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EATING DISORDERS

Eating Disorders Effect on the Pregnant Woman

Minnie Germano, Mariah Johnson, Mackenzie Larch, Brianna Simmons

Bitonte College of Health and Human Services, Youngstown State University

NURS 3749 Nursing Research

Dr. Danielle Class

6 April 2022
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EATING DISORDERS

Eating Disorders Effect on the Pregnant Woman

Eating disorders can cause several consequences to the human body, especially one

carrying a fetus. Whether an individual is suffering from anorexia nervosa, bulimia nervosa, or

binge eating, the repercussions are extensive. Eating disorders can result in hormonal/electrolyte

imbalances, muscle loss and weakness, severe dehydration, fainting and fatigue, and numerous

acquired health disorders such as hypertension, diabetes mellitus, hypercholesterolemia, and

heart disease. Pregnant women who suffer from eating disorders can acquire even more issues

and carry a high risk of passing these problems onto their child. The significance of this problem

is relevant to the ongoing knowledge women of childbearing years have access to. For this

literature review, the focus was on how the presence of eating disorders, in general, can lead to

infertility and/or miscarriage, poor nutrition in both the fetus and/or mother, and postpartum

depression.

PICOT

This literature review was conducted to identify complications of eating disorders in

pregnant women. The following PICOT question was developed: “For childbearing women, does

the presence of eating disorders lead to a higher incidence of infertility, miscarriage, poor

nutrition in the mother and/or baby, and postpartum depression compared to women who do not

have eating disorders.”

Search Strategy

Using EBSCOhost, a search was initiated using a combination of terms with the phrase

“eating disorders,” including, infertility, miscarriage, poor nutrition, and postpartum depression.

Databases used included Cumulative Index to Nursing and Allied Health Literature (CINAHL)
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with Full Text (EBSCO), MEDLINE (PubMed), and Medline with Full text (EBSCO). The

search was limited to literature from 2017-2022, except for one article being from 2015.

Inclusion criteria consisted of articles that were written in English, had full PDF access, and were

peer reviewed. The initial literature search yielded 18,859 articles. Abstracts were reviewed for

inclusion criteria and relevancy to the literature search to identify articles that were related to

eating disorders and pregnancy outcomes. Minimal results that included specific consequences of

said disorders were found in literature search and the search strategy was changed to include

“infertility,” “miscarriage,” “nutrition/poor nutrition,” and “depression/postpartum depression.”

The addition of the limitations narrowed the search to less than 500 articles each time. Titles and

abstracts were reviewed, and the articles were narrowed to the eight used in this literature

review.

Literature Review

Four themes that had potential to impact pregnancy related to eating disorders were

identified in the literature. Themes identified were the risk of infertility and miscarriage, poor

nutrition of the baby and/or mother, and the potential of the mother suffering from severe

postpartum depression.

Infertility

Infertility is a major consequence in women with eating disorders. “Eating disorders such

as anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating

disorders are prevalent in females in their reproductive age” (Paslakis, Zwaan, 2019, p. 215).

There is a medical side as to why eating disorders and infertility are so closely linked to one

another. Extreme weight loss and decrease in caloric intake, that comes with eating disorders,
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EATING DISORDERS

suppresses hormones being released from the pituitary gland that are needed to maintain normal

levels of Estrogen. One of the main hormones seen is called Leptin. “Leptin levels below 2 ug 1

^ -1 are thought to be the threshold for developing amenorrhea (absence of mensuration).

Functionally this results in dysfunction in ovulation, endometrial development, menstruation,

and bone growth” (Kimmel et al., 2015, p. 262). Without normal levels of Estrogen, ovulation

cannot occur (which is when the woman’s ovaries produce an egg to be fertilized by sperm)

which in turn causes infertility to develop.

A study was performed in 2016 regarding obstetric and gynecological problems

associated with eating disorders, and the following were the results regarding amenorrhea:

“Absence of menstruation of more than 3 months occurred in an estimated 66-84% of women

with anorexia nervosa and approximately 36-64% in women with bulimia nervosa” (Kimmel et

al., 2015, p. 261). In the absence of having a menstrual cycle, it becomes nearly impossible for a

female to become pregnant due to her not being able to ovulate.

In a more recent study conducted in 2022, “Women suffering from infertility of

hypothalamic origin were found to have a history of ED that was four times higher than those in

the control group with another type of infertility” (Floch et al., 2022, p. 3). There was also a

higher prevalence of eating disorders in infertile women who underwent fertility treatment as

compared to normal women (Floch et al., 2022, p. 8). Thereafter, international guidelines have

recommended early and multidisciplinary treatment of eating disorders to improve possible fetal

outcomes, and that early identification of any ED would be of major interest for the trying mom

(Floch et al., 2022, p. 2).

Miscarriage
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EATING DISORDERS

Women who suffer from eating disorders are more prone to having miscarriages. A

miscarriage occurs when the pregnancy separates from the maternal uterus and passes out of the

body. A miscarriage is more likely to happen within the first 12 weeks of pregnancy due to the

embryo’s increased susceptibility to maternal risks. Therefore, when the mother is not taking in

enough calories and nutrients, a miscarriage is more than likely to occur. It is recommended that

a pregnant mother consumes about 1,800 calories per day during the first trimester. If the mom to

be has an eating disorder (such as anorexia nervosa) causing her to not take in the required

calorie amount, then the baby cannot sustain in the womb. The rates of both miscarriages and

induced abortions (a procedure done to end a pregnancy, most commonly in the first 12 weeks)

are higher in females who have a history of eating disorders (Paslakis & Zwaan, 2019, p. 216).

Anorexia nervosa, bulimia nervosa, and binge eating disorders are three of the most

common eating disorders that end in a miscarriage. “Several large studies have shown the

negative impact of EDs on pregnancy outcomes, such as premature birth, low birth weight, low

Apgar scores, and even perinatal death” (Paslakis & Zwaan, 2019, p. 216). These complications

cause an array of stressors on the mother, which in turn, can lead to more detrimental outcomes.

Eating disorders cause increased stress in women, due to them not feeling good enough in their

own skin, not wanting to gain weight, feeling guilty, etc. That stress can lead to hypertension

making it harder for the baby to get adequate amounts of oxygen and nutrients to survive and

grow. Even if it does not end up as a complete miscarriage, the fetus can still be born with issues,

including coming out a stillborn, being born prematurely, or having a low birth weight. Signs of

a miscarriage include symptoms such as bloody fluid passing from the vagina, or pain in the

lower back (flank pain) radiating to the abdomen. Eating disorders, such as anorexia and bulimia,

create a barrier for women to get pregnant and stay pregnant.

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EATING DISORDERS

Poor Nutrition

Poor nutrition in pregnant women is a major complication of eating disorders (ED) which

can affect not only the mother, but the neonate too. A well-balanced diet during pregnancy is

crucial for the well-being of both lives. Diets that lack key nutrients such as folate, calcium, iron,

iodine, and zinc may lead to devastating events such as maternal pre-eclampsia, hemorrhage, or

even death. Many women with eating disorders fear gaining weight and develop disorders such

as anorexia nervosa. Anorexia nervosa can be described as extreme self-starvation, which

severely interferes with the body's ability to function properly, especially when pregnant. When a

woman becomes pregnant, weight gain is inevitable. This is something that many women with

disordered eating have a very difficult time coping with. The immense fear of gaining weight can

hinder their ability to nourish their bodies appropriately for pregnancy. The likely effects of

disordered eating and poor nutrition are just as catastrophic for the neonate as they are for the

mother.

A research journal that focuses on pregnant women with eating disorders stated that

“Women with ED are also more likely to experience labor and delivery complications such as c-

section, fetal distress, preterm birth, or infant death at birth” (Goutaudier et al., 2020, p. 245).

Regarding these findings, it is important to take into consideration the unfavorable effects that

these labor and delivery complications may have. For instance, having a cesarean section puts

both the mother and baby at an increased risk for infection. Also, a preterm birth puts the infant
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at high risk for respiratory complications, cardiac complications, and many other complications

that may have been avoidable if proper maternal nutrition was sustained. 

Poor nutrition does not only stem from self-starvation eating disorders such as anorexia

nervosa, but also from overeating disorders such as purging. Purging is a disorder that leads to

self-induced vomiting, excessive exercise, or excessive use of laxatives. Although people who

suffer from purging might have an adequate intake of food and nutrients, it is typically not able

to be absorbed or metabolized properly before it is excreted from the body. A study that focused

on purging in pregnant women came up with the following results:

Moreover, we found that women with a lifetime history of purging had higher odds of

having offspring who were SGA. Hence, women with a history of purging may be at

increased risk of having obstetric complications, suggesting that women with lifetime

history of ED should be asked about current and previous purging behaviors when

pregnant. (Eik et al., 2018, p. 1141)

As seen in pregnant women with anorexia nervosa, the lack of important nutrients caused by

purging can have harmful effects on the mother and the infant. The study found that an extensive

history of purging in a mother relates to a higher incidence of the baby being small for

gestational age (SGA). This may be a direct result of maternal eating disorders. An extensive

history of purging also puts the mother at increased risk for obstetric complications that can be

due to abnormal mineral and electrolyte levels. 

As stated previously, poor nutrition during pregnancy due to an eating disorder can lead

to an array of health complications for the mother and the neonate. Pregnancy is often thought to

be the most beautiful experience in a woman's life. Yet for some women, this may not be the

case. Some women may have an unplanned pregnancy or may be having a difficult time
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EATING DISORDERS

adjusting to pregnancy. In a research study where individuals were interviewed about their eating

disorders, it was found that “Participants told of using ED behaviors as something that they could

control when things were difficult. It also seemed that having an ED was a way of detaching

from other problems” (Reid et al., 2020, p. 985). The use of an eating disorder as a coping

mechanism can lead to poor nutrition and complications for both the mother and the child. It can

be very difficult for a mother with an eating disorder to recover from it, especially when dealing

with the stress and major life changes that come with pregnancy. However, the process of

recovery from an eating disorder is very important to promote the health of the mother and the

child.

Postpartum Depression

Postpartum depression is another major issue that can occur due to eating disorders in

pregnant women. This is a depression that transpires specifically in women after giving birth.

Those who develop this depression are at a much higher risk for developing depression later in

life as well. The signs are variable, ranging from some experiencing a loss of appetite, to others

suffering from insomnia and irritability. The major sign is difficulty with bonding and forming a

healthy relationship with the baby. If not treated, it can lead to postpartum psychosis, which is a

very serious condition that can drive the mother to conduct terrible, senseless acts on the

newborn (perhaps even ending in death). Postpartum depression and psychosis are different from

just having the baby blues, which are mild mood swings that come and go due to the hormonal

shifts of the new mother. This is normal and usually only lasts a few weeks.

A study was conducted among pregnant women to establish the connection between their

depression and eating disorders. Originally, there was 25 participants, however, one mother

suffered a miscarriage, resulting in 24 participants’ total. The research committee conducted

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interviews every two weeks, both during pregnancy and after giving birth, and used various tests

to determine the outcomes. According to The risk of eating disorder relapse during pregnancy

and after delivery and postpartum depression among women recovered from eating disorders,

“Sixteen participants (67%) experienced ED relapse during pregnancy and twelve (50%)

relapsed after birth. Twelve (50%) had postpartum depression, four of whom (33%) had low-

birth-weight infants. Among the participants who did not have postpartum depression, there were

no low-body-weight infants” (Makino et al., 2020, p. 1). The information gathered and collected

during this period verify that eating disorders (ED) can progress to postpartum depression and

have a negative effect on pregnant women.

Support factors that could be offered to the mother include counseling and referrals for

therapy. Treatment may include antidepressants, such as SSRIs, or relaxation techniques to

reduce stress overload, such as guided imagery, deep breathing, yoga, meditation, and light

exercise. The article concluded, “Our study revealed that the recurrence of EDs and occurrence

of postpartum depression were higher in our study population (24 women with EDs who had

recovered), indicating that EDs need to be closely monitored during pregnancy and after giving

birth” (Makino et al., 2020, p. 6). Overall, this study highlights the significance of helping our

new mothers with mental health challenges during this new, dramatic lifestyle change.

Anxiety and stress caused by pregnancy symptoms is worse in women who have eating

disorders during their nine months of carrying the fetus. Some of these women may experience

HG, or Hyperemesis Gravidarum, which is a condition that causes the mother to vomit during

her pregnancy and leads to an unhealthy weight loss. These women report more depressive

symptoms than those who are not diagnosed with HG. A study was performed on 40 different

women with HG. According to Anxiety and Coping Strategies Among Women with Hyperemesis
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EATING DISORDERS

Gravidarum in Malaysia, “69% of pregnant women suffer from anxiety due to HG, the most

common cause of psychological distress. A study by O’Brien et al. (2002) on hospitalized

women with HG determined the coping mechanisms utilized to handle this medical condition.”

The severity of these symptoms tends to increase, thus leading the expectant mothers to have to

convey their feelings to others, which is a challenge within itself. (Khodabakhsh & Ramasamy,

2021, p. 421). Thus, eating disorders lead to uncontrolled vomiting, resulting in extreme anxiety.

The objective of this specific study was to identify the different levels of anxiety to

determine multiple coping strategies amongst these women. Data was collected and analyzed.

The results revealed that income factors and employment status significantly affected these

mothers, leading to excessive anxiety and depression. In conclusion, “Conceptualizing the bio-

psychosocial model and Lazarus and Folkman’s transactional model of stress has further

established the relationship between anxiety and the coping mechanism that was utilized

following HG. Regarding coping strategy, instrumental support is being adopted in seeking help”

(Khodabakhsh & Ramasamy, 2021, p. 427). Further saying, socioeconomic status, such as

household income and/or employment, influences the level of anxiety amongst HG patients.

Recommendations

For any trying mother, it is always recommended that they practice healthy lifestyles. The

best thing for a woman with an eating disorder that is trying to get pregnant is to be honest about

her ED. It is crucial that those women understand the importance of ingesting proper caloric

intake, vitamins, and minerals. From an emotional standpoint, it is recommended that pregnant

women with ED’s practice healthy mindsets and coping, including practicing guided imagery,

deep breathing, yoga, meditation, and light exercise. To produce a higher likelihood of what is
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considered a “healthy pregnancy,” it is important for soon to be moms to understand the potential

harm they may be placing their baby in, but it is also important that they have a strong support

team standing behind them to help them get better.

Conclusion

For this literature review, the focus was on how the presence of eating disorders, in

general, can lead to infertility and/or miscarriage, poor nutrition in both the fetus and/or mother,

and postpartum depression. The studies included in this review have concurred that ED’s cause a

higher incidence of infertility and/or miscarriage, insufficient consumption needed for the growth

and development of the fetus, and postpartum depression potentially leading to postpartum

psychosis. Women with ED’s need to be closely monitored during their term because of the

added stress and anxiety brought on by hormonal changes. It is vital that health care providers

pay close attention to worsening symptoms related to ED’s throughout the course of a woman’s

pregnancy.
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References

Eik, N. T. T., Horn, J., Strohmaier, S., Holmen, T. L., Micali, N., & Bjørnelv, S. (2018).

Impact of eating disorders on obstetric outcomes in a large clinical sample: A comparison with

the HUNT study. International Journal of Eating Disorders, 51(10), 1134–1143. https://doi-

org.eps.cc.ysu.edu/10.1002/eat.22916.

Goutaudier, N., Ayache, R., Aubé, H., & Chabrol, H. (2020). Traumatic anticipation of

childbirth and disordered eating during pregnancy. Journal of Reproductive & Infant

Psychology, 38(3), 243–258. https://doi-org.eps.cc.ysu.edu/10.1080/02646838.2020.1741525.

Khodabakhsh, S., & Ramasamy, S. (2021). Anxiety and Coping Strategies among

Women with Hyperemesis Gravidarum in Malaysia. Central European Journal of Nursing &

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Kimmel, M. C., Ferguson, E. H., Zerwas, S., Bulik, C. M., & Meltzer, B. S. (2016).

Obstetric and gynecologic problems associated with eating disorders. International Journal of

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