* Inform your safe network (health care provider, spouse, and friends) of your eating disorder and the increased risk of postpartum depression; ask them to be available after the birth.

* Contact a lactation consultant to help with early breastfeeding.

* Find a nutritionist who can help work with you to stay healthy, manage your weight, and invest in your baby.

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Eating Disorders during Pregnancy Section 38.2 Pica "Pica," 2009 A.D.A.M., Inc. Reprinted with permission.

Definition Pica is a pattern of eating non-food materials (such as dirt or paper).

Causes Pica is seen more in young children than adults. Between 10 and 32% of children ages 16 have these behaviors.

Pica can occur during pregnancy. In some cases, a lack of certain nutrients, such as iron deficiency anemia and zinc deficiency, may trigger the unusual cravings. Pica may also occur in adults who crave a certain texture in their mouth.

Symptoms Children and adults with pica may eat: * animal feces; * clay; * dirt; * hairb.a.l.l.s; * ice; * paint; * sand.

This pattern of eating should last at least 1 month to fit the diagnosis of pica.

Exams and Tests There is no single test that confirms pica. However, because pica can occur in people who have lower-than-normal nutrient levels and 323 Pregnancy and Birth Sourcebook, Third Edition poor nutrition (malnutrition), the health care provider should test blood levels of iron and zinc.

Hemoglobin can also be checked to test for anemia. Lead levels should always be checked in children who may have eaten paint or objects covered in lead-paint dust. The health care provider should test for infection if the person has been eating contaminated soil or animal waste.

Treatment Treatment should first address any missing nutrients and other medical problems, such as lead exposure.

Treatment involves behavior and development, environmental, and family education approaches. Other successful treatments include a.s.sociating the pica behavior with bad consequences or punishment (mild aversion therapy) followed by positive reinforcement for eating the right foods.

Medications may help reduce the abnormal eating behavior, if pica occurs as part of a developmental disorder such as mental r.e.t.a.r.dation.

Outlook (Prognosis) Treatment success varies. In many cases, the disorder lasts several months, then disappears on its own. In some cases, it may continue into the teen years or adulthood, especially when it occurs with developmental disorders.

Possible Complications * bezoar * infection * intestinal obstruction * lead poisoning * malnutrition When to Contact a Medical Professional Call your health care provider if you notice that a child (or adult) often eats non-food materials.

Prevention There is no specific prevention. Getting enough nutrition may help.

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Chapter 39.

Overweight, Obesity, and Pregnancy Chapter Contents.Section 39.1-Pregnancy and the Overweight Woman ............ 326 Section 39.2-Obesity before Pregnancy Linked to Childhood Weight Problems ............................... 328 Section 39.3-Pregnancy after Weight-Loss Surgery .............. 330 325.

Pregnancy and Birth Sourcebook, Third Edition Section 39.1 Pregnancy and the Overweight Woman "Pregnancy and the Overweight Woman," 2008 March of Dimes Birth Defects Foundation. All rights reserved. For additional information, contact the March of Dimes at their website www.marchofdimes.com.

If a woman is overweight or obese before pregnancy, she faces special health risks. But she can take steps to protect her own health and the health of her baby. To find out if you are overweight or obese, you'll need to know your height and weight. You then can calculate your body ma.s.s index (BMI). BMI helps to determine if your weight is appropriate for your height.

Health Risks during Pregnancy for Overweight and Obese Women Women who have a high BMI are more likely to have high blood pressure and diabetes during pregnancy. They are also more likely to have problems in childbirth. Their babies may also have serious health problems.

Gestational hypertension (high blood pressure): Gestational hypertension happens when a pregnant woman has a sudden rise in blood pressure during the second half of her pregnancy. Health care providers can find this condition during regular blood pressure checks. Gestational hypertension happens when a pregnant woman has a sudden rise in blood pressure during the second half of her pregnancy. Health care providers can find this condition during regular blood pressure checks.

If a pregnant woman has high blood pressure, she may need medicine and more frequent checkups in the weeks before delivery. Gestational hypertension usually goes away after the baby is born. High blood pressure during pregnancy can be a sign of preeclampsia.

Preeclampsia and eclampsia: Preeclampsia is a potentially serious illness marked by high blood pressure and protein in the urine. Preeclampsia is a potentially serious illness marked by high blood pressure and protein in the urine.

If untreated, it can become a rare, life-threatening condition called eclampsia. Eclampsia can cause seizures and, in some cases, coma. Fortunately, eclampsia is rare in women who receive regular prenatal care.

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Overweight, Obesity, and Pregnancy After delivery, a woman with preeclampsia may need to stay in the hospital longer than usual. This is done for the safety of both her and her baby.

Pregnant women should be on the lookout for these warning signs: * Headaches * Vision trouble * Quick weight gain * Swelling of the hands and face * Pain in the right upper belly Gestational diabetes: Gestational diabetes occurs when a pregnant woman's system has trouble controlling the level of glucose (sugar) in her body. Glucose is the body's main source of fuel. If your glucose levels are too high, serious health problems can arise for you and your baby. Gestational diabetes occurs when a pregnant woman's system has trouble controlling the level of glucose (sugar) in her body. Glucose is the body's main source of fuel. If your glucose levels are too high, serious health problems can arise for you and your baby.

Out of every 100 pregnant women, 3 to 5 develop gestational diabetes. While gestational diabetes usually goes away once the baby is born, over half of the women develop diabetes later in life.

Childbirth An overweight woman is at increased risk of having problems during and after childbirth. The higher her BMI, the more likely she may need a cesarean delivery, which is major surgery. Compared to other pregnant women, very overweight women may have more trouble recovering from a c-section. Also, they may need to stay in the hospital longer.

Babies Born to Overweight and Obese Mothers Babies born to overweight and obese mothers may face their own challenges. These newborns are at increased risk of: * Being born prematurely; * Having certain birth defects; * Needing special care in a neonatal intensive care unit (NICU); * Being obese in childhood.

What You Can Do Before pregnancy: To help avoid these health problems, have regular medical checkups before getting pregnant. If you're overweight 327 To help avoid these health problems, have regular medical checkups before getting pregnant. If you're overweight 327 Pregnancy and Birth Sourcebook, Third Edition or obese, your health care provider or a registered diet.i.tian can help you lose pounds so that you reach a healthier weight before trying to get pregnant. They will talk with you about exercise and eating healthy.

Check out MyPyramid, an online tool from the U.S. Department of Agriculture. It can help you plan a healthy diet based on your age, weight, height and physical activity.

During pregnancy: If you are overweight at the start of pregnancy, do not start dieting. Fad diets can reduce the nutrients your baby needs for his growth and health. Generally, overweight women should gain between 1525 pounds during pregnancy. If you are overweight at the start of pregnancy, do not start dieting. Fad diets can reduce the nutrients your baby needs for his growth and health. Generally, overweight women should gain between 1525 pounds during pregnancy.

Remember: Every woman's body is unique. Always talk to your health care provider about the healthiest steps for you and your baby.

Section 39.2 Obesity before Pregnancy Linked to Childhood Weight Problems Excerpted from "Obesity Before Pregnancy Linked to Childhood Weight Problems," by the National Inst.i.tutes of Health, December 5, 2005.

A study shows that a child's weight may be influenced by the mother even before the child is actually born. The study, conducted by researchers from Ohio State University (OSU) College of Nursing and School of Public Health, appears in the December 5, 2005 issue of the journal Pediatrics Pediatrics and was supported by the National Inst.i.tute of Nursing Research (NINR), one of the National Inst.i.tutes of Health (NIH). and was supported by the National Inst.i.tute of Nursing Research (NINR), one of the National Inst.i.tutes of Health (NIH).

The study showed that a child is more likely to be overweight at a very young age-at 2 or 3 years old-if the mother was overweight or obese before she became pregnant. The data also indicate that other prenatal characteristics, particularly race, ethnicity, and maternal smoking during pregnancy, place a child at greater risk of becoming overweight. Specifically, a child is at greater risk of becoming overweight if born to a black or Hispanic mother, or to a mother who smoked during her pregnancy, according to the study.

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Overweight, Obesity, and Pregnancy Pamela Salsberry, PhD, the study's lead author and an a.s.sociate professor at OSU, noted that "there's a good chance that an overweight child will stay overweight for the rest of his or her life." "A child who is overweight by her second birthday is more likely to be overweight at a later age," said Dr. Salsberry. "Prevention of childhood obesity needs to begin before a woman becomes pregnant," she added.

"Dr. Salsberry's work underscores the importance of prenatal care and how the health habits of the mother prior to and during pregnancy may impact the health of her child through the early years of childhood and possibly through adulthood," said NINR Director Dr. Patricia A. Grady.

"Understanding how these factors may contribute to obesity very early in life will better equip us to fight the increasing problem of obesity in America and help to prevent diseases a.s.sociated with obesity, such as type 2 diabetes, heart disease, and some forms of cancer," Dr. Grady added.

The researchers a.n.a.lyzed the data for 3,022 children included in the National Longitudinal Survey of Youth's (NLSY) Child-Mother file. In this study, children were weighed at three age intervals-3, 5 and 7 years.

The survey also gathered information on each child's race and ethnicity as well as the mother's prepregnancy weight. Each mother was also asked if she had smoked while pregnant and if she had breast-fed her child.

Children were considered overweight if their body ma.s.s index (BMI) was greater than or equal to the 95th percentile for their age and gender. BMI is a calculation that takes into account both height and weight. A child in the 95th percentile for his or her weight is heavier than 95 percent of children at that age.

The study showed a significant relationship between a mother's weight prior to pregnancy and her child's weight. A mother's weight within 1 to 2 months before she became pregnant had the greatest impact on a child's weight at all three age intervals.

If a woman was overweight before she became pregnant, her child was nearly three times more likely to be overweight by age 7 compared to a child whose mother was not overweight or obese, according to the study. The risk that a child would be overweight at a young age increased with the degree of the mother's obesity.

The investigators reported that at each age interval, about 4 to 6 percent more black and Hispanic children were overweight than white children. However, the percentage of all children who were overweight, regardless of race or ethnicity, decreased with age. "Some children lose extra body weight and become leaner as they grow," Salsberry said.

Children of mothers who smoked during pregnancy were more likely to be heavy at all three age intervals. "Obviously smoking during pregnancy causes a host of serious problems, but this finding adds to 329 Pregnancy and Birth Sourcebook, Third Edition the growing body of evidence that suggests that smoking during pregnancy may be a key risk factor that increases a child's chances of being overweight," Salsberry said.

Breast-feeding had a slight effect on weight at each measurement: As much as 5 percent fewer children who were breast-fed were also overweight, compared to bottle-fed babies.

The researchers also looked at other factors that may affect a child's weight, such as the age of the mother when she gave birth, the child's gender, and whether or not the mother was married. None of these factors had the same degree of effect on childhood weight as a mother's weight prior to pregnancy, race, ethnicity, or smoking.

Two out of three children who were overweight at their final weighing were also overweight during at least one prior weighing. Three out of four children who were at a normal weight at the final weighing had always been at a normal weight.

"A child's weight at 3 years is a good prediction of what his weight will be at age 5, and so on," Salsberry said. "Weight states tend to persist over time. "Obesity continues to rise in adults," she said. "And that risk has increased in children, too. Interventions should begin immediately for children who are already overweight at these young ages."

Section 39.3 Pregnancy after Weight-Loss Surgery "Pregnancy after Weight-Loss Surgery," by John G. Kral, MD, PhD, FACS, Obesity Action Coalition, April 2007. 2007 Obesity Action Coalition. Reprinted with permission.

According to some U.S. statistics 4050 percent of pregnancies are unplanned, so it is difficult to warn obese young women to delay pregnancy until after weight loss.

Taking into consideration that obesity causes earlier menarche and is more common among the poor and uneducated, and among African American and Hispanic women, it is obvious that huge educational, cultural, and societal resources are required to limit the growing obesity epidemic.

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Overweight, Obesity, and Pregnancy Women's health education in schools and homes should emphasize the importance of planning pregnancies and should encourage medical consultation while planning a pregnancy. This is especially important in the obese.

How Does Surgical Treatment of Obesity Fit into the Picture? Or Does It?

Not knowing the dangers of obese pregnancies is only part of the problem. The other part is lacking access to effective means of achiev-ing weight loss, or even maintaining a stable weight among those p.r.o.ne to weight gain. Regardless of reason(s) for undergoing weight-loss surgery, the fact is that rapidly increasing numbers of younger and younger women are having weight-loss operations. The majority of them are expected to become pregnant. In fact, obesity is a common cause of infertility, and weight loss by surgery or other means often cures such infertility.

What should obese women considering surgery, or having undergone weight-loss surgery, know about its effects on pregnancy outcomes?

First, it is important to understand the differences between the two major types of operations. Most operations nowadays are (or should be) performed using a laparoscope and three or four instruments inserted through half-inch cuts in the belly wall, instead of one large cut eight to 12 inches long.

One type of operation is purely "gastric restrictive," creating a small stomach pouch by placing an adjustable band around the top of the stomach. The inflated band makes a very small opening for the food to pa.s.s into the large stomach below the band. This causes small amounts of solid food to stretch the stomach pouch wall creating a sense of fullness as well as slowing the emptying of solid food from the small pouch. Liquids and melting foods (chocolate, cookies, chips) go straight through unless solid food is blocking the opening.

The other type of operation combines restriction (a small pouch) with bypa.s.s of more than 95 percent of the stomach and the first portions of the small bowel. The restrictive sense of fullness disappears over the first 1018 months because the pouch and the opening between the pouch and the small bowel stretch.

The bypa.s.s operations work better because the undigested solid food and liquids cause fullness even after the pouch and opening have stretched. Clearly the restrictive action of the operations can cause vomiting, especially if the patient eats quickly and chews poorly. Pills or capsules can similarly cause vomiting if they are sufficiently large.

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Pregnancy and Birth Sourcebook, Third Edition Weight-loss operations are designed to cause rapid weight loss which obviously is what the "customer" desires. I've already answered the question: "Will weight-loss surgery influence my ability to become pregnant?" But, what about the effects on the pregnancy, the fetus, the delivery, and the developing infant on its way into childhood, adolescence, and adulthood?

Effects on Pregnancy Outcomes It is always recommended that young women, who have undergone weight-loss surgery and have the capacity to conceive, should take precautions to prevent pregnancy during the phase of rapid weight loss, and at least for 18 months to two years after their surgery.

Pregnancy outcomes after all types of weight-loss surgery-even the problematic old intestinal bypa.s.s operations and the complex modern aggressive operations with the ability to cause deficiencies and other nutritional problems-are universally safer and better than outcomes of obese pregnancies. Even if mothers are still obese after their surgery, the outcomes are better than if they haven't had surgery.

Having said this, it is important to recognize that there are risks caused by weight-loss operations if the mother fails to follow recommendations about responding to vomiting, diarrhea, or feelings of weakness. Patients must take recommended supplements, and blood levels of critical nutrients must be monitored as part of responsible prenatal care. As is the case for all patients who have had obesity surgery, the rules of eating and vomiting must be followed.

The most recent information about outcomes after obesity surgery suggests that guidelines for "healthy weight gain" should be revised.

Commonly, normal-weight women with a body ma.s.s index (BMI) of 19.826 are recommended to gain 2535 pounds, while those in the "high range" (BMI of 26.129) should have a "recommended target weight gain of at least 15 pounds" according to the Inst.i.tute of Medicine of the National Academy of Sciences.

The dramatically increasing numbers of obese women have provided more statistics on pregnancy weight change in severely obese women (BMI greater than 35) allowing the development of new guidelines. Severely obese women often lose weight during pregnancy and the outcomes after weight-loss surgery, even during the non-recommended early rapid weight-loss phase, are healthy despite the absence of any weight gain.

Thus, it is important to "spread the word" that severely obese women (those with a BMI greater than 35) and those who have undergone weight-loss surgery can actually lose weight with a healthy outcome for 332 Overweight, Obesity, and Pregnancy the offspring. However, never forget that essential vitamins, minerals, and other nutrients must be monitored and supplemented as needed to optimize pregnancy outcomes in the obese, before and after surgery.

Effects on the Child Obese mothers give birth to small for age or underweight infants more often than lean mothers. After having weight-loss surgery, mothers do not have any increase in the numbers of small offspring compared to when they were obese. Only recently it has been recognized that small children are "healthy." In fact, it is dangerous for small (or even premature) infants to gain weight quickly. Rapid weight often leads to childhood obesity. It is important to realize that obese pregnancies and early rearing practices can cause many problems. No more, are the old expressions as acceptable: "cute baby fat," "she'll grow out of it." Round pudgy cheeks are not the signs of a "healthy baby."

Obese women do not breast-feed as commonly as non-obese women.

When they do breast-feed, obese women do so for a much shorter period of time. Shorter breast-feeding practices are a.s.sociated with greater postnatal body weight in the mother and increased obesity in the child. Everything must be done to encourage breast-feeding. It is a very healthy and rewarding practice, and it has a role in preventing obesity in the mother and child.

Conclusions * Obese pregnancies are dangerous pregnancies.

* Pregnancies following weight-loss surgery are safer than obese pregnancies for mother and child.

* Pregnancies after weight-loss surgery, regardless of weight: a.) should be prevented during the first 18 months after surgery; b.) should be monitored for nutrient deficiencies to guide taking supplements.

Recommendations for Pregnant Women Who Have Undergone Gastric Restrictive Weight-Loss Operations Eating Behavior To reduce the risk of vomiting: * Eat slowly with minimal stress and distraction.

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Pregnancy and Birth Sourcebook, Third Edition * Progress your diet from liquids to semisolid food to solid food.

* Eat small portions.

* Chew well before swallowing.

* If you feel your pouch, stop eating.

* Do not drink with your food-wait at least one hour after eating.

Response to Vomiting If you vomit or regurgitate: * Try to identify the reasons.

* Do not drink for four hours.

* Progress your diet slowly, starting with liquids.

* If nausea or vomiting during progression occurs, consume nothing by mouth for 12 hours.

* If you continue to vomit, despite above measures, contact your surgeon.

About the Author.John G. Kral, MD, PhD, FACS, received his MA degree in Psychol-ogy in 1961 from the University of Goteborg, Sweden, where he then attended medical school, completed specialty training in surgery and subsequently defended a PhD thesis ent.i.tled, Surgical Reduction of Adipose Tissue in 1976. In 1980, Dr. Kral was recruited to St. Luke's Hospital Center, Columbia University College of Physicians and Surgeons, to develop a program of surgical metabolism and anti-obesity surgery where he investigated eating behavior and continued studies on severe obesity and effects of long-term maintenance of significant weight-loss on body composition after malabsorptive and gastric restrictive operations.

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