9 Anorexia Nervosa and Bulimia Nervosa During Pregnancy
Chapter 9 / Anorexia Nervosa and Bulimia Nervosa During Pregnancy 129
9.10 MONITORING AND EVALUATION
At each prenatal visit, eating disorders screening may be conducted (see Table 9.4) along with measurement and documentation of parameters or outcomes related to nutrition interventions and diagnoses. Body weight and rate of weight gain should be tracked and evaluated. Adjustments in energy intake should be based on appropri-ateness of weight changes. Eating behaviors and dietary intake should be examined at each prenatal visit to assess the adequacy of dietary composition and patterns of intake. Changes in purging and nonpurging behaviors should be noted and addressed.
Fingersticks to check hematocrit and glucose may be useful in the monitoring of iron status and hypoglycemia or hyperglycemia. In women with established eating dis-orders, urinalysis may detect starvation or dehydration as noted by urinary ketones, elevated specific gravity, and alkaline urine. Vital signs will show any change in gen-eral health status. Glucose tolerance testing should be conducted in the 24th to 28th week of pregnancy to screen for gestational diabetes mellitus (see Chap. 10, “Diabetes and Pregnancy”). Resolution of any nutrition diagnoses should be documented and any new issues addressed.
More aggressive and intensive inpatient care may be warranted if monitoring and evaluation shows a worsening of the eating disorder, IUGR, or other fetal growth and development problems. In AN or BN, a reduction in body weight to less than 75%
of expected; hypokalemia, hyponatremia, or hypochloremic alkalosis; dehydration;
hyperemesis gravidarum; cardiovascular changes; prolonged fasting; uncontrolled binge eating–purging cycles; severe depression; suicidal ideation; and any obstetrical complication are justification for hospitalization.
9.11 PLANNING FOR POSTPARTUM CARE
Relapses in eating disorders often occur in the postpartum period [46–50, 55]. More-over, the rate of PPD in women with eating disorders is high (see Chap. 19, “Postpar-tum Depression and the Role of Nutritional Factors”). Changes in estrogen status and estrogen-beta-receptor function or other gene–nutrient interactions may be responsible for observed relapses. The registered dietitian should work closely with the patient toward the end of pregnancy to set realistic goals for dietary intake, weight loss, eating behaviors, and expectations during lactation.
9.11.1 Interdisciplinary Care
Nutrition care is but one part of treatment for AN or BN. These complex disorders require multidisciplinary and integrated care, due to the multifactorial etiology and wide scope of signs and symptoms. The obstetrician, nurse practitioner, psychologist or psychiatrist, dietitian, dentist, social worker, family therapist, occupational therapist, pharmacist, certified exercise physiologist, and other allied health care professionals must openly and cohesively interact with one another and most importantly with the patient to provide effective treatment. Cognitive-behavioral therapy is used to modify anorexic and bulimic behaviors. Medications may be used in treatment, but a risk–benefit assessment for use during pregnancy should be completed (Table 9.7). An increased frequency of prenatal visits is warranted in these high-risk conditions. Monitoring of fetal heart rate and more frequent ultrasounds may shift the center of attention from the mother’s AN or BN
Table 9.7 Selected Medications Used in the Treatment of Anorexia Nervosa or Bulimia Nervosa Food and Drug Administration Medication Classifi cation Drug–nutrient interactions pregnancy category* • Desipramine • Antidepressant, tricyclic • Limit caffeine B • Increase ribofl avin intake • Avoid alcohol • Incompatible with lactation • Fluoxetine • Antidepressant, antibulimic, • Avoid tryptophan supplements C selective serotonin reuptake inhibitor • Avoid alcohol • Incompatible with lactation • Nortriptyline • Antidepressant, tricyclic • Limit caffeine C • Increase ribofl avin intake • Avoid alcohol • Incompatible with lactation • Paroxetine • Antidepressant, selective • Avoid tryptophan supplements C serotonin reuptake inhibitor • Avoid alcohol • Incompatible with lactation • Phenelzine • Antidepressant, monoamine • Avoid high-tyramine-containing foods, such as aged cheeses, C oxidase inhibitor avocados, grapes, prunes raisins, beef liver, soy sauce, nuts, chocolate, and Chianti wine, among other foods • Limit caffeine • Avoid tryptophan supplements • Increase pyridoxine (B6) intake • Avoid alcohol • Incompatible with lactation • Tranylcypromine • Antidepressant, monoamine • Avoid high-tyramine-containing foods C oxidase inhibitor • Limit caffeine • Avoid tryptophan supplements • Avoid alcohol • Incompatible with lactation * Category A includes drugs which were shown to have no increased risk of fetal abnormalities in well-controlled studies including pregnant women; Category B includes drugs which failed to demonstrate any risk to the fetus in well-controlled studies including pregnant women, although animal studies demonstrated an adverse effect or animal studies resulted in no harm to the fetus, but well-controlled studies including pregnant women were not available; Category C includes drugs which resulted in harm to the fetus in animal studies and well-controlled studies including pregnant women were not available or no animal and well-controlled studies including pregnant women have been conducted; Category D includes drugs which resulted in risk to the fetus in well-controlled or observational studies including pregnant women; however, the benefi ts of the drug may outweigh risk of harm to the fetus; Category X includes drugs which produced fetal abnormalities in well-controlled studies including pregnant women or animals, and the use of the drug is not recommended during pregnancy or by women who may become pregnant.
Chapter 9 / Anorexia Nervosa and Bulimia Nervosa During Pregnancy 131 behaviors to the growing fetus. An informal or formal support network that includes friends, family members, and possibly other patients can provide more constant reassurance, advice, assistance, and positive reinforcement, often valued by women with AN or BN.
9.12 CONCLUSION
Women with active AN or BN during pregnancy are at high risk for adverse outcomes.
Ideally, treatment of the AN or BN should occur prior to conception. If not feasible, screening for and assessment of eating disorders during prenatal visits is critical. If an eating disorder is detected, then interdisciplinary care is vital to address all medical issues of the mother and developing fetus. Nutrition requirements of both the mother and fetus must be addressed, and eating patterns and behaviors that optimize a consistent and appropriate stream of nutrients to mother and fetus are key components of care.
Treatment of the woman with AN or BN during pregnancy should not end at delivery, but rather, must continue into the postpartum period and beyond.
9.13 CASE STUDY: BULIMIA NERVOSA DURING PREGNANCY
T.J. is a 32-year-old Caucasian, married woman, gravida 2, para 1, seeking prenatal care in the 11th week of gestation. Medical history reveals current BN, the onset of which occurred in the third month postpartum of her previous pregnancy. Since the onset of BN at age 27, T.J. has engaged in binge eating–purging cycles at least twice per day, consuming approximately 2,200 kcal of high-fat, high-carbohydrate snack-type foods during each binge with subsequent vomiting. She reports “problems with my teeth” and
“frequent heartburn.” T.J. denies laxative, diuretic, or enema use, but admits to moderate exercise of “fast-paced walking” of up to 2 h per day. She was dissatisfied with her body shape and inability to quickly lose weight after her first pregnancy and is fearful that she will lose control of her body weight during this pregnancy. She gained 47 lb during her first pregnancy. T.J. currently weighs 145 lb and is 5¢ 7². Laboratory values are within normal limits. She reports having the “baby blues” after her first delivery and “frustra-tion” with her husband who “travels too much to be of any help with our child.” T.J.
has not confided in her husband regarding her BN and engages in binge eating–purging episodes “in secret.”
1. Calculate T.J.’s body mass index and determine an appropriate weight gain for T.J. for her current pregnancy.
2. Estimate T.J.’s energy needs for weight maintenance and weight gain during pregnancy.
3. With T.J., plan a 7-day menu that includes appropriate food choices to meet nutrient needs of pregnancy and strategies to avoid binge eating.
4. Identify potential adverse outcomes for T.J. and her fetus if BN continues during this pregnancy.
5. Discuss the impact of T.J.’s exercise habits on her energy needs and course of pregnancy.
6. Establish criteria to monitor and evaluate T.J.’s BN during pregnancy on an outpa-tient basis. Identify key indicators that will be used to determine if inpaoutpa-tient care is needed.
7. List all of the health professionals and others who should be involved in T.J.’s prenatal care and provide reasons for their involvement.
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