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Pregnancy, obstetric, and perinatal health outcomes in eating disorders

  • Milla S. Linna
    Correspondence
    Reprints: Milla Linna, MD, Hjelt Institute, Department of Public Health, PO Box 41, 00014 University of Helsinki, Finland.
    Affiliations
    Department of Public Health, Hjelt Institute, University of Helsinki, Helsinki, Finland
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  • Anu Raevuori
    Affiliations
    Department of Public Health, Hjelt Institute, University of Helsinki, Helsinki, Finland

    Department of Adolescent Psychiatry, Helsinki University Central Hospital, Helsinki, Finland

    Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland

    Institute of Clinical Medicine, Child Psychiatry, University of Turku, Turku, Finland
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  • Jari Haukka
    Affiliations
    Department of Public Health, Hjelt Institute, University of Helsinki, Helsinki, Finland

    Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland
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  • Jaana M. Suvisaari
    Affiliations
    Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland

    Department of Social Psychiatry, Tampere School of Public Health, Tampere, Finland
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  • Jaana T. Suokas
    Affiliations
    Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare, Helsinki, Finland

    Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland
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  • Mika Gissler
    Affiliations
    National Institute for Health and Welfare, Helsinki, Finland

    Nordic School of Public Health, Gothenburg, Sweden
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Published:April 07, 2014DOI:https://doi.org/10.1016/j.ajog.2014.03.067

      Objective

      The purpose of this study was to assess pregnancy, obstetric, and perinatal health outcomes and complications in women with lifetime eating disorders.

      Study Design

      Female patients (n = 2257) who were treated at the Eating Disorder Clinic of Helsinki University Central Hospital from 1995-2010 were compared with unexposed women from the population (n = 9028). Register-based information on pregnancy, obstetric, and perinatal health outcomes and complications were acquired for all singleton births during the follow-up period among women with broad anorexia nervosa (AN; n = 302 births), broad bulimia nervosa (BN; n = 724), binge eating disorder (BED; n = 52), and unexposed women (n = 6319).

      Results

      Women with AN and BN gave birth to babies with lower birthweight compared with unexposed women, but the opposite was observed in women with BED. Maternal AN was related to anemia, slow fetal growth, premature contractions, short duration of the first stage of labor, very premature birth, small for gestational age, low birthweight, and perinatal death. Increased odds of premature contractions, resuscitation of the neonate, and very low Apgar score at 1 minute were observed in mothers with BN. BED was associated positively with maternal hypertension, long duration of the first and second stage of labor, and birth of large-for-gestational-age infants.

      Conclusion

      Eating disorders appear to be associated with several adverse perinatal outcomes, particularly in offspring. We recommend close monitoring of pregnant women with either a past or current eating disorder. Attention should be paid to children who are born to these mothers.

      Key words

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      References

        • Bulik C.M.
        • Von Holle A.
        • Hamer R.
        • et al.
        Patterns of remission, continuation and incidence of broadly defined eating disorders during early pregnancy in the Norwegian Mother and Child Cohort study (MoBa).
        Psychol Med. 2007; 37: 1109-1118
        • Easter A.
        • Bye A.
        • Taborelli E.
        • et al.
        Recognising the symptoms: how common are eating disorders in pregnancy?.
        Eur Eat Disord Rev. 2013; 21: 340-344
        • Watson H.J.
        • Von Holle A.
        • Hamer R.M.
        • et al.
        Remission, continuation and incidence of eating disorders during early pregnancy: a validation study in a population-based birth cohort.
        Psychol Med. 2012; 20: 1-12
        • Fichter M.M.
        • Quadflieg N.
        Twelve-year course and outcome of bulimia nervosa.
        Psychol Med. 2004; 34: 1395-1406
        • Fichter M.M.
        • Quadflieg N.
        • Hedlund S.
        Twelve-year course and outcome predictors of anorexia nervosa.
        Int J Eat Disord. 2006; 39: 87-100
        • Lähteenmäki S.
        • Saarni S.
        • Suokas J.
        • et al.
        Prevalence and correlates of eating disorders among young adults in Finland.
        Nord J Psychiatry. 2014; 68: 196-203
        • Micali N.
        • Treasure J.
        • Simonoff E.
        Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity.
        J Psychosom Res. 2007; 63: 297-303
        • Micali N.
        • Treasure J.
        Biological effects of a maternal ED on pregnancy and foetal development: a review.
        Eur Eat Disord Rev. 2009; 17: 448-454
        • Micali N.
        • Simonoff E.
        • Treasure J.
        Risk of major adverse perinatal outcomes in women with eating disorders.
        Br J Psychiatry. 2007; 190: 255-259
        • 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: 1493-1502
        • Bulik C.M.
        • Sullivan P.F.
        • Fear J.L.
        • Pickering A.
        • Dawn A.
        • McCullin M.
        Fertility and reproduction in women with anorexia nervosa: a controlled study.
        J Clin Psychiatry. 1999; 60: 130-135
        • Bulik C.M.
        • Von Holle A.
        • Siega-Riz A.M.
        • et al.
        Birth outcomes in women with eating disorders in the Norwegian Mother and Child cohort study (MoBa).
        Int J Eat Disord. 2009; 42: 9-18
        • Ekéus C.
        • Lindberg L.
        • Lindblad F.
        • Hjern A.
        Birth outcomes and pregnancy complications in women with a history of anorexia nervosa.
        BJOG. 2006; 113: 925-929
        • Solmi F.
        • Sallis H.
        • Stahl D.
        • Treasure J.
        • Micali N.
        Low birth weight in the offspring of women with anorexia nervosa.
        Epidemiol Rev. 2014; 36: 49-56
        • Brinch M.
        • Isager T.
        • Tolstrup K.
        Anorexia nervosa and motherhood: reproduction pattern and mothering behavior of 50 women.
        Acta Psychiatr Scand. 1988; 77: 611-617
        • Abraham S.
        Sexuality and reproduction in bulimia nervosa patients over 10 years.
        J Psychosomat Res. 1998; 44: 491-502
        • Morgan J.F.
        • Lacey J.H.
        • Chung E.
        Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: retrospective controlled study.
        Psychosom Med. 2006; 68: 487-492
        • Bansil P.
        • Kuklina E.V.
        • Whiteman M.K.
        • et al.
        Eating disorders among delivery hospitalizations: prevalence and outcomes.
        J Womens Health (Larchmt). 2008; 17: 1523-1528
        • Koubaa S.
        • Hällström T.
        • Lindholm C.
        • Hirschberg A.L.
        Pregnancy and neonatal outcomes in women with eating disorders.
        Obstet Gynecol. 2005; 105: 255-260
        • Suokas J.T.
        • Suvisaari J.M.
        • Gissler M.
        • et al.
        Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010.
        Psychiatry Res. 2013; 210: 1101-1106
        • Linna M.S.
        • Raevuori A.
        • Haukka J.
        • Suvisaari J.M.
        • Suokas J.T.
        • Gissler M.
        Reproductive health outcomes in eating disorders.
        Int J Eat Disord. 2013; 46: 826-833
        • World Health Organization
        ICD-10: International statistical classification of disease and related health problems. vol. 1. WHO, Geneva, Switzerland1992
        • Gissler M.
        • Teperi J.
        • Hemminki E.
        • Merilainen J.
        Data quality after restructuring a national medical registry.
        Scand J Soc Med. 1995; 23: 75-80
        • Pihkala J.
        • Hakala T.
        • Voutilainen P.
        • Raivio K.
        Uudet suomalaiset sikiön kasvukäyrät (Characteristics of recent fetal growth curves in Finland, in Finnish).
        Duodecim. 1989; 105: 1540-1546
        • Williams R.L.
        A note on robust variance estimation for cluster-correlated data.
        Biometrics. 2000; 56: 645-646
        • Sollid C.P.
        • Wisborg K.
        • Hjort J.
        • Secher N.J.
        Eating disorder that was diagnosed before pregnancy and pregnancy outcome.
        Am J Obstet Gynecol. 2004; 190: 206-210
        • Sebire N.J.
        • Jolly M.
        • Harris J.
        • Regan L.
        • Robinson S.
        Is maternal underweight really a risk factor for adverse pregnancy outcome? A population-based study in London.
        BJOG. 2001; 108: 61-66
        • Rondó P.H.
        • Ferreira R.F.
        • Nogueira F.
        • Ribeiro M.C.
        • Lobert H.
        • Artes R.
        Maternal psychological stress and distress as predictors of low birth weight, prematurity and intrauterine growth retardation.
        Eur J Clin Nutr. 2003; 57: 266-272
        • van der Spuy Z.M.
        • Steer P.J.
        • McCusker M.
        • Steele S.J.
        • Jacobs H.S.
        Outcome of pregnancy in underweight women after spontaneous and induced ovulation.
        BMJ. 1988; 296: 962-965
        • McTernan C.L.
        • Draper N.
        • Nicholson H.
        • et al.
        Reduced placental 11beta-hydroxysteroid dehydrogenase type 2 mRNA levels in human pregnancies complicated by intrauterine growth restriction: an analysis of possible mechanisms.
        J Clin Endocrinol Metab. 2001; 86: 4979-4983
        • Schieve L.A.
        • Cogswell M.E.
        • Scanlon K.S.
        • et al.
        Prepregnancy body mass index and pregnancy weight gain: associations with preterm delivery.
        Obstet Gynecol. 2000; 96: 194-200
        • Baker P.N.
        • Wheeler S.J.
        • Sanders T.A.
        • et al.
        A prospective study of micronutrient status in adolescent pregnancy.
        Am J Clin Nutr. 2009; 89: 1114-1124
        • Boyar R.M.
        • Hellman L.D.
        • Roffwarg H.
        • et al.
        Cortisol secretion and metabolism in anorexia nervosa.
        N Engl J Med. 1977; 296: 190-193
        • Facchinetti F.
        • Ottolini F.
        • Fazzio M.
        • Rigatelli M.
        • Volpe A.
        Psychosocial factors associated with preterm uterine contractions.
        Psychoter Psychosom. 2007; 76: 391-394
        • Stephansson O.
        • Dickman P.W.
        • Johansson A.
        • Cnattingius S.
        Maternal weight, pregnancy weight gain, and the risk of antepartum stillbirth.
        Am J Obstet Gynecol. 2001; 184: 463-469
        • Kristensen J.
        • Vestergaard M.
        • Wisborg K.
        • Kesmodel U.
        • Secher N.J.
        Pre-pregnancy weight and the risk of stillbirth and neonatal death.
        BJOG. 2005; 112: 403-408
        • Tennant P.W.
        • Rankin J.
        • Bell R.
        Maternal body mass index and the risk of fetal and infant death: a cohort study from the North of England.
        Hum Reprod. 2011; 26: 1501-1511
        • Eagles J.M.
        • Lee A.J.
        • Raja E.A.
        • Millar H.R.
        • Bhattacharya S.
        Pregnancy outcomes of women with and without a history of anorexia nervosa.
        Psychol Med. 2012; 42: 2651-2660
        • Frøen J.F.
        • Gordijn S.J.
        • Abdel-Aleem H.
        • et al.
        Making stillbirths count, making numbers talk - issues in data collection for stillbirths.
        BMC Pregnancy Childbirth. 2009; 9: 58
        • Mohangoo A.D.
        • Blondel B.
        • Gissler M.
        • et al.
        International comparisons of fetal and neonatal mortality rates in high-income countries: should exclusion thresholds be based on birth weight or gestational age?.
        PLoS ONE. 2013; 8: e64869
        • Stewart D.E.
        • Raskin J.
        • Garfinkel P.E.
        • MacDonald O.L.
        • Robinson G.E.
        Anorexia nervosa, bulimia, and pregnancy.
        Am J Obstet Gynecol. 1987; 157: 1194-1198
        • Casey B.M.
        • McIntire D.D.
        • Leveno K.J.
        The continuing value of the Apgar score for the assessment of newborn infants.
        N Engl J Med. 2001; 344: 467-471
        • Chu S.Y.
        • Callaghan W.M.
        • Kim S.Y.
        • et al.
        Maternal obesity and risk of gestational diabetes mellitus.
        Diabetes Care. 2007; 30: 2070-2076
        • Sebire N.J.
        • Jolly M.
        • Harris J.P.
        • et al.
        Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London.
        Int J Obes Relat Metab Disord. 2001; 25: 1175-1182
        • Cnattingius S.
        • Villamor E.
        • Johansson S.
        • et al.
        Maternal obesity and risk of preterm delivery.
        JAMA. 2013; 309: 2362-2370
        • Shepard M.J.
        • Saftlas A.F.
        • Leo-Summers L.
        • Bracken M.B.
        Maternal anthropometric factors and risk of primary cesarean delivery.
        Am J Public Health. 1998; 88: 1534-1538
        • Ehrenberg H.M.
        • Durnwald C.P.
        • Catalano P.
        • Mercer B.M.
        The influence of obesity and diabetes on the risk of cesarean delivery.
        Am J Obstet Gynecol. 2004; 191: 969-974
        • Ehrenberg H.M.
        • Mercer B.M.
        • Catalano P.M.
        The influence of obesity and diabetes on the prevalence of macrosomia.
        Am J Obstet Gynecol. 2004; 191: 964-968
        • Stothard K.J.
        • Tennant P.W.
        • Bell R.
        • Rankin J.
        Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis.
        JAMA. 2009; 301: 636-650
        • Chu S.Y.
        • Kim S.Y.
        • Lau J.
        • et al.
        Maternal obesity and risk of stillbirth: a metaanalysis.
        Am J Obstet Gynecol. 2007; 197: 223-228
        • Siega-Riz A.M.
        • Von Holle A.
        • Haugen M.
        • et al.
        Gestational weight gain of women with eating disorders in the Norwegian pregnancy cohort.
        Int J Eat Disord. 2011; 44: 428-434
        • Koubaa S.
        • Hällström T.
        • Hagenäs L.
        • Hirschberg A.L.
        Retarded head growth and neurocognitive development in infants of mothers with a history of eating disorders: longitudinal cohort study.
        BJOG. 2013; 120: 1413-1422
        • Bergman K.
        • Sarkar P.
        • O'Connor T.G.
        • Modi N.
        • Glover V.
        Maternal stress during pregnancy predicts cognitive ability and fearfulness in infancy.
        J Am Acad Child Adolesc Psychiatry. 2007; 46: 1454-1463
        • O'Connor T.G.
        • Heron J.
        • Golding J.
        • Beveridge M.
        • Glover V.
        Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children.
        Br J Psychiatry. 2002; 180: 502-508
        • Cnattingius S.
        • Hultman C.M.
        • Dahl M.
        • Sparén P.
        Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls.
        Arch Gen Psychiatry. 1999; 56: 634-638
        • Favaro A.
        • Tenconi E.
        • Santonastaso P.
        Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa.
        Arch Gen Psychiatry. 2006; 63: 82-88
        • Bulik C.M.
        • Reba L.
        • Siega-Riz A.M.
        • Reichborn-Kjennerud T.
        Anorexia nervosa: definition, epidemiology, and cycle of risk.
        Int J Eat Disord. 2005; 37: S2-S9

      Linked Article

      • Statistical significance of eating disorders and adverse perinatal outcomes
        American Journal of Obstetrics & GynecologyVol. 213Issue 1
        • Preview
          The study by Linna et al1 posited that “eating disorders appear to be associated with several adverse perinatal outcomes, particularly in offspring.” The adverse outcomes included anemia, slow fetal growth, premature contractions, and perinatal death. However, this conclusion cannot be supported by the data because the authors failed to correct the standard value of P = .05 to account for the large number of hypothesis tests. This leads to what is known as type 2 error and causes a hypothesis to be accepted that is actually false.
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