6. Physical examination
   1. Assess body mass index (BMI).
      • Calculated by the weight in kilograms divided by the height in meters squared
      • Reference to calculate BMI: www.nhlbisupport.com/bmi
      • Refer to Table 1 below.
   2. Possible physical findings in an individual with an eating disorder
      • Oral mucosa damage
      • Tooth decay
      • Elevated blood urea nitrogen (BUN) and creatinine due to dehydration or low BUN and creatinine due to protein malnutrition
      • Metabolic alkalosis due to vomiting
      • Metabolic acidosis due to laxative use (also associated constipation, rectal bleeding, and edema)
      • Electrolyte imbalance such as low potassium, low magnesium
      • Muscle wasting
      • Hypotension
      • Bradycardia
      • Cold intolerance
      • Lanugo (soft, baby-like hair)
      • Abnormal electrocardiogram (EKG) (due to electrolyte abnormalities, impaired conduction due to cardiac muscle wasting)
      • Osteopenia or osteoporosis related to amenorrhea, high cortisol, smoking, poor nutrition. Bone density (dual energy x-ray absorptiometry [DEXA]) is indicated in anyone who has been amenorrheic for six months.
      • Russell's sign - scabs on the metacarpophalangeal joints (MCP) from using the fingers to induce vomiting
      • Hypercarotenemia - orange tinge to skin because of decreased hepatic clearance of carotene (of no clinical consequence)

7. Laboratory tests are of limited utility in making a diagnosis, but may be helpful to exclude other medical illness associated with weight loss. The initial laboratory evaluation for the patient with an eating disorder includes (Andersen & Berg, 2007):
   1. Complete blood count for anemia
   2. Electrolytes, BUN, and creatinine if the patient is dehydrated and/or purging is suspected.
   3. Other tests obtained depend upon the review of systems and the need to exclude other diagnoses.
   4. Baseline EKG to assess for QT prolongation or bradycardia

8. Abnormal laboratory values associated with eating disorders
   1. Hypokalemia
   2. Hypophosphatemia
   3. Hyponatremia
   4. Hypochloremia
   5. Elevated bicarbonate level
   6. Hypomagnesemia
   7. Increased urine specific gravity
   8. Alkaline urine (due to laxative abuse, diuretic abuse, or vomiting)
   9. Ketonuria
   10. Leukopenia
   11. Thrombocytopenia
   12. Normochromic, normocytic anemia
   13. Increased liver function tests (LFTs)
   14. Increased salivary amylase
   15. Hyperaldosterone
   16. Decreased thyroxine (T4) levels, high reverse triiodothyronine (rT3), normal thyroid stimulating hormone (TSH) level, although thyroid tests may be altered by physiologic changes in pregnancy. For instance, hyperthyroidism may commonly be detected during an episode of hyperemesis gravidarum, and will usually resolve by 20 weeks of gestation without treatment.
   17. Hypercortisolemia
   18. Decreased erythrocyte sedimentation rate (ESR)
   19. Elevated serum cholesterol

9. Associated complications co-occurring with eating disorders in pregnancy (Andersen & Berg, 2007; Franko et al., 2001; Sollid et al., 2004)
   1. Inadequate or excessive weight gain
   2. Hyperemesis gravidarum
   3. Hypotension (in anorexia) or hypertension (in bulimia)
   4. Syncope/presyncope from cardiac arrhythmias and electrolyte disturbances
   5. Anemia (in anorexia)
   6. Pregnancy termination (spontaneous or therapeutic)
   7. Small for term infant
   8. Stillbirth
   9. Breech pregnancy
   10. Pre-eclampsia
   11. Cesarean section
   12. Post-episiotomy suture tearing
   13. Vaginal bleeding
   14. Increased rate of perinatal difficulties
   15. Postpartum depression risk
   16. Cardiac changes (Sollid et al., 2004)
       • Increased incidence of mitral valve prolapse may be attributed to enhanced detection with intravascular volume depletion as seen in the starving state.
       • Silent pericardial effusion in 20-30% of severely underweight patients detected by echocardiogram
       • Acquired Long QT Syndrome may be noted in this population. A prolonged QT interval warrants immediate attention in underweight, bradycardic patients because it is an independent marker for arrhythmia and sudden death.
       • There is an elevated risk of heart failure with Refeeding Syndrome.
   17. Refeeding Syndrome (occurs primarily in patients who are aggressively refed)
       • Assiduous supervision is necessary in refeeding patients with severe anorexia (<70% of expected body weight) or those who have lost a large amount of weight rapidly. They may experience complications which mostly emanate from severe hypophosphatemia.
       • Rare during pregnancy, but has been reported. May be exacerbated by the normal volume expansion during pregnancy (Franko et al., 2001)
       • May include cardiovascular collapse, rhabdomyolysis, delirium and seizures Cardiac failure may be the result of increased volume on the impaired heart. Thiamine should be given during refeeding to prevent Wernicke's encephalopathy due to thiamine deficiency.
       • Patients should be evaluated for edema, signs of congestive heart failure, and mental status changes. Vital signs and electrolytes, especially phosphorus, potassium, and magnesium should be closely monitored for the first five days, then every other day for several weeks afterward.

10. Potential risks to children of mothers with eating disorders (American Psychiatric Association, 2006; Andersen & Berg, 2007; Stewart, 1992; Kouba et al., 2005)
    1. Premature birth
    2. Perinatal mortality (six-fold increase)
    3. Cleft lip & cleft palate
    4. Epilepsy
    5. Developmental delays
    6. Abnormal growth
    7. Food fussiness and feeding difficulties
    8. Low birth weight (significant for mothers with anorexia nervosa due to low prepregnancy BMI) (Micali, Simonoff, & Treasure, 2007)
    9. Microcephaly
    10. Low APGAR scores

Management (See Table below)

Treatment Recommendations [American Psychiatric Association, 2006]

1. Ideally, obtain treatment for eating disorder prior to attempting to conceive. This improves fertility and decreases the risk for perinatal complications associated with active eating disorders.
2. Management of the pregnant women with a current or past eating disorder
   1. Factual management of weight gain issues
      • How are you feeling about your weight gain?
      • What is it like for you to be weighed at every visit?
      • How are you feeling about the physical changes in your body shape?
   2. Educate that the patient may have an increased risk for hyperemesis gravidarum and depression.
   3. Teach what the ideal weight gain is for the optimal growth and development of the fetus.
   4. Ask about the patient's preferences regarding weighing (some prefer not to look at the numbers on the scale). Weigh the patient in the same clothing each time with empty pockets and an empty bladder. Make note in chart regarding special attention to this portion of the exam.
   5. Co-manage the patient's care with a collaborative team of experts in eating disorders (nutritionists/mental health specialists).
3. Short term hospitalization may be considered for the patient with vital sign abnormalities, severe dehydration, cardiac arrhythmia, and critical electrolyte disturbances. Patients with persistent eating disorders who have failed to gain weight over time or demonstrate a decline on oral intake may also require hospitalization. If they have failed intensive outpatient therapy, consideration should be given to inpatient supervision, enteral tube feedings, or parenteral nutrition, with psychiatric and nutrition consults.
4. The patient with inadequate weight gain and lagging fundal height should receive an ultrasound for fetal growth assessment. If growth restriction is detected, antenatal surveillance should be initiated.
5. Patients with histories of depression and/or obsessive compulsive disorder (OCD) who are taking antidepressant and anti-OCD medications should be counseled on the benefits of continuing medications (considerable) vs. risk to fetus (relatively low rates for selective serotonin reuptake inhibitors). Consultation with a psychiatrist with expertise in women's mental health should be sought to discuss the latest evidence weighing the risks versus benefits of the various available psychiatric medications.

Table: Evaluation and Treatment Suggestions for Physical Complications of Eating Disorders**

**Any pregnant patient with the diagnosis of an eating disorder is optimally treated on a continual basis with a multidisciplinary team, including an obstetrician, mental health professional, and dietician. Treating this disorder (including weight gain in the underweight patient) and any other co-morbid psychiatric conditions is paramount. More specific treatments for complicating physical conditions are listed here.

References open in a new window

Electronic copies: Available from the University of Arkansas for Medical Sciences, ANGELS (Antenatal & Neonatal Guidelines, Education and Learning System) Web site.

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