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OBSTETRICS
Pregnancy, obstetric, and perinatal health
outcomes in eating disorders
Milla S. Linna, MD; Anu Raevuori, MD, PhD; Jari Haukka, PhD;
Jaana M. Suvisaari, MD, PhD; Jaana T. Suokas, MD, PhD; Mika Gissler, MD, PhD
OBJECTIVE: The purpose of this study was to assess pregnancy, slow fetal growth, premature contractions, short duration of the first
obstetric, and perinatal health outcomes and complications in women stage of labor, very premature birth, small for gestational age, low
with lifetime eating disorders. birthweight, and perinatal death. Increased odds of premature con-
tractions, resuscitation of the neonate, and very low Apgar score at 1
STUDY DESIGN: Female patients (n 2257) who were treated at the
minute were observed in mothers with BN. BED was associated
Eating Disorder Clinic of Helsinki University Central Hospital from 1995-
positively with maternal hypertension, long duration of the first and
2010 were compared with unexposed women from the population (n
second stage of labor, and birth of large-for-gestational-age infants.
9028). Register-based information on pregnancy, obstetric, and peri-
natal health outcomes and complications were acquired for all singleton CONCLUSION: Eating disorders appear to be associated with several
births during the follow-up period among women with broad anorexia adverse perinatal outcomes, particularly in offspring. We recommend
nervosa (AN; n 302 births), broad bulimia nervosa (BN; n 724), close monitoring of pregnant women with either a past or current
binge eating disorder (BED; n 52), and unexposed women (n 6319). eating disorder. Attention should be paid to children who are born to
these mothers.
RESULTS: Women with AN and BN gave birth to babies with lower
birthweight compared with unexposed women, but the opposite was Key words: eating disorder, obstetric complication, perinatal health,
observed in women with BED. Maternal AN was related to anemia, pregnancy, reproductive health
Cite this article as: Linna MS, Raevuori A, Haukka J, et al. Pregnancy, obstetric, and perinatal health outcomes in eating disorders. Am J Obstet Gynecol
2014;211:392.e1-8.
From the Department of Public Health, Hjelt Institute, University of Helsinki (Drs Linna, Raevuori, and Haukka); Department of Adolescent Psychiatry,
Helsinki University Central Hospital (Dr Raevuori); Department of Mental Health and Substance Abuse Services, National Institute for Health and Welfare
(Drs Raevuori, Haukka, Suvisaari, and Suokas); Department of Psychiatry, Helsinki University Central Hospital (Dr Suokas); and National Institute for
Health and Welfare (Dr Gissler), Helsinki; Institute of Clinical Medicine, Child Psychiatry, University of Turku, Turku (Dr Raevuori); and Department of Social
Psychiatry, Tampere School of Public Health, Tampere (Dr Suvisaari), Finland, and Nordic School of Public Health, Gothenburg, Sweden (Dr Gissler).
Received Dec. 10, 2013; revised Feb. 18, 2014; accepted March 31, 2014.
Supported by doctoral programs in Public Health, Academy of Finland, and by research grants from Helsinki University Central Hospital.
The funders were not involved in the conduct of the study, collection, management, or analysis and interpretation of the data.
J.T.S. and J.M.S. have been involved in a research collaboration with Janssen-Cilag. J.T.S. has received fees for giving expert opinions to Lightlake
Sinclair and attended one international conference supported by Janssen-Cilag. J.M.S. has received a lecturing fee from AstraZeneca. J.H. has been in
research collaboration with Janssen-Cilag and Eli Lilly and has been a member of the expert advisory group for Astellas. The other authors report no
conict of interest.
Presented at the International Conference on Eating Disorders, Montreal, QC, Canada, May 2-4, 2013.
Reprints: Milla Linna, MD, Hjelt Institute, Department of Public Health, PO Box 41, 00014 University of Helsinki, Finland. milla.linna@helsinki.
0002-9378/$36.00 2014 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ajog.2014.03.067
Ethical considerations elevated number of hospital outpatient Perinatal health outcomes and
The Ethics committee of National Insti- visits before delivery. The mean number complications
tute of Health and Welfare has reviewed of prenatal care visits was 16.7 0.3 Women with AN and BN gave birth to
the study with a positive statement (P not signicant) in women with babies with lower birthweight compared
(DnroTHL/184/6.02.00/2011). Data AN, of which 3.6 0.2 (P < .001) were with unexposed women (mean, 3302
handling was performed according to hospital outpatient visits, 17.2 0.2 562 g; adjusted P < .001 in women
the Finnish data protection legislation (P < .001) in women with BN, of which with AN; mean, 3464 563 g; adjusted
and the rules of National Institute of 3.7 0.1 (P < .001) were in the hos- P .037 in women with BN; mean, 3520
Health and Welfare. All institutions gave pital, 19.6 0.9 (P < .001) in women 539 g in unexposed women), whereas
their permission to use their register with BED, of which 4.7 0.5 (P < .001) birthweight was higher among babies of
data in this study. The authors did not were in the hospital, and 16.4 0.06 women with BED (mean, 3812 519 g;
have access to the personal identication in unexposed women, of which 2.9 adjusted P < .001). Similarly, women
data; only research codes were used in all 0.03 were in the hospital. with AN had an increased odds for SGA
analyses. infants and infants with low birthweight
Pregnancy complications (Table 2), whereas odds for LGA infants
R ESULTS was increased among women with BED.
Most of the pregnancy complications
We identied 1078 singleton births Gestational age was the lowest among
occurred in similar percentages across
among patients and 6319 among unex- women with AN and the highest among
the exposure groups (Table 1).
posed women during the follow-up
Anemia was more frequent among women with BED (AN: mean, 39.6 2.1
period. Mothers with broad AN (n weeks; adjusted P .032; BN: mean
women with AN compared with unex-
182) delivered 302 babies; mothers with
posed women. The risk of maternal 39.7 1.9 weeks; adjusted P .026;
broad BN (n 436) and BED (n 39) BED: mean, 40.1 1.4 weeks; adjusted
hypertension was elevated in women
delivered 724 and 52 babies, respectively.
with BED. Furthermore, slow fetal P .27; unexposed: mean, 39.9 1.8
Unexposed mothers (n 3642) deliv- weeks). Women with AN had an
growth was observed more frequently in
ered 6319 babies. Only singleton child- increased risk of very premature birth.
women with AN compared with unex-
births are reported here. All 3 cases of very premature birth
posed women. Women with AN and
BN had increased odds of premature among women with AN were sponta-
Demographic characteristics neous in nature. Assisted ventilation and
contractions compared with unexposed
The mean age at childbirth was 29.4 monitoring of the neonate occurred in
women.
5.0 (SD) years in women with AN, 30.4 similar percentages across the groups,
1.2 years in women with BN, 30.2 whereas resuscitation and very low Apgar
1.0 years in women with BED, and Obstetric complications score at 1 minute after the birth were
29.1 4.8 years in unexposed women. The rate of induction of labor was more common among infants born to
Being married was less common among 14.8% in women with AN, 18.2% in women with BN compared with unex-
women with AN compared with unex- women with BN, 26.4% in women with posed women. Babies of women with AN
posed women (P < .001), and being BED, and 15.5% in unexposed women had a 4-fold risk of perinatal death
divorced was more common in women (P not signicant). The elective ce- (adjusted odds ratio, 4.06; 95% con-
with AN and BED (P < .001 and .005, sarean section rate was 7.1% in women dence interval, 1.15e14.35). All of these
respectively). There were no differences with AN, 7.3% in women with BN, 3 babies were born prematurely; 2 of
across the groups in being single. 11.3% in women with BED, and 5.9% in them were born very prematurely at <28
Among those who gave birth, parity was unexposed women (P not signicant). weeks gestation.
distributed equally in women with AN Duration of the rst stage of labor
and BED compared with unexposed was the shortest among women with C OMMENT
women, whereas the number of previ- AN (mean, 733 401 minutes, adjusted In this study, offspring of mothers with
ous births was lower among women P .031) and the most lengthy among a history of treatment for an ED were at
with BN (P .005). Smoking during women with BED (mean, 1249 309 risk of several negative fetal and perinatal
pregnancy was less common among minutes; adjusted P < .001) relative to health outcomes. Maternal AN was
women with an ED compared with unexposed women (mean, 811 503 related to maternal anemia, slow fetal
unexposed women (P .04 for BN; minutes). Similarly, the second stage of growth, premature contractions, giving
not signicant for AN and BED). labor was prolonged among women with birth to low birthweight and SGA in-
BED (mean, 110 73 minutes) com- fants, and very premature birth as was
Prenatal care paring with unexposed women (mean, expected based on previous literature;
The total number of prenatal care 43 55 minutes; adjusted P .018). the risk of perinatal death was increased
visits was higher among women with There were no statistically signicant when compared with unexposed women.
BN and BED compared with unexposed differences between the exposure groups In women who were treated for BN, risk
women, and all patient groups had an in terms of other obstetric outcomes. of premature contractions, and perhaps
TABLE 1
Pregnancy complications in women with an eating disorder compared with unexposed women
Pregnancy complication Anorexia nervosa Bulimia nervosa Binge eating disorder Unexposed
Gestational diabetes mellitus
n (%) 5 (1.66) 27 (3.73) 2 (3.85) 257 (4.07)
Odds ratio (95% CI)
Crude 0.40 (0.14e1.13) 0.91 (0.57e1.46) 0.94 (0.24e3.75) 1
Adjusted 0.38 (0.13e1.10) 0.81 (0.51e1.31) 0.85 (0.22e3.23) 1
Anemia
n (%) 12 (3.97) 12 (1.66) 0 97 (1.54)
Odds ratio (95% CI)
Crude 2.65 (1.38e5.11)a 1.08 (0.57e2.06) 1
Adjusted 2.39 (1.20e4.76)a 1.05 (0.54e2.03) 1
Hypertensionb
n (%) 3 (1.4) 6 (1.22) 4 (22.22) 87 (2.24)
Odds ratio (95% CI)
Crude 0.62 (0.19e1.98) 0.54 (0.21e1.4) 12.48 (3.82e40.82)a 1
a
Adjusted 0.63 (0.20e2.00) 0.51 (0.20e1.33) 13.29 (4.03e43.81) 1
b
Slow fetal growth
n (%) 14 (4.64) 22 (3.04) 0 122 (1.93)
Odds ratio (95% CI)
Crude 2.47 (1.36e4.48)a 1.59 (0.99e2.55) 1
a
Adjusted 2.59 (1.43e4.71) 1.53 (0.94e2.48) 1
b
Fast fetal growth
n (%) 0 7 (1.42) 1 (5.56) 36 (0.93)
Odds ratio (95% CI)
Crude 1.54 (0.68e3.51) 6.29 (0.80e49.67) 1
Adjusted 1.54 (0.69e3.47) 6.06 (0.72e50.99) 1
a
Premature contractions
n (%) 7 (3.26) 16 (3.25) 1 (5.56) 59 (1.52)
Odds ratio (95% CI)
Crude 2.18 (0.99e4.83) 2.18 (1.18e4.00)a 3.82 (0.49e29.77) 1
a a
Adjusted 2.31 (1.05e5.11) 2.20 (1.17e4.14) 3.96 (0.51e30.95) 1
Results of logistic regression models are provided.
CI, confidence interval; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th revision.
a
Statistically significant findings; b Information is based on ICD-10 diagnosis.
Linna. Pregnancy outcomes in eating disorders. Am J Obstet Gynecol 2014.
surprisingly, risks of resuscitation of the infants were observed among mothers the ndings of a recent metaanalysis.14
neonate and very low Apgar score at with BED. Despite these observed ad- A similar pattern was found for SGA.
1 minute from birth were increased. In verse outcomes, the course of pregnancy Our study also provides evidence for
line with previous studies, elevated risks was favorable for most women who higher risk of very premature birth in
of hypertension, prolonged rst and had been treated for an ED. mothers with AN. However, it should be
second stage of labor, higher birthweight Our nding of lower birthweight of noted that the number of very premature
of infants, and, in a similar vein, LGA infants in mothers with AN parallels births was small. Previous literature on
TABLE 2
Perinatal health complications in infants of women with an eating disorder compared with unexposed women
Perinatal health complication Anorexia nervosa Bulimia nervosa Binge eating disorder Unexposed
Resuscitation
n (%) 3 (0.99) 15 (2.07) 0 58 (0.92)
Odds ratio (95% CI)
Crude 1.08 (0.34e3.45) 2.28 (1.29e4.03)a 1
a
Adjusted 1.06 (0.33e3.37) 2.12 (1.18e3.79)
Perinatal death
n (%) 3 (0.99) 3 (0.41) 1 (1.92) 21 (0.33)
Odds ratio (95% CI)
Crude 3.00 (0.89e10.2) 1.25 (0.37e4.20) 5.88 (0.79e43.57) 1
Adjusted 4.06 (1.15e14.35)a 1.78 (0.51e6.19) 9.51 (1.33e68.26)a
Small for gestational age
n (%) 13 (4.30) 23 (3.18) 0 133 (2.10)
Odds ratio (95% CI)
Crude 2.09 (1.17e3.73)a 1.53 (0.94e2.47) 1
a
Adjusted 2.20 (1.23e3.93) 1.51 (0.92e2.48)
Large for gestational age
n (%) 1 (0.33) 19 (2.62) 5 (9.62) 155 (2.45)
Odds ratio (95% CI)
Crude 0.13 (0.02e0.94)a 1.07 (0.65e1.78) 4.23 (1.64e10.92)a 1
a a
Adjusted 0.13 (0.02e0.91) 1.10 (0.66e1.84) 4.32 (1.64e11.36)
Premature birth
n (%) 15 (4.98) 36 (5.01) 0 259 (4.11)
Odds ratio (95% CI)
Crude 1.22 (0.67e2.22) 1.23 (0.82e1.84) 1
Adjusted 1.28 (0.71e2.33) 1.28 (0.85e1.91)
Very premature birth
n (%) 3 (0.99) 3 (0.42) 0 18 (0.29)
Odds ratio (95% CI)
Crude 3.51 (1.02e12.09)a 1.46 (0.43e5.01) 1
a
Adjusted 4.59 (1.25e16.87) 1.84 (0.51e6.62)
Low birthweight
n (%) 19 (6.31) 30 (4.16) 0 201 (3.19)
Odds ratio (95% CI)
Crude 2.05 (1.23e3.40)a 1.32 (0.88e1.98) 1
a
Adjusted 2.16 (1.30e3.58) 1.37 (0.90e2.07)
Linna. Pregnancy outcomes in eating disorders. Am J Obstet Gynecol 2014. (continued)
prematurity is conicting, but most of and specically in women with AN,11,15 purging, and in women with BED.12
the literature suggests an elevated risk in women with BN,17 in women with A lower risk of preterm births in women
of preterm birth in EDs in general18,26 eating disorder not otherwise speciede with AN and BN has been reported by
TABLE 2
Perinatal health complications in infants of women with an eating disorder compared with unexposed women
(continued)
Perinatal health complication Anorexia nervosa Bulimia nervosa Binge eating disorder Unexposed
Very low birthweight
n (%) 3 (0.99) 6 (0.83) 0 34 (0.54)
Odds ratio (95% CI)
Crude 1.86 (0.56e6.11) 1.55 (0.65e3.70) 1
Adjusted 2.14 (0.64e7.20) 1.81 (0.72e4.57)
Low Apgar score at 1 min (<7)
n (%) 16 (5.39) 39 (5.41) 5 (9.62) 299 (4.75)
Odds ratio (95% CI)
Crude 1.14 (0.67e1.96) 1.15 (0.82e1.61) 2.13 (0.72e6.35) 1
Adjusted 1.17 (0.68e2.01) 1.13 (0.79e1.60) 2.23 (0.74e6.68)
Very low Apgar score at 1 min (<3)
n (%) 4 (1.35) 19 (2.64) 1 (1.92) 80 (1.27)
Odds ratio (95% CI)
Crude 1.06 (0.39e2.89) 2.10 (1.25e3.54)a 1.52 (0.21e10.87) 1
a
Adjusted 1.16 (0.42e3.20) 2.31 (1.34e3.98) 1.74 (0.25e12.1)
Results of logistic regression models are provided.
a
Statistically significant findings.
Linna. Pregnancy outcomes in eating disorders. Am J Obstet Gynecol 2014.
Bulik et al.12 Low prepregnancy body the expected rate of perinatal death has reported. In general, low and very low
mass index, small weight gain during been described by Brinch et al15 in Apgar scores predict lower survival of the
pregnancy, and fetal exposure to high women with AN (mostly because of infant42 and should be taken as signals
cortisol levels have been associated prematurity), and Micali et al9 found an for intensied follow-up evaluation. The
extensively with infant low birth- almost 2-fold rate of fetal death in observed severe complications might be
weight,9,27,28 fetal growth restriction,29,30 women with AN (no signicant differ- attributable to a number of factors (ie,
and preterm delivery.27,28,31 Further- ence). Studies by Stephansson et al,35 binge and purge episodes that lead to
more, low folate and iron intake have Kristensen et al,36 and Tennant et al37 rapid shifts in metabolic balance of
been shown to increase the risk of SGA.32 found no excess risk of stillbirth among mothers body and, respectively, subse-
In women with AN, these factors may underweight women. However, fetal quent nutritional supply for fetal growth
mediate the effect on the fetal growth and growth restriction has been described in or other unknown factors).
on the length of gestation, because AN is pregnancies of mothers with a history of Our ndings of higher birthweight
associated with restrictive eating, elevated AN38 and in the cause of antepartum and LGA infants among mothers with
levels of stress, and low bodyweight. death.39 We consider our nding to be BED are in line with those of Bulik
In our study, women with AN and surprising, given the very low overall et al,12 who observed heavier babies, a
BN were also at elevated risk of pre- perinatal infant mortality rate in lower risk of SGA, and a higher risk
mature contractions. This could be re- Finland40 and the relatively high quality of LGA in women with BED. Higher
lated to overall increased stress hormone public maternal healthcare that covers maternal weight and gestational weight
levels in women with EDs33 because, practically all pregnant women. gain may mediate the effects. Overall,
among other things, stress is known Neonates of mothers with BN had a research on pregnancy outcomes in
to induce preterm contractions and la- 2-fold risk of resuscitation and of very women with BED are limited, but
bor.28,34 A serious nding in our study low Apgar score at 1 minute, neither of several pregnancy, delivery, and peri-
was the increased risk of perinatal death which has been reported earlier. How- natal health complications are shown to
of infants of women with AN, even ever, in a smaller clinical study by Stew- be associated with maternal obesity.
though this was based on a low number art et al,41 a lower 5-minute Apgar score These include increased risk of gesta-
of perinatal deaths. Previously, 6-fold in infants of mothers with BN has been tional diabetes mellitus,43,44 preterm
delivery,45 cesarean delivery,44,46,47 development of children at the age of 5 disorders during early pregnancy: a validation
LGA,44,48 congenital anomalies,49 and years who were born to mothers with an study in a population-based birth cohort. Psy-
chol Med 2012;20:1-12.
stillbirth,35,36,44,50 whereas obesity is ED. It is also known that maternal stress 4. Fichter MM, Quadieg N. Twelve-year course
common in women with BED. Binge and anxiety during pregnancy have pro- and outcome of bulimia nervosa. Psychol Med
eating persists in many women with found, far-reaching effects on the off- 2004;34:1395-406.
BED during pregnancy. Moreover, preg- springs later cognitive development and 5. Fichter MM, Quadieg N, Hedlund S.
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vere cases of EDs may be over-presented. might be mediated through metabolic adverse perinatal outcomes in women with
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