Pregnancy Poses Challenges for Those with Eating Disorders

Women with a lifetime history of eating disorders have special challenges throughout pregnancy and during the postpartum period. Pregnancy can exacerbate eating disorders symptoms and may lead to greater dietary restraint and poorer nutrition, and increased use of purging. Other women become over-concerned about gaining weight and changes in their shape. Perinatal problems linked to a lifetime history of an eating disorder include an increased risk of hyperemesis, smoking during pregnancy, and lower birth weights.

Sexual and physical abuse increased risk of depression

A history of childhood sexual and physical abuse also increases the risk of perinatal depression among pregnant women with eating disorders, according to Dr. Samantha Meltzer-Brody and colleagues at the University of North Carolina, Chapel Hill, and the University of Maryland, Baltimore (J Women’s Health 2011;20:863). Dr. Meltzer-Brody and co-workers studied data from 267 consecutive women patients seen in a Women’s Mood Disorders Clinic at the University of North Carolina from September 2006 to April 2009, and compared the data with that for a comparison group of women without eating disorders.

The researchers recruited participants for 12 months postpartum because many women do not seek care for perinatal depression until many months after delivery. The women were assessed with the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report screening questionnaire. The EPDS was developed specifically for assessing postpartum depression and relies much less than standard depression screens on somatic or physical symptoms; in addition, it specifically assesses for anxiety.

The women also were evaluated for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified, with purging (EDNOS-P), in accordance with DSM-IV symptom guidelines. Individual questions were adapted from the Structured Clinical Interview for DSM-IV (SCID-1). They also were studied with the Spielberger State-Trait Anxiety Inventory.

To test specifically for trauma or sexual or physical abuse, the authors adapted a structured interview they had developed from their previous research. This interview measured lifetime traumas by assigning 1 point for each of the following: childhood sexual abuse, adult sexual abuse, life-threatening attack, other physical abuse, parental alcohol or drug abuse or mental illness, being in foster care, a reform school or prison before age 18, close friend or family member killed by drunk driver or murdered, parent or sibling dying before the subject was 18, and child having life-threatening illness or death. Finally, they administered a brief version of the Patient Health Questionnaire.

Symptoms were more extreme with BN and EDNOS-P

Thirty-seven percent of the women reported a putative eating disorders history. Ten percent reported a lifetime history of AN; 10% reported lifetime BN; 10% reported lifetime EDNOS-P; and 7% reported having a lifetime history of BED. Women with BN reported significantly more symptoms of depression compared with women with perinatal depression and no history of eating disorders. Women with BN and those with EDNOS-P reported more severe depression than did women in the comparison group. Women with EDNOS-P reported significantly higher state anxiety than the referent group.

As for scores on comorbid trauma histories, physical and sexual abuses were common among the women with eating disorders: with 48.7% reporting either physical or sexual abuse. Women with AN and BN repotted higher frequencies of both physical and sexual abuse than the referent group. Overall, 81.3% of women with AN and 75% of women with BN reported lifetime sexual or physical abuse, compared to 41.4% of women in the comparison group.

The authors feel their findings underscore the importance of having the obstetrics/gynecology community embrace the importance of assessing a history of eating disorders early in a patient’s pregnancy. A system of referral and support for mental health treatment should be developed in order to encourage mental health screening by the obstetrics/gynecology community. The high prevalence of psychiatric comorbidity seen in this sample stresses how critical it is for women of reproductive age who are seeking prenatal care to receive comprehensive mental health evaluations for histories of eating disorders, depression, and trauma.