Anorexia nervosa and risk of complications in pregnancy

Findings from a retrospective population-based study show and link between severe eating disorder anorexia and a significantly increased risk of adverse pregnancy outcomes.

Women diagnosed with anorexia nervosa are on average five times (500%) more likely to have small-for-gestational age (SGA) babies, according to a comprehensive new study. Results presented at the 2022 ESHRE Annual Meeting also show a significantly increased risk (298%) of a premature birth and more than tripled the likelihood (341%) of placental abruption, compared to mothers without anorexia.

The analysis is based on data from more than 9 million women living in North America, both with and without anorexia, a severe psychiatric disorder characterized by self-hunger and malnutrition. In presenting the data, Dr Michael Dahan of McGill University, Montreal, said the prevalence of SGA newborns in the anorexia group was ‘unexpected and striking’ compared to outcomes for women of healthy weight.

Dahan said the results of the study conveyed a serious health message about the management of such patients during and after pregnancy. Women with anorexia who are planning to become pregnant, he added, should be encouraged to seek support and arrange before they become pregnant, and those using fertility services should be screened for anorexia before treatment.

Eating disorders can have an impact on cycle regularity, but women with anorexia do get pregnant naturally or using fertility drugs to stimulate ovulation. In his presentation, Dahn referred to a systematic review from 2021 that found that the incidence of current eating disorders ranged from 0.5% -16.7%, with anorexia reported in up to 2% of patients, and a history of anorexia in up to 18.5%.

Still other evidence, he said, based on a survey among fertility doctors showed that only a small proportion (35%) who responded said they were regularly screened for eating disorders. Those who do do so are faced with the dilemma of treating malnourished women or, by refusing to do so, possibly preventing these patients from parenting.

Dahn and his group, including lead author Ido Feferkorn, used data from a large publicly available database of U.S. hospital inpatient care records. All births between 2004 and 2014 were included related to women with a diagnosis of anorexia during pregnancy (n = 214) and those who did not (n = 9,096,574). Age range was from under 25 years to age 35 or older. The criteria for an anorexia diagnosis were based on the Diagnostic and Statistical Manual (DSM) definition, which includes a refusal to maintain body weight at / or above a minimum normal weight for age and height.

Overall, results showed significant adverse pregnancy outcomes for women with anorexia. In addition, they showed that these individuals were more likely to have another psychiatric problem in addition to anorexia, such as anxiety disorder (15% vs 0.9%), bipolar disorder (6.1% vs 0.5%) and depression (8.4% vs 0.4 )%). They were also likely to be smokers, thyroid disease, being white or having a higher income. No difference was found in rates for other conditions that may affect women during pregnancy, such as hypertensive disorders or gestational diabetes. The proportion requiring a caesarean section was similar (30.8% vs 32.3%) in both groups.

Although the study authors were unable to determine the severity of anorexia, nor compliance with treatment, Dahan said the findings likely represent an ‘underdiagnosis of risk’ for women with the eating disorder.

His closing message to the audience was that women with anorexia do get pregnant, and on this basis healthcare providers and specifically fertility specialists should be aware of the ‘extent of adverse outcomes’ associated with pregnancy in women with anorexia.

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