First Comprehensive Guidelines for Managing Anorexia in Pregnancy

Megan Brooks

March 30, 2022

The first comprehensive guidelines to manage pregnant women with anorexia nervosa (AN) have been released.

Pregnant women with AN are at greater risk of poor outcomes including stillbirth, underweight infant, or pre-term birth, yet there are no clear guidelines on the management of the condition.

"Anorexia in pregnancy has been an overlooked area of clinical care as many believed only women in remission become pregnant, and it is clear that is not the case," lead author Megan Galbally, MBBS, PhD, professor and director, Centre of Women's and Children's Mental Health at Monash University School of Clinical Sciences, Melbourne, Australia, told Medscape Medical News.

Dr Megan Galbally

"There are great opportunities to support women in their mental health and give them and their babies a healthier start to parenthood and life," said Galbally.

"For instance, reducing the likelihood of prematurity or low birth weight at birth that can be associated with anorexia in pregnancy has extraordinary benefits for that child for lifelong health and well-being," she added.

The guidelines were published online March 24 in Lancet Psychiatry.

Spike in Cases

Galbally noted that during her 20 years of working in perinatal mental health within tertiary maternity services, she only ever saw an occasional pregnant woman with current AN.

In contrast, over the last 3 to 4 years, there has been a "steep increase in women presenting in pregnancy with very low body mass index (BMI) and current anorexia nervosa requiring treatment in pregnancy," Galbally said.

Despite the complexity of managing AN in pregnancy, few studies are available to guide care. In a systematic literature review, the researchers identified only eight studies that addressed the management of AN in pregnancy. These studies were case studies or case reports examining narrow aspects of management.

Digging deeper, the researchers conducted a state-of-the-art research review in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy. They synthesized their findings into "recommendations and principles" for multidisciplinary care of pregnant women with AN.

The researchers note that AN in pregnancy is associated with increased risks of pregnancy complications and poorer outcomes for infants, and measures such as BMI are less accurate in pregnancy for assessing severity or change in anorexia nervosa.

Anorexia affects pregnancy and neonatal outcomes through low calorie intake, nutritional and vitamin deficiencies, stress, fasting, low body mass, and poor placentation and uteroplacental function.

The authors note that managing AN in pregnancy requires multidisciplinary care that considers the substantial physiological changes for women and requirements for monitoring fetal growth and development.

At a minimum, they recommend monitoring the following:

  • Sodium, potassium, magnesium, phosphate, and chloride concentration

  • Iron status, vitamin D and bone mineral density, blood sugar concentration (fasting or random), and A1c

  • Liver function (including bilirubin, aspartate transaminase, alanine aminotransferase, and gamma-glutamyl transferase) and bone marrow function (including full blood examination, white cell count, neutrophil count, platelets, and hemoglobin)

  • Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate)

  • Cardiac function (electrocardiogram and echocardiogram)

  • Blood pressure and heart rate (lying and standing) and body temperature

"There are considerable risks for women and their unborn child in managing moderate to severe AN in pregnancy," said Galbally.

"While we have provided some recommendations, it still requires considerable adaptation to individual presentations and circumstances and this is best done with a maternity service that manages other high-risk pregnancies such as through maternal-fetal medicine teams," she said.

"While this area of clinical care can be new to high-risk pregnancy teams, it is clearly important that high-risk pregnancy services and mental health work together to improve care for women with anorexia in pregnancy," Galbally added.

A Nightmare, a Dream Come True

Reached for comment, Kamryn T. Eddy, PhD, co-director, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, said, "for many with anorexia nervosa, pregnancy realizes their greatest nightmare and dream come true, both at once."

"The physical demands of pregnancy can be taxing and for those with anorexia nervosa, closer clinical management makes sense and may help to support patients who are at risk for return to or worsening of symptoms with the increased nutritional needs and weight gain that occur in pregnancy," Eddy, associate professor, Department of Psychiatry, Harvard Medical School, Boston, told Medscape Medical News.

"At the same time, the desire to have a child can be a strong motivator for patients to make the changes needed to recover, and for some, the transition to mother, can also help in recovery by broadening the range of things that influence their self-worth," Eddy added.

This research had no specific funding. Galbally and Eddy report no relevant conflicts of interest.

Lancet Psychiatry. Published online March 24, 2022. Abstract

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