Bariatric
Surgery and
Pregnancy
John Finney
Bariatric Dietitian
Doncaster Royal Infirmary
Discussion Points
Obesity
Bariatric



in Pregnancy
Surgery
Gastric Bypass
Gastric Band
Sleeve Gastrectomy
Post
op diet
Bariatric
Surgery and Pregnancy
Recommendations
Areas

of Limited Evidence
Gestational Diabetes
Case
studies
Obesity

Global epidemic (WHO, 2000)

Obesity rates in the UK continue to rise (HSE, 2012)

Obesity prevalence in women of reproductive age
24.2% and expected to rise (Ono, 2005)
Obesity

Bariatric surgery is an effective tool for treating obesity
(Shah, 2006)

Many co-morbidities can improve following weight loss
surgery (Perry, 2008)

Significantly more women than men have bariatric
surgery

Many of these women are of a reproductive age
Obesity in Pregnancy

Prior to conception associated with infertility

Increases risks in pregnancy





Maternal death
Gestational diabetes
Pre eclampsia
Hypertension
And many more ………
Criteria for Referral

New Clinical Commissioning Policy

Published April 2013

NICE guidance (2006)


BMI >40kg/m²
Or 35-40kg/m² with other significant disease

Obesity present for at least 5 years

Complied with a local specialist MDT obesity service weight
loss programme for 12-24 months (for BMI>50kg/m2, minimum
period is 6/12)
Keyhole Surgery
Gastric Bypass Surgery
Gastric Bypass
Gastric Bypass Complications

Leak from the joins

Narrowing or
blockage

Nutritional deficiencies
Gastric Band Surgery
Gastric Band
Gastric Band Complications

Band slippage

Band erosion

Infection

Port disconnection

Band leakage
Sleeve Gastrectomy
Sleeve Gastrectomy
Sleeve Gastrectomy
Complications

Staple line leak/bleed

Narrowing or
blockage

Nutritional deficiencies
Post Operative Diet
Following Bariatric Surgery

Post surgery staged process



to allow the body to get used to the operation
let swelling decrease
Not put excessive pressure on joins / dislodge bands

Individual time spent at each stage depends on procedure
and the patient is progressing

Important not to rush through the stages, it will take longer in
the end
Post Operative Diet Following
Bariatric Surgery
• Four Stages

Stage 1
 Liquid only (1 week)

Stage 2
 Blended / Pureed textured
diet
Post Operative Diet Following
Bariatric Surgery
• Four Stages

Stage 3
 Soft diet

Stage 4

Normal textured diet
Pre Op Guidance for Post
Op Success



Regular meals
Control snacking
Healthy choices – long term small portions

Speed – important to eat slowly – 15 – 20 minutes to eat a
meal
Chewing – chew well, 20 – 30 times
Drinking and eating – avoid
Fizzy drinks – reduce and avoid

Physical activity



Vitamin and Mineral
Supplements
% Excess Weight Loss Overall
% Excess Wt Loss
Seminar
6m
12 m
24 m
0
10
20
%
30
Gastric
Bypass
40
50
Sleeve
Gastrectomy
60
Gastric Band
70
80
Co-morbidity Improvements
100
90
80
% improvement
70
60
50
40
30
20
10
0
Diabetes
OSA
Depression
Co-morbidity
Functional
Status
Asthma
Effects of Bariatric Surgery
on Pregnancy

Lack of evidence in controlled trials

Varying evidence amongst papers

However, research tends to suggest, patients having
undergone bariatric surgery and lost significant weight have
improved outcomes and there is no increased risk to the
mother or infant
Recommendations

Varying practice nationally at surgery centres

Patients should contact centre where had surgery if
possible, and if necessary referred back there

Patients within 2 years of surgery (NHS) will generally still
be under the surgery team’s care

Ante natal team should be encouraged to
communicate with the surgery centre
Recommendations

Patients are advised not to become pregnant within 18
months of surgery (ACOG, 2005)



Rapid weight loss in this phase
Potential for greater risk of nutritional deficiencies
Anecdotally – patients in the earlier phases of their
weight loss journey fair poorer in terms of weight loss

Oral contraception may not be as effective (gastric
bypass)

Patients do become pregnant earlier than advised!
Recommendations

All patients should be taking multivitamin and mineral
supplements – need to ensure they take a pregnancy
safe one

BMI>30 kg/m2


folic acid 5mg
Vitamin D (10mcg/d) (nb. May already be taking vitamin
D supplement depending on surgery)

Gastric Bypass / Sleeve Gastrectomy – continue with
Vitamin B12 injections

Gastric Bypass – continue with Adcal D3 bd and ferrous
sulphate tds
Recommendations

Diet as per normal advice in pregnancy



regular meals
healthy food choices (Patients will be aware of limitations
within diet)
portions will generally be smaller

Food safety advice in pregnancy

Micronutrient monitoring
Bariatric Issues in
Pregnancy

Weight loss / maintenance / gain

Micronutrient issues



Iron
Calcium / Vit D
Dietary habits / restrictions

+ the effect of pregnancy on appetite / cravings
Areas of Limited Evidence

Monitoring



Band adjusting


Regular, depending on stage of surgery and pregnancy
Scans? Some papers suggest more frequent?
Varying suggestions around the country full deflation vs.
monitoring of symptoms and weight
Gestational diabetes
Gestational Diabetes and
Bariatric Surgery

Patients with BMI>30 are at risk of developing
gestational diabetes

Normal test is GTT

However, in RYGB – contraindicated due to potential for
dumping syndrome and false readings

Alternative testing required
Gestational Diabetes and
Bariatric Surgery

No best practice guidance

Suggestion

Fasting blood glucose and HbA1c at booking – if readings in
the diabetes range – early review and treatment

If normal and no hx of T2 DM prior to bariatric surgery, then
~26 weeks – fasting glucose and post prandial glucose (1-2
hours?) for approximately 1/52. Then referral to antenatal
team if appropriate

Liaise with surgical team and diabetes team
Useful Resources

Tommy’s Guide (2013) – Managing obesity in pregnant women: an
online guide for health professionals


NICE (2010) Weight Management before, during and after pregnancy
Our Experience …

3 patients have become pregnant within 2 years



2 RYGB
1 Sleeve Gastrectomy
All 3 have given birth and reported that babies are progressing
well
Patient 1 – Gastric Bypass

Pre op – 140.6kg (22st 11lb), BMI – 50.4kg/m2

Reported as compliant post op. Got pregnant approx 9/12 post
RYBG. Wt approx 90kg

Lost further 6kg through pregnancy – did stabilise

Developed gestational DM (put on insulin) and had vit D deficiency

Were concerns at 35/40 pregnancy that foetus had stopped growing

Uncomplicated birth 3/12 ago

Now 18/12 post RYGB wt 78.1 kg (12 4lb), BMI 28kg/m2. Xs wt loss
88.2%
Patient 2 – Sleeve
Gastrectomy

Pre op – 115.6kg (18st 2lb). BMI 48.1kg/m2

Compliance issues post op – non attender, did not appear to be
following advice

Pregnant approx 10/12 post sleeve

Wt difficult to asses – approx 100kg (15st 11lb)

Gained wt during pregnancy, ? Amount – at least 9kg

Therefore, overall % xs weight loss – approx 11.5%

Complicated birth. Now 24/24 post sleeve, wt 105kg (16st 7lb). BMI
43.7kg/m2. XS wt loss 19.3%
Patient 3 – Gastric Bypass

Pre surgery wt 154.4kg (24st 4lb). BMI 53.8kg/m2

Compliant post op. Got pregnant 8/12 post RYGB. Had miscarriage at
around 12 weeks

Got pregnant again 13/12 post RYGB. Wt approx 99.4kg (15st 9lb) 66% xs
wt loss

Continued with generally good compliance.

Wt decreased approx 9kg but had slight regain. Remained controlled.
Had vit D deficiency

Uncomplicated birth

Attended clinic 24/12 post RYGB for discharge. Wt 77kg (12st 2lb). BMI 27
kg/m2. 93.3% xs wt loss
 Contact

John Finney




Details
Specialist Dietitian for Bariatric Surgery
John.finney@dbh.nhs.uk
#4110 / 07766070570
Louise Parsons / Katie Kirk



Clinical Nurse Specialists for Bariatric Surgery
Louise.parsons@dbh.nhs.uk / katie.kirk@dbh.nhs.uk
# 4294 / 07766070570
References

Health Survey for England (HSE) (2012) http://www.hscic.gov.uk/catalogue/PUB13218

Heslehurst, N., Brown, A. (2010) Managing obesity in pregnant women: an online guide for health
professionals. Tommy’s

National Institute for Clinical Excellence (2006) Obesity: the prevention, identification, assessment and
management of overweight and obesity in adults and children. Department of Health

National Institute for Clinical Excellence (2010) Weight Management Before, During and After
Pregnancy. Department of Health

NHS Commissioning Board Clinical Reference Group for Severe and Complex Obesity (2013) Clinical
Commissioning Policy: Complex and Specialised Obesity Surgery. NHS Commisioning Board

Ono, Y., Guthold, R., Strong, K. (2005) WHO Global Comparable Estimates
http://apps.who.int/infobase

Perry CD, Hutter MM, Smith DB, Newhouse JP, McNeil BJ. (2008) Ann Surg. Jan;247(1):21-7. Survival and
changes in comorbidities after bariatric surgery

Shah M, Simha V, Garg A. (2006)J Clin Endocrinol Metab. Nov;91(11):4223-31. Epub 2006 Sep 5.
Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status.

World Health Organisation (2000) Obesity; Preventing and Managing the Global Epidemic. Geneva:
WHO