Eating Disorders, Fertility, and Pregnancy

P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy: Relationships and Complications Women are becoming heavier with each generation although the ideal female image emphasizes slimness. This focus results in the development of eating disorders in a significant number of women. The most common eating disorders are anorexia nervosa and bulimia nervosa. Eating disorder behaviors during pregnancy are associated with complications such as preterm delivery, low birthweight, intrauterine growth restriction, Caesarean birth, and low Apgar scores. Increasing the understanding of eating disorders assists health care professionals to accurately assess and intervene to improve a woman’s nutritional status, monitor eating behaviors that may negatively affect a woman’s health and fertility, and promote positive outcomes during pregnancy. Key words: adolescence, eating disorders, nursing assessments, nursing interventions, pregnancy Dotti C. James, PhD, RN Assistant Professor, Perinatal Nursing Saint Louis University School of Nursing St. Louis, MO Submitted for publication: Accepted for publication: 36 INTRODUCTION In the United States and Western industrialized countries, body size and type contribute to feelings of self-worth. In these societies, women are becoming heavier as the ideal image becomes slimmer. Today’s culture reveres emaciation, even though an estimated 97 million adults in the United States are overweight or obese.1,2 Thinness is associated with goodness, intelligence, and success; non-thin is typified as bad, stupid, and weak. In an attempt to meet these societal expectations, many women adopt altered eating patterns; some of these women develop eating disorders. Eating disorders can be life threatening, from complications related to the disease process itself to suicide.3 More than 5 million Americans have an eating disorder, 85– 95% of these are female.4–6 Today, fewer cases of eating disorders are going undiagnosed, especially in the young adolescent population who are more likely to be living with parents. Increasing the understanding of eating disorders will assist health care professionals to accurately assess and intervene to improve a woman’s J Perinat Neonat Nurs 2001;15(2):36–48 2001 Aspen Publishers, Inc. c ° P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy nutritional status. Understanding the diseases of anorexia nervosa and bulimia nervosa will facilitate understanding the possible effects these diseases have in pregnant women. Disordered eating complicates approximately 1% of pregnancies.7 Eating disorders during pregnancy are associated with miscarriage, low birthweight, obstetric complications, and postpartum depression.8 Women often discuss the fear of becoming fat during pregnancy, and for those women already concerned with weight and body shape, pregnancy increases that anxiety. Personal issues that had been suppressed may surface and pose challenges for the pregnant woman. Eating disorders are thought to involve issues related to control. Pregnancy may be seen as a loss of control. The woman may fear the messages her body is giving.9 These messages include an increased appetite, an enlarging abdomen, and larger breasts—a contrast to the goal of a slim, straight body. These changes cause conflicting feelings.1 The purpose of this article is to discuss the two most common eating disorders— anorexia nervosa and bulimia nervosa— and their effects on reproduction. These two diseases frequently coexist, prompting a need to fully understand them and the problems they cause. Almost half of women with anorexia exhibit bulimic behaviors, and 30%–80% of women with bulimia have a history of anorexia.3 Anorexia Nervosa Anorexia has serious consequences, so early diagnosis and intervention are critical. Anorexia nervosa is described in the Diagnostic and Statistical Manual of Mental Disorders (DSMIV)10 as a condition characterized by a 15% reduction in weight below normal range, coupled with a lack of menses for three months. 37 Anorexia nervosa accounts for 0.5–3% of the general population of 15- to 30-yearold women.11,12 The incidence is higher if the adolescent period (15–19 years of age) is considered exclusively. Anorexia is the third most common chronic disease in this age group.3,4 In anorexia, the appetite is initially normal. As the disease worsens, the appetite decreases. Anorexia is classified into two types: restrictive, in which types and amounts of foods are limited severely; and binge eating or purging, in which patients engage in self-induced vomiting or other purging methods, such as laxatives, diuretics, or enemas.3,12 These behaviors cause a deterioration of overall health and threaten reproductive health. Initially, the altered eating behaviors of the woman with anorexia reinforce feelings of control over her environment; later the woman reports insomnia and feelings of loss of control.3 A woman is unable or unwilling to maintain normal minimal body weight and remains fearful of becoming obese. To the patient, anorexia is seen as an accomplishment rather than a pathology. The pathologically thin body, concealed with baggy clothes, is still seen as fat. Depression and obsessive-compulsive behaviors occur frequently with anorexia. Bulimia Nervosa Bulimia nervosa comes from the words meaning “oxlike hunger of nervous origin.” It is defined as two or more episodes of binge eating every week for 3 weeks, followed by vomiting or purging through the use of laxatives or diuretics. This binge/purge cycle may alternate with exercise or fasting. These behaviors result in a classification of bulimia into two types: purging and nonpurging. Patients with bulimia experience powerlessness to control these behaviors. Women with bulimia may P1: FBK AS089-03 August 25, 2001 38 JO U RN A L 15:7 OF Char Count= 0 PERIN ATA L AND NEO N ATA L NU RSIN G /SEPTEM BER 2001 be normal weight, underweight, or slightly overweight. Bulimia can develop at any age from early adolescence to age 40.13,14 It is two to three times more common than anorexia nervosa, with approximately 10–19% of women experiencing bulimia or bulimic episodes at some time during their lifetime, with up to 5% of U.S. college women affected.1,3 Symptoms of bulimia often fade with age and are uncommon after age 40. Familial factors such as dieting and comments about weight, shape, and eating are positively associated with bulimia nervosa.12 In contrast to anorexia, most young women with bulimia are distressed by the illness.12 ETIOLOGY, PATHOPHYSIOLOGY, AND CLINICAL MANIFESTATIONS An exact etiology for eating disorders is still unknown. Anorexia nervosa exerts physiological stresses on the body and its functions, and stress-induced alterations in gonadotropin-releasing hormone pulse generators mediated by neurotransmitters. Theories assert that anorexia nervosa may result from imbalances in the activity of the hormones and neurotransmitters that preserve a balance between energy output and food intake. This disruption of the hypothalamic-pituitarygonadal axis also causes decreased levels of plasma estradiol, luteinizing hormone, and follicle-stimulating hormone as well as menstrual dysfunction.3,12 Serotonin levels are found to be lower than normal in patients with anorexia and bulimia.15 Alteration of these hormone levels influences appetite, weight, mood, and stress responses. This further alters the reproductive hormone balance. Structural changes have been reported in the brains of women with anorexia and bulimia and in their electroencephalograms.3,17 These include enlargement of the ventricles, intracranial cerebrospinal fluid spaces, and sulci. In addition, research suggests that neuropsychological effects, such as difficulty concentrating, deficits in visuospatial abilities, problem solving, and insight occur in these diseases.3,16,17 It is thought that these alterations influence the woman’s ability to process and act on education about health care issues. A possible genetic link and common familial vulnerability for anorexia nervosa and bulimia nervosa may exist. In a family with a mother or sister who had anorexia, the incidence increases to 2–10%. These diseases have been diagnosed more frequently in identical twins than in fraternal twins.15,18,19 The mortality rate for anorexia nervosa alone is 0.56% each year, 12 times higher than the mortality rate for women in the general population.6 Over a 10-year period, 5–10% of young women with severe anorexia die, primarily from cardiac failure.1,20 After 20 years of disease, the mortality rate approaches 20% in the population of women with anorexia.3,13,21 Cardiac irregularities may result from lowered potassium levels, the most common electrolyte abnormality in eating disorders.3 Therefore, the physical assessment of the pregnant woman with anorexia must include a thorough cardiac assessment, paying particular attention to complaints that might indicate an irregular heartbeat, such as palpitations, “butterflies,” or pounding in the chest. The mortality rate for bulimia is approximately 7% for those with a 5-year history of the disease.6,12 In addition, bulimia may cause unpleasant effects, such as fatigue, weakness, constipation/ileus, gastric distention, fluid retention with P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy bloating, swollen parotid salivary glands, erosion of dental enamel, and sore throat. Repeated episodes of self-induced vomiting cause Russell’s sign, or scarring or abrasions on the dorsal side of the hand.20 Frequent self-induced vomiting stimulates the salivary glands and may result in enlargement of the salivary glands and increased amylase production and an elevation of salivary amylase levels.22 These signs should be discussed during clinical appointments. Physical symptoms and complaints that prompt more focused questions, assessments, and laboratory testing in the woman with anorexia are listed in Table 1. These symptoms include hypotension, bradycardia, and anemia. The hypotension may occur with dangerously low systolic readings at 70 or lower. Bradycardia (30– 60 beats per minute) indicates impaired cardiac function and has been reported to be as high as 10–21% among women with Table 1. Symptoms associated with anorexia nervosa • Drowsiness • Lethargy • Dry skin, brittle nails/hair (sandpaperlike, scaly; with yellowish color on palms) • Anemia • Swollen joints • Acrocyanosis • Hypertrophy of parotid glands → Chipmunk-like face • Lanugo (presence of fine downy hair on limbs and face) • Hypothermia • Bradycardia • Hypotension • Renal dysfunction 39 If anemia occurs in anorexia, it is often accompanied by hypocellular bone marrow with a decreased fat content. bulimia. This rate is adequate to meet tissue oxygen needs due to a decrease in the basal metabolic rate.4,12 If anemia occurs in anorexia, it is often accompanied by hypocellular bone marrow with a decreased fat content. In addition, the patient may exhibit a marked decrease in adipose tissue, loss of pubic hair, and a delay in deep-tendon reflexes. Most women with a severe eating disorder will demonstrate cardiovascular changes, but these changes occur less frequently in women with bulimia.3,23 Cardiovascular changes such as microcardia may also occur and are found more frequently when there has been a 30% or greater weight loss. This decrease in cardiac dimensions can be demonstrated by echocardiography. A reduction in cardiac muscle mass, especially the left ventricular mass, leads to decreased chamber size and impaired myocardial contractility, with resulting decreased cardiac output and left ventricular forces.23 The reduced mass or atrophy can cause the cardiac valves to sag, with subsequent mitral valve prolapse with its characteristic click.3,6 Women who use syrup of ipecac frequently are at risk for emetine cardiomyopathy, which can be fatal.4,12 Symptoms of toxicity related to ipecac include precordial pain, generalized muscle weakness, dyspnea, tachycardia, and electrocardiogram (ECG) abnormalities.12 An ECG is indicated for women with significant disease involvement, as well as a circulatory assessment for orthostatic hypotension. The ECG may show prolonged Q-T intervals, related to hypocalcemia P1: FBK AS089-03 August 25, 2001 40 JO U RN A L 15:7 OF Char Count= 0 PERIN ATA L AND NEO N ATA L NU RSIN G /SEPTEM BER 2001 or hypomagnesemia; T-wave inversion or flattening from hypokalemia; and ST depression, possibly indicating myocardial ischemia but more likely resulting from abnormalities in intracellular electrolytes.4 These changes may be treated with beta blockers such as propranolol. In the most severe cases, a temporary pacemaker may be inserted with the goal of preventing the development of ventricular tachycardia. During pregnancy, a decreased cardiac output may result in fetal compromise due to circulatory impairment.20 Prolonged use of laxatives in women with a purging type of eating disorder may cause stomach upset and digestive problems, such as malabsorption syndromes or protein-losing gastroenteropathy.20 Gastrointestinal effects resulting from purging are listed in Table 2.4,12,13 The gastric transit time may increase three to five times.4,12,13 The use of laxatives and emetics can be detected by laboratory analysis of serum, urine, or stool for the presence of emetine or phenolphthalein.4 Bulimia results in metabolic effects such as low serum glucose levels and low Cpeptide levels/normal insulin levels. If a woman with bulimia also has diabetes, the young woman may decrease the insulin dosage after binging to decrease weight with resulting hyperglycemia. This causes eye tissue damage and places the woman at increased risk for diabetic retinopathy. This retinopathy, while rare, may occur in women using this practice over time (3– 5 years). Elevated β-hydroxybutyric acid levels may also be seen. Starvation ketosis has been associated with elevated levels of fetal hemoglobin (HgbF) in these women. Normally, there is a 1% HgbF level in adults, but starvation is associated with increased levels.24 This elevation of HgbF results in anemia. If the anorexia is longstanding, the woman may develop osteopenia and osteoporosis as sequelae of hypoestrogenism. These conditions are the result of abnormal hormonal function that is needed for bone formation, inadequate dietary calcium and vitamin D, and hypercortisolemia.3,6 The risk for osteoporosis is increased in women who have missed 50% of their expected menstrual periods by age 20.25 In young women with anorexia, treatment with estrogen has not been supported in the literature, most probably due to the lack of body fat needed for estrogen storage. The effectiveness of oral contraceptives or hormone replacement to reduce osteopenia has not been proven.4,12 If estrogen treatment of these women is suggested, the estrogen supplementation should begin within 6 months of the onset of amenorrhea.25 Even with adherence to the recommended calcium intake and appropriate exercise, this condition may not be reversible and may Table 2. Gastrointestinal effects of purging behaviors • • • • • • Constipation Delayed gastric emptying GI bleeding/peptic ulcer Malabsorption syndromes Stomach upset and digestive problems Gastric dilation • • • • • • Protein-losing gastroenteropathy Loss of gag reflex Esophageal tearing Pancreatitis Excessive thirst/increased urination Enlargement of parotid gland P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy influence whether a woman is able to breastfeed her infant. Women with anorexia may impose rules about food—when to eat, what to eat, how to eat—as a substitute for genuine independence. This self-imposed starvation helps to control feelings of emotional emptiness. Weight loss that makes a normal dieter happy with her appearance makes the woman with anorexia more dissatisfied with her appearance and leads to the setting of progressively lower goals for weight loss or ideal weight. This chronic dissatisfaction with self may result in severe depression and suicidal ideation. FERTILITY AND PREGNANCY Research focused on pregnant women with anorexia or bulimia suggests a need for careful management. Stewart et al.26 reported on a study of 74 women ages 14–23 years with active disease. During these pregnancies, 11 women required hospitalization one to three times for complications related to the bulimia. The average weight gain was 8 pounds, with a gestational age of 37 to 38 weeks. Ninety percent of the women delivered vaginally, although the infants received lower Apgar scores. Brinch, Isager, and Tolstrug27 reported on the pregnancies of 50 women, which resulted in 75 children. In this group, the perinatal mortality was 14%, or six times the norm. In the 75 children, 7 had abnormal physical development, 1 had a severe visual handicap related to prematurity, and over the early childhood period, 6 were reported to have eating or weight problems such as failure to thrive. Morgan, Lacey, and Sedgwick28 reported that the symptoms of 57% of bulimic women worsened following pregnancy, but 34% experienced complete absence of symptoms. 41 Amenorrhea due to starvation is a diagnostic criterion for anorexia. Menstrual irregularities are common in women with bulimia. Inadequate body fat results in inadequate estrogen levels because estrogen is stored in body fat. A lowered estrogen level may lead to infertility problems in these women. The typical female pattern of fat distribution is absent in women with anorexia, but generally other manifestations of female hormone levels such as hair distribution (axillary and pubic) remain unchanged.21 Although anovulation is common, long-term infertility is not.1 Body fat levels can be assessed through a body mass index that is calculated by dividing the woman’s weight (pounds) by height squared (inches) divided by 704.5. To begin or resume normal menses requires approximately 17% body fat. The prepuberty ratio of body weight to fat is 5:1; and 3:1 at the time of menarche. Many believe that the amenorrhea, common in women with anorexia nervosa, indicates anovulation, but gestation may begin without prior menstruation. The body fat levels of women with bulimia may be decreased or in the normal range, and infertility problems in these women depend on the extent of body fat reduction. Education about contraception is necessary, as is pregnancy testing with sexually active women. The psychological factors accompanying anorexia may lead to a denial of the possibility of pregnancy and a delay in seeking care. Studies focusing on eating disorders and pregnancy have not resulted in a consensus on the effect of pregnancy on eating disorder symptomatology.28–30 Pregnancy in women with an eating disorder is prone to complications. Anorexia and bulimia are often grouped together during discussions of pregnancy and eating disorders, making differentiation between the two conditions during P1: FBK AS089-03 August 25, 2001 42 JO U RN A L 15:7 OF Char Count= 0 PERIN ATA L AND NEO N ATA L NU RSIN G /SEPTEM BER 2001 Table 3. Pregnancy complications associated with bulimia • • • • • • • • • • • • • Inadequate/excessive weight gain Hyperemesis Low birthweight Vaginal bleeding Damage to episiotomy sutures Fetal abnormalities Breech delivery Miscarriage Premature delivery Low Apgar scores Hypertension Prenatal mortality Stillbirth pregnancy more difficult. Research suggests that while pregnancy in anorexia is rarely expected, birth complications can occur. They include preterm delivery, low birthweight, higher incidence of Caesarean birth, and low Apgar scores.8,18,20 In addition to the complications seen in pregnancy accompanied by anorexia, pregnancy and bulimia are associated with low or high maternal weight gain, miscarriage, hypertension, stillbirth, breech delivery, and cleft palates.31,32 Hyperemesis has been identified in 10–25% of bulimic women (see Table 3).8,10,31 Alterations in electrolyte balance occur in 50% of women with bulimia. The specific alteration is related to the behaviors used by the woman to control body weight.1 While bulimic behaviors decrease during pregnancy, the risk of relapse and the incidence of postpartum depression increase following pregnancy.7,29 Therefore, it is important to continue monitoring women following birth, providing nutritional and counseling referrals as indicated. One of the difficulties in caring for a woman with an eating disorder during pregnancy is that many of the early symptoms of pregnancy that would prompt a woman to seek health care are similar to those typically experienced by women with anorexia. Therefore, there may be a delay in diagnosing the pregnancy at a time when the woman is in need of care and counseling.20,30 Women with bulimia experience similar symptoms, depending on the extent of their disease. The low body fat levels and inadequate fat storage in anorexia contribute to the urgency of early identification of the pregnancy because successful pregnancy, birth, and lactation require large amounts of stored energy. Once a diagnosis of anorexia is made, frequent assessments for the most common problems are imperative. Pregnancy management of women with anorexia begins with an appreciation that the early symptoms of pregnancy are an exaggeration of a normal phenomenon that includes fatigue, lethargy, weakness, and general malaise. Preventive counseling about the orthostatic hypotension that occurs frequently can prevent falls and subsequent injuries to the pregnant woman. In addition to the physical care of the pregnant woman with anorexia, providers need to evaluate the psychological symptoms commonly present in such women. One common theme is self-punishment, operationalized through the imposition of harsh dietary restrictions. The patient will appear serious, well behaved, orderly, and perfectionistic. Women with anorexia tend to be hypersensitive to rejection and feel irrational guilt and obsessive worry. These characteristics must be kept in mind while managing the pregnancy. A woman may be inclined to irrational guilt and obsessive worry about the pregnancy and the physical changes involved. Focused questions about body weight, weight control behaviors, eating behaviors and P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy patterns, and rituals surrounding eating during the assessment process will guide appropriate interventions.31 Initiate a referral to a mental health practitioner if the woman does not currently receive therapy. NUTRITION DURING PREGNANCY The weight gain curve during the pregnancy of a woman with anorexia resembles normal pregnancies although initial weight gain and total weight gain are lower. Underweight women have higher rates of pregnancy loss and infants born small for gestational age.18,33 There should be a heightened concern if the caloric consumption is less than 1000 calories each day. Due to this starvation and subsequent ketosis, urine ketones should be checked at each office or clinic visit; the woman should be instructed how to do this at home and when to contact the practitioner. Collaboration with a dietitian skilled in the management of eating disorders is valuable.34 Incorporating as many of the woman’s food preferences and rituals as possible increases adherence to the recommendations and provides feelings of security in a fear-provoking situation. If caloric intake goals cannot be maintained, parenteral nutrition or carefully supervised oral nutrition may be indicated. Inadequate nutrition during the pregnancy has been associated with a decrease in the infant birthweight of up to Incorporating as many of the woman’s food preferences and rituals as possible increases adherence to the recommendations and provides feelings of security in a fear-provoking situation. 43 550 grams.33,34 If dietary restrictions are severe, deterioration in the physical status may require admission to the hospital for total parenteral nutrition (TPN). Care must be used in the formulation of the TPN solution as hypophosphatemia from phosphate-depleted solutions can result in a shift of the oxyhemoglobin dissociation curve to left, indicating a decrease in the release of oxygen from hemoglobin to the tissues. The oxyhemoglobin dissociation curve shows the relationship between dissolved oxygen and hemoglobinbound oxygen. The shifts change the way oxygen is taken up by the hemoglobin molecule at alveolar levels and delivered at tissue levels. Using high-density protein supplements is not without risk and can result in weight depression in the infant. Aggressive refeeding and rapid weight gain can result in atrial arrhythmias, conduction delays, first and second-degree heart block, and congestive heart failure, especially if recovery of the heart chamber volume exceeds the stroke volume.3,12 LABORATORY TESTING DURING PREGNANCY Specific laboratory evaluation provides objective data about the physical condition of the woman. Restrictive eating coupled with purging places the woman at risk for an electrolyte imbalance, such as hypokalemia, hypophosphatemia, hyponatremia, or hypochloremia.3,12 Signs of hypokalemia include weakness, confusion, and palpitations. It is not typically seen with restricting behaviors alone. Hypokalemia coupled with an increase in serum bicarbonate indicates frequent vomiting or abuse of diuretics.6 Hypomagnesemia can hinder the correction of hypokalemia.12 Hyponatremia is common in anorexia and is indicative of P1: FBK AS089-03 August 25, 2001 44 JO U RN A L 15:7 OF Char Count= 0 PERIN ATA L AND NEO N ATA L NU RSIN G /SEPTEM BER 2001 water-loading to add temporary weight prior to a weigh-in or of the inappropriate regulation of antidiuretic hormone.5 Hypophosphatemia is correlated with poor nutrition. Protein synthesis and glucose phosphorylation require inorganic phosphate to move intracellularly, resulting in a sudden decrease of serum levels. This may cause neurological complications and abnormal functioning of the cardiac muscle.12 Dehydration, a frequent finding in eating disorders, can be assessed with urine specific gravity. Alkaline urine (pH greater than 7) is associated with metabolic alkalosis, often related to laxative or diuretic abuse and self-induced vomiting.4 The specific gravity of urine increases with dehydration, a frequently identified byproduct in anorexia. Elevated ketone levels may indicate starvation and dehydration. The hypocaloric diet adopted by women with eating disorders increases the risk of chronic ketosis. Chronic ketosis has been found to result in developmental delays in children, lower intelligence quotients, and an increase in learning disabilities.34,35 A complete blood count often shows leukopenia and low platelets. Normochromic, normocytic anemia may also occur.5,12 Other characteristic laboratory results include hypercarotenemia, elevation of serum liver enzymes reflecting fatty degeneration of liver, hypochloremia, elevated bicarbonate, elevated serum amylase, hypomagnesemia, hyperaldosteronism, and hypophosphatemia.3,12 These abnormalities may continue even during weight gain. Signs of hypothyroidism may be seen as well (low normal T4 , low total T3 , elevated reverse T3 , normal TSH). Plasma cortisol levels may be normal or elevated.12.20 The erythrocyte sedimentation rate is low in malnutrition and may be an obstacle in accurately identifying concurrent pathology. A woman may exhibit symptoms of diabetes insipidus secondary to depressed or erratic levels of vasopressin leading to polyuria. Depressed or erratic vasopressin levels can result in endocrine dysfunction such as diabetes insipidus with polyuria. Carbohydrate restriction and hypoglycemia can directly alter hypothalamic function and blood sugar. PHYSICAL CHANGES AFFECTING NURSING CARE Serious bodily changes are more common in women with a long history of eating disorders. This is especially true if purging is part of the disease process, and it places a woman at increased risk if general anesthesia is necessary. There is a decrease in lung elasticity from dehydration and malnutrition that causes decreased lung compliance. This possibility must be considered when planning respiratory support during anesthesia. The use of vomiting to control weight may result in mechanical and chemical injury to the esophagus. These injuries include strictures from acid exposure, Mallory-Weiss tears in the esophageal lining, and reflux esophagitis with delayed gastric emptying. Vomiting places a woman at risk for aspiration pneumonitis.20 Maintaining body temperature during and following a surgical procedure may be problematic. To prevent complications related to hypothermia, a warming blanket and the use of a heat and moisture exchanger may be helpful. Application of heat and moisture to the patient’s breathing circuit, coupled with warm, humidified, inspired gases may be necessary. Warming IV fluids will assist in maintaining an adequate temperature. P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy The marked cachexia, common in anorexia, may result in neurological impairments from the loss of normal cushioning. These include peripheral nerve palsies and delayed deep-tendon reflex relaxation. Nursing interventions to prevent this problem include providing extra padding to bony prominences and joints, the use of additional padding on all bed surfaces, and care to avoid pressure on any body part by equipment or safety belts or straps. GENERAL TREATMENT OPTIONS FOR EATING DISORDERS DURING PREGNANCY A multidisciplinary approach is most effective in treating the woman with an eating disorder in pregnancy. The use of cognitive-behavioral techniques and supportive psychotherapy may help to decrease anorexic or bulimic behaviors, especially purging.5,12,15 These treatments require collaboration between the obstetrical health care providers, nurses, therapists, and significant supportive family members. These collaborative efforts create a “holding” or stabilizing environment in which the woman can experience being “safe” and accepted as an individual of worth. Focused education about relaxation techniques is useful for times when guilt about eating or weight gain is experienced. Eating disorder behaviors respond weakly to serotonin (neurotransmitter) and to cholecystokinin (hormone inducing fullness) but appear to improve with the use of antidepressants. Traditional antidepressant medications have not shown to be effective in depression accompanying eating disorders when the woman is severely underweight or has anorexia.12,35,36 In contrast, most 45 antidepressants are effective in decreasing binging episodes and depression in women with bulimia.12 Tricyclic antidepressants, such as fluoxetine (pregnancy risk category B), and monoamine oxidase inhibitors (MAOIs), such as phenelzine and tranylcypromine (pregnancy risk category C), have not been reported to increase the risk of fetal malformations. MAOIs are not generally used in pregnancy as they are contraindicated with tocolytic agents (beta mimetics). All these medications cross the placenta and require a careful evaluation of the risk/benefit ratio. Avoiding medications during the first trimester when vital organs and systems are forming is optimal if the woman’s clinical condition and symptomatology permit. With long-acting medications, i.e. fluoxetine, the amount should be gradually decreased and discontinued one month prior to the due date, or if the disease is severe, switched to a medication with a shorter half-life, i.e. tricyclics (desipramine or nortriptyline, pregnancy risk NR) or paroxetine (pregnancy risk category B). Desipramine has been associated with neonatal tachycardia, tachypnea, irritability, myoclonus, tremors, urinary retention, and a poor sucking reflex. These effects may reflect withdrawal or toxicity and can be reduced or eliminated with the withdrawal of medication 1 to 2 weeks prior to delivery. All medications are secreted in breast milk but the concentration varies widely and is not directly related to maternal serum levels. Assays of the infant’s serum levels may be indicated. Antidepressants may not be effective when the woman is severely underweight.13 Indicators for further evaluation of a woman with an eating disorder include weight loss or lack of weight gain for two consecutive appointments during the P1: FBK AS089-03 August 25, 2001 46 JO U RN A L 15:7 OF Char Count= 0 PERIN ATA L AND NEO N ATA L NU RSIN G /SEPTEM BER 2001 second trimester, previously diagnosed eating disorder, or hyperemesis gravidarum.10 Hospitalization should be considered if weight loss is severe. Other secondary conditions requiring inpatient management include persistent hypokalemia, symptoms of inadequate cerebral perfusion (syncope, dizziness), or severe depression or suicidal thoughts.12,20 Depression is a significant variable in the overall pathology of eating disorders.3 To help a woman avoid a resumption of negative behaviors during the postpartum period, meeting with a dietitian experienced in the management of eating disorders can be helpful. If a woman desires to breastfeed, it is critical to refer her to a lactation consultant. Nursing interventions to create a stabilizing environment are beneficial because the precipitous drop in the reproductive hormones during the postpartum period, accompanied by sleep deprivation and societal expectations for the new mother, places great demands on the woman tenuously in control of disordered eating patterns. Reinforcement of positive behaviors and consultations with a dietitian and therapist may be helpful in restor- ing balance and control during the new experience of motherhood. Not all women experience this, however, and for some, the new infant is a stimulus to healthy behaviors. CONCLUSION Eating disorders are classified as a psychiatric illness according to the DSMIV, and these diseases exert a negative economic and psychosocial effect on the family and society. Women with these diseases seeking routine health care or pregnancy-related care require a collaborative and interdisciplinary approach. It has been reported that when physicians knew about a previous history of psychiatric illness, they were less likely to investigate the medical complaints voiced by these patients.37 Yet awareness of potential medical problems permits early interventions. The women and their families may need assistance in evaluating and making judgments about the accuracy and validity of information from nonmedical sources. Today, women and their family members seek information using the World Table 4. Comparison of symptoms of anorexia and pregnancy Anorexia Pregnancy • Amenorrhea (Occurs after loss of 10–15% of body weight or 1/3 of body fat) • Bloated abdomen • Nausea • Vomiting • Fatigue • Engorgement/tenderness of breasts • Lightheadedness • Constipation Amenorrhea Abdominal enlargement Nausea Vomiting Fatigue Engorgement/tenderness of breasts Lightheadedness Constipation P1: FBK AS089-03 August 25, 2001 15:7 Char Count= 0 Eating Disorders, Fertility, and Pregnancy 47 Table 5. Eating disorder web sites American Anorexia Bulimia Association American Psychological Association American Academy of Child & Adolescent Psychiatry American Association of Psychiatric Nurses American Dietetic Association American Psychiatric Association Anorexia Nervosa and Related Eating Disorders Eating Disorders Awareness and Prevention (EDAP) Gurze Books National Association of Anorexia Nervosa and Associated Disorders (NAANAD) National Eating Disorders Centre (Canada) National Institutes of Health (NIH) Something Fishy Organization Wide Web. Nurses may find that familiarity with some commonly used sites helpful in planning interventions (Table 4). Some of the sites are sponsored by professional organizations; others are created by individuals with strong opinions that may not be www.aabainc.org www.apa.org/ www.aacap.org/info families/index.htm www.apna.org www.eatright.org/ www.psych.org www.anred.com/ www.edap.org www.gurze.com www.anad.org/ www.nedic.on.ca www.nih.gov. www.something-fishy.org/ based in science. Accurate and appropriate education about the effect of nutrition on pregnancy may provide a buffer to the negative messages conveyed by the woman about foods and mealtimes that influence the health of the next generation.18 REFERENCES 1. Ambroz JR. Eating disorders and pregnancy. Midwifery Today. 1996;40:24–25. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Executive Summary. Washington, DC: U.S. Government Printing Office; 1998. NIH Publication No. 98–4083. 3. Muscari ME. 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