Pregnancy and Eating Disorders
Anorexia and bulimia typically affect young women during their peak ages of reproductive functioning and for this reason, eating disorders can impact the entire reproductive process. This impact increases along with the severity of the eating disorder.
Because of menstrual abnormalities experienced by women with eating disorders, achieving pregnancy may be difficult. By definition, women with anorexia nervosa lack a menstrual period—a condition called amenorrhea. However, at least 50% of women with bulimia also have minimal or absent menstrual periods and many women with some but not all symptoms of anorexia or bulimia (those diagnosed with EDNOS or eating disorder not otherwise specified) also have irregular or minimal menses.
These disruptions of the menstrual cycle are primarily the result of caloric restriction, excessive exercise, and/or psychological stress, which, in turn, may produce hormonal abnormalities and diminishment of the ovaries. Obviously, when such disruptions are present, pregnancy is difficult to achieve. As a result, women with anorexia or bulimia will commonly get pregnant through medication-induced ovulation. However, even if ovulation and subsequent fertilization do occur, the uterine environment may not be conducive to implantation. As a result, one study showed that 17% of female patients seeking assistance at an infertility clinic had eating disorders—at least four times the expected number given eating disorders’ population base rates.
The risk for obstetrical complications
If a woman with an eating disorder does achieve pregnancy, the risk for obstetrical complications rises in proportion to the severity of the eating disorder. Although data are limited, one study of pregnant women with anorexia revealed a 6-fold increase in perinatal mortality, 2-fold increase in prematurity, increased infant death in the first week following birth, low infant birth weight, and an increase in failure to thrive during the child’s first year of life. Studies of pregnant women with bulimia suggest maternal weight gain only 20% of normal, lower infant birth weights, twice the rate of fetal loss, 5 minute APGAR scores (which measure newborn infant health) up to 5 points lower than expected, and high rates of breach presentation, multiple pregnancy, and fetal abnormalities. Both those with anorexia and bulimia may evidence greater need for caesarian section.
Pregnancy also poses a variety of physical and emotional difficulties for the woman herself. For reasons that are not entirely clear, physical complications include more vaginal bleeding during pregnancy and greater difficulty healing in the episiotomy area. With bulimia, some women may gain a great deal of weight, increasing risk for hypertension.
Pregnant women with eating disorders often experience profound anguish and emotional conflict because of their expanding and changing bodies. Some manage to maintain health throughout the pregnancy for the sake of their unborn child, then return to their eating disorder following delivery.
Some authorities have gone as far as recommending hospitalization for pregnant women with active bulimia, although in practice this is more the exception than the rule. However, for those with both anorexia and bulimia, hospitalization during pregnancy may be needed if the mother demonstrates persistent weight loss, persistent vomiting and dehydration, electrolyte imbalance, or where fetal intrauterine growth retardation or other medical complications of eating disorders occur. In these more severe cases, aggressive intervention with possible tube feeding may be required to ensure the health of both baby and mother.
Following the birth of the child, women with eating disorders also have a higher incidence of postpartum depression than other women. They have more problems breast feeding, including insufficient lactation or negative reactions to breast milk in their babies. Inadequate breast milk is often the result of dehydration. For these reasons, women with eating disorders often discontinue breast feeding prematurely.
Many women with anorexia and bulimia deny that they even have an eating disorder, and the desire to become pregnant or pregnancy itself may not alter this secrecy. For example, women with bulimia sometimes claim that their vomiting is due to morning sickness rather than purging due to their eating disorder. Therefore, medical professionals must take great care with patients who exhibit eating disordered symptoms.
If anorexia is suspected, attention should be paid to maternal weight gain, and regular ultrasounds may be needed to determine fetal growth and development. If bulimia is suspected, particularly if excessive vomiting may be present, maternal electrolyte levels and hydration should be medically monitored to protect the health of both mother and child.
Although there are obvious risks, a woman with an eating disorder who manages to gain normal weight throughout her pregnancy will most likely notexperience a higher risk of pregnancy complications or birth defects. Sometimes, by focusing on the health of her developing baby and her wish to be the best mother she can, a woman will discover the desire—and make a commitment—to recover from her eating disorder.
Although seeking pregnancy is not recommended as a means of eating disorder recovery, the power and beauty of motherhood can have long-lasting, life-changing effects for certain highly motivated individuals.
By Joel P. Jahraus, MD
Reprinted with permission from Eating Disorders Recovery Today
Winter 2003-2004 Volume 2, Number 2
©2003 Gürze Books
About the Author
Joel P. Jahraus, MD, is the Director of Primary Care Medicine at Remuda Ranch Center for Anorexia and Bulimia, Inc.