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Guideline Summary
Guideline Title
Eating disorders during pregnancy and postpartum.
Bibliographic Source(s)
Eating disorders during pregnancy and postpartum. Little Rock (AR): University of Arkansas for Medical Sciences, ANGELS; 2010 Sep 16. 13 p. [26 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Eating disorders during pregnancy and postpartum. Little Rock (AR): University of Arkansas for Medical Sciences, ANGELS; 2009 Feb 19. 12 p.

Scope

Disease/Condition(s)
  • Pregnancy
  • Pregnancy complications
  • Psychiatric disorders
  • Eating disorders: bulimia, anorexia, not otherwise specified
  • Physical complications of eating disorders
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Screening
Treatment
Clinical Specialty
Nutrition
Obstetrics and Gynecology
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
  • To aid practitioners in mental health screening and management of obstetrics patients who suffer from eating disorders to prevent perinatal complications
  • To improve health care access in Arkansas and to aid health care providers in making decisions about appropriate patient care
Target Population

Obstetrics patients diagnosed with eating disorders

Interventions and Practices Considered

Diagnosis/Evaluation/Screening

  1. Assessment
    • Current or past eating disorders
    • Previous history of amenorrhea or oligomenorrhea
    • Whether pregnancy is planned
    • Patient's body image: weight, shape, changes due to pregnancy
    • Current dietary/weight management practices
  2. Physical examination
    • Weight
    • Body mass index
    • Physical findings related to eating disorder
  3. Laboratory tests: complete blood count, electrolytes, blood urea nitrogen, creatinine, baseline electrocardiogram, and others
  4. Complications co-occurring with eating disorders in pregnancy
  5. Potential risks to children of mothers with eating disorders
  6. Postpartum assessment of depression, eating disorder exacerbations, and difficulties in parenting

Treatment/Management

  1. Obtaining treatment prior to conception
  2. Counseling and education of patient on weight gain during pregnancy, risk for hyperemesis gravidarum, and depression
  3. Comanagement of patient with collaborative team
  4. Short-term hospitalization, if necessary
  5. Enteral and parental feedings, if necessary
  6. Ultrasound for fetal growth assessment
  7. Counseling patient on risk and benefits of continuing medications for depression and obsessive-compulsive disorder
  8. Psychiatric consultation
  9. Postpartum involvement of the pediatrician and the family
Major Outcomes Considered
  • Prevalence of eating disorders
  • Mortality
  • Postpartum depression
  • Eating disorder exacerbations
  • Difficulties in parenting
  • Complications in children born to mothers with eating disorders

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search for September 2010 Update

The following databases were searched for this ANGELS update: All Evidence-Based Medicine (EBM) Databases (Cochrane Database of Systematic Reviews, American College of Physicians [ACP] Journal Club, Database of Abstracts of Reviews of Effects [DARE], Cochrane Central Register of Controlled Trials [CCTR], Cochrane Methodology Register [CMR], Health Technology Assessment [HTA], and National Health Service Economic Evaluation Database [NHSEED] Collection) via OVID, MEDLINE and MEDLINE In Process via OVID, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and HealthSource: Nursing/Academic and PsycINFO via EBSCO, Science Citation Index Expanded, the University of Arkansas Medical Science (UAMS) Library Catalog, the National Library of Medicine Catalog and the National Guideline Clearinghouse. All searches were run between March 23, 2010 and March 30, 2010.

Since this was an update, the results were limited to 2009-2010. Note: the MEDLINE search results were limited to the Entry date of Dec.1, 2008-Present since the last search was run in Nov. 2008. Other limits included were English language and human studies.

A search strategy was used for MEDLINE and was the basis for searches in other databases, though reformatted to the specifics of each search system and utilizing controlled vocabularies where applicable for each database.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The University of Arkansas for Medical Sciences' ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System) interactive video teleconference series solicited recommendations from rural and urban providers to define researched best practices. The leader for the American Psychiatric Association's Practice Guidelines in the Treatment of Eating Disorders participated in the review and final recommendations. The recommendations issued in the provided guideline represent recommendations melding evidence-based literature review and physician peer review with consensus.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The leader for the American Psychiatric Association's Practice Guidelines in the Treatment of Eating Disorders participated in the review and final recommendations.

The University of Arkansas for Medical Sciences' ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System) interactive video teleconference series invited rural and urban providers ranging from obstetrical to psychiatric practice to review the evidence-based guideline draft to suggest changes and further refinement to ensure interpretation into practice. Through this interaction, the physician group reached a consensus on best practices and finalized the provided evidence-based guideline. Methods also include a yearly revision and review, weaving the newest evidence into finalized guidelines.

Recommendations

Major Recommendations

Assessment (see algorithm – Figure 1 in the original guideline document)

  1. Ask whether the patient has a current or past history of an eating disorder.
  2. Ask whether this is a planned pregnancy. If not, her fears of weight gain will likely be more pronounced and the eating disorder at higher risk of complicating the pregnancy as well as being difficult to manage.
  3. Ask about past amenorrhea or oligomenorrhea.
  4. Ask what the patient's perceived ideal body weight is and how she currently views her body shape.
  5. Questions to ask about current dietary and weight management practices
    1. Current dieting?
    2. Current smoking?
    3. Binge eating episodes?
    4. Body weight history – highest and lowest weight since reaching adult height?
    5. Fear of weight gain in pregnancy?
    6. Purging and compensatory behaviors (laxatives, diuretics, enemas, excessive exercise)?
  1. Physical examination
    1. Assess body mass index (BMI).
      • Calculated by the weight in kilograms divided by the height in meters squared
      • Reference to calculate BMI: www.nhlbisupport.com/bmi External Web Site Policy
      • Refer to Table 1 below.
      • If BMI <19, refer to Figure 1: Screening Pregnant Women for Eating Disorders in the original guideline document
    1. Possible physical findings in an individual with an eating disorder
      • Oral mucosa damage
      • Tooth decay from chronic exposure of gastric contents
      • Dehydration (elevated blood urea nitrogen [BUN] and creatinine)
      • Protein malnutrition (low BUN and creatinine)
      • Metabolic alkalosis (due to vomiting)
      • Metabolic acidosis (due to laxative use) with possible associated constipation, rectal bleeding, and edema
      • Muscle wasting
      • Hypotension
      • Bradycardia
      • Cold intolerance
      • Lanugo (soft, baby-like hair)
      • Abnormal electrocardiogram (EKG) (due to electrolyte abnormalities, impaired conduction due to cardiac muscle wasting)
      • Osteopenia or osteoporosis related to amenorrhea, high cortisol, smoking, poor nutrition. Bone density (dual energy x-ray absorptiometry [DEXA]) is indicated in anyone who has been amenorrheic for six months.
      • Russell's sign - scabs on the metacarpophalangeal joints (MCP) from using the fingers to induce vomiting
      • Hypercarotenemia - orange tinge to skin because of decreased hepatic clearance of carotene (of no clinical consequence)
  1. Laboratory tests are of limited utility in making a diagnosis, but may be helpful to exclude other medical illness associated with weight loss. The initial laboratory evaluation for the patient with an eating disorder includes (Andersen & Berg, 2007):
    1. Complete blood count for anemia
    2. Electrolytes, BUN, and creatinine if the patient is dehydrated and/or purging is suspected.
    3. Other tests obtained depend upon the review of systems and the need to exclude other diagnoses.
    4. Baseline EKG to assess for QT prolongation or bradycardia
  1. Abnormal laboratory values associated with eating disorders
    1. Hypokalemia
    2. Hypophosphatemia
    3. Hyponatremia
    4. Hypochloremia
    5. Elevated bicarbonate level
    6. Hypomagnesemia
    7. Increased urine specific gravity
    8. Alkaline urine (due to laxative abuse, diuretic abuse, or vomiting)
    9. Ketonuria
    10. Leukopenia
    11. Thrombocytopenia
    12. Normochromic, normocytic anemia
    13. Increased liver function tests (LFTs)
    14. Increased salivary amylase
    15. Hyperaldosterone
    16. Decreased thyroxine (T4) levels, high reverse triiodothyronine (rT3), normal thyroid stimulating hormone (TSH) level, although thyroid tests may be altered by physiologic changes in pregnancy. For instance, hyperthyroidism may commonly be detected during an episode of hyperemesis gravidarum, and will usually resolve by 20 weeks of gestation without treatment.
    17. Hypercortisolemia
    18. Decreased erythrocyte sedimentation rate (ESR)
    19. Elevated serum cholesterol
  1. Associated complications co-occurring with eating disorders in pregnancy (Andersen & Berg, 2007; Franko et al., 2001; Sollid et al., 2004)
    1. Inadequate or excessive weight gain
    2. Hyperemesis gravidarum
    3. Hypotension (in anorexia) or hypertension (in bulimia)
    4. Syncope/presyncope from cardiac arrhythmias and electrolyte disturbances
    5. Anemia (in anorexia)
    6. Pregnancy termination (spontaneous or therapeutic)
    7. Small for term infant
    8. Stillbirth
    9. Breech pregnancy
    10. Pre-eclampsia
    11. Cesarean section
    12. Post-episiotomy suture tearing
    13. Vaginal bleeding
    14. Increased rate of perinatal difficulties
    15. Postpartum depression risk
    16. Cardiac changes (Sollid et al., 2004)
      • Increased incidence of mitral valve prolapse may be attributed to enhanced detection with intravascular volume depletion as seen in the starving state.
      • Silent pericardial effusion in 20% to 30% of severely underweight patients detected by echocardiogram
      • Acquired Long QT Syndrome may be noted in this population. A prolonged QT interval warrants immediate attention in underweight, bradycardic patients because it is an independent marker for arrhythmia and sudden death.
      • There is an elevated risk of heart failure with refeeding syndrome.
    1. Refeeding syndrome (occurs primarily in patients who are aggressively refed)
      • Assiduous supervision is necessary in refeeding patients with severe anorexia (<70% of expected body weight) or those who have lost a large amount of weight rapidly. They may experience complications which mostly emanate from severe hypophosphatemia.
      • Is rare during pregnancy, but has been reported. May be exacerbated by the normal volume expansion during pregnancy (Franko et al., 2001)
      • May include cardiovascular collapse, rhabdomyolysis, delirium and seizures. Cardiac failure may be the result of increased volume on the impaired heart. Thiamine should be given during refeeding to prevent Wernicke's encephalopathy due to thiamine deficiency.
      • Patients should be evaluated for edema, signs of congestive heart failure, and mental status changes. Vital signs and electrolytes, especially phosphorus, potassium, and magnesium should be closely monitored for the first five days, then every other day for several weeks afterward.
  1. Potential risks to children of mothers with eating disorders (European Society of Human Reproduction and Embryology [ESHRE] Capri Workshop Group, 2006; Andersen & Berg, 2007; Stewart, 1992; Koubaa et al., 2005)
    1. Premature birth
    2. Perinatal mortality (six-fold increase)
    3. Cleft lip and cleft palate
    4. Epilepsy
    5. Developmental delays
    6. Abnormal growth
    7. Food fussiness and feeding difficulties
    8. Low birth weight (significant for mothers with anorexia nervosa due to low prepregnancy BMI) (Micali, Simonoff, & Treasure, 2007)
    9. Microcephaly
    10. Low APGAR scores

Management (see Table 1 below)

Treatment Recommendations: Preconceptual (American Psychiatric Association, 2006)

  1. Ideally, obtain treatment for eating disorder prior to attempting to conceive. This improves fertility and decreases the risk for perinatal complications associated with active eating disorders.
  2. Assess risks for osteoporosis preconceptually since pregnancy may exacerbate bone loss

Treatment Recommendations: During Pregnancy (American Psychiatric Association, 2006)

  1. Management of the pregnant woman with a current or past eating disorder
    1. Factual management of weight gain issues
      • How are you feeling about your weight gain?
      • What is it like for you to be weighed at every visit?
      • How are you feeling about the physical changes in your body shape?
    1. Teach what the ideal weight gain is for the optimal growth and development of the fetus. (See Table 2 below.)
    2. Ask about the patient's preferences regarding weighing (some prefer not to look at the numbers on the scale). Weigh the patient in the same clothing each time with empty pockets and an empty bladder. Make note in chart regarding special attention to this portion of the exam.
    3. Co-manage the patient's care with a collaborative team of experts in eating disorders (nutritionists/mental health specialists). Women with eating disorders are at higher risk for nicotine dependence (Bulik et al., 2009) (refer to ANGELS Nicotine Dependence Guideline) and postpartum depression, and those women with purging behaviors associated with their eating disorder (ED) are at higher risk for pregnancy associated nausea and vomiting (Torgersen et al., 2008).
  1. Short term hospitalization may be considered for the patient with vital sign abnormalities, severe dehydration, cardiac arrhythmia, and critical electrolyte disturbances. Patients with persistent eating disorders who have failed to gain weight over time or demonstrate a decline on oral intake may also require hospitalization. If they have failed intensive outpatient therapy, consideration should be given to inpatient supervision, enteral tube feedings, or parenteral nutrition, with psychiatric and nutrition consults.
  2. The patient with inadequate weight gain and lagging fundal height should receive an ultrasound for fetal growth assessment. If growth restriction is detected, antenatal surveillance should be initiated.
  3. Patients with histories of depression and/or obsessive compulsive disorder (OCD) who are taking antidepressant anti-OCD medications should be counseled on the benefits of continuing medications (considerable) vs. risk to fetus (relatively low). Work collaboratively with a psychiatrist with expertise in women's mental health to determine the optimal treatment approach on a case by case basis. Involve the patient and her partner, when appropriate, in the discussion of the latest evidence available of the potential risks versus the benefits of various treatment approaches.

Treatment Recommendations: Postpartum (American Psychiatric Association, 2006)

  1. New mothers with histories of eating disorders are at risk for postpartum depression, eating disorder exacerbations and difficulties in parenting (Astrachan-Fletcher et al., 2008). They may benefit from close follow up, participation in postpartum support groups and in supportive parenting classes.
  2. Women with anorexia are more likely to underfeed their infants than women without anorexia. Involving the pediatrician and the family in treatment may be of benefit in these situations (Russell, Treasure, & Eisler, 1998).

Table 1: Evaluation and Treatment Suggestions for Physical Complications of Eating Disorders**

Physical Complication Concerning Signs and Symptoms Suggested Clinical Action
Autonomic instability Orthostatic hypotension (increase in pulse of 20 beats per minute or a drop in blood pressure of 20 mm Hg upon standing), bradycardia (<40 bpm) or tachycardia (>110 bpm), inability to sustain core body temperature Hospitalization with immediate attention to dehydration
Electrolyte abnormalities Hypokalemia, hypomagnesemia, hypophosphatemia, hyponatremia, hypoglycemia Hospitalization with electrolyte replacement for critical values. EKG for critical hypokalemia
Malnutrition Failure to gain weight with rapid or persistent decline in oral intake Hospitalization with consideration of structured meals, enteral tube feedings or parenteral nutrition
Hyperemesis Gravidarum More prevalent in patients with eating disorders than in the general population See ANGELS guideline Hyperemesis Gravidarum.
Intrauterine growth restriction (IUGR) Lagging fundal height and inadequate maternal weight gain These findings combined with a persistent eating disorder should prompt serial ultrasound surveillance for fetal growth.
Cardiovascular abnormalities Heart palpitations, irregular heart rhythm or rate EKG to detect QT interval prolongation or echocardiography if mitral valve prolapse is suspected. The patient with severe anorexia must be monitored closely during initiation of refeeding due to risk of volume overload and heart failure.
Anemia (in anorexia) May be due to physiologic hemodilution during pregnancy. More likely due to anorexia if associated with leukopenia or thrombocytopenia. Check serum ferritin, B12 and folate if anemia is severe, followed by supplementation as indicated.
Gastrointestinal complications Complaints of bloating, constipation and nausea due to impaired gut motility are common. Hematemesis is possible with bulimia. Promotility agents such as metoclopramide may be used to alleviate symptoms. Suspicion of Mallory-Weiss tears should prompt hospital admission.
Dental erosion (seen with vomiting) May be associated with parotid gland hypertrophy Refer to dentist.
Skin changes Dryness, lanugo, alopecia, bruising, lesions on the fingers/knuckles used to induce vomiting in bulimics (Russell's sign), acrocyanosis Symptomatic treatment

**Any pregnant patient with the diagnosis of an eating disorder is optimally treated on a continual basis with a multidisciplinary team, including an obstetrician, mental health professional, and dietician. Treating this disorder (including weight gain in the underweight patient) and any other co-morbid psychiatric conditions is paramount. More specific treatments for complicating physical conditions are listed here.

Table 2: Implications of Eating Disorders for Reproductive-aged Female Planning to Conceive

Complication Key Points Recommendation
Infertility Amenorrhea or oligomenorrhea commonly occur when body weight is less than 85% of expected Weight gain is recommended before infertility treatments are pursued and until healthy menstruation and ovulation resume.
Osteopenia or osteoporosis Increased risk when amenorrhea persists for greater than 6 months and may be exacerbated by bone loss associated with pregnancy. Bone densitometry (if not pregnant); start calcium and Vitamin D in all patients.
Clinical Algorithm(s)

The original guideline document provides an algorithm for Screening Pregnant Women for Eating Disorders.

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate mental health care provided to patients diagnosed with eating disorders resulting in improved fertility and decreased risk for perinatal complications

Potential Harms
  • Patients with histories of depression and/or obsessive compulsive disorder (OCD) who are taking antidepressant and anti-OCD medications should be counseled on the benefits of continuing medications (considerable) vs. risk to fetus (relatively low). Work collaboratively with a psychiatrist with expertise in women's mental health to determine the optimal treatment approach on a case by case basis. Involve the patient and her partner, when appropriate, in the discussion of the latest evidence available of the potential risks versus the benefits of various treatment approaches.
  • The patient with severe anorexia must be monitored closely during initiation of refeeding due to risk of volume overload and heart failure.

Qualifying Statements

Qualifying Statements

This guideline was developed to improve health care access in Arkansas and to aid health care providers in making decisions about appropriate patient care. The needs of the individual patient, resources available, and limitations unique to the institution or type of practice may warrant variations.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Eating disorders during pregnancy and postpartum. Little Rock (AR): University of Arkansas for Medical Sciences, ANGELS; 2010 Sep 16. 13 p. [26 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2007 May 3 (revised 2010 Sep 16)
Guideline Developer(s)
University of Arkansas for Medical Sciences, ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System) - Academic Institution
Source(s) of Funding

Arkansas Department of Human Services, Division of Medical Services, University of Arkansas for Medical Sciences, ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System)

Guideline Committee

University of Arkansas for Medical Sciences, ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System)

Composition of Group That Authored the Guideline

Authors: Linda Worley, MD, in collaboration with Samantha McKelvey, MD, Sara Tariq, MD, Joel Yager, MD, Curtis Lowery, MD, and the ANGELS Team. Editor: Rachel Ott, BA

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Eating disorders during pregnancy and postpartum. Little Rock (AR): University of Arkansas for Medical Sciences, ANGELS; 2009 Feb 19. 12 p.

Guideline Availability
Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 10, 2009. The information was verified by the guideline developer on August 7, 2009. This summary was updated by ECRI Institute on March 11, 2011. The updated information was verified by the guideline developer on April 21, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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