10/25/2002

1. 10/25/2002

2. Disordered Eating • Hypertensive Disorders • Gestational Diabetes • Adolescence

3. Disordered Eating & Pregnancy • Few data on prevalence of disordered eating in pregnancy • Difficult to adequately capture this information from women • No good, prospective studies • Results of published studies are confusing - some find improvement with pregnancy - others find increased symptoms

4. Disordered Eating & Pregnancy • 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. • 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.

5. Disordered Eating & Pregnancy • Many women experience concerning food and body image behaviors in pregnancy

6. Attitudes to body weight, weight gain and eating behavior in pregnancy, (Abraham et al J Psychosom Obstet Gynecol, 1994) • N=100, exclusions were no hx of drug use or major psychiatric illness, baby not in ICU • Questionnaires completed at 3 days pp.

7. Attitudes to body weight, weight gain and eating behavior in pregnancy, (Abraham et al J Psychosom Obstet Gynecol, 1994)

8. Methods of Weight Control Used(Abraham et al J Psychosom Obstet Gynecol, 1994)

9. 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

10. 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)

11. Reported complications of pregnancy and eating disorders: Anorexia Nervosa

12. Reported complications of pregnancy and eating disorders: Bulemia Nervosa

13. 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.

14. 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.

15. Eating Habits and Attitudes in the Post Partum Period(Stein et al. Psychosomatic Med., 1996) ** = p <0.05, ***= p< 0.01, ****=p<0.001

16. Number Meeting DSM-IV Diagnostic Criteria for Clinical Eating Disorder NOS (Stein et al. Psychosomatic Med., 1996)

17. Eating Habits and Attitudes in the Post Partum Period(Stein et al. Psychosomatic Med., 1996) • No cases of bulimia nervosa or anorexia nervosa • No women who met criteria before pregnancy were cases during pregnancy • All cases during pregnancy were do novo - but two had history of bulimia nervosa • At postpartum, three cases were de novo

18. 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

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

20. Play Behaviors ( Stein et al., J Child Psychol Psychiat, 1994)

21. 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

22. www.anred.com • You could become depressed and frantic because of weight gain during pregnancy. You might feel so out of control of your life and body that you would try to hurt yourself or the unborn baby. You might worry and feel guilty about the damage you could be causing the baby.

23. Some women with eating disorders welcome pregnancy as a vacation from weight worries. They believe they are doing something important by having a baby and are able to set aside their fear of fat in service to the health of the child. Others fall into black depression and intolerable anxiety when their bellies begin to swell. Most fall somewhere between these two extremes.

24. You might underfeed your child to make her thin, or, you might overfeed her to show the world that you are a nurturing parent. Power struggles over food and eating often plague families where someone has an eating disorder. You could continue that pattern with your child.

25. Motherhood is stressful. If you are not strong in your recovery, you will be tempted to fall back on the starving and stuffing coping behaviors that are so familiar to you. Ideally, as you begin raising a family, you will already have learned, and will have had practice using, other more healthy and effective behaviors when you feel overwhelmed.

26. 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.

27. 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

28. Clinical Interventions: Psychosocial • Making the fetus as real as possible to the patient very early. • 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

29. Clinical Interventions: Nutrition • 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

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

31. 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

32. Hypertensive Disorders During Pregnancy • Incidence • Definitions • Etiology/pathophysiology • Nutritional Implications

33. N A T I O N A L I N S T I T U T E S O F H E A L T H N A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E WORKING GROUP REPORT ON HIGH BLOOD PRESSURE IN PREGNANCY July 2000

34. Incidence • Second leading cause of maternal mortality in US • 15% of maternal deaths (abruptio placentae, disseminated intravascular coagulation, cerebral hemorrhgae, hepatic failure, acute renal failure) • Hypertensive disorders occur in 6 to 8% of pregnancies • Contribute to neonatal morbitidy and mortality

35. High risk • First pregnancy and under age 17 or over 35 • Family history of hypertension • Multiple gestation • Poor nutritional status • Smoking • Overweight • Other health problems such as renal disease, diabetes

36. Chronic Hypertension • Known hypertension before pregnancy or rise in blood pressure to > 140/90 mm Hg before 20 weeks • Hypertension that is diagnosed for the first time during pregnancy and that does not resolve postpartum is also classified as chronic hypertension.

37. Gestational Hypertension Hypertension in pregnancy is present when diastolic BP is 90 or greater, systolic BP is 140 or greater (the use of BP increases of 30 mm Hg systolic and 15 mm Hg diastolic has not been recommended - women in this group not likely to have increased adverse outcomes)

38. Preeclampsia Preeclampsia is defined as the presence of hypertension accompanied by proteinuria • In the absence of proteinuria the disease is highly suspect when increased blood pressure with headache, blurred vision, and abdominal pain, or with abnormal laboratory tests, specifically, low platelet counts and abnormal liver enzymes.

39. Proteinuria • Proteinuria is defined as the urinary excretion of 0.3 g protein or greater in a 24-hour specimen. • This will usually correlate with 30 mg/dL (“1+ dipstick”) or greater in a random urine determination with no evidence of urinary tract infection. • because of the discrepancy between random protein determinations and24-hour urine protein in preeclampsia it is recommended that the diagnosis be based on a 24-hour urine if at all possible

40. Findings that increase the possibility of Eclampsia and indicate need for FU

42. Edema

43. Dx of Superimposed Preeclampsia

44. Eclampsia • Occurrence in a woman with preeclampsia, of seizures that can not be attributed to other causes

45. Etiology • Not fully understood • Characterized by: • Vasospasm • Activation of the coagulation system • Perturbations in systems related to volume and blood pressure control

46. Pathogenic Mechanisms Delivery is only known cure - research has focused on placenta • failure of the spiral arteries (terminal branches of uterine artery) to remodel • alterations in immune response at the maternal interface • increase in inflammatory cytokines in placenta and maternal circulation, “natural killer” cells, and neutrophil activation

47. Pathophysiology • Decreased blood flow • Decreased renal blood flow, decreased GFR, Na retention • Tissue hypoxia • Damage to organs

48. Pathophysiology • Decreased blood volume • Decreased placental blood flow may occur 3-4 weeks before increased BP • Hypoxia • Decreased nutrient delivery

49. Outcomes • Increased LBW and IUGR for infant • There is mounting evidence that children born to mothers whose blood pressure was elevated during pregnancy are at greater risk for elevated blood pressure during childhood and adolescence • Also long term maternal health may be affected by consequences of maternal damage to renal and CV systems.

50. Focus of Possible Interventions • Smooth muscle contraction • Prostaglandin synthesis