

Eating disorders, pregnancy and the postnatal period: a review of the recent literature

PURPOSE OF REVIEW

Eating disorders (ED) are severe psychiatric disorders that affect women in reproductive age. The purpose of this review is to provide an up-to-date overview of the impact of maternal ED on pregnancy and the postnatal period. The clinical implications for identification and management of maternal ED are also discussed.

RECENT FINDINGS

In the last 2 years, 15 articles focused on the impact of maternal ED in pregnancy and postpartum. Findings from this review indicate that around 15% of pregnant women are likely to have had an ED at some point in their lifetime, and about 5% have an ED in pregnancy. Although ED symptoms tend to decrease during pregnancy, remission is often only temporary with symptoms typically resurfacing in the postnatal period. Women with ED are prone to psychiatric comorbidities such as depression and anxiety during the perinatal period, with up to a third of women with ED reporting postnatal depression in clinical studies and prevalence ranging between 40% and 66% in general population samples. Furthermore, recent findings continue to highlight that current and prior history of maternal ED are associated with a heightened risk of adverse pregnancy and birth outcomes, most notably preterm birth and adverse birth weight outcomes.

SUMMARY

These findings continue to emphasise the clinical importance of early identification and response to maternal ED to mitigate potentially adverse maternal and infant outcomes.

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.

Prevalence of lifetime eating disorders in infertile women seeking pregnancy with pulsatile gonadotropin-releasing hormone therapy

OBJECTIVES

Relationships between weight and fertility are well known. The aim of this study is to assess the prevalence of lifetime eating disorder (ED) in a sample of infertile women seeking a specific infertility treatment, pulsatile gonadotropin-releasing hormone (pGnRH) treatment, and to compare it to the prevalence of lifetime ED in a sample of infertile women seeking other types of assisted reproductive technology (ART) treatments.

DESIGN

Non-randomized, observational study including infertile female patients. Two-group design including consecutive women treated with GnRH pump (pGnRH) or with other types of ART.

SETTING

Multi-centric infertility centers, France METHODS: Twenty one consecutive women treated with pGnRH treatment were compared to 21 consecutive women receiving other types of infertility treatment. Diagnosis of ED was based on DSM-IV and the Composite International Diagnostic Interview (CIDI).

RESULTS

Twenty patients (95.2%) from the sample of women treated with pulsatile GnRH treatment and 5 patients (23.8%) from the patients receiving other types of infertility treatment met the criteria of lifetime ED diagnosis (p < 0.000).

CONCLUSION

This study highlights the fact that the prevalence of ED is considerably higher in women receiving GnRH pulsatile treatment, when compared to women receiving other kinds of infertility treatment. In our study population ED were under-diagnosed, particularly in women receiving pulsatile GnRH treatment. Fertility clinicians should use reliable diagnostic tools to identify promptly ED in women presenting with hypothalamic amenorrhea and difficulties in conceiving. Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Environment-Wide Association Study (En WAS) of Prenatal and Perinatal Factors Associated With Autistic Traits: A Population-Based Study

A combination of genetic and environmental factors contributes to the origins of autism spectrum disorder (ASD). While a number of studies have described specific environmental factors associating with emerging ASD, studies that compare and contrast multiple environmental factors in the same study are lacking. Thus, the goal of this study was to perform a prospective, data-driven environmental-wide association study of pre- and perinatal factors associated with the later development of autistic symptoms in childhood. The participants included 3891 6-year-old children from a birth cohort with pre- and perinatal data. Autistic symptoms were measured using the Social Responsiveness Scale in all children. Prior to any analyses, the sample was randomly split into a discovery set (2920) and a test set (921). Multiple linear regression analyses were performed for each of 920 variables, correcting for six of the most common covariates in epidemiological studies. We found 111 different pre- and perinatal factors associated with autistic traits during childhood. In secondary analyses where we controlled for parental psychopathology, 23 variables in the domains of family and interpersonal relationships were associated with the development of autistic symptoms during childhood. In conclusion, a data-driven approach was used to identify a number of pre- and perinatal risk factors associating with higher childhood autistic symptoms. These factors include measures of parental psychopathology and family and interpersonal relationships. These measures could potentially be used for the early identification of those at increased risk to develop ASD. LAY SUMMARY: A combination of genetic and environmental factors contributes to the development of autism spectrum disorder (ASD). Each environmental factor may affect the risk of ASD. In a study on 6-year-old children, a number of pre- and perinatal risk factors were identified that are associated with autistic symptoms in childhood. These factors include measures of parental psychopathology and family and interpersonal relationships. These variables could potentially serve as markers to identify those at increased risk to develop ASD or autistic symptoms. Autism Res 2020, 13: 1582-1600. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.

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.

Traumatic anticipation of childbirth and disordered eating during pregnancy

BACKGROUND

While research on Fear Of Childbirth (FOC) during pregnancy is on the rise, research regarding pretraumatic stress reactions is lacking. Moreover, less is known regarding negative anticipation of childbirth and Eating Disorders (ED). This study aims at identifying typologies of women in the prepartum period based on FOC and pretraumatic stress symptoms and investigating whether or not the identified profiles differ on levels of bulimic symptoms and Drive for Thinness (DT).

PARTICIPANTS AND METHODS

a sample of 213 pregnant women completed questionnaires assessing FOC, pretraumatic stress, DT and bulimic symptoms.

RESULTS

four clusters based on pretraumatic stress and FOC symptoms were identified: one characterised by traumatic symptoms, one showing moderated FOC symptoms, one with high symptomatology and one with low symptoms. Higher ED symptoms were found in women with both FOC and pretraumatic stress symptoms, and in the cluster showing elevated pretraumatic stress symptomatology.

CONCLUSIONS

To our knowledge, this is the first study focusing on anticipated traumatic reactions and ED in pregnant women. While some women evidenced FOC and pretraumatic stress symptoms, two different clusters, one with FOC and one with pretraumatic stress, were found. These findings suggest that, while sharing similarities, these constructs are different.

Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes

IMPORTANCE

The prevalence of eating disorders is high among women of reproductive age, yet the association of eating disorders with pregnancy complications and neonatal health has not been investigated in detail, to our knowledge.

OBJECTIVE

To investigate the relative risk of adverse pregnancy and neonatal outcomes for women with eating disorders.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all singleton births included in the Swedish Medical Birth Register from January 1, 2003, to December 31, 2014. A total of 7542 women with eating disorders were compared with 1 225 321 women without eating disorders. Statistical analysis was performed from January 1, 2018, to April 30, 2019. Via linkage with the national patient register, women with eating disorders were identified and compared with women free of any eating disorder. Eating disorders were further stratified into active or previous disease based on last time of diagnosis.

MAIN OUTCOMES AND MEASURES

The risk of adverse pregnancy outcomes (hyperemesis, anemia, preeclampsia, and antepartum hemorrhage), the mode of delivery (cesarean delivery, vaginal delivery, or instrumental vaginal delivery), and the neonatal outcomes (preterm birth, small and large sizes for gestational age, Apgar score <7 at 5 minutes, and microcephaly) were calculated using Poisson regression analysis to estimate risk ratios (RRs). Models were adjusted for age, parity, smoking status, and birth year.

RESULTS

There were 2769 women with anorexia nervosa (mean [SD] age, 29.4 [5.3] years), 1378 women with bulimia nervosa (mean [SD] age, 30.2 [4.9] years), and 3395 women with an eating disorder not otherwise specified (EDNOS; mean [SD] age, 28.9 [5.3] years), and they were analyzed and compared with 1 225 321 women without eating disorders (mean [SD] age, 30.3 [5.2] years). All subtypes of maternal eating disorders were associated with an approximately 2-fold increased risk of hyperemesis during pregnancy (anorexia nervosa: RR, 2.1 [95% CI, 1.8-2.5]; bulimia nervosa: RR, 2.1 [95% CI, 1.6-2.7]; EDNOS: RR, 2.6 [95% CI, 2.3-3.0]). The risk of anemia during pregnancy was doubled for women with active anorexia nervosa (RR, 2.1 [95% CI, 1.3-3.2]) or EDNOS (RR, 2.1 [95% CI, 1.5-2.8]). Maternal anorexia nervosa was associated with an increased risk of antepartum hemorrhage (RR, 1.6 [95% CI, 1.2-2.1]), which was more pronounced in active vs previous disease. Women with anorexia nervosa (RR, 0.7 [95% CI, 0.6-0.9]) and women with EDNOS (RR, 0.8 [95% CI, 0.7-1.0]) were at decreased risk of instrumental-assisted vaginal births; otherwise, there were no major differences in mode of delivery. Women with eating disorders, all subtypes, were at increased risk of a preterm birth (anorexia nervosa: RR, 1.6 [95% CI, 1.4-1.8]; bulimia nervosa: RR, 1.3 [95% CI, 1.0-1.6]; and EDNOS: RR, 1.4 [95% CI, 1.2-1.6]) and of delivering neonates with microcephaly (anorexia nervosa: RR, 1.9 [95% CI, 1.5-2.4]; bulimia nervosa: RR, 1.6 [95% CI, 1.1-2.4]; EDNOS: RR, 1.4 [95% CI, 1.2-1.9]).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that women with active or previous eating disorders, regardless of subtype, are at increased risk of adverse pregnancy and neonatal outcomes and may need increased surveillance in antenatal and delivery care.

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.

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.

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.

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

Predictors and long-term health outcomes of eating disorders

Anorexia and bulimia nervosa may have long-term effects on overall and reproductive health. We studied predictors of self-reported eating disorders and associations with later health events. We estimated odds ratios (ORs) for these associations in 47,759 participants from the Sister Study. Two percent (n = 967) of participants reported a history of an eating disorder. Risk factors included being non-Hispanic white, having well-educated parents, recent birth cohort (OR = 2.16, 95% confidence interval [CI]: 2.01–2.32 per decade), and having a sister with an eating disorder (OR = 3.68, CI: 1.92–7.02). As adults, women who had experienced eating disorders were more likely to smoke, to be underweight, to have had depression, to have had a later first birth, to have experienced bleeding or nausea during pregnancy, or to have had a miscarriage or induced abortion. In this descriptive analysis, we identified predictors of and possible long-term health consequences of eating disorders. Eating disorders may have become more common over time. Interventions should focus on prevention and mitigation of long-term adverse health effects.

Maternal history of eating disorders: Diet quality during pregnancy and infant feeding

We studied associations of maternal history of eating disorders (EDs) with diet quality of pregnant women and their infants, and breastfeeding practices. We included 6196 mother-child pairs from Generation R, a population-based cohort in the Netherlands. Maternal history of lifetime EDs was assessed during pregnancy with a questionnaire. Dietary intake during pregnancy and in infancy was assessed with food-frequency questionnaires and diet quality scores were calculated, reflecting adherence to dietary guidelines. Breastfeeding practices were assessed with questionnaires at 2, 6, and 12 months. We observed that, after adjustment for socioeconomic and lifestyle factors, women with a history of EDs had a higher diet quality than women without a history of EDs (B = 0.24 SD, 95%CI: 0.15; 0.33). Mothers with a history of EDs were less likely to breastfeed (unadjusted OR = 0.68, 95%CI: 0.51; 0.93), although no longer statistically significant after adjustment (OR = 0.75, 95%CI: 0.55; 1.03). These findings suggest that mothers with a history of EDs seem slightly less likely to initiate breastfeeding, however, this warrants further investigation. At the age of 1 year, infants of mothers with a history of EDs had a higher diet quality (B = 0.15 SD, 95%CI: 0.02; 0.27). We conclude that mothers with a history of EDs and their infants have a relative good diet quality, although follow-up studies are needed to assess long-term associations with diet in later childhood and adolescence.

Childhood psychopathology in children of women with eating disorders

OBJECTIVE

We aimed to investigate the effect of maternal eating disorders (ED) on childhood psychopathology, early delays in cognitive, motor and language development, mother and child relationship, and child temperament in a community-based cohort: the Danish National Birth Cohort (DNBC).

METHOD

Data were obtained prospectively on 48 403 children at 18 months and 46 156 children at 7 years. Data on cognitive, motor and language development, temperament and attachment were obtained at 18 months; data on child psychopathology were obtained at 7 years of age, using the Strengths and Difficulties Questionnaire (SDQ). Children of mothers with lifetime diagnosis of anorexia nervosa (AN, n = 931), lifetime diagnosis of bulimia nervosa (BN, n = 906) and both (AN & BN = 360) were compared to children of mothers without an ED (n = 46 206).

RESULTS

Girls of women with lifetime AN had higher odds of having emotional problems, and girls of women with lifetime BN of having conduct problems compared with children of healthy women. Boys of women with lifetime AN had higher odds of total, emotional and conduct problems; boys of women with lifetime BN had higher odds of total, conduct, hyperactivity and peer difficulties compared to children of women without an ED. Boys of women with lifetime AN and BN had higher odds of total, emotional and peer problems compared to children of healthy women.

CONCLUSION

Maternal ED is associated with childhood psychopathology in both boys and girls. Boys seemed at higher risk for psychopathology in this sample. Associations between emotional disorders across genders in children of mothers with lifetime AN, and hyperactivity and peer difficulties in boys of mothers with lifetime BN confirm and extend previous findings and point to possible shared risk between ED and other psychopathology.

Social patterning of overeating, binge eating, compensatory behaviours and symptoms of bulimia nervosa in young adult women: results from the Australian Longitudinal Study on Women's Health

Objective

To study social patterning of overeating and symptoms of disordered eating in a general population.

Design

A representative, population-based cohort study.

Setting

The Australian Longitudinal Study on Women’s Health (ALSWH), Survey 1 in 1996 and Survey 2 in 2000.

Subjects

Women (n 12 599) aged 18–23 years completed a questionnaire survey at baseline, of whom 6866 could be studied prospectively.

Results

Seventeen per cent of women reported episodes of overeating, 16 % reported binge eating and 10 % reported compensatory behaviours. Almost 4 % of women reported symptoms consistent with bulimia nervosa. Low education, not living with family, perceived financial difficulty (OR=1·8 and 1·3 for women with severe and some financial difficulty, respectively, compared with none) and European language other than English spoken at home (OR=1·5 for European compared with Australian/English) were associated with higher prevalence of binge eating. Furthermore, longitudinal analyses indicated increased risk of persistent binge eating among women with a history of being overweight in childhood, those residing in metropolitan Australia, women with higher BMI, smokers and binge drinkers.

Conclusions

Overeating, binge eating and symptoms of bulimia nervosa are common among young Australian women and cluster with binge drinking. Perceived financial stress appears to increase the risk of binge eating and bulimia nervosa. It is unclear whether women of European origin and those with a history of childhood overweight carry higher risk of binge eating because of genetic or cultural reasons.

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.

Intimate partner violence among women with eating disorders during the perinatal period

OBJECTIVE

Prevalence of intimate partner violence (IPV) during pregnancy is estimated to be 4%-8%. Women with mental health difficulties are at increased risk for IPV during the perinatal period. Prevalence of IPV is high among women with eating disorders (ED); however, prevalence of IPV during the perinatal period among women with ED is unknown.

METHOD

We studied women from a population-based cohort, the Avon Longitudinal Study of Parents and Children. Prevalence and odds of physical and emotional IPV during and after the perinatal period was investigated among women with lifetime ED, with (n = 174) or without pregnancy shape and weight concern and/or purging behaviors (n = 189), and women with no ED (n = 8723).

RESULTS

Women with lifetime ED showed higher prevalence of IPV during and after the perinatal period (physical = 9.6%-14.3% and emotional = 24.1%-28.1%). Lifetime ED was associated with higher odds of physical IPV during the perinatal period (odds ratio: 2.34, 95% confidence interval: 1.11-4.93, p = .03). Lifetime ED with and without pregnancy shape and weight concerns and/or purging was associated with higher odds of IPV after the perinatal period, and higher odds of reporting emotional IPV at all time points. Associations were moderated by partner's response to pregnancy and maternal experience of childhood sexual abuse.

DISCUSSION

Mothers with ED and their children may be vulnerable to negative effects due to maternal ED and IPV combined, both of which have been associated with severe and long-lasting harmful consequences. Partner's response to pregnancy and maternal experience of childhood sexual abuse might contribute to the association between ED and IPV perinatally.

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.

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.

The effects of maternal eating disorders on offspring childhood and early adolescent psychiatric disorders

OBJECTIVE

There is evidence that parental psychiatric disorders are associated with offspring psychiatric disorder. Very few small studies have investigated the effect of maternal eating disorders on offspring psychopathology throughout childhood and early adolescence. We aimed to investigate psychiatric disorders at age 7, 10, and 13 years in offspring of women with eating disorders prior to pregnancy and investigate the relative contribution of other psychiatric disorders.

METHOD

Women (N = 12,035) from a large population-based longitudinal cohort: the Avon Longitudinal Study of Parents and Children (ALSPAC). A brief prepregnancy psychiatric history was obtained at enrollment to determine exposure. Offspring psychiatric disorder was measured using the developmental and well-being assessment at ages 7, 10, and 13.

RESULTS

Maternal eating disorders were associated with a psychiatric diagnosis in the offspring at age 7 and 10, particularly emotional disorders (Odds ratio = 1.9, 95%CI: 1.1-2.8). Maternal psychiatric disorders other than eating disorders predicted psychiatric diagnoses across ages, and acted in an additive fashion with maternal eating disorders.

DISCUSSION

Maternal eating disorders together with comorbid psychopathology increase risk for psychiatric disorders in childhood and early adolescence, in particular for emotional disorders. This has important implications for prevention and future research.

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.

Childhood psychopathology in children of women with eating disorders: understanding risk mechanisms

BACKGROUND

Very few studies have investigated psychopathology in children of mothers with eating disorders (ED). We aimed to determine the effect of maternal ED on childhood psychopathology in a large population-based cohort and investigate relevant risk pathways using structural equation modeling (SEM).

METHODS

Data on emotional and behavioral problems at 3½ years were obtained prospectively on 8,622 children from the Avon Longitudinal Study of Parents and Children (ALSPAC). Children of exposed women who self-reported lifetime anorexia nervosa (AN, N = 193) or bulimia nervosa (BN, N = 158) in pregnancy were compared with children of unexposed women (N = 8,271) using linear and logistic regression models. SEM was used to determine best-fitting risk models by child gender.

RESULTS

There was evidence that girls of AN women were more likely to have emotional, conduct, and hyperactivity disorders [Odds Ratio (OR): 1.7 (95% Confidence Intervals 1.0-3.0); OR: 2.2 (1.2-4.0); OR: 1.8 (1.1-3.1), respectively] and boys of AN women to have emotional disorders compared with unexposed [OR: 2.0(1.2-3.4)]. Girls of women with BN were more likely to show hyperactivity [OR: 1.7 (1.0-3.1)]; and boys to show emotional and conduct disorders compared with unexposed [OR: 2.2 (1.2-3.9); OR: 2.4 (1.4-4.2), respectively]. SEM models showed that pregnancy anxiety and depression mediated the effect of maternal ED on child psychopathology.

CONCLUSIONS

Maternal ED are associated with different childhood psychopathology outcomes in boys and girls. Pregnancy anxiety and depression and active ED symptoms are important mediators of risk and are preventable; the direct effect of maternal lifetime ED was small.

The early cognitive development of children at high risk of developing an eating disorder

Diagnosis of an eating disorder (ED) has been associated with differences in cognition. Recent evidence suggests that differences may be present prior to onset. Children at familial high risk for ED show cognitive differences at ages 8-10 years. Research is required to investigate differences in cognitive development at various time points. This is the first study to investigate cognitive development in children at high risk at 18 months (Griffiths Mental Development Scale; n=982) and 4 years old (Wechsler Preschool and Primary Scale of Intelligence-Revised; n=582), in comparison with children not at risk, using a general population sample, the Avon Longitudinal Study of Parents and Children. Children of women with lifetime anorexia nervosa revealed difficulties in social understanding, visual-motor function, planning and abstract reasoning. Cognitive differences observed here have also been observed in clinical groups. This suggests difficulties may be present prior to onset, potentially affecting risk status for development of ED. Findings contribute to an understanding of aetiology, and design of prevention/intervention strategies.

2D:4D ratio in children at familial high-risk for eating disorders: The role of prenatal testosterone exposure

OBJECTIVES

Markers of prenatal hormone exposure have been associated with the development of eating disorder (ED) behaviors. Our aim was to determine whether 2D:4D ratio, a marker for in utero testosterone exposure, is associated with risk for ED in a large population-based cohort: the Avon Longitudinal Study of Parents and Children (ALSPAC).

METHODS

This is the first study to investigate prenatal testosterone exposure in children at high-risk for ED, using 2D:4D as a marker. We compared children whose mothers reported a lifetime ED (anorexia, bulimia, or both; N = 446) to children whose mothers did not (n = 5,367).

RESULTS

Daughters of women with lifetime bulimia nervosa (BN) had lower 2D:4D ratio (B: -0.01, 95% CI: -0.02 to -0.002, P = 0.02), indicating higher prenatal testosterone exposure, than daughters of mothers unaffected by ED. No differences were observed in the male children of women with an ED.

CONCLUSIONS

Findings suggest that children at high-risk for BN may be exposed to higher levels of testosterone in utero. Fetal exposure to androgen excess is thought to be causal in the development of polycystic ovary syndrome (PCOS), a disorder which is highly comorbid with binge eating and BN. Future research should investigate the potential role of testosterone exposure in utero as a risk factor for BN and binge eating.

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.

Low birth weight in the offspring of women with anorexia nervosa

A growing body of literature has investigated the association between maternal anorexia nervosa and pregnancy outcomes. Infant low birth weight is associated with a number of neurodevelopmental and physical sequelae; however, consistent results on its association with maternal anorexia nervosa are scant. Therefore, a systematic review and meta-analysis of the existing literature were undertaken. PubMed, Embase, and PsychInfo were searched for studies comparing the mean birth weight of babies delivered by mothers with (a history of) anorexia nervosa against those of healthy mothers. Studies were excluded from the meta-analysis if not presenting data from an unexposed comparison group and if using multiple eating disorders as exposure without presenting individual results. Fourteen studies were included in the systematic review and 9 in the meta-analysis, undertaken between 1999 and 2012 in Denmark, the Netherlands, New Zealand, Norway, Sweden, and the United Kingdom. Birth weights were standardized by dividing the difference in mean birth weight by the pooled standard deviation (equivalent to Cohen's d). Results showed a standardized mean difference of -0.19 kg (95% confidence interval: -0.25, -0.15; P = 0.01) in the birth weight of children of mothers with anorexia nervosa, and some bias in favor of papers presenting lower birth weight results for exposed mothers was detected. However, the small power of the analysis due to the small number of available studies and, thus, chance could partially account for this result. Our results confirm that maternal anorexia nervosa predicts lower birth weight and, despite some limitations, they have important clinical implications for prevention of adverse child outcomes.

Antihistamines and other prognostic factors for adverse outcome in hyperemesis gravidarum

OBJECTIVE

The purpose of this study is to determine the frequency of adverse perinatal outcome in women with hyperemesis gravidarum and identify prognostic factors.

STUDY DESIGN

This is a case-control study in which outcomes of first pregnancies were compared between 254 women with hyperemesis gravidarum treated with intravenous fluids and 308 controls. Prognostic factors were identified by comparing the clinical profile of patients with hyperemesis gravidarum with a normal and an adverse pregnancy outcome. Binary responses were analyzed using either a Chi-square or Fisher exact test and continuous responses were analyzed using a t-test.

RESULTS

Women with hyperemesis gravidarum have over a 4-fold increased risk of poor outcome including preterm birth and lower birth weight (p<0.0001). Among maternal characteristics, only gestational hypertension had an influence on outcome (p<0.0001). Treatment as an outpatient and/or by alternative medicine (acupuncture/acupressure/Bowen massage) was associated with a positive outcome (p<0.0089). Poor outcomes were associated with early start of symptoms (p<0.019), and treatment with methylprednisolone (p<0.0217), promethazine (p<0.0386), and other antihistamines [diphenhydramine (Benadryl), dimenhydrinate (Gravol), doxylamine (Unisom), hydroxyzine (Vistaril/Atarax), doxylamine and pyridoxine (Diclectin/Bendectin)] (p<0.0151) independent of effectiveness. Among these medications, only the other antihistamines were prescribed independent of severity: they were effective in less than 20% of cases and were taken by almost 50% of patients with an adverse outcome.

CONCLUSION

Poor outcomes are significantly greater in women with HG and are associated with gestational hypertension, early symptoms, and antihistamine use. Given these results, there is an urgent need to address the safety and effectiveness of medications containing antihistamines in women with severe nausea of pregnancy.