Q&A: Study introduces comprehensive guidelines for managing anorexia nervosa in pregnancy
Click Here to Manage Email Alerts
Researchers developed the first comprehensive set of guidelines for managing anorexia nervosa in pregnancy through a systematic review.
The recommendations, which were published in The Lancet Psychiatry, include monitoring and careful management of nutritional intake.
Healio spoke with Megan Galbally, PhD, professor and director of the Centre for Women’s and Children’s Mental Health at Monash University School of Clinical Sciences and the Monash Medical Centre in Australia, to learn more about the team’s recommendations.
Healio: Why is it important to manage anorexia in pregnancy?
Galbally: Anorexia nervosa in pregnancy, if left untreated, can be associated with serious impacts on both maternal and fetal health outcomes. While it is challenging to ensure pregnant women with anorexia nervosa get all the care they require for optimal outcomes, it also represents an opportunity to ensure a good start to parenthood and also a healthy start to life for their baby. Anorexia in pregnancy has been an overlooked area of clinical care, as many believed only women in remission become pregnant. It is clear that is not the case. I have worked in perinatal mental health within tertiary maternity services for 20 years and previously only ever saw an occasional woman with current anorexia nervosa, whereas in the last 3 to 4 years I have seen a steep increase in women presenting in pregnancy with very low BMI and current anorexia nervosa requiring treatment in pregnancy.
Healio: Why have there not been guidelines on managing it?
Galbally: It is likely there are no guidelines because this is a lower prevalence mental health condition in pregnancy — impacting around 1 in 200 women — compared with more common mental health conditions in pregnancy such as depression and anxiety that impact 1 in 5 women. As far as I am aware, there are no comprehensive guidelines for managing anorexia nervosa in pregnancy. There is no mention of anorexia nervosa in the Australian Pregnancy Care Guidelines or the Australian Perinatal Mental Health Guideline. While there is a brief mention in U.K. National Institute for Health and Care Excellence antenatal and postnatal mental health guideline, there is no comprehensive guidance; these guidelines refer back to the recommendations for adult management of anorexia nervosa. Recommendations developed for managing anorexia in nonpregnant adults require alterations and adaptations — as well as consideration of additional areas of care such as monitoring fetal growth and development — when managing anorexia nervosa in pregnancy.
Healio: How did you develop these recommendations?
Galbally: This systematic and state-of-the-art review and subsequent recommendations for care came from our collective experience of managing increasing numbers of women presenting with moderate to severe anorexia nervosa in pregnancy. It led us to develop local hospital guidelines and develop a model of care. In doing this, we identified a gap in any form of comprehensive guidance across quite complex areas of clinical work, including managing the physical comorbidities of anorexia nervosa in pregnancy when there are other significant physiological changes and challenges; monitoring fetal growth and managing pregnancy complications; managing nutritional rehabilitation when it was frequently required; and adapting care from adult recommendations to pregnancy. When we realized there was no adequate guidance, we confirmed this by undertaking a systematic review and a state-of-the-art review. In the review, each of the discipline co-author leads — which included maternal-fetal medicine obstetrics, obstetric medicine, dietetics and mental health such as eating disorders and perinatal mental health — reviewed relevant research and clinical recommendations in their aspect of care. We also involved a community representative as a co-author to bring that important perspective when developing clinical recommendations.
Healio: What guidelines do you outline?
Galbally: We provide information and recommendations on assessment and monitoring across pregnancy for anorexia nervosa; general health management; management of nutrition, including where inpatient care is required; and assessment and management of mental health, including pharmacological and psychological interventions. We also provide information on early parenting and postpartum care.
Healio: What work still needs to be done to properly manage anorexia in pregnancy?
Galbally: We need comprehensive multidisciplinary models of care to be implemented and evaluated for outcomes for women and infants. There are considerable risks for women and their unborn child in managing moderate to severe anorexia nervosa in pregnancy, and while we have provided some recommendations, it still requires considerable adaptation to individual presentations and circumstances. This is best done with a maternity service, such as maternal-fetal medicine teams, that manages other high-risk pregnancies. While this area of clinical care can be new to high-risk pregnancy teams, it is important that high-risk pregnancy services and mental health work together to improve care for women with anorexia in pregnancy.
Healio: Is there anything else you would like to add?
Galbally: When managing women with anorexia nervosa, there are challenges and a need for caution and comprehensive multidisciplinary care from those expert in high-risk pregnancies. However, there are also great opportunities to support women in their mental health and give them and their babies a healthier start to parenthood and life, respectively. For instance, reducing the likelihood of prematurity or low birth weight that can be associated with anorexia in pregnancy has extraordinary benefits for a child’s lifelong health and well-being.