Fertility and Pregnancy in Eating Disorders

Fertility and Pregnancy in Eating Disorders

by Mittsi Crossman, MD, CEDS

Fertility and pregnancy in eating disorders are important topics, as eating disorders affect many young women. The purpose of this article is to provide an overview of these areas as well as recommendations for further reading. Consider the following vignettes:

Vignette 1

A young woman with irregular menses and anorexia nervosa (AN), restricting type, since her early teens struggles to get pregnant. After consultations with endocrinologists and fertility specialists, and continued work with her treatment team, which specializes in eating disorders, she slowly weight restores and eventually conceives. During pregnancy, she…

1. continues to gain weight appropriately, learns to integrate regular eating, finds normalization in meals and hunger and fullness cues, and carries to full term without complications.
2. struggles to gain the weight needed. She also has increasing anxiety, depression, and worsening body image. Her pregnancy, labor, and delivery are significant for a healthy-but-small-for-gestational-age baby.
3. believes that the weight she gained while trying to become pregnant should be adequate for the duration of her pregnancy. Eating disorder symptoms increase as she struggles to prevent additional weight gain. She experiences a fall from a spontaneous hip fracture early in her third trimester, which induces preterm labor. Her premature baby requires treatment in the neonatal intensive care unit (NICU).

Vignette 2

A young woman with a history of nicotine and alcohol use disorder, as well as bulimia nervosa (BN) with irregular and infrequent periods, becomes pregnant. She stops smoking and drinking alcohol, and significantly minimizes purging. She struggles with urges to binge. During the first trimester, she experiences significant morning sickness (hyperemesis gravidarum), which she finds confusing and triggering. She strengthens her skills to tolerate the physical discomfort and nausea more easily than she did with BN because she accepts these physical symptoms as “normal” in pregnancy. During checkups with her obstetrician, she has blinded weigh-ins. Her previous fear of weight gain if she stopped purging is obscured by the expected weight gain of pregnancy. With this neutralization of weight-gain fears, she is able to put her efforts into stopping purging and, eventually, bingeing. After delivery of her baby, she…

1. continues to maintain the skills that she accomplished during pregnancy.
2. finds that without the protective factor of the baby in utero, she is more susceptible to engaging in bingeing and purging again.
3. continues to refrain from bingeing and purging but begins to restrict, especially with the justifications of stress and the busy life of new motherhood.

Vignette 3

A young woman, a self-proclaimed “exercise addict,” fad-dieter, and emotional overeater, prone to depression and anxiety, finds herself unexpectedly pregnant with her long-term partner. During her first trimester, she continues to exercise at pre-pregnancy levels and is pleased to find that her weight remains relatively stable. As she enters her second trimester, her exercise tolerance diminishes and her body begins to change more visibly, yet she fully embraces pregnancy as she shares her exciting news with family and friends. During this time, she relishes her food cravings and gives in to them, trusting that her baby must “need” the foods that she usually wouldn’t eat. As pregnancy continues…

1. she continues to struggle with cravings, overeating, and binge eating, as well as low-grade depression and anxiety.
2. she gains weight in excess of her expectations as her tolerance for exercise diminishes and she indulges in foods that she had normally considered forbidden. She doesn’t see the point in “dieting” while pregnant and develops symptoms consistent with binge eating disorder (BED). She has complications during labor and requires a Cesarean section.
3. she develops gestational diabetes and begins working with a dietitian. She learns about intuitive eating and better understands her eating behaviors. She remains nourished in pregnancy, and overeating diminishes. She delivers a healthy baby without complications.

FERTILITY in Eating Disorders

Hormones

Eating disorders occur more frequently in women than in men and frequently coincide with puberty, when sex hormone levels increase. Within a menstrual cycle, food intake and meal size can fluctuate cyclically. During pregnancy, estradiol and progesterone increase until childbirth and then decrease postpartum; however, eating disorder symptoms don’t seem to correlate with hormone increases. At menopause, there are decreases in estradiol and progesterone. Menopause is associated with increased body weight, fat accumulation, and food intake, and hormone replacement with estradiol reverses these postmenopausal effects (the risks and benefits of hormone replacement therapy should be discussed with one’s doctor). See Box 1 for more details about the sex hormones.

Nutrition and Menstruation

Nutritional deficits found in eating disorders cause decreased production of hormones, including the sex hormones estradiol and progesterone, which regulate menstrual cycles, ovulation, and pregnancy. With malnutrition, the primitive hardwired brain registers famine or extreme stress, and the body downregulates hormone production to preserve available resources for the most vital life-maintenance functions. We are still learning the precise biological mechanisms as to how hormone production is regulated, but it may include leptin in individuals with AN or BN, and insulin and testosterone in individuals with BED.^1,2,3

About two-thirds of women with AN and around half of women with BN report amenorrhea (no menstruation for three months or longer) or irregular menstruation. Half of these women will menstruate within the first three months of reaching their target weight.⁴ However, despite weight restoration, decreased leptin levels are associated with continued amenorrhea, and higher leptin levels with resumption of menses.^3,5 Leptin administration is being investigated for a potential role in hormone normalization and menstruation.⁶ In BN, up to half of normal-weight women can have menstrual abnormalities. Chaotic eating behaviors such as bingeing, purging, dietary restriction, and overexercise in normal-weight women are associated with hormonal insufficiencies and menstrual problems.⁴ Pelvic ultrasound can visualize the ovaries to evaluate continued menstrual abnormalities despite weight restoration and normal hormone levels.

For the woman with an eating disorder and regular menses, sometimes she, and sometimes even clinicians, can minimize the eating disorder because she still menstruates. Even more common, a woman taking an oral contraceptive pill (OCP) assumes menstruation is preserved, but it is unknown if she actually would be able to menstruate without the OCP’s hormonal help. While OCPs are commonly prescribed to regulate mood symptoms or for polycystic ovarian syndrome (PCOS), they can unfortunately be erroneously prescribed to preserve bone density in women with irregular periods/amenorrhea and an eating disorder. Studies show that OCPs do not protect bone density⁷ and can distract from the nutritional rehabilitation needed to treat amenorrhea.

Menstruation and pubertal body changes heralding developing sexuality can have many psychodynamic meanings. Issues related to sexuality, sexual trauma, motherhood, and “womanliness” are important to explore.

Fertility

Fertility problems found in women with eating disorders are usually due to menstrual dysfunction from hormonal abnormalities. Fertility problems also occur with PCOS, which is often comorbid with BN and BED.⁸ In the Avon Longitudinal Study of Parents and Children, an epidemiological study of more than 14,000 mothers in the U.K., women with AN or BN were more likely to take longer than six months to conceive, to have seen a doctor for fertility problems, and to require fertility treatments.⁹ Twenty percent of study participants from a private infertility center reported a past or current eating disorder.¹⁰ However, other studies have found no differences in pregnancy or infertility rates in women with AN.¹¹

Unplanned pregnancies, a fertility issue on the other end of the spectrum, are also found in women with eating disorders. Ovulation can still occur despite irregular or no menses. Disordered eating was associated with more sexual partners and less condom use in an epidemiological study of nearly 6,000 18- to 26-year-old women.¹² Traits of impulsivity are more common in BN and BED than in AN, which could contribute to accidental pregnancies. Also, women with amenorrhea may assume that they aren’t at risk for pregnancy and forgo contraception, resulting in an unexpected pregnancy.

PREGNANCY

Old Challenges Presenting Anew

For a woman with a previous or current eating disorder, pregnancy can multiply her struggles around food and her body, and those struggles are punctuated regularly at appointments with obstetricians. Psychodynamically, issues related to sexuality, motherhood, and “womanliness” abound. Just as individual reactions to menstruation and pubertal changes are varied, some women accept the breasts and curves accompanying pregnancy and impending motherhood, while others may be horrified by these body changes. In pregnancy, there are novel food, weight, body size, and body image triggers that can be of particular concern. There are “forbidden foods” that are unsafe in pregnancy and body changes that require a change in wardrobe. The average recommended weight gain during pregnancy is 25 to 35 pounds. For a woman with a BMI under 18.5, the recommended weight gain is 28 to 40 pounds.¹³ For those with an eating disorder, these weight recommendations can seem insurmountable.

Stay Vigilant During Pregnancy

Just as menstruation can result in relief or disappointment, a positive pregnancy test may also result in joy, fear, or a multitude of layered feelings. Both the presence of regular menses and/or pregnancy could be perceived as a sign to a woman with an eating disorder that she is “recovered” when, in fact, menstruation and ovulation can present erratically and should not be used as the indicator that the eating disorder has remitted.

Pregnancy or the Eating Disorder?

Pregnancy-related nausea, vomiting, changes in appetite, and focus on weight gain can be complicated for a woman with an eating disorder. Morning sickness symptoms such as nausea and lack of appetite can mimic and trigger eating disorder urges and behaviors. The woman with an eating disorder might be confused as to what is pregnancy-related and what is the sometimes insidious return of the eating disorder.

Cravings

Some women find that pregnancy presents an exception where rules can be broken with indulgence in “forbidden foods.” Contrary to possible hypotheses of nutritional or hormonal causes, food cravings seem to follow an approach-avoidance model. This model describes that innate taste preferences for high-calorie, sweet, and fatty foods conflict with cultural norms of the “thin ideal.” Pregnancy is a culturally sanctioned permissive period that allows the expectant mother to eat previously avoided foods, which can be experienced as food cravings.¹⁴

What Happens to the Eating Disorder During Pregnancy?

Rates of eating disorders in pregnancy have been studied within the Norwegian Mother and Child Cohort Study (MoBa), a population-based study of 46,000 pregnant women. About one-third of women with a previous eating disorder had remission in the first half of pregnancy. The proportion of AN found during pregnancy was less than in the general population, indicating that fewer women with AN might become pregnant compared with women with other eating disorders.^15,16 For women in recovery from AN, 33 percent had a relapse during pregnancy.¹⁷ Symptoms of BN tended to remit or decrease, but there tended to be more body dissatisfaction.¹⁸ In BED, about one-third of women improve during the first half of pregnancy, but there are increased rates of new-onset binge eating.¹⁹ Those whose BED did not remit were more likely to have pregnancy-related weight-gain worries. Higher levels of anxiety and depression, and low self-esteem and life satisfaction have been found to correlate with continued symptoms of BN and BED during pregnancy.²⁰

Pregnancy, Labor, and Delivery Risks

Eating disorders in pregnancy have been associated with a multitude of obstetric complications: BN and BED have been associated with increased risks of miscarriage; hyperemesis gravidarum and C-sections in women with BN, purging type; and induced abortion with a lifetime history of BN.^21,22,23 Babies may be born with low birth weight to women with AN and BN, or higher birth weight to women with BED.²⁴ For women with a lifetime history of AN, their babies have an increased risk of being born small for gestational age.²² Findings vary and may be connected to the sample size as well as the severity of the eating disorder in the population studied (clinical study versus epidemiologic sample).¹¹ In a large population-based study of subthreshold eating disorder symptoms in 1,470 women in Hong Kong, levels of disordered eating during pregnancy were associated with birth-weight abnormalities and one-minute Apgar scores.²⁵ Mothers of newborns in the NICU had gained less weight during pregnancy and had more disordered eating attitudes.²⁶ Babies born to women with eating disorders are more likely to develop feeding problems and to have nonorganic failure to thrive.²⁷

Future Generations

The fetal programming hypothesis proposes that in utero conditions can determine susceptibility to diseases later in life. In the large MoBa study, prenatal and perinatal factors were examined, and mothers who weighed more at their own birth were more likely to develop BED in their life, while those who weighed less at birth were more likely to develop AN.²⁸This is the first study of its kind, and future research will be needed to better understand the role that the fetal programming hypothesis might have in eating disorders.

POSTPARTUM

The postpartum time period holds unique risks as the new mother experiences multiple new challenges:

• Mothering a new baby and navigating the impact on the family unit. Self-care and sleep are often sacrificed, and a new mother may find herself vulnerable.
• Living in a body at a higher weight. Many mothers find it incredibly difficult to accept that once the baby is delivered, they still hold excess weight above their pre-pregnancy weight. Some find a challenge in expediting the weight loss and frequently call on their eating disorder as the means to that end.
• Lack of the protective factor of the growing baby in utero also opens the door for self-destructive behaviors to re-emerge.

Research studies have found a resurgence of both AN and BN back to pre-pregnancy levels in the postpartum period.^29,30However, studies have found more optimistic results, where women with BN continued to maintain a significant reduction in their symptoms at nine months postpartum.²⁹ Studies of breast-feeding rates are mixed, with possible early cessation of breast-feeding in women with AN. More severe postpartum depression has been found in women with BN, BED, perfectionism, or history of physical or sexual trauma.¹¹

THE PREGNANT THERAPIST

The pregnant therapist who works with individuals with eating disorders can present a unique twist within the treatment relationship. General literature about pregnant therapists identifies increases in themes of envy, competition, rejection and abandonment, deprivation, dependence and impending loss, sexual conflicts, fertility concerns, past pregnancies/abortions, familial issues (e.g., exclusion and sibling rivalry), and, potentially, identification for those patients with children.³¹ In working with individuals with eating disorders, oftentimes the therapist and patient are similarly aged women, which can intensify transference feelings.³² The patient’s reactions may become more pronounced when learning that the therapist is pregnant, during final appointments before maternity leave, during the leave, and when the therapist returns to the office, as the patient holds an awareness of the therapist’s personal life and demands outside the office.³¹For the woman with an eating disorder, the therapist’s body and weight changes can trigger strong reactions. This time period can also be associated with increased sexual promiscuity and pregnancies for the patient of the pregnant therapist.³²

For the pregnant therapist, guilt is a primary feeling that has been identified: about holding a secret prior to disclosing pregnancy, at having to “abandon” either patients or the baby, and especially when working with those who are unhappily single, having fertility problems, etc.³² Other feelings that the pregnant therapist may navigate are excitement and anticipation, preoccupation with herself, and possibly less empathy and more irritability than previously. The pregnant therapist’s new tasks include juggling her own identity issues (such as first-time motherhood), her career and professional goals, and her availability to her patients both concretely (e.g., maternity leave) as well as emotionally.³¹ The therapist’s pregnancy can provide an opportunity to explore feelings about fertility and maternity. For those therapists with a previous eating disorder (approximately a quarter to half of the therapists who work with individuals with eating disorders had a previous eating disorder), supervision and/or therapy may be especially crucial during this time period.³⁴

BOX 1: SEX HORMONE OVERVIEW^4,35

What Are Hormones?

A hormone is a chemical substance that acts as a messenger. It is secreted from one organ into the bloodstream to send a message to another organ and regulate some particular action.

Estradiol (an estrogen hormone)

• Estradiol is an estrogen, the main sex hormone. Estradiol is synthesized from cholesterol mainly in the ovaries (and the placenta during pregnancy). Estrogen receptors are in the ovaries, breasts, and uterus.
• Estradiol is responsible for the secondary sexual changes of puberty: breast development and uterine development to allow for menstruation. It has roles in bone storage, fat storage, and sexual desire (along with testosterone).
• Estradiol is released by the developing egg follicle and, when levels are high enough, signals ovulation. Levels peak at ovulation.
• Estrogen plays an overall role in decreasing food intake.
• Rats have decreased food intake between ovulation and menstruation, the part of the menstrual cycle when estrogen levels are highest.
• Estradiol also affects the response to cholecystokinin (a peptide that signals satiety) and ghrelin (a peptide that regulates eating).
• An animal study suggests that binge eating disrupts the ability of estrogen to regulate and decrease food intake.
• Studies have found lower estradiol in women with bulimia and binge eating.

Progesterone

• Progesterone is a steroid hormone that works with estrogen for many of its functions. Similar to estradiol, it is synthesized from cholesterol, mainly in the ovaries.
• Progesterone prepares the uterus for potential implantation and has key roles in supporting the changes of pregnancy.
• After ovulation, the empty egg follicle signals the release of progesterone. Between ovulation and menstruation, estrogen is at its height; then it decreases while progesterone is dramatically increasing to its height. Progesterone, in the presence of estrogen, blocks estrogen’s normal food decreasing effects, resulting in overall increased food intake during the second half of the menstrual cycle. In the absence of estrogen, progesterone alone does not cause increased food intake.
• Body dissatisfaction (i.e., dissatisfaction with the size and shape of one’s body) and drive for thinness (i.e., preoccupation with weight, dieting, and pursuit of thinness) were found to be associated with higher progesterone and lower estradiol concentrations in a community sample.
• In a study of individuals with bulimia nervosa, estradiol and progesterone levels accounted for 24 percent of the variance in binge eating, after mood effects were controlled.
• Binge eating and disordered eating have been associated with higher progesterone levels.

Testosterone

• Testosterone is an anabolic steroid hormone that is also synthesized from cholesterol and is produced by the adrenal glands, ovaries, and placenta in pregnant women.
• Testosterone is involved in the development of hair, acne, and sweat gland changes during puberty and has a role in sexual behavior. Levels fluctuate during the menstrual cycle.
• Less is known about testosterone in women. Testosterone is known to stimulate appetite and may increase the number of meals (versus the size of meals).
• Psychological symptoms of impulsivity, irritability, and aggressiveness and polycystic ovary syndrome are associated with elevated testosterone levels.
• Testosterone levels may be elevated in bulimia and decreased in anorexia. 

CONCLUSION

Hopefully, this article has provided food for thought in working with women with eating disorders. The book suggestions are helpful resources for both the patient and clinicians working with this population. The vignettes at the beginning of this article represent possible outcomes for any given patient. With awareness and support for fertility and pregnancy issues that may arise in women with eating disorders, my hope is that each patient’s outcome is the best possible.

About the author:

Dr. Mittsi Crossman attended college at Yale University and earned a Bachelor of Arts with Honors in Psychology. During her undergraduate education, she worked with research teams at the Yale Child Study Center and Yale Conduct Clinic. She attended medical school in her home state of Florida at the University of South Florida College of Medicine in Tampa. She returned to the northeast for residency in General Psychiatry at New York University School of Medicine, and worked at the reputable Bellevue Hospital.  She continued at NYU for a fellowship in Addiction Psychiatry and after graduation, held a position as the Unit Chief of the Dual Diagnosis Inpatient Unit at Bellevue Hospital. Dr. Crossman is double board certified by the American Board of Psychiatry and Neurology in both General Psychiatry and Addiction Psychiatry.  Her interest in the overlap of addictions and eating disorders prompted pursuit of further training as a Certified Eating Disorder Specialist (CEDS). She has expertise in trauma, addictions, eating disorders, and personality disorders and has been intensively trained in Dialectical Behavior Therapy. Dr. Crossman is a licensed prescriber of buprenorphine, and has additional interests in reproductive psychiatry and women’s health issues. She has a private practice in New York City and is President of the New York Chapter of the International Association of Eating Disorder Professionals (iaedp).

FURTHER READING (for patients and clinicians):

Cabrera, D., & Wierenga, E. T. (2013). Mom in the Mirror: Body Image, Beauty, and Life After Pregnancy. Rowman & Littlefield Publishers.

This book has a unique focus on the psychosocial aspects unique to girls and women that can contribute to the development of eating disorders and affect the experiences of pregnancy and motherhood. Each chapter ends with “Reflection” and “Tools” sections that include therapeutic questions and skills to practice. The authors also each give examples from their lives throughout the book.

Contains this list (p. 41) which is helpful for women to understand how pregnancy weight is distributed:

• Baby: 7 to 8 pounds
• Larger breasts: 2 pounds
• Larger uterus: 2 pounds
• Placenta: 1.5 pounds
• Amniotic fluid: 2 pounds
• Increased blood volume: 3 to 4 pounds
• Increased fluid volume: 3 to 4 pounds
• Fat stores: 6 to 8 pounds

Chapters 9 to 15 of the book include more on mothering, identity, and a woman’s life as a mother:

Chapter 9 – Like Mother, Like Daughter: Your Personal Legacy

Chapter 10 – Being the Mirror: How to Inspire Beauty in Our Children

Chapter 11 – The Anxious Mother: Using Food, Exercise, or Work as an Escape

Chapter 12 – Friendly Competition: Your Relationship with Other Women

Chapter 13 – As They Grow: Your Changing Role as a Mom and a Woman

Chapter 14 – Getting Help: Hope and a Cure

Chapter 15 – Identity Crisis: Discovering True Self-Worth 

Daigle, K. B. (2019). The Clinical Guide to Fertility, Motherhood, and Eating Disorders: From Shame to Self-Acceptance. Routledge.

This book is a wonderful compilation of research for clinicians and the educated patient. It provides a comprehensive overview of the medical and psychological issues around fertility, infertility treatments, and even male infertility. Daigle delves into topics of miscarriage, polycystic ovarian syndrome, birth trauma, “survivor’s guilt” (especially in those with previous infertility), postpartum attachment, and postpartum mood disorders. It includes the chapter “What the Medical Community Needs to Know to Support Clients,” which addresses myths around body size, weight, and health. This book will enlighten both the clinician and individuals who are undergoing fertility evaluation and treatment. Clinical Tools and Case Studies are especially useful for clinicians.

McCabe, L. S. (2019). The Recovery Mama Guide to Your Eating Disorder Recovery in Pregnancy and Postpartum. Jessica Kingsley Publishers.

“This is a book that encourages you to find and cultivate a fiercely compassionate mothering voice inside yourself as you learn to parent a newborn, outside yourself…to help [you] through the rite of passage of motherhood and eating disorder recovery.” (pp. 27-28)

Includes chapters on body image (during and after pregnancy); postpartum depression and perinatal mood disorders; sleep; food (during pregnancy and when raising children), labor, delivery, and postpartum; breast-feeding (or not); distress tolerance; spirituality, recovery, and motherhood (including mindfulness and meditation exercises); stay at home vs. work (discusses guilt, choices, “killing the myth of supermom”); and advanced maternal age (older than 35 years old) pregnancy. Includes many quotes from other women. Chapter 5 considers birth plans and provides an overview of medical and nonmedical interventions during labor and delivery.

Good Enough Mama Recovery Pledge (pp. 174-177):

• I will not measure my worth on the scale.
• I will listen to my body’s hunger and satiety cues.
• I will not try to do it alone. I will reach out for, and say yes to, support.
• I will sleep when I can, in the way I can.
• I will treat myself with as much kindness, respect, tenderness, and fierce, protective care as I do my newborn.
• If I make a plan, I will be perfectly imperfect, implementing it.
• I will lower my expectations.

The journey of motherhood can be difficult, easy, effortful, intuitive, and counterintuitive, just like recovery. Motherhood takes practice, support, endurance, surrender, and fierceness. I commit to staying on the journey. I commit to fierce compassion. I commit to being Good Enough.

Mysko, C., & Amadeï, M. (2009). Does This Pregnancy Make Me Look Fat?: The Essential Guide to Loving Your Body Before and After Baby. Health Communications, Inc.

“This book will serve up some practical tips on how to love and respect your body through amazing, awe-inspiring, and, yes, sometimes downright shocking changes of pregnancy and motherhood.” Includes quotes from other women as well as the author’s candid experiences.

Chapter 1 – Body image, body confidence

Chapter 2 – Celebrity pregnancy coverage and society’s pressure

Chapter 3 – Sex, relationships during pregnancy and postpartum

Chapter 4 – Fashion, beauty, self-care, preparing for a changing body size

Chapter 5 – Eating disorders/disordered eating, impact of weight changes

Chapter 6 – Breast-feeding

Chapter 7 – How to deal with others’ comments and intrusions while pregnant

Chapter 8 – “Beauty-baby balance,” parenting, and intergenerational transmission of food relationships and eating disorders

About the author:

Dr. Mittsi Crossman attended college at Yale University and earned a Bachelor of Arts with Honors in Psychology. During her undergraduate education, she worked with research teams at the Yale Child Study Center and Yale Conduct Clinic. She attended medical school in her home state of Florida at the University of South Florida College of Medicine in Tampa. She returned to the northeast for residency in General Psychiatry at New York University School of Medicine, and worked at the reputable Bellevue Hospital.  She continued at NYU for a fellowship in Addiction Psychiatry and after graduation, held a position as the Unit Chief of the Dual Diagnosis Inpatient Unit at Bellevue Hospital. Dr. Crossman is double board certified by the American Board of Psychiatry and Neurology in both General Psychiatry and Addiction Psychiatry. Her interest in the overlap of addictions and eating disorders prompted pursuit of further training as a Certified Eating Disorder Specialist (CEDS). She has expertise in trauma, addictions, eating disorders, and personality disorders and has been intensively trained in Dialectical Behavior Therapy. Dr. Crossman is a licensed prescriber of buprenorphine, and has additional interests in reproductive psychiatry and women’s health issues. She has a private practice in New York City and is President of the New York Chapter of the International Association of Eating Disorder Professionals (iaedp). 

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21. Eik‐Nes, 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.
22. Torgersen, L., Von Holle, A., Reichborn‐Kjennerud, T., Berg, C. K., Hamer, R., Sullivan, P., & Bulik, C. M. (2008). Nausea and vomiting of pregnancy in women with bulimia nervosa and eating disorders not otherwise specified. International Journal of Eating Disorders, 41(8), 722-727.
23. Linna, M. S., Raevuori, A., Haukka, J., Suvisaari, J. M., Suokas, J. T., & Gissler, M. (2014). Pregnancy, obstetric, and perinatal health outcomes in eating disorders. American Journal of Obstetrics and Gynecology, 211(4), 392.e1-392.e8.
24. Chan, C. Y., Lee, A. M., Koh, Y. W., Lam, S. K., Lee, C. P., Leung, K. Y., & Tang, C. S. K. (2019). Course, risk factors, and adverse outcomes of disordered eating in pregnancy. International Journal of Eating Disorders, 52(6), 652-658.
25. Czech-Szczapa, B., Szczapa, T., Merritt, T. A., Wysocki, J., Gadzinowski, J., Ptaszyński, T., & Drews, K. (2015). Disordered eating attitudes during pregnancy in mothers of newborns requiring Neonatal Intensive Care Unit admission: a case control study. The Journal of Maternal-Fetal & Neonatal Medicine, 28(14), 1711-1715.
26. Whelan, E., & Cooper, P. J. (2000). The association between childhood feeding problems and maternal eating disorder: a community study. Psychological Medicine, 30(1), 69-77.
27. Watson, H. J., Diemer, E. W., Zerwas, S., Gustavson, K., Knudsen, G. P., Torgersen, L., Reichborn‐Kjennerud, T., & Bulik, C. M. (2019). Prenatal and perinatal risk factors for eating disorders in women: a population cohort study. International Journal of Eating Disorders, 52(6), 643-651.
28. Blais, M. A., Becker, A. E., Burwell, R. A., Flores, A. T., Nussbaum, K. M., Greenwood, D. N., Ekeblad, E. R., & Herzog, D. B. (2000). Pregnancy: outcome and impact on symptomatology in a cohort of eating‐disordered women. International Journal of Eating Disorders, 27(2), 140-149.
29. Crow, S. J., Agras, W. S., Crosby, R., Halmi, K., & Mitchell, J. E. (2008). Eating disorder symptoms in pregnancy: a prospective study. International Journal of Eating Disorders, 41(3), 277-279.
30. Tinsley, J. A., & Mellman, L. A. (2003). Patient reactions to a psychiatrist’s pregnancy. American Journal of Psychiatry, 160(1), 27-31.
31. Katzman, M. A. (1993). The pregnant therapist and the eating disordered woman: the challenge of fertility: Eating Disorders, 1(1), 17-30.
32. Baum, N. (2006). Pregnant field students’ guilt. Journal of Social Work Education, 42(3), 561-578.
33. De Vos, J. A., Netten, C., & Noordenbos, G. (2016). Recovered eating disorder therapists using their experiential knowledge in therapy: a qualitative examination of the therapists’ and the patients’ view. Eating Disorders, 24(3), 207-223.
34. Baker, J. H., Girdler, S. S., & Bulik, C. M. (2012). The role of reproductive hormones in the development and maintenance of eating disorders. Expert Review of Obstetrics & Gynecology, 7(6), 573-583.

*A comprehensive review of obstetric and gynecologic problems associated with eating disorders for further information.

Books about the pregnant therapist:

Fallon, A. E., & Brabender, V. (2003). Awaiting the Therapist’s Baby: A Guide for Expectant Parent-Practitioners. Routledge.

Fenster, S., Phillips, S. B., & Rapoport, E. R. (1986). The Therapist’s Pregnancy: Intrusion in the Analytic Space. Analytic Press, Inc.

Figures from: Vink, A. S., Clur, S. A. B., Wilde, A. A., & Blom, N. A. (2018). Effect of age and gender on the QTc-interval in healthy individuals and patients with long-QT syndrome. Trends in Cardiovascular Medicine, 28(1), 64-75.