tion with shoulder dystocia than without it, as the same Brachial plexus palsy associated with cesarean
iated with cesarean section: An in utero
conditions can cause both to occur. We believe that
Erb’s palsy results from the forces of propulsion and
occurs before shoulder dystocia.2,8
What is the basis for the belief that Erb’s palsy is
caused by the birth attendant pulling too hard on the
baby’s head? Does it explain all cases or even some of
the cases? How do those who assert that excessive
lateral traction is the cause know that excessive
lateral traction actually occurred? Is it not time to
stop blaming the birth attendant for most of the Erb’s
palsy cases? The indirect evidence presented here
supports the propulsive nature of the stretching of
the nerves involved.
References
1. Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC
III, Hankins GD, et al. Williams obstetrics, 20th ed. Norwalk,
Connecticut: Appleton & Lange, 1997:450.
2. Gherman RB, Ouzounian JG, Miller DA, Kwok RN, Goodwin TM.
Spontaneous vaginal delivery: A risk factor for Erb’s palsy? Am J
Obstet Gynecol 1998;178:423–7.
3. Hankins GDV, Clark SL. Brachial plexus palsy involving the pos-
terior shoulder at spontaneous vaginal delivery. Am J Perinatol
1995;12:44 –5.
4. Gherman RB, Goodwin TM, Ouzounian JG, Miller DA, Paul RH.
Detection and management of
eating disorders during
pregnancy
Debra L. Franko, PhD, and
Emily B. Spurrell, PhD
Eating disorders such as anorexia nervosa and bulimia
nervosa are associated with potential negative consequences
during pregnancy, including higher rates of miscarriage, low
birth weight, obstetric complications, and postpartum de-
pression. Women with eating disorders are reluctant to
disclose symptoms to health care providers, so it is impor-
tant for obstetric clinicians to be aware of warning signs and
assessment techniques to identify them. Signs suggestive of
eating disorders include lack of weight gain, hyperemesis
gravidarum, and a history of eating disorders. Recent studies
showed that the Eating Disorder Examination, a newly
developed assessment tool, can ascertain whether someone
From the Harvard Eating Disorders Center, Harvard Medical School,
Boston, Massachusetts; and Women and Infants’ Hospital, Brown
University, Providence, Rhode Island.
942 Franko and Spurrell Eating Disorders and Pregnancy
injury? Am J Obstet Gynecol 1997;177:1162– 4.
5. Sandmire HF, DeMott RK. The Green Bay Cesarean Section Study.
IV. The physician factor as a determinant of cesarean birth rates for
the large fetus. Am J Obstet Gynecol 1996;174:1557– 64.
6. Acker DB, Gregory KD, Sachs BP, Friedman EA. Risk factors for
Erb-Duchenne Palsy. Obstet Gynecol 1988;71:389 –92.
7. Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers
for shoulder dystocia and associated fetal morbidity. Am J Obstet
Gynecol 1998;178:1126 –30.
8. Ouzounian JG, Korst LM, Phelan JP. Permanent Erb palsy: A
traction-related injury? Obstet Gynecol 1997;89:139 – 41.
9. Jennett RJ, Tarby TJ, Kreinick CJ. Brachial plexus injury: An old
problem revisited. Am J Obstet Gynecol 1992;166:1673–7.
Address reprint requests to:
Herbert F. Sandmire, MD
ob.gyn Associates of Green Bay
704 S. Webster Avenue
Green Bay, WI 54301
Received September 13, 1999.
Received in revised form November 15, 1999.
Accepted December 2, 1999.
Copyright © 2000 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
has an eating disorder. Questions from the Eating Disorder
Examination about body image, food avoidance, food rules,
and dieting behaviors have successfully differentiated
women with eating disorders from healthy controls. We
offer an approach to the clinical care of individuals identi-
fied or suspected of having eating disorders. We recommend
a team approach that emphasizes ongoing communication
and clear goal setting for the care of pregnant women with
eating disorders. (Obstet Gynecol 2000;95:942– 6. © 2000 by
The American College of Obstetricians and Gynecologists.)
Although little is known about the effects of eating
disorders on pregnancy, the available evidence sug-
gests that there are potentially detrimental conse-
quences for women and fetuses. The purposes of this
paper are to highlight relevant literature on potential
interactions between pregnancy and eating disorders,
alert obstetric professionals to warning signs of eating
disorders and suggest a simple state-of-the-art assess-
ment strategy, and offer treatment guidelines for preg-
nant women with eating disorders. Based on our clini-
cal experience, we believe that obstetricians should be
aware of risk factors and advances in assessment of
eating disorders to better treat pregnant women.
Obstetrics & Gynecology
Potential Interactions Between Pregnancy and
Eating Disorders
Eating disorders are associated with nutritional, meta-
bolic, endocrine, and psychologic changes that have
potentially negative effects on fetal development. Em-
piric information on the effects of anorexic and bulimic
symptoms during pregnancy is limited because pub-
lished studies are primarily retrospective or are case
reports. The most often cited complications in anorexic
and bulimic pregnant women include inadequate or
excessive weight gain, miscarriage, and hyperemesis
gravidarum. There also have been case reports of vag-
inal bleeding, hypertension, and postepisiotomy suture
damage in pregnant women with eating disorders. The
most frequently reported birth complications include
preterm delivery, low birth weight (LBW), cesarean
delivery, and low Apgar score. Case reports also have
detailed prenatal mortality, fetal abnormality, stillbirth,
breech delivery, and fetal cleft palate in pregnant
women with eating disorders.
Several documented obstetric and fetal complications
are of particular concern: miscarriage rate appears to be
higher in women with eating disorders than in normal
controls,1,2 for unknown reasons, but possibly owing to
compromised health status or nutritional deficits. Al-
though the number of studies is small, we recommend
that obstetricians be alerted to the greater risk of mis-
carriage in this population.
Hyperemesis gravidarum is more common in women
with eating disorders than in controls. Abraham1 re-
ported that although the community prevalence of
hyperemesis gravidarum was one in 1000 pregnant
women, nearly 10% of the 25 actively bulimic women
had it during their pregnancies. This was consistent
with Stewart3 who reported hyperemesis gravidarum
more frequently in eating-disordered women who had
ovulation induced because of infertility. One possible
explanation for greater frequency of reported hy-
peremesis gravidarum in bulimic women is that it
might be a way to rationalize dysfunctional behavior
with more normal consequences of pregnancy. In a
sense, it might allow bulimic women to continue symp-
tomatic behavior and to hide it under the pretense of a
medical consequence of pregnancy.
The well-documented relationship between preg-
nancy weight gain and birth weight poses a challenge in
eating-disordered pregnant women. It has been re-
ported that such women gain less weight and have
smaller infants than healthy women.1,2 Using an inno-
vative design, Conti et al4 investigated the association
between pregnancy outcome and eating behaviors in 88
women who delivered LBW infants. The group was
divided into 34 women who delivered small-for-
VOL. 95, NO. 6, PART 1, JUNE 2000
gestational-age (SGA) infants at term and 54 who de-
livered preterm infants (before 37 weeks). Women who
delivered SGA infants at term reported more disturbed
eating behaviors before, during, and after pregnancy. In
that study, the unique predictors of having an SGA
infant included low prepregnancy weight, smoking,
low weekly maternal weight gain, and an elevated score
on a self-report bulimia screening questionnaire. Fac-
tors that predicted preterm births were lower occupa-
tional status, vomiting during pregnancy, and lower
dietary restraint. The authors concluded that growth
restriction in SGA infants could be determined partly
by maternal eating behavior and patterns of disturbed
eating before and during pregnancy.
Besides higher frequency of miscarriage, hypereme-
sis, and LBW, the rate of cesarean delivery was higher
in women with eating disorders than in controls. Bulik
et al2 reported a rate of 16% in anorexic women com-
pared with 3% in healthy controls. Women with eating
disorders might be seen as higher risks by obstetricians,
which might increase the possibility of cesarean. The
symptomatic behaviors of anorexic and bulimic women
also might lead to complications in labor and delivery.
Data thus far do not offer precise understanding of why
cesareans are more common in that population; how-
ever, increased rates of cesareans were found in a
relatively large sample (n ⫽ 66) of eating-disordered
women, suggesting that they should be considered at
risk for complicated deliveries.
A high rate of postpartum depression also has been
found in eating-disordered women.1,3 Morgan et al5
reported that one third of a sample of 94 women with
eating disorders had postpartum depression confirmed
by medical records, compared with the normal popu-
lation rate of 3–12%.6 We believe that women with
eating disorders have stresses that healthy women
might not have (body image issues, weight concerns,
anxiety, symptomatic behaviors) that make them more
vulnerable to postpartum depression. Approximately
40% of women with eating disorders have histories of
affective disorders, which also puts them at risk of
postpartum depression.
Warning Signs of Eating Disorders
There is some evidence that anorexic and bulimic
women are reluctant to disclose their symptoms and
behaviors to health care professionals. In one small case
sample, women were reluctant to volunteer that infor-
mation during their pregnancies.7 Stewart3 reported in
a series of 66 consecutive women who presented for
infertility that 17% were diagnosed with eating disor-
ders, and none disclosed it to the health care providers.
These studies suggest that familiarity with warning
Franko and Spurrell Eating Disorders and Pregnancy 943
signs, early detection, and assessment strategies for
women with eating disorders are important for provid-
ers of obstetric care because it is likely that women will
be hesitant to disclose such information spontaneously.
There are no reliable laboratory indicators for eating
disorders, so detection depends on careful questioning
and vigilance by the providers. High levels of shame
and secrecy are extremely common in these women,
making it important that questions are asked in an
open-ended manner to maximize disclosure.
Not every woman needs a full assessment for eating
disorders, so we propose three warning signs for fur-
ther assessment: lack of weight gain in two consecutive
visits in the second trimester, history of an eating
disorder, and hyperemesis gravidarum. Inadequate
weight gain, particularly in the second trimester, is a
clear indication that something is amiss and should be
investigated thoroughly, from medical and psychologic
perspectives. Brinch et al8 reported that simply having
a history of eating disorders can pose serious risk to
pregnancy outcomes. Several authors suggested that
eating disorders should be considered whenever hy-
peremesis occurs, and some data support that relation-
ship.1,3 We assume that most health care providers are
familiar with the characteristic symptoms of eating
disorders, so we will not review them. We will focus on
how to assess women whom physicians suspect might
have eating disorders.
Assessing Suspected Eating Disorders
A relatively new advance in the field is a reliable and
well-validated interview that consistently distinguishes
between eating-disordered and healthy individuals.
This is particularly difficult given the normative nature
of body dissatisfaction and weight concern for women
in our culture, and the shame that prevents many with
eating disorders from disclosing overt symptoms. This
Eating Disorder Examination9 has proven able to dif-
ferentiate normative discontent, dieting, and eating
concerns from more dysfunctional behaviors and atti-
tudes. Studies have found that it has good discriminant
validity, internal consistency, and concurrent validity.10
It is now considered by many investigators to be the
method of choice for assessing the specific psychopa-
thology of eating disorders. While accurate administra-
tion of the Eating Disorder Examination requires exten-
sive training, a self-report version of the instrument has
produced similar ratings on most of the items,11 which
suggests that the types of questions that comprise it
might help clinical obstetricians assess eating disorders.
The 12th edition of the Eating Disorder Examination
includes four subscales (Restraint, Shape Concern,
Weight Concern, and Eating Concern) and frequency
944 Franko and Spurrell Eating Disorders and Pregnancy
ratings of the key behaviors, such as binge eating,
vomiting, laxative abuse, and excessive exercise. Each
of the four subscales is composed of specific questions
that assess behaviors and beliefs associated with eating
disorders, but not necessarily required for diagnosis.
The items are so specific that they are often a good
“backdoor” assessment strategy when women deny
more overt symptoms.
For example, dietary restraint (eg, dieting behavior) is
typical in eating disorder patients and is common in the
general population. Some of the Eating Disorder Exam-
ination items that assess restraint are: “In the past 28
days, how many days have you 1) tried to restrict what
you ate whether or not you succeeded? 2) tried to
follow rigid rules around eating, such as a calorie limit?
3) tried to avoid certain foods altogether? and 4) gone
for 8 or more waking hours without eating anything?”
Each item is rated by how many days in the past 4
weeks someone tried to adhere to it, to understand their
eating behaviors. Extreme scores indicate that someone
tried to restrict, follow rules, avoid foods, and avoid
eating for 22 of the past 28 days.
The Eating Disorder Examination requires that the
threshold be high on all items. For example, a food rule
is different than simply trying to eat healthily. A rule is:
“I should not eat fried foods ever,” while trying to eat
healthily is more like following a guideline of: “I try not
to eat fried foods.” A rule, unlike a guideline, is not
flexible and when broken causes distress about having
done something wrong. Another example of a high
threshold is when one is assessing food avoidance.
Many people might avoid foods that are high in fat or
calories. To meet criteria for this item, however, indi-
viduals must completely avoid a food they like. They
must endorse that they attempt to avoid the food
altogether and would likely feel distress if they did not
avoid it. The issue of not eating for prolonged periods
while awake must be intentional and must be 8 hours or
more. The answers to Eating Disorder Examination
questions must be extreme responses to indicate an
eating disorder.
Table 1 outlines several particularly useful items from
the Eating Disorders Examination and the means that
studies have shown differentiate women with anorexia
and bulimia from normal controls. While those items
are obviously too inclusive for typical office visits, they
do provide practitioners with useful questions when
women present with suspected eating disorders.
Chances are that if women endorse several of the items,
even if they are denying frank eating disorder symp-
toms, a referral for more specialized evaluation is
warranted.
The Eating Disorder Examination is one assessment
tool for identifying eating-disordered women, but other
Obstetrics & Gynecology
useful questions have been empirically validated. If an
obstetrician wants to ask only a few questions, Freund
et al12 reported that asking “Are you satisfied with your
eating patterns?” and “Do you eat in secret?” success-
fully differentiated women with bulimia nervosa from
healthy controls in a primary care setting. Both ques-
tions had sensitivity of 1.00 and specificity of .90 in a
sample of 172 women, suggesting that a negative re-
sponse to the first question and a positive response to
the second question would indicate the need for further
evaluation for possible eating disorders.
Treatment Guidelines
The importance of a team approach to treatment that
includes obstetricians, mental health professionals, and
dietitians cannot be overemphasized, and the women’s
agreement to the collaboration must be sought. It is the
responsibility of the mental health clinician to coordi-
nate the treatment team and make appropriate addi-
tional referrals (eg, dietitian and psychiatrist). Obstetri-
cians should support women and encourage them to
remain in treatment with the eating-disorders team.
Although obstetric staff will not be the primary
treatment providers for eating-disordered women, it
might be useful to keep in mind several treatment
guidelines. Obstetric staff should be aware of tactics that
might be used by women with eating disorders to
undermine treatment. Such women generally have sig-
nificant fears about weight gain, so at each visit eating-
disorder patients should be weighed in scant clothing
or a hospital gown. It is well-known that anorexic
patients might try to conceal their true weight by
adding articles of clothing or carrying heavy objects in
their pockets. It is appropriate to ask women whether or
not they want to know their weight. Women with
eating disorders might prefer not to be told their
weights, which should be respected, unless they are not
gaining adequately. In those cases, women should be
told in a concerned and noncritical manner, without
“scare tactics.” A discussion of the importance of nutri-
tion for the developing fetus might offer the woman an
incentive to eat. An explanation of the size, anatomical
development, and gestational age of the fetus can provide
information to the woman that might help her eat “for the
baby,” with less focus on her own increasing weight.
Regular communication with other members of the
treatment team is essential in the overall care of obstet-
ric patients with eating disorders. In some cases,
women with eating disorders might try to “split” the
treatment team, by misrepresenting what others have
said, or telling important information to one, but not all,
team members. If the mental health clinician, obstetri-
cian, and dietitian communicate regularly, that poten-
VOL. 95, NO. 6, PART 1, JUNE 2000
Table 1. Sample Items From the Eating Disorders
Examination and Mean Item Responses for Eating-
Disordered and Non–Eating-Disordered
Populations
Eating Non eating
Sample of subscale items disorder disorder
Over the past 4 weeks have you:
Been consciously trying to restrict what you 4.7* 1.7
eat, whether or not you have succeeded?
Gone for 8 or more waking hours without 1.4 0.3
eating anything?
Tried to avoid eating any foods that you 3.2 1.9
like, whether or not you have succeeded?
Tried to follow certain definite rules 3.0 0.5
regarding your eating, for example, a
calorie limit, preset quantities of food, or
rules about what you should eat and
when you should eat it?
Been afraid of losing control over eating? 2.8 0.1
Eaten in secret? 1.4 0.3
Felt guilty after eating?† 2.6 0.2
Been afraid of gaining weight (is this a 4.4 0.2
definite fear)?
Sample of items assessing key behaviors:
Have there been times when you felt like 2.8 0.0
you ate a large amount of food and
experienced a sense of loss of control, like
you could not stop eating once you
started?
Made yourself sick as a means of 30.8‡ 0.0
controlling your weight or shape? 18.0§
* Scores for each item range from 0 to 6, where higher scores indicate
more severe dysfunction. Data presented are means between two
populations originally in Wilfley et al.11 Subjects were 100 anorexia
and bulimia nervosa patients and 42 normal-weight control subjects.
All means are significantly different from one another at P ⬍ .001.
†
This item is rated on a scale of the proportion of times someone
feels guilty after eating during the past 4 weeks, not number of days.
‡
Bulimic patients.
§
Anorexic patients.
tial treatment problem can often be avoided. It is also
common that women with eating disorders express
positive feelings toward one of their health care provid-
ers, and disparage the rest of the team, attempting to
undermine the treatment. Agreement among team
members on important issues, such as the rate of weight
gain, will help women achieve their goals. Clear expla-
nations about the potential consequences of inadequate
weight gain should be communicated to patients in an
atmosphere of care and concern. They might need to be
seen by the treatment team more frequently than
healthy patients, or they might need to be hospitalized
to ensure appropriate weight gain. Eating disorders
often represent chronic and sometimes lifelong condi-
tions. Antidepressant drugs might be helpful for treat-
ing bulimia nervosa.
Although the recommendations put forth here are
based on available research, only one prospective longi-
tudinal study of pregnancy and eating disorders has been
Franko and Spurrell Eating Disorders and Pregnancy 945
conducted to date. Given the accumulating evidence of
serious potential risk in women with histories of or frank
eating disorders, we suggest that obstetric staff be aware
of those possibilities in their patients and follow our
proposed guidelines for adequate assessment and care.
References
1. Abraham S. Sexuality and reproduction in bulimia nervosa pa-
tients over 10 years. J Psychosom Res 1998;44:491–502.
2. Bulik CM, Sullivan PF, Fear JL, Pickering A, Dawn A, McCullin M.
Fertility and reproduction in women with anorexia nervosa: A
controlled study. J Clin Psychiatry 1999;60:130 –5.
3. Stewart DE. Reproductive functions in eating disorders. Ann Med
1992;24:287–91.
4. Conti J, Abraham S, Taylor A. Eating behavior and pregnancy
outcome. J Psychosom Res 1998;44:465–77.
5. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on
bulimia nervosa. Br J Psych 1999;174:135– 40.
6. Gotlib IH. Postpartum depression. In: Blechman EA, Brownell KD,
eds. Behavioral medicine and women: A comprehensive hand-
book. New York: Guilford Press, 1998:489 –94.
7. Hollifield J, Hobdy J. The course of pregnancy complicated by
bulimia. Psychotherapy 1990;27:249 –55.
8. Brinch M, Isager T, Tolstrup K. Anorexia nervosa and motherhood:
Reproduction pattern and mothering behavior of 50 women. Acta
Psychiatr Scand 1988;77:98 –104.
946 Franko and Spurrell Eating Disorders and Pregnancy
9. Fairburn CG, Cooper Z. The Eating Disorder Examination. 12th ed.
In: Fairburn CG, Wilson GT, eds. Binge eating: Nature, assessment,
and treatment. New York: Guilford Press, 1993:317–56.
10. Williamson DA, Anderson DA, Jackman LP, Jackson SR. Assessment
of eating disordered thoughts, feelings, and behaviors. In: Allison DB,
ed. Handbook of assessment methods for eating behaviors and
weight-related problems: Measures, theory, and research. Thousand
Oaks, California: Sage Publications, 1995:347–86.
11. Wilfley DE, Schwartz MB, Spurrell EB, Fairburn CG. Using the
Eating Disorder Examination to identify the specific psychopathol-
ogy of binge eating disorder. Int J Eat Disord 2000;27:259 – 69.
12. Freund KM, Graham SM, Lesky LG, Moskowitz MA. Detection of
bulimia in a primary care setting. J Gen Intern Med 1993;8:236 – 42.
Address reprint requests to:
Debra L. Franko, PhD
Harvard Eating Disorders Center
356 Boylston Street
Boston, MA 02116
E-mail: dlf@hedc.org
Received June 23, 1999.
Received in revised form December 14, 1999.
Accepted December 28, 1999.
Copyright © 2000 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology