Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes | Neonatology | JAMA Psychiatry | JAMA Network
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1.
Schaumberg  K, Welch  E, Breithaupt  L,  et al.  The science behind the academy for eating disorders’ nine truths about eating disorders.  Eur Eat Disord Rev. 2017;25(6):432-450. doi:10.1002/erv.2553PubMedGoogle ScholarCrossref
2.
Zipfel  S, Giel  KE, Bulik  CM, Hay  P, Schmidt  U.  Anorexia nervosa: aetiology, assessment, and treatment.  Lancet Psychiatry. 2015;2(12):1099-1111. doi:10.1016/S2215-0366(15)00356-9PubMedGoogle ScholarCrossref
3.
Currin  L, Schmidt  U, Treasure  J, Jick  H.  Time trends in eating disorder incidence.  Br J Psychiatry. 2005;186:132-135. doi:10.1192/bjp.186.2.132PubMedGoogle ScholarCrossref
4.
Sollid  CP, Wisborg  K, Hjort  J, Secher  NJ.  Eating disorder that was diagnosed before pregnancy and pregnancy outcome.  Am J Obstet Gynecol. 2004;190(1):206-210. doi:10.1016/S0002-9378(03)00900-1PubMedGoogle ScholarCrossref
5.
Pasternak  Y, Weintraub  AY, Shoham-Vardi  I,  et al.  Obstetric and perinatal outcomes in women with eating disorders.  J Womens Health (Larchmt). 2012;21(1):61-65. doi:10.1089/jwh.2011.2907PubMedGoogle ScholarCrossref
6.
Koubaa  S, Hällström  T, Lindholm  C, Hirschberg  AL.  Pregnancy and neonatal outcomes in women with eating disorders  [published correction appears in Obstet Gynecol. 2008;111(5):1217].  Obstet Gynecol. 2005;105(2):255-260. doi:10.1097/01.AOG.0000148265.90984.c3PubMedGoogle ScholarCrossref
7.
Linna  MS, Raevuori  A, Haukka  J, Suvisaari  JM, Suokas  JT, Gissler  M.  Pregnancy, obstetric, and perinatal health outcomes in eating disorders.  Am J Obstet Gynecol. 2014;211(4):392.e1-392.e8. doi:10.1016/j.ajog.2014.03.067PubMedGoogle ScholarCrossref
8.
Morgan  JF, Lacey  JH, Chung  E.  Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study.  Psychosom Med. 2006;68(3):487-492. doi:10.1097/01.psy.0000221265.43407.89PubMedGoogle ScholarCrossref
9.
Bansil  P, Kuklina  EV, Whiteman  MK,  et al.  Eating disorders among delivery hospitalizations: prevalence and outcomes.  J Womens Health (Larchmt). 2008;17(9):1523-1528. doi:10.1089/jwh.2007.0779PubMedGoogle ScholarCrossref
10.
Watson  HJ, Zerwas  S, Torgersen  L,  et al.  Maternal eating disorders and perinatal outcomes: a three-generation study in the Norwegian Mother and Child Cohort Study.  J Abnorm Psychol. 2017;126(5):552-564. doi:10.1037/abn0000241PubMedGoogle ScholarCrossref
11.
Ekéus  C, Lindberg  L, Lindblad  F, Hjern  A.  Birth outcomes and pregnancy complications in women with a history of anorexia nervosa.  BJOG. 2006;113(8):925-929. doi:10.1111/j.1471-0528.2006.01012.xPubMedGoogle ScholarCrossref
12.
Micali  N, De Stavola  B, dos-Santos-Silva  I,  et al.  Perinatal outcomes and gestational weight gain in women with eating disorders: a population-based cohort study.  BJOG. 2012;119(12):1493-1502. doi:10.1111/j.1471-0528.2012.03467.xPubMedGoogle ScholarCrossref
13.
Ludvigsson  JF, Otterblad-Olausson  P, Pettersson  BU, Ekbom  A.  The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research.  Eur J Epidemiol. 2009;24(11):659-667. doi:10.1007/s10654-009-9350-yPubMedGoogle ScholarCrossref
14.
Cnattingius  S, Ericson  A, Gunnarskog  J, Källén  B.  A quality study of a medical birth registry.  Scand J Soc Med. 1990;18(2):143-148. doi:10.1177/140349489001800209PubMedGoogle ScholarCrossref
15.
Ludvigsson  JF, Andersson  E, Ekbom  A,  et al.  External review and validation of the Swedish national inpatient register.  BMC Public Health. 2011;11:450. doi:10.1186/1471-2458-11-450PubMedGoogle ScholarCrossref
16.
Cnattingius  S, Norman  M, Granath  F, Petersson  G, Stephansson  O, Frisell  T.  Apgar score components at 5 minutes: risks and prediction of neonatal mortality.  Paediatr Perinat Epidemiol. 2017;31(4):328-337. doi:10.1111/ppe.12360PubMedGoogle ScholarCrossref
17.
Marsál  K, Persson  PH, Larsen  T, Lilja  H, Selbing  A, Sultan  B.  Intrauterine growth curves based on ultrasonically estimated foetal weights.  Acta Paediatr. 1996;85(7):843-848. doi:10.1111/j.1651-2227.1996.tb14164.xPubMedGoogle ScholarCrossref
18.
Koubaa  S, Hällström  T, Brismar  K, Hellström  PM, Hirschberg  AL.  Biomarkers of nutrition and stress in pregnant women with a history of eating disorders in relation to head circumference and neurocognitive function of the offspring.  BMC Pregnancy Childbirth. 2015;15:318. doi:10.1186/s12884-015-0741-7PubMedGoogle ScholarCrossref
19.
Deutsch  AB, Lynch  O, Alio  AP, Salihu  HM, Spellacy  WN.  Increased risk of placental abruption in underweight women.  Am J Perinatol. 2010;27(3):235-240. doi:10.1055/s-0029-1239490PubMedGoogle ScholarCrossref
20.
Aliyu  MH, Alio  AP, Lynch  O, Mbah  A, Salihu  HM.  Maternal pre-gravid body weight and risk for placental abruption among twin pregnancies.  J Matern Fetal Neonatal Med. 2009;22(9):745-750. doi:10.3109/14767050902994523PubMedGoogle ScholarCrossref
21.
Baumann  P, Blackwell  SC, Schild  C, Berry  SM, Friedrich  HJ.  Mathematic modeling to predict abruptio placentae.  Am J Obstet Gynecol. 2000;183(4):815-822. doi:10.1067/mob.2000.108847PubMedGoogle ScholarCrossref
22.
Ray  JG, Laskin  CA.  Folic acid and homocyst(e)ine metabolic defects and the risk of placental abruption, pre-eclampsia and spontaneous pregnancy loss: a systematic review.  Placenta. 1999;20(7):519-529. doi:10.1053/plac.1999.0417PubMedGoogle ScholarCrossref
23.
Vollset  SE, Refsum  H, Irgens  LM,  et al.  Plasma total homocysteine, pregnancy complications, and adverse pregnancy outcomes: the Hordaland Homocysteine Study.  Am J Clin Nutr. 2000;71(4):962-968. doi:10.1093/ajcn/71.4.962PubMedGoogle ScholarCrossref
24.
Ananth  CV, Oyelese  Y, Srinivas  N, Yeo  L, Vintzileos  AM.  Preterm premature rupture of membranes, intrauterine infection, and oligohydramnios: risk factors for placental abruption.  Obstet Gynecol. 2004;104(1):71-77. doi:10.1097/01.AOG.0000128172.71408.a0PubMedGoogle ScholarCrossref
25.
Hütter  G, Ganepola  S, Hofmann  WK.  The hematology of anorexia nervosa.  Int J Eat Disord. 2009;42(4):293-300. doi:10.1002/eat.20610PubMedGoogle ScholarCrossref
26.
Koubaa  S, Hällström  T, Hagenäs  L, Hirschberg  AL.  Retarded head growth and neurocognitive development in infants of mothers with a history of eating disorders: longitudinal cohort study.  BJOG. 2013;120(11):1413-1422. doi:10.1111/1471-0528.12370PubMedGoogle ScholarCrossref
27.
Ruiz  RJ, Fullerton  J, Dudley  DJ.  The interrelationship of maternal stress, endocrine factors and inflammation on gestational length.  Obstet Gynecol Surv. 2003;58(6):415-428. doi:10.1097/01.OGX.0000071160.26072.DEPubMedGoogle Scholar
28.
Wadhwa  PD, Culhane  JF, Rauh  V, Barve  SS.  Stress and preterm birth: neuroendocrine, immune/inflammatory, and vascular mechanisms.  Matern Child Health J. 2001;5(2):119-125. doi:10.1023/A:1011353216619PubMedGoogle ScholarCrossref
29.
Casanueva  E, Ripoll  C, Meza-Camacho  C, Coutiño  B, Ramírez-Peredo  J, Parra  A.  Possible interplay between vitamin C deficiency and prolactin in pregnant women with premature rupture of membranes: facts and hypothesis.  Med Hypotheses. 2005;64(2):241-247. doi:10.1016/j.mehy.2004.08.002PubMedGoogle ScholarCrossref
30.
Schmidt  U, Adan  R, Böhm  I,  et al.  Eating disorders: the big issue.  Lancet Psychiatry. 2016;3(4):313-315. doi:10.1016/S2215-0366(16)00081-XPubMedGoogle ScholarCrossref
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    Maternal anorexia nervosa and risk of adverse pregnancy/neonatal outcomes
    Tomoyuki Kawada, MD | Nippon Medical School
    Mantel et al. investigated the risk of adverse pregnancy and neonatal outcomes in women with eating disorders (1). The adjusted risk ratios (RRs) (95% confidence intervals [CIs]) of maternal anorexia nervosa for hyperemesis during pregnancy were 2.1 (1.8-2.5). In addition, the adjusted RRs (95% CIs) of maternal anorexia nervosa for anemia and antepartum hemorrhage were 2.1 (1.3-3.2), and 1.6 (1.2-2.1), respectively. Furthermore, the adjusted RRs (95% CIs) of maternal anorexia nervosa for a preterm birth and delivering neonates with microcephaly were 1.6 (1.4-1.8) and 1.9 (1.5-2.4), respectively. Women with anorexia nervosa presented increased risks of adverse pregnancy and neonatal outcomes, and I present additional information regarding the risk of pregnancy/neonatal outcomes in women with anorexia nervosa.

    Ante et al. conducted a retrospective cohort study, and the adjusted RR (95% CI) of anorexia nervosa hospitalization for the risk of stillbirth, preterm birth, low birth weight, and small-for-gestational age birth were 1.99 (1.20-3.30), 1.32 (1.13-1.55), 1.69 (1.44-1.99), and 1.52 (1.35-1.72), respectively (2). In addition, hospitalization for anorexia nervosa was also significantly associated with some maternal adverse outcomes, such as precipitate labor, acute liver failure, and admission to an intensive care unit. By the recognition for the risk of adverse pregnancy/neonatal outcomes in women with anorexia nervosa, appropriate medical interventions can be presented and the rapid action might lead to better health conditions in pregnant women and neonates.

    References
    1. Mantel Ä, Hirschberg AL, Stephansson O. Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes. JAMA Psychiatry 2020;77(3):285-293.
    2. Ante Z, Luu TM, Healy-Profitós J, He S, Taddeo D, Lo E, Auger N. Pregnancy outcomes in women with anorexia nervosa. Int J Eat Disord 2020;53(5):403-412.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    November 20, 2019

    Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes

    Author Affiliations
    • 1Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
    • 2Theme Children’s and Women’s Health, Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
    • 3Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
    • 4Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
    JAMA Psychiatry. 2020;77(3):285-293. doi:10.1001/jamapsychiatry.2019.3664
    Key Points

    Question  Are maternal eating disorders associated with an increased risk of adverse pregnancy and neonatal outcomes?

    Findings  In this cohort study comprising all singleton births in Sweden between 2003 and 2014, maternal eating disorders were associated with adverse pregnancy outcomes, such as antepartum hemorrhage, and with adverse neonatal outcomes, such as preterm birth, small size for gestational age, and microcephaly. The risk of most of these outcomes was most pronounced in women with an active eating disorder but was also significantly increased in women with a previous eating disorder.

    Meaning  Eating disorders appear to be associated with an increased risk of adverse pregnancy and neonatal outcomes; these results highlight the importance of acknowledging eating disorders among pregnant women and considering the potential association with maternal and neonatal health.

    Abstract

    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.

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