In my last post, I left you with this question, "So, what should you do if an eating disorder patient tells you that she is pregnant?"
Read on for some helpful suggestions for treating expectant mothers with a history of eating disorders...
Address the sense of loss of control over eating while pregnant.As previously mentioned, an expectant mother with an eating disorder history risks a return of disordered behaviors, both while pregnant and after giving birth. Therefore, monitoring a patient's symptoms, even if she has been in recovery for some time, is important throughout the duration of the pregnancy as well as postpartum.
Address patient motivation. Try to increase her emotional connection to the fetus and make the baby seem as real as possible. This has been shown to be helpful in cases of an eating disorder because it emphasizes that weight gained is for the sake of the baby (For example, emphasizing that most of the weight a woman gains during the last trimester is the weight of the BABY can be helpful). A sense of connectedness to the fetus can also prove to be a motivator for abstaining from purging behaviors and the use of laxatives and diuretics, which pose a danger to the developing fetus.
Connect the patient as soon as possible to an OB/GYN who understands her situation. A doctor with an understanding of eating disorders may be more sympathetic to her patient's weight concerns. If her OB/GYN is unfamiliar with eating disorders, consider brining in an Internist or GP who does in order to work as a team. Collaborate as you would with any treatment team (for example, when appropriate, you may wish to request that the OB/GYN agree to weigh the expectant mother backwards at the monthly weight checks so the patient can't see the numbers on the scale).
American College of Obstetricians and Gynecologists ( ACOG ) recommends that the average woman gain 25-30 pounds during pregnancy. However, a woman who is under weight as she begins her pregnancy will need to gain more (a BMI under 20 should gain between 28-40 pounds), while a woman who is severely overweight may need to gain a little less.
Education is key. Eating disorders expert Pauline Powers suggests that knowledge of possible consequences of disturbed eating and misuse of laxatives may facilitate a patient's decision to discontinue those behaviors during pregnancy. In addition, you may wish to remind your patient that weight gain during pregnancy is temporary. Explain the necessity of vital nutrients in order to produce a healthy baby. Marcia Herrin, author of Nutrition Counseling in the Treatment of Eating Disorders, suggests that depending upon the circumstances, it may be appropriate to tell the patient that you will help her lose the weight in a healthy way after the baby is born, just as you are now helping her gain the appropriate amount of weight now, for the sake of the baby. This can assist in decreasing an expectant mother's anxiety about weight gain. In addition, be sure to advise a patient to only engage in exercise that is appropriate for pregnancy. When appropriate, prenatal exercise can be a healthy form of physical activity during pregnancy and can yield benefits physically, mentally and spiritually.
Be sure to connect the patient to a dietitian in order to ensure that the patient is getting the proper nutrients in her diet.
Encourage the expectant mother to remain active in therapy and consider activity with a support group for additional support. In addition, family therapy or couple support can be helpful as pregnancy brings many changes to family relationships and patient anxieties due to expectations of adult responsibilities.
Women with a history of bulimia appear to be at increased risk for hyperemesis gravidum, so be sure to consider appropriate interventions. In some cases, hospitalization may be necessary.
Medication: Remember that some women with a history of eating disorders and/or co-occurring mood or anxiety disorders may take psychotropic medication. According to Diane Mickley, M.D., it is ideal if medication can be discontinued during pregnancy, at least for the first trimester. However, this may not be possible, in order to protect the mother's health. Thus, Mickley recommends that medication during pregnancy be looked at in phases. "During the 6 to 12 months before a planned pregnancy, medication can be tapered or changed to drugs that are safer during pregnancy. Fluoxetine (Prozac) is widely used during pregnancy and studies have been done on babies with in utero exposure showing normal physical, intellectual, and emotional well-being up to 6 years of age. An unintended pregnancy may require immediate discontinuation of medication that may be harmful to the baby, as well as a decision on whether to substitute a safer alternative. While the hormone surge of early pregnancy lifts the mood of some women, others will experience psychological symptoms that require ongoing management. As delivery approaches, additional decisions arise. Women on medication during pregnancy will have to consider whether an adjustment is needed to minimize discontinuation of symptoms after delivery." (Mickley, 2005).
Mickley further states, women with a history of anorexia or bulimia should discuss with their physician the possibility of taking antidepressant medication after delivery. Some medications (Mickley states paroxetine as an example) are available that are not excreted in breast milk and can be used even during nursing. When no longer breast-feeding, a woman may reassess her options from a wider range of choices (see Source reference below).
A Body's Changing Shape
Experts, such as Dr. Diana Dell of Duke University, a specialist in postpartum depression, points out that when women are pregnant, society says it is "OK" for them to eat more and gain weight. Once the baby is out, Dell states. "that cultural protection is gone. Plus, there is cultural pressure to regain the previous level of thinness." It is important, therefore, to normalize anxiety about postpartum weight and to remind new mothers that for most women, it takes a while—sometimes longer than the nine months it took to gain it—to lose pregnancy weight.
In addition to weight concerns, w omen with eating disorders may be increasingly vulnerable to postpartum depression given that many may have experienced symptoms of depression prior to their pregnancy. Some expectant mothers report that their depressive symptoms dissipate during pregnancy, yet may resurface after their baby is born. Therefore, monitor your patient's symptoms at all stages of pregnancy and postpartum and encourage an honest exploration of feelings. Maintaining a strong therapeutic relationship with your patient and providing practical answers and support can go a long way to encouraging proper self-care on the part of an expectant mother.
The good news is that the majority of women with eating disorders can have healthy babies. Monitoring a healthy weight gain during pregnancy reduces the risk of potential complications and provides an opportunity for the expectant mother to learn about healthy nutrition for herself, and for her soon-to-arrive new son or daughter. Treatment providers have the unique and distinct pleasure of helping a new mother jump-start her child's nutritional health while assisting the mother in remaining on the road to personal recovery.
Source: Mickley, D. (2005). Pregnancy and Eating Disorders .Eating Disorders Today, 3 (3).