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  • Slide 1
  • High Risk Pregnancy - 2007
  • Slide 2
  • High Risk Pregnancies Disordered Eating Obesity Hypertensive Disorders Gestational Diabetes
  • Slide 3
  • Disordered Eating & Pregnancy: Prevalence Few data on prevalence of disordered eating in pregnancy Difficult to adequately capture this information from women. Women may have needs for secrecy and denial so information about history of eating disorders is often not given to health care providers during pregnancy Some published numbers for disordered eating in the population ( (Mitchell et al. J midwifery & womens health, 2006) Prevalence of binge eating disorder ~ 1.2%-4.5% Prevalence of anorexia nervosa in young females is 0.03% About 25% of individuals with anorexia nervosa develop a chronic course.
  • Slide 4
  • Diagnostic Criteria: Anorexia Nervosa (American Psychiatric Association) Refusal to maintain body weigh at or above normal weight for age and height Intense fear of gaining weight or becoming fat, even through underweight Disturbance in the way in which ones body weigh or shape is experienced, Undue influence of body weigh or self-evaluation or denial of the seriousness of current low body weight In postmenarcheal females, amenorrhea (absence of at least three consecutive menstrual cycles)
  • Slide 5
  • Diagnostic Criteria: Bulimia Nervosa (American Psychiatric Association) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: In a discrete period of time, eating an amount of food definitely larger than most people would eat A sense of lack of control over eating during the episode Recurrent inappropriate compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications. Binge eating and inappropriate compensatory behaviors occur at least twice a week for 3 months Self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during anorexia nervosa.
  • Slide 6
  • Diagnostic Criteria: Not otherwise specified (American Psychiatric Association) For females, all the criteria for AN are met, except that the individual has regular menstrual cycles. All criteria for AN is met, except the weight is WNL, despite significant weight loss Regular use of inappropriate compensatory behaviors in an individual of normal weight after eating small amounts of food Repeated chewing and spitting out food, but not swallowing Binge-eating disorder: recurrent episodes of binge eating in the absence of regular use of compensatory behaviors characteristic of BN
  • Slide 7
  • Disordered Eating & Pregnancy Results of published studies are inconsistent Developmental tasks of pregnancy are often about the same issues that arise in some women with eating disorders Body changes Alterations in roles Concerns about a womans own mothering and needs for psychological separation.
  • Slide 8
  • Pregnancy and Eating Disorders: A review and clinical Implications (Franko and Walton, Int.J. Eating Disorders, 1993) British report on 6 of 327 women who had attended eating disorder clinic and got pregnant Median BMI was 16.8 (range 14.9-18.1) Median length of time with AN was 15 years (range 11-17) Average weight gain was 8 kg (range 5-14) - recommendations for low BMI are 13-18 Poor third trimester fetal growth was found in all 5 babies who were monitored Babies had some catch up in infancy
  • Slide 9
  • Pregnancy Outcome and Disordered Eating (Abraham et al J Psychosom Obstet Gynecol, 1994) 24 women reported previous problems with disordered eating. These women had higher rates of antenatal complications such as IUGR, PIH, edema, GDM, vaginal bleeding (p 6 months) not associated with different outcomes No difference in SGA and any other negative birth outcomes for mother or baby
  • Slide 17
  • Birth outcomes and pregnancy complications in women with a history of AN (Ekeus et al, BJOG, 2006) Authors explanation of findings: Our findings may be a result of gradual improvement in the care process, both AN and maternity care. A country with a satisfactory maternity surveillance, outcome of pregnancy and delivery may be just as good for women with a hx of AN as for the general population. OR..the fertility problems associated with AN mean that pregnancy will only occur in less severe cases
  • Slide 18
  • Avon Longitudinal Study of Parents and Children N=14,472 Representative of women in the UK 85=90% of women who were expected to deliver babies in Avon geographical area between April 1991 and December 1992
  • Slide 19
  • Associated Risks: Percents (Micali et al. Br J Psych., 2007) AN (n=171) BM (n=191) AN + BN (n=82) Other Pysch. Disord (n=1166) General Population (n=10,636) Smoking T1 282640 21 Smoking T2 2021243316 Alcohol T1 1219251915
  • Slide 20
  • Recency of ED (Micali et al. J Psychosom. Research, 2007) N=12,252 57 reported recent episode of ED (6 AN, 51 BN) 395 reported past history of ED Note: recent not defined in paper. Asked about behaviors at 18 weeks and 36 weeks via mailed questionnaire
  • Slide 21
  • Recent EDPast EDNon-obese controls Laxative use in pg 8.20.80.2 Pregnancy SIV26.53.90.7 High exercise in pregnancy 32.731.221.2 Strong desire to loose weight 63.531.422.2 Loss of control over eating 72.542.836.1
  • Slide 22
  • Postpartum eating and Body Image for all Women It is of note that in a general population of postpartum women, eating disorder behaviors increase markedly in the first 3 months post-partum and remain high for the next 9 months. Some women actually first experience clinical eating disorders during this time.
  • Slide 23
  • Eating Habits and Attitudes in the Post Partum Period (Stein et al. Psychosomatic Med., 1996) N=97, prospective cohort study of primip. women followed during pregnancy and at 3 and 6 mos pp. Eating Disorder Examination (EDE): restraint, eating concern, shape concern, weight concern and global scores about state over last 28 days Repeated measures ANOVA indicated that changes in eating disorder pathology pp were largely due to changes in body weight.
  • Slide 24
  • Eating Habits and Attitudes in the Post Partum Period (Stein et al. Psychosomatic Med., 1996) ** = p
  • Infant Outcomes Large infants - effect is independent of maternal diabetes- rates of macrosomia (>4000 g): Normal weight women: 8 % Obese women: 13% Morbidly obese women: 15% Increased infant mortality - RR for infants born to obese women was 4.0 compared to women with BMI < 20
  • Slide 49
  • Long Term Risks to Infant Children born to obese mothers twice as likely to be above 95 th percentile BMI at age 2 Metabolic syndrome in at age 11: Hazard ratio = 2.19 (1.25-3.82) if LGA Hazard ratio = 1.81 (1.03-3.19) if maternal obesity
  • Slide 50
  • Swedish population-based study (Cedergren, 2004) n=805,275 Morbid obesity (BMI>40) compared to normal weight 5 fold risk of preeclampsia 3 fold risk of still birth after 28 weeks 4 fold risk of LGA BMI >35,
  • Cost Costs were 3.2 times higher for women with BMI > 35 Longer hospitalizations
  • Slide 52
  • Emerging Issues: Bariatric Surgery Outcomes Challenges of studies: Appropriate control groups? Outcomes to measure? Selection bias Changes in procedures over time Clinical recommendations
  • Slide 53
  • Outcomes After Malabsorptive Procedures such as Roux-en-Y (Bernert et al. Diabetes Metab. 2007; Catalono. Obstet Gynecol, 2007) Associated Complications: Small bowel ischemia Nutrient deficiencies (iron, folate, B 12) Fetal abnormalities SGA & preterm birth Cesarean delivery
  • Slide 54
  • Pregnancy Outcomes after Gastric-Bypass Surgery Dao, et al. Am J Surg, 2006 N= 21 pregnant within first year post- surgery; 13 pregnant after first year (Texas) Author's conclusions: Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes or pregnancy complications.
  • Slide 55
  • Pregnancy following gastric-bypass (Dao, 2006) < 1 year (21)> 1 year (13) Mean BMI: At surgery At pregnancy 49 35 46 28 Mean weight gain4 #34# Mean birthweight2868 g (2 sets twins) 2727 g (3 sets twins) Major pregnancy complications 51 Minor pregnancy complications 53
  • Slide 56
  • Birth Outcomes in Obese Women After Laparoscopic Adjustable Gastric Banding Dixon et al. Obstet Gynecology. 2005 N=79 (Australia) Mean maternal weight gain= 9.6 +/- 9.0 kg Mean birthweight = 3,397 Incidence of PIH, GDM, stillbirth, preterm delivery low and high birth weights more similar to population than obese women.
  • Slide 57
  • Dixon Conclusions: Pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women. The adjustability of the LABG assists in achieving these outcomes.
  • Slide 58
  • Pregnancy Outcome of Patients with Gestational Diabetes Mellitus Following Bariatric Surgery Sheiner et al. Am J Obstet Gynecol. 2006 N= 28 (16 gastric banding) Compared to 7988 GDM pregnancies without surgery Israel between 1988 and 2002 No differences in: obstetric characteristics, perinatal outcomes, congenital malformations, Apgar, Hgb A1c, fasting glucose.
  • Slide 59
  • Sheiner et

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