Pregnancy & Fertility of Women with Severe Eating Disorders

Eating disorders can impact a woman’s fertility, pregnancy, and postpartum health, increasing risks for anemia, fetal growth restriction, depression and more. Nutritional rehabilitation and medical monitoring are essential to support a healthy pregnancy and reduce complications in women with eating disorders. Postpartum, women with eating disorders may face relapse and mental health challenges, highlighting the need for continued care. Understanding these risks can help improve maternal and infant outcomes through early intervention and specialized treatment.

Pregnancy & Eating Disorders

Around 7.5% of women experience an eating disorder during pregnancy, which can impact pre-pregnancy body mass index (BMI) and weight gain during pregnancy.^1,2

Pregnancy can be a high-risk period of relapse for women with a history of an eating disorder. One small study suggests that up to 25% of women relapse during pregnancy, most often within the first 20 weeks of pregnancy or early postpartum.³

Weight gain and the natural changes in body shape that occur during pregnancy can be very triggering for patients and exacerbate disordered eating behaviors. Trying to become pregnant or difficulty carrying to term are also two situations where women may come to terms with the severity and impact of their eating disorder.

Eating Disorders: Impacts on Female Fertility

Do eating disorders affect fertility?

Research shows that anorexia nervosa is unlikely to permanently affect fertility as long as the individual seeks appropriate eating disorder treatment and weight restoration.^5,6 However, malnutrition, loss of menstrual cycle and/or irregular menses can make family planning more difficult.

Amenorrhea & oligomenorrhea

Amenorrhea is a common in patients with a history of anorexia nervosa, affecting up to 84% of women with anorexia nervosa and 40% of women with bulimia nervosa.⁴ Oligomenorrhea – infrequent periods – are also common, affecting 11% of those with anorexia nervosa and up to 64% of those with bulimia nervosa.⁴

Many patients become concerned about their fertility because they experienced amenorrhea (loss of menses). However, in patients with eating disorders, amenorrhea primarily occurs due to low body weight and the resulting hormonal changes, rather than primary dysfunction of the ovaries or uterus. Patients can expect to regain their menses with adequate weight gain and refeeding.

Unplanned pregnancies

Unplanned pregnancies and delays in the diagnosis of pregnancies are more common in women with anorexia nervosa, which may be explained by patient misunderstandings about fertility and eating disorders, given that ovulation (egg release from the ovary) can still occur without menstruation.

Delivery Complications

Premature birth

Women with a history of hospitalization due to anorexia nervosa are more likely to experience delivery complications, including an increased likelihood of premature birth.⁷

Other effects on labor

Maternal eating disorders are also associated with premature contractions and labor induction.⁸

Maternal Medical Complications

Hyperemesis gravidarum

Research suggests a bidirectional relationship between eating disorders and hyperemesis gravidarum, or excessive vomiting and nausea during pregnancy.

Not only does an active eating disorder increase the risk of developing hyperemesis gravidarum, women who experience hyperemesis gravidarum are also more likely to develop an eating disorder after pregnancy.⁹

Anemia

Women with eating disorders are also more likely to experience anemia during pregnancy, particularly those with anorexia nervosa or other specified feeding or eating disorder (OSFED).⁷

Anemia during pregnancy occurs because blood volume increases and the body uses iron to produce more blood to deliver oxygen to the fetus, necessitating a higher iron intake. An existing lack of dietary intake of iron from food restriction may exacerbate anemia during pregnancy.

Severe iron deficiency during pregnancy increases the risk of:¹⁰

• Placental abruption
• Preterm birth
• Severe postpartum hemorrhage
• Fetal malformation
• Maternal shock
• ICU admission
• Maternal death
• Fetal growth restriction
• Stillbirth
• Antepartum hemorrhaging

Antepartum hemorrhage

Women with an active anorexia disorder were at a 60% increased risk for antepartum hemorrhage (bleeding during pregnancy), mostly caused by a low-lying placenta, abruptio placentae (separation of the placenta before birth) and unspecified bleeding.⁷

Bleeding complications during pregnancy were highest among patients with active anorexia nervosa compared to those with a history of anorexia nervosa.⁷

Fetal Growth Restriction

Chronic malnourishment can cause the fetus to develop chronic fetal growth restriction (FGR), formally known as intrauterine growth restriction (IUGR), which is when a fetus is smaller than expected its gestational age.¹¹ Those with anorexia nervosa and OSFED are at triple the risk of having an infant that is small for their gestational age (SGA).⁷

Growth restriction occurs as an adaptation to a low nutrient intake. The fetus prioritizes survival over growth, expending more energy to maintain the brain and energy-dependent basal metabolic functions than for growth of subcutaneous tissue, muscle and bone. FGR can cause:

• Low birth weight
• Stunting
• Wasting
• Low blood sugar
• Low body temperature
• High red blood cell count
• Micronutrient deficiencies
• Difficulty fighting infections

There are no treatments or nutritional interventions for FGR, therefore the focus should be on nutrition support prior to pregnancy. Fortunately, targeted nutrition intervention during key periods of early development can improve these outcomes.

It’s also important to look at history of eating disorder within the last two years, as low birth weight and SGA weights were also higher in infants of women who have been hospitalized for anorexia nervosa within two years of delivery.⁸

Neonatal Medical Complication

Low weight & medical fragility

Maternal eating disorders are associated with lower birth weights, likely caused by low pre-pregnancy BMI.¹² Lower birth weights are associated with difficulty:

• Eating
• Gaining weight
• Fighting infections
• Regulating temperature.

If infants are premature, it also puts them at risk for a host of complications due to their prematurity. Maternal eating disorders can also cause very low Apgar scores at 1 minute, resuscitation of the infant and perinatal death.¹³

Microcephaly

Additionally, anorexia nervosa, bulimia nervosa and OSFED all increase the likelihood of microcephaly (smaller head than expected), likely caused by limited fetal growth due to maternal malnutrition.⁷ Infants with microcephaly are like to suffer from other complications, which are often dependent on the severity of the microcephaly, such as:

• Seizures
• Developmental delay
• Intellectual disability
• Problems with movement and balance
• Feeding problems, such as difficulty swallowing
• Hearing loss
• Vision problems

Is Pregnancy an Eating Disorder Trigger?

Pregnancy may trigger an eating disorder. Changes in body shape or weight after pregnancy can be triggering and patients may experience more anxiety or body image disturbance related to their postpartum body. Stress from caring for an infant, routine disruption and little time for self-care may also exacerbate disordered eating behaviors.

Studies show that many women with eating disorders experience a decrease in disordered eating symptomology during pregnancy, but symptoms often become worse during the postpartum period.¹⁴

Additionally, while some women maintain remittance at 18 and 36 months postpartum, a significant portion have an active eating disorder at 36 months postpartum, including: ¹⁵

• 40% of those with anorexia nervosa
• 70% of those with bulimia nervosa
• 43% of those with OSFED
• 58% of those with binge eating disorder (BED)

Peripartum Depression & Eating Disorders

Eating disorder symptoms during pregnancy put patients at a higher risk of developing peripartum (formerly postpartum) depression (PPD).³Women who struggle with PPD often experience sadness, hopelessness and emptiness. Peripartum depression typically occurs up to a year after birth and affects 1 in 8 mothers.¹⁷PPD may manifest in a number of ways, ranging from:

• Sleep disorders
• Mood swings
• Changes in appetite
• Fear of injury
• Serious concerns about the baby
• Frequent sadness and crying
• Sense of doubt
• Difficulty concentrating
• Lack of interest in daily activities
• Thoughts of death or suicide

Risk factors for PPD include:

• Major depression disorder during pregnancy
• Anxiety during pregnancy
• History of major depressive disorder (MDD)
• History of moderate to severe premenstrual syndrome (PMS)
• History of PMDD
• High risk pregnancy or postpartum complications
• Stressful life events during pregnancy or soon afterwards
• Poor social support
• Young maternal age

Women with eating disorders are also more likely to report difficulty to adjusting to postpartum life, with half of them seeking out mental health care during this time.¹⁶

How common is peripartum depression?

Small studies suggest that women with eating disorders are more likely to suffer from PPD, with about 50% of those with a history of eating disorders experience peripartum depression.¹⁸37% of women admitted to perinatal psychiatry clinics report a lifetime eating disorder history, including:¹⁹

• Anorexia nervosa (10%)
• Bulimia nervosa (10%)
• OSFED (10%)
• BED (7%)

Preconception Care for Women with Anorexia

Ideally, care for anorexia nervosa should start before pregnancy. Women diagnosed with anorexia nervosa should be offered treatment as soon as possible. Besides medical treatment, mental health care and psychoeducation, all women of childbearing age should receive contraception and pregnancy planning guidance to help improve their physical and mental health before conception.

Medical Care for Pregnant Women with Anorexia

Pregnancy is associated with a variety of physiological changes, however many of the usual recommendations and guidance for managing care in pregnant patients may not apply to patients with eating disorders. There exists little guidance on the management of pregnancy in active eating disorder patients, with the existing literature primarily focusing on patients with anorexia nervosa.

In 2022, the first comprehensive guidelines were released to help providers manage pregnancy for women with anorexia nervosa.²⁰ Unfortunately, guidelines don’t exist for the management of pregnancy with other eating disorders.

Monitoring BMI & weight gain

During pregnancy, fluid volume increases and placental and fetal weight can vary, making monitoring weight gain increasingly difficult. Weight gain varies greatly amongst individuals during pregnancy and it is difficult to account for weight from fluid, the uterus, placenta and fetus.

While professional organizations have outlined expected weight gain across BMIs during pregnancy, there is no available pregnancy guidance available for individuals with an extremely low weight (BMI ≤15 kg/m²) before or during pregnancy.

Lab monitoring

Many of the blood markers used to monitor the severity of weight loss are altered by the physiological changes of pregnancy, which needs to be considered when analyzing test results. Aspects of chronic malnutrition also require specific consideration, such as the implications of muscle wasting on labor.

Other factors should be monitored throughout pregnancy include:

• Sodium, potassium, magnesium, phosphate and chloride concentrations
• Iron studies
• Vitamin D and bone mineral density
• Blood sugar concentration (fasting or random) and HbA1c
• Liver function (including bilirubin, aspartate transaminase, alanine aminotransferase and gamma-glutamyl transferase)
• Bone marrow function (including full blood examination, white cell count, neutrophil count, platelets and hemoglobin)
• Inflammatory markers
• Cardiac function (electrocardiogram and echocardiogram)
• Blood pressure and heart rate (lying and standing)
• Body temperature

Nutritional rehabilitation

During pregnancy, admission should be considered in the context of lack of weight gain or low weight for pregnancy, not only weight loss. A maternal BMI in pregnancy of less than 18 kg/m² with a pre-pregnancy BMI of 18 kg/m² or less should be a consideration for nutritional support.

Nutritional support should also be considered if there is:

• Suboptimal fetal growth
• Clinically significant changes in blood parameters
• Clinically significant changes in physiological markers
• Changes on ECG
• Hypoglycemia

Medical stabilization

Inpatient medical stabilization may be necessary to facilitate treatment for the effects of starvation, including nutrition rehabilitation, weight restoration, and monitoring for development of refeeding syndrome.

When deciding on the level of care, various factors should be considered, including:

• BMI
• Rate of weight lost or lack of weight gain during pregnancy
• Concerns with fetal growth
• The need to actively monitor medical risk parameters
• Patient’s current overall physical health
• Patient’s specific mental and physical comorbidities
• Frequency of laxative use or other purging behaviors
• Whether family, caregivers or a partner can support a patient and keep them from serious harm

Postpartum Care for Women with Anorexia Nervosa

Because patients with anorexia are at risk of relapse and PPD, a comprehensive treatment in the postpartum period is necessary to support the healthy development of mother and infant. Treatment should include:

• Ongoing eating disorder support and management
• Breastfeeding counseling (if applicable)
• Meal planning
• Screening and monitoring for depression, anxiety and difficulty parenting

Parts of postpartum care can be managed by a general practitioner (GP). A GP can monitor weekly blood tests, blood pressure, pulse and temperature for the first 4-6 weeks for signs of nutritional improvement or decline. As a patient improves, frequency can be reduced.

If a higher level of care is required, given that it is safe and appropriate for the baby to stay with their mother, it is recommended that the mother be admitted to a mother and baby unit. While mother and baby unit services are not accessible to all patients, it is preferable when available to avoid prolonged separation between mom and baby.

Nutrition support

Breastfeeding can impact nutritional needs postpartum. Patients considering breastfeeding should be referred to a dietitian for ongoing nutritional support postpartum.

Psychotherapy & Pharmacological Interventions for Peripartum Depression

Psychotherapy

PPD should be addressed in conjunction with an eating disorder. Firstline treatment for peripartum depression includes psychotherapy and antidepressant medication. For patients with mild to moderate peripartum depression, who are breastfeeding or are hesitant about starting psychiatric medication, psychotherapy may be adequate.

Antidepressants

For women with moderate to severe PPD, antidepressant drugs are recommended. Selective serotonin reuptake inhibitors (SSRIs) are the most common choice, but serotonin-norepinephrine reuptake inhibitors (SSNRIs) and mirtazapine can be used if SSRIs are ineffective.

Providers should discuss the benefits of breastfeeding against the risks of antidepressant use during breastfeeding and the risks of untreated illness with patients who are hesitant about taking antidepressants.

Other interventions

For patients who do not see improvement with psychotherapy or antidepressants, transcranial magnetic stimulation (TMS) or electroconvulsion therapy (ECT) are additional non-pharmacologic treatment options. ECT has been shown to be particularly useful in patients with severe symptoms, such as intent or plans of suicide or infanticide.²¹

For patients with particularly resistant PPD, the intravenous drug brexanolone may be considered.

Finding Support for an Eating Disorder While Pregnant

Having an eating disorder while pregnant can feel overwhelming, but help is available. Getting the right support – from doctors, dietitians, and mental health professionals—can keep both you and your baby safe. Nutrition guidance is adjusted for pregnancy, helping your body and your baby get what you both need, and with the right care, recovery is possible.

References

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