High Risk Pregnancy - 2009

1. High Risk Pregnancy - 2009

2. Disordered Eating Obesity Hypertensive Disorders Gestational Diabetes High Risk Pregnancies

3. Disordered Eating & Pregnancy: Prevalence • Few data on prevalence of disordered eating in pregnancy • Difficult to adequately capture this information from women. Women may have needs for secrecy and denial so information about history of eating disorders is often not given to health care providers during pregnancy • Some published numbers for disordered eating in the population ((Mitchell et al. J midwifery & women’s health, 2006) • Prevalence of binge eating disorder ~ 1.2%-4.5% • Prevalence of anorexia nervosa in young females is 0.03% • About 25% of individuals with anorexia nervosa develop a chronic course.

4. Diagnostic Criteria: Anorexia Nervosa (American Psychiatric Association) • Refusal to maintain body weigh at or above normal weight for age and height • Intense fear of gaining weight or becoming fat, even through underweight • Disturbance in the way in which one’s body weigh or shape is experienced, • Undue influence of body weigh or self-evaluation or denial of the seriousness of current low body weight • In postmenarcheal females, amenorrhea (absence of at least three consecutive menstrual cycles)

5. Diagnostic Criteria: Bulimia Nervosa (American Psychiatric Association) • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • In a discrete period of time, eating an amount of food definitely larger than most people would eat • A sense of lack of control over eating during the episode • Recurrent inappropriate compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enemas or other medications. • Binge eating and inappropriate compensatory behaviors occur at least twice a week for 3 months • Self-evaluation is unduly influenced by body shape and weight • The disturbance does not occur exclusively during anorexia nervosa.

6. Diagnostic Criteria: Not otherwise specified (American Psychiatric Association) • For females, all the criteria for AN are met, except that the individual has regular menstrual cycles. • All criteria for AN is met, except the weight is WNL, despite significant weight loss • Regular use of inappropriate compensatory behaviors in an individual of normal weight after eating small amounts of food • Repeated chewing and spitting out food, but not swallowing • Binge-eating disorder: recurrent episodes of binge eating in the absence of regular use of compensatory behaviors characteristic of BN

7. Disordered Eating & Pregnancy • Results of published studies are inconsistent • Developmental tasks of pregnancy are often about the same issues that arise in some women with eating disorders • Body changes • Alterations in roles • Concerns about a woman’s own mothering and needs for psychological separation.

8. Pregnancy and Eating Disorders: A review and clinical Implications (Franko and Walton, Int.J. Eating Disorders, 1993) British report on 6 of 327 women who had attended eating disorder clinic and got pregnant • Median BMI was 16.8 (range 14.9-18.1) • Median length of time with AN was 15 years (range 11-17) • Average weight gain was 8 kg (range 5-14) -recommendations for low BMI are 13-18 • Poor third trimester fetal growth was found in all 5 babies who were monitored • Babies had some catch up in infancy

9. Pregnancy Outcome and Disordered Eating(Abraham et al J Psychosom Obstet Gynecol, 1994) • 24 women reported previous problems with disordered eating. • These women had higher rates of antenatal complications such as IUGR, PIH, edema, GDM, vaginal bleeding (p<0.05) • These women also were more likely to have infants with birthweights < 25th % ile (p<0.02)

10. Bulimia Symptoms and other risk behaviors during pregnancy in women with Bulimia Nervosa (Crow et al, Int J Eat Disord, 2004) • 129 participants in a long-term follow up study of women who had been treated for BN at the University of Minnesota • 322 pregnancies

11. Crow et al., 2004

12. 2 Studies from Sweden….

13. Pregnancy and neonatal outcomes in women with eating disorders (Kouba et al. Obstet Gynecol, 2005) • Recruited women from 13 Swedish prenatal clinics & screened and diagnosed eating disorders. • 68 controls & 49 nulliparous, nonsmoking women diagnosed with: • 24 AN • 20 BN • 5 NOS • Mean duration of eating disorders was 9 years (range 3-15) • 16 (33%) of women with hx of eating disorders had received TX • 11 (22%) of women with eating disorders had a relapse during pregnancy that led to contact with a psychologist or psychiatrist.

14. Kouba, 2005

15. Kouba, 2005

16. Birth outcomes and pregnancy complications in women with a history of AN (Ekeus et al, BJOG, 2006) • Birth register study • 1000 primiparous women who were discharged from hospital with dx of AN from 1973-1996 who gave birth 1983-2002 • All non AN births (827,582) • Birthweights lower (p=0.005) in AN group: • Mean AN, 3387 • General population mean, 3431 • Longer hospital say for AN (> 6 months) not associated with different outcomes • No difference in SGA and any other negative birth outcomes for mother or baby

17. Birth outcomes and pregnancy complications in women with a history of AN (Ekeus et al, BJOG, 2006) • Authors’ explanation of findings: • “Our findings may be a result of gradual improvement in the care process, both AN and maternity care.” • “A country with a satisfactory maternity surveillance, outcome of pregnancy and delivery may be just as good for women with a hx of AN as for the general population.” • OR…..the fertility problems associated with AN mean that pregnancy will only occur in less severe cases…

18. Recency of ED(Micali et al. J Psychosom. Research, 2007) • N=12,252 • 57 reported recent episode of ED (6 AN, 51 BN) • 395 reported past history of ED • Note: “recent” not defined in paper. • Asked about behaviors at 18 weeks and 36 weeks via mailed questionnaire

20. Postpartum eating and Body Image for all Women • It is of note that in a general population of postpartum women, eating disorder behaviors increase markedly in the first 3 months post-partum and remain high for the next 9 months. • Some women actually first experience clinical eating disorders during this time. (Stein et al Eating Habits and Attitudes in the Post Partum Period. Psychosomatic Med., 1996)

21. Eating Habits and Attitudes in the Post Partum Period(Stein et al. Psychosomatic Med., 1996) • N=97, prospective cohort study of primip. women followed during pregnancy and at 3 and 6 mos pp. • Eating Disorder Examination (EDE): restraint, eating concern, shape concern, weight concern and global scores about state over last 28 days • Repeated measures ANOVA indicated that changes in eating disorder pathology pp were largely due to changes in body weight.

22. An observational study of mothers with eating disorders and their infants ( Stein et al., J Child Psychol Psychiat, 1994) • 2 groups of primips: • Index group, women who had met EDE criteria for disordered eating during pp period, n=34 • Control group, balanced for SES, age, and child’s gender, n=24 • At one year: • EDE • Child’s growth • Structured observation of child and mother at task and mealtime

23. Mealtime Behaviors ( Stein et al., J Child Psychol Psychiat, 1994)

24. Discussion ( Stein et al., J Child Psychol Psychiat, 1994) • Index mothers were more intrusive than control mothers • About 1/3 of the index infants and one of the control infants had growth faltering • Regression analysis models to predict infant weights were best fit when included: • maternal height, • infant birthweight • conflict during meals • mothers concern about own body shape

25. Also, eating disordered women make poor role models. Your influence could lead your daughters to their own eating disorders and your sons to believe that the most important thing about women is their weight.

26. Clinical Implications • Careful screening and monitoring • Possible use of self administered, computer assisted screening tool • Psychotherapy may be indicated • Interventions are not evidence based at this time, but based on case studies & individual counselor’s experiences

27. Clinical Interventions: Nutrition • “Frequent weigh-ins, lectures about weight gain, and even well-meaning comments by clinical staff can be triggers for increasing the frequency of eating disordered behaviors.” (Mitchell et al. J midwifery & women’s health, 2006) • If appropriate: • Discuss and provide materials about nutrients and food in pregnancy • Design individual food plan • Determine optimal range of weight gain • Discuss hydration shifts in pregnancy and need for fluid

28. Clinical Interventions: Exercise • Assess exercise level • Suggest joining exercise groups and new mothers groups to normalize experience of weight concerns

29. Clinical Interventions: Psychosocial • Making the fetus as real as possible to the patient very early • Focus on fundal measurements? • Empathetically addressing fears of weight gain and feelings of being out of control • Assurance about normal weight gain and patterns of pp weight loss • Education of significant others

30. Clinical Intervention: Infant Feeding • Offer assistance with parenting concerns • Offer information about infant feeding: • infant’s ability to self regulate • attention to infant cues & signals • use of food as reward or control mechanism

31. Bulik Hypothesis (Int J Eat Disord, 2005) • Preterm birth is associated with threefold increase in risk of AN • Neurodevelopmental insults in premature infants could contribute to delayed oral-motor growth and onset of early eating problems. • Women with low prepreg BMI & inadequate nutrition during gestation have increased risk for preterm delivery – cycle of risk is established.

32. Maternal Obesity • Rates of obesity are increasing world-wide • Obesity before pregnancy is associated with risk of several adverse outcomes

33. Pregnancy Concerns Associated with Maternal Obesity • Nutrition and Pregnancy Outcome. Henriksen, Nutrition Reviews, 2006 • Management of Obesity in Pregnancy. Catalono. Obstetrics and Gynacology, 2007 • Position of the American Dietetic Association and American Society for Nutrition: Obesity, Reproduction, and Pregnancy Outcomes. J Am Diet Assoc. 2009;109:918-927

34. Fertility • Obesity associated with increased time to conception • 25% of ovulatory infertility attributed to obesity • Less success with assisted reproductive technologies • Potential mechanisms • Adipose tissue impact on hormone availability • Insulin resistance associated with lowered fertility

35. Diagnosis of Pregnancy • Menses tend to be irregular and pelvic exams and ultrasound exams may be difficult • AFP values are lower in obese women due to increased plasma volume • Blood pressure monitoring may be difficult

36. Antepartum Outcomes • Higher rates of NTD even with folic acid supplementation (RR = 3.0 in one study) • Increased risk for both chronic and pregnancy induced hypertension • Increased risk for severe preeclampsia (BMI < 32.3, risk was 3.5 times that of controls) • Increased risk of GDM, IDD and NIDD • Increased twining • Increased UTI

37. Fetal Outcomes • Morbidly obese women have increased risk of preterm delivery • 25% of preterm births are indicated because of maternal medical/ob problems • Neonatal death - stillbirth • Increase in overweight women twice that of normal weight women • Increase in morbidly obese women is 240% greater

38. Labor and Birth Outcomes • Increased incidence of cesarean births in nulliparous women • BMI < 30: 21% • BMI 30-35: 34% • BMI 35-40: 48% • VBAC success rates: • Normal weight women = 71% • Overweight women = 66% • Obese women = 55%

39. Concerns with surgical births • Operative times are longer • Increased incidence of blood loss during surgery • Differences in responses to anesthesia (greater spread/higher levels) • Increased risk of post-op complications • Wound infections • Deep venous thrombophlebitis • endometritis

40. Postpartum Outcomes • Increased risk for endometrial infection • Increased prevalence of urinary incontinence • Decreased rates of lactation success • Initiation • Duration • Amount of milk produced

41. Infant Outcomes • Large infants - effect is independent of maternal diabetes- rates of macrosomia (>4000 g): • Normal weight women: 8 % • Obese women: 13% • Morbidly obese women: 15% • Increased infant mortality - RR for infants born to obese women was 4.0 compared to women with BMI < 20

42. Long Term Risks to Infant • Children born to obese mothers twice as likely to be above 95th percentile BMI at age 2 • Metabolic syndrome in at age 11: • Hazard ratio = 2.19 (1.25-3.82) if LGA • Hazard ratio = 1.81 (1.03-3.19) if maternal obesity

43. Swedish population-based study (Cedergren, 2004) • n=805,275 • Morbid obesity (BMI>40) compared to “normal” weight • 5 fold risk of preeclampsia • 3 fold risk of still birth after 28 weeks • 4 fold risk of LGA • BMI >35, <40, associations remain, but not as strong

44. Cost • Costs were 3.2 times higher for women with BMI > 35 • Longer hospitalizations

45. ADA Position Statement, 2009 “Given the detrimental influence of maternal overweight and obesity on reproductive and pregnancy outcomes for the mother and child, it is the position of the ADA and the American Society for Nutrition that all overweight and obese women of reproductive age should receive counseling prior to pregnancy, during pregnancy, and in the interconceptional period on the roles of diet and physical activity in reproductive health, in order to ameliorate these adverse outcomes.”

46. Emerging Issues: Bariatric Surgery • Outcomes • Challenges of studies: • Appropriate control groups? • Outcomes to measure? • Selection bias • Changes in procedures over time • Clinical recommendations

47. Outcomes After Malabsorptive Procedures such as Roux-en-Y(Bernert et al. Diabetes Metab. 2007; Catalono. Obstet Gynecol, 2007) • Associated Complications: • Small bowel ischemia • Nutrient deficiencies (iron, folate, B12) • Fetal abnormalities • SGA & preterm birth • Cesarean delivery

48. Pregnancy Outcomes after Gastric-Bypass Surgery • Dao, et al. Am J Surg, 2006 • N= 21 pregnant within first year post-surgery; 13 pregnant after first year (Texas) • Author's conclusions: “Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes or pregnancy complications.”

49. Pregnancy following gastric-bypass (Dao, 2006)

50. Birth Outcomes in Obese Women After Laparoscopic Adjustable Gastric Banding • Dixon et al. Obstet Gynecology. 2005 • N=79 (Australia) • Mean maternal weight gain= 9.6 +/- 9.0 kg • Mean birthweight = 3,397 • Incidence of PIH, GDM, stillbirth, preterm delivery low and high birth weights more similar to population than obese women.