CCC 1072±4133/98/040288±02$17.50 European Eating Disorders Review*c 1998 John Wiley & Sons, Ltd and Eating Disorders Association. 6(4), 288±289 (1998)

European Eating Disorders Review

Eur. Eat. Disorders Rev. 6, 288±289 (1998)

Nibbles

Victoria Sullivan*Leicester General Hospital, Leicester

Let's consider eating disorders and pregnancy. This may seem like a ratherbizarre discussion topic for someone with all the maternal instincts of KingHerod, but recent events at work sparked my interest in this topic. Myinspiration was the fact that a number of patients (eight at the last count) havebecome pregnant over the last few months, and the only thing other than aneating disorder linking them, has been the fact that they've all seen the same( female!) therapist.

Assuming the therapist in question is not an undeclared fertility goddess,and so ruling her out as the missing link, I wanted to know whether thisincidence was normal amongst eating disordered patients. Available literaturein recent years provided some interesting facts, ranging from the use ofrepeated pregnancies and abortions to provide a similar function to bingeingand vomiting (El-Mallakh and Tasman 1991) to the effects an eating disordercan have on mother and child (see below), but was unable to provide rates.

The majority of eating disordered patients tend to be female and of child-bearing age, so we should perhaps not be surprised by a high incidence ofpregnancy in this population. There is a tendency to assume that anorexicscannot become pregnant as their amenorrhea implies anovulation. However,pregnancy without return of menstruation has been reported many times.Anorexia nervosa is not an infallible contraceptive. For instance, Bonne et al.(1996) report two cases where a diagnosis of anorexia led to delayedrecognition of pregnancy, because the bloated abdomen, amenorrhea, nausea,vomiting and fatigue were assumed to be symptoms of anorexia. In one, theunwanted pregnancy was not identi®ed until after the cut-off for a termina-tion, causing the patient considerable distress.

In anorexia sufferers, where the pregnancy is recognized and wanted, variouscomplications for both mother (inadequate weight gain, miscarriage) andchild (low birth weight, delayed development, or premature births) can occur(Franko and Walton 1993). One study reports twice the expected rate ofprematurity, and six times the expected rate of prenatal mortality (Brinch et al.,1988), in an anorexic population where 72 per cent had recovered.

*Correspondence to: Victoria Sullivan, University Department of Psychiatry, Brandon Unit, LeicesterGeneral Hospital, Leicester LE5 4PW.

In bulimics, the available evidence was more confusing, mainly due to noconsensus on the effects of pregnancy on bulimic symptomatology (and viceversa). Some reports suggest a remission of symptoms during pregnancy, with aresumption after the birth of normal-weight infants, while others describecases where bingeing and purging has continued through the pregnancy,leading to low maternal weight gain, low birth weights, and miscarriages (seeFranko and Walton (1993) for a review). In an analysis restricted to bulimicswho continued bingeing, using laxatives, or vomiting through most of theirpregnancy, eight out of 20 pregnancies ended in miscarriage (Mitchell et al.,1991). Lacey and Smith (1987) found that even in patients whose symptomshad resolved, the incidence of birth abnormalities was still higher thanexpected, although they did not investigate the role of other variables that cancause birth abnormalities (e.g. smoking and drinking).

In conclusion, it appears that eating disordered patients who becomepregnant, regardless of symptom severity, may face an increased chance ofphysical complications. This adds to the psychological impact of pregnancy onthe individual. From a treatment perspective, pregnancy can increase concernsabout weight, shape and role issues, which add to those often exhibited byeating disordered patients, and may confound treatment attempts. In the lightof such problems, it seems the talents of our fertility goddess could be betteremployed far, far away from the eating disorders service!

REFERENCES

BONNE, O. B., Rubinoff, B. and Berry, E. M. (1996). Delayed detection of pregnancyin patients with anorexia nervosa: two case reports. International Journal ofEating Disorders, 20, 423±425.

BRINCH, M., Isager, T. and Tolstrup, K. (1988). Anorexia nervosa and motherhood:Reproductional pattern and mothering behaviour of 50 women. ActaPsychiatrica Scandinavica, 77, 93±104.

EL-MALLAKH, R. S. and Tasman, A. (1991). Recurrent abortions in a bulimic:implications regarding pathogenesis. International Journal of Eating Disorders,10, 215±219.

FRANKO, D. L. and Walton, B. E. (1993). Pregnancy and eating disorders: a reviewand clinical implications. International Journal of Eating Disorders, 13, 41±48.

LACEY, J. H. and Smith, G. (1987). Bulimia nervosa: the impact of pregnancy onmother and baby. British Journal of Psychiatry, 150, 777±781.

MITCHELL, J. E., Seim, H. C., Glotter, D., Soll, E. A. and Pyle, R. L. (1991). Aretrospective study of pregnancy in bulimia nervosa. International Journal ofEating Disorders, 10, 209±214.

Eur. Eat. Disorders Rev. 6, 288±289 (1998) Nibbles

*c 1998 John Wiley & Sons, Ltd and Eating Disorders Association. 289