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  • Slide 1
  • High Risk Pregnancy - 2009
  • 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
  • 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 19
  • 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 20
  • 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. (Stein et al Eating Habits and Attitudes in the Post Partum Period. Psychosomatic Med., 1996)
  • Slide 21
  • 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 22
  • An observational study of mothers with eating disorders and their infants ( Stein et al., J Child Psychol Psychiat, 1994) 2 groups of primips: Index group, women who had met EDE criteria for disordered eating during pp period, n=34 Control group, balanced for SES, age, and childs gender, n=24 At one year: EDE Childs growth Structured observation of child and mother at task and mealtime
  • Slide 23
  • Mealtime Behaviors ( Stein et al., J Child Psychol Psychiat, 1994)
  • Slide 24
  • Discussion ( Stein et al., J Child Psychol Psychiat, 1994) Index mothers were more intrusive than control mothers About 1/3 of the index infants and one of the control infants had growth faltering Regression analysis models to predict infant weights were best fit when included: maternal height, infant birthweight conflict during meals mothers concern about own body shape
  • Slide 25
  • Also, eating disordered women make poor role models. Your influence could lead your daughters to their own eating disorders and your sons to believe that the most important thing about women is their weight.
  • Slide 26
  • Clinical Implications Careful screening and monitoring Possible use of self administered, computer assisted screening tool Psychotherapy may be indicated Interventions are not evidence based at this time, but based on case studies & individual counselors experiences
  • Slide 27
  • Clinical Interventions: Nutrition Frequent weigh-ins, lectures about weight gain, and even well-meaning comments by clinical staff can be triggers for increasing the frequency of eating disordered behaviors. (Mitchell et al. J midwifery & womens health, 2006) If appropriate: Discuss and provide materials about nutrients and food in pregnancy Design individual food plan Determine optimal range of weight gain Discuss hydration shifts in pregnancy and need for fluid
  • Slide 28
  • Clinical Interventions: Exercise Assess exercise level Suggest joining exercise groups and new mothers groups to normalize experience of weight concerns
  • Slide 29
  • Clinical Interventions: Psychosocial Making the fetus as real as possible to the patient very early Focus on fundal measurements? Empathetically addressing fears of weight gain and feelings of being out of control Assurance about normal weight gain and patterns of pp weight loss Education of significant others
  • Slide 30
  • Clinical Intervention: Infant Feeding Offer assistance with parenting concerns Offer information about infant feeding: infants ability to self regulate attention to infant cues & signals use of food as reward or control mechanism
  • Slide 31
  • Bulik Hypothesis (Int J Eat Disord, 2005) Preterm birth is associated with threefold increase in risk of AN Neurodevelopmental insults in premature infants could contribute to delayed oral-motor growth and onset of early eating problems. Women with low prepreg BMI & inadequate nutrition during gestation have increased risk for preterm delivery cycle of risk is established.
  • Slide 32
  • Maternal Obesity Rates of obesity are increasing world- wide Obesity before pregnancy is associated with risk of several adverse outcomes
  • Slide 33
  • Nutrition and Pregnancy Outcome. Henriksen, Nutrition Reviews, 2006 Management of Obesity in Pregnancy. Catalono. Obstetrics and Gynacology, 2007 Position of the American Dietetic Association and American Society for Nutrition: Obesity, Reproduction, and Pregnancy Outcomes. J Am Diet Assoc. 2009;109:918-927 Pregnancy Concerns Associa

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