Female Reproductive
Issues Following Bariatric
Surgery
Joseph R. Wax, M.D.
Professor of Obstetrics and Gynecology
University of Vermont School of Medicine
Maine Medical Center
Portland, Maine
A Tale of Two Patients…
1. 25 year old G0 12 months after gastric bypass
-
Pre-conception care?
Pregnancy management?
2. 35 year old G3P1011 at 21 weeks with 2 days
progressive abdominal pain. RYGB 18 months
earlier.
-
Differential diagnosis?
Evaluation and treatment?
Goals
• Describe commonly performed bariatric
procedures and implications for female
reproductive health
• Review consequences of bariatric surgery with
regard to preconception care
• Describe complications of bariatric surgery in
pregnancy and their management
• Review pregnancy outcomes following bariatric
surgery
Obesity in American Women
Overweight or Obese
Obese
(BMI > 25)
(BMI > 30)
62%
33%
Extremely Obese
(BMI > 40 or > 35 with comorbidity)
7%
Ogden, C.L. JAMA 2006
Obesity-Related Morbidity
Hypertension
Dyslipidemia
Arthritis
Sleep Apnea
Diabetes
CAD
Stroke
Gallbladder
Cancer
-colon
-breast
-endometrial
*Second leading cause of death*
Obesity-Related Obstetrical
Morbidity
Infertility
Miscarriage
Gestational diabetes
Hypertension
Macrosomia
Cesarean
Anesthesia
Blood loss
Wound Infection
Recent Trends in Bariatric Surgery
• Almost 20-fold increase last decade
– 2005 >100,000
– 2006 >200,000
• 5x as many procedures in women as men
• >50% of all procedures in reproductive-aged
women
• Only effective treatment of morbid obesity
CDC 2006
Bariatric Surgery –
Prerequisites
•
•
•
•
Multidisciplinary care
Attempt non-surgical weight loss
Preoperative medical evaluation
Preconception consultation and care
Bariatric Procedures – Roux-en-Y
Gastric Bypass
• Restrictive and
malabsorptive
• Lose
– 100 lb
– 65-70% EBW
– 35% BMI
• 0.5% mortality
• 5% operative morbidity
Buchwald, H. Obes Surg 2002
Roux-en-Y Gastric Bypass
Laparoscopic vs. Open
Laparoscopic
Advantages
Shorter hospital stay
Open
Tactile control of dissection
Less post-operative
Easier adhesiolysis
discomfort
Fewer wound complications Ability to use fine sutures
Disadvantages
Fewer cardiopulmonary
complications
Ease of performing ancillary
procedures
Fewer long-term
complications
Increased intra-abdominal
complications
Ventral hernia formation
Simpfendorfer, C.H. Surg Clin N Am 2005
Bariatric Procedures – Laparoscopic
Adjustable Gastric Banding
• Restrictive
• Lose
– 50% EBW
– 25% BMI
• 0.1% mortality
• 5% morbidity
Buchwald, H. JACS 2005
Bariatric Procedures –Vertical
Banded Gastroplasty
• Restrictive
• Efficacy, morbidity,
mortality similar to
LAGB
Buchwald, H. Obes Surg 2002
Perioperative Reproductive Issues
• Rapid weight loss over
12-18 months
– Resolution of
• PCOS
• anovulation
• irregular menses
– Improved fertility and
fecundity
• Reliable contraception
Teitelman, M. Obes Surg 2006
Eid, G. M. Surg Obes Rel Dis 2005
Bilenka, B. Acta Obstet Gynecol Scand 1995
Deitel, M. J Am Coll Nutr 1988
Gastric Bypass and Malabsorption
• Supplements
– ferrous sulfate or
fumarate
– B12
• 500-1000 µgm po qd
or
• 500-1000 µgm IM qm
– folic acid
• 400 µgm po qd
– calcium citrate
• 1200 mg po qd
Preconception Care
• Avoid MVI with > 5000 IU vitamin A
• Address other obesity-related comorbidities
– hypertension
– diabetes
– obesity
Rothman, K. M. NEJM 1995
Late Surgical Complications in
Pregnancy – Bowel Obstruction
• 6-8% pregnancies
-Internal hernia
-Intussusception
-Volvulus
• 9-25 months after RYGB
• Delay in diagnosis or treatment →
2 maternal
and
1 fetal
death
Wax, J.R. OG Survey 2007
Bowel Obstruction in
Pregnancy
• Nonspecific nature of abdominal complaints
• Confusion with common obstetrical phenomena
• Distracted from inciting event by 2° pancreatitis
* Have low threshold to consult bariatric surgeon*
* Have low threshold to explore pregnant patient for
obstruction*
Internal Hernia in Pregnancy
A. Lesser sac into
mesocolic tunnel
B. Petersen (below
Roux limb)
C. Leaves of small
bowel mesentery
Karkala, N OG 2005
Intussusception in Pregnancy
• 21 weeks’ gestation
• RYGB 18 months earlier
• Several days abdominal
discomfort
• Six hours constant pain
• Suspected internal hernia
Wax, J.R. Obes Surg 2007
Late Surgical Complications in
Pregnancy – Malabsorption
• Iron deficiency
– usually mild, responsive to oral therapy
– rare cases of needing parenteral iron
– recommend trimesterly CBC
• Folate and B12
– continue preconception supplements
– recommend MSAFP and targeted ultrasound
Does Gastric Bypass Increase
ONTD Risk?
• 3 cases of ONTDs remote from
RYGB (2-8 yrs)
– no maternal vitamin supplements
– 2 ↓B12, 1 ↓folate
• Later studies
– no ONTDs in 129 RYGB
pregnancies
– no increased risk of anomalies after
bariatric surgery 15/289 cases vs.
6333/158,912 controls
Haddow, J.E. Lancet 1986
Sheiner, C.S. AJOG 2004
Knudsen, L.B. Lancet 1986
Malabsorption and Carbohydrates
Obesity
RYGB
Decreased
caloric intake
& absorption
Hyperinsulinemic
Hypoglycemia
Pregnancy
Insulin Resistance
Pancreatic β cell
hyperfunction
Decreased
fasting blood
glucose
Unfulfilled
increased
caloric intake
Hyperinsulinemic
Hypoglycemia
• Diagnosis
– glucose < 55 mg/dL
– insulin ≥ 3 mcU/mL
– c-peptide ≥ 0.6 ng/mL
– no sulfonylurea
Halverson, J.D. Surgery 1982
Hyperinsulinemic
Hypoglycemia
• Affects approximately 4% pregnancies
• Treatment = Dietary Modification
– Avoid refined/simple sugars
– Increase
• protein
• complex carbohydrates
– Consume liquids well before and after meals
• Consult bariatric nutritionist
Hyperinsulinemic Hypoglycemia
in Pregnancy
•
•
•
•
•
36-year old at 24 weeks
RYGB 39 months earlier
Lightheadedness, syncope
Postprandial glucose 34-57 mg/dL
Normal glucose, no symptoms after:
– increase calories 1000 → 1500/day
– increase protein 56g → 80g/day
– avoid refined sugars
Wax, J.R. Obes Surg 2007
Managing Dietary Failures
• Rare, no reports in pregnancy
• Reversal of bariatric procedure
• Partial or total pancreatectomy
Dumping Syndrome
• Affects small proportion of RYGB patients
• Can be associated with postprandial
hyperinsulinemic hypoglycemia
• Precipitated by liquids, simple, refined sugars
Vecht, J. Scand J Gastroent Suppl 1997
Hasler,W.L. Curr Treat Options Gast 2002
Ukleja, A. Nutr Clin Pract 2005
Dumping Syndrome – Early Phase
(10-30 min)
Rapid transit of nutrients
to small intestine
Osmotic fluid shifts
Vasomotor Symptoms
•
•
•
•
•
palpitations
syncope
diaphoresis
flushing
headache
Abdominal Symptoms
•
•
•
•
nausea
diarrhea
cramping
bloating
Dumping Syndrome – Late Phase
(1-3 hrs)
Reactive
Hyperinsulinemic Hypoglycemia
Vasomotor Symptoms
Dumping Syndrome – Treatment
• Dietary Modification
– Avoid refined/simple sugars
– Increase
• protein
• complex carbohydrates
– Consume liquids well before and after meals
Managing Dietary Failures
• Rare, no reports in pregnancy
• Medication
– Acarbose (inhibits glucose absorption)
• 25-50 mg after meals (TID)
• S/E flatulence, diarrhea
• category B
– Octreotide (somatostatin analog)
• 25-100 mcgm SQ 15-60 min before meals
• category B
Dumping Syndrome – Implications
for Pregnancy
• Avoid glucose challenge test
– Home glucose monitoring
• 1-2 weeks at 26-28 weeks
• treat if consistently elevated
Pregnancy Outcomes After
Bariatric Surgery
• Case reports and series
• Case-control studies
– small
– subjects as own controls
– women without bariatric surgery as controls
• obese
• non-obese
– unspecified bariatric surgical procedure
Pregnancy after LAGB
Martin
(n=23)
Weiss
(n=7)
Skull*
(n=49)
Dixon*†
(n=79)
Years
1990-5
1996-2000
1996-2003
1995-2003
SAB
2 (9%)
2 (28.6%)
-
-
CS
4 (22%)
2 (40%)
0
-
BW
3676g
-
0
0
-
-
↓
↓
DM
0 (0)
0 (0)
↓
↓
HTN
0 (0)
0 (0)
↓
↓
Band
0 (0)
2 (28.6%)
2 (4.1%)
0 (0)
Outcome
Wt gain
* vs. last presurgical pregnancy
† vs. matched obese controls
Pregnancy After RYGB
Outcome
SAB
CS
BW
≥ 4 kg
< 2.5 kg
Preterm
Wt gain
DM
HTN
Printen
(n=54)
2 (4.2%)
4 (8.7%)
Wittgrove
(n=36)
0
Richards
(n=57)
0
Patel
(n=26)
0
1078-4230g
7 (18.4%)
7 (15.2%)
-
↓
0
↓
↓
0
0
↓
↓
↓
↓
0
0
0
0
0
0
-
↓

0
0
Pregnancy After RYGB
Outcome
Crude OR (95% CI)
Adjusted * OR (95% CI)
Hypertension
3.67 (1.36, 9.92)
2.62 (0.66, 10.50)
PPROM
0.33 (0.04, 2.77)
0.24 (0.02, 3.38)
Oligohydramnios
2.00 (0.65, 6.20)
2.39 (0.66, 8.61)
Gestational age
> 41 wks
0.50 (0.11, 2.36)
0.57 (0.11, 2.97)
*adjusted for BMI at delivery
Wax, J.R. et al Obes Surg 2008
Pregnancy After RYGB- Impact of Timing
Outcome
SAB
Rand
( 10 early, 8 late)
Dao
(21 early, 13 late)
Wax
(20 early, 32 late)
-
0
-
CS
0
0
0
BW
-
0
0
Preterm
-
0
0
Wt gain
-

0
DM
-
-
0
HTN
-
0
0
Pregnancy After LAGB/RYGB
Compared to Pre-Surgical Pregnancy
Less
Similar
Unclear
Wt gain
CS
SAB
DM
BW
Growth restriction
HTN
Preterm
BW ≥ 4kg
Bariatric Surgery and the
Puerperium
• Weight loss
– limited descriptive data
– rate similar to nonbariatric delivered patients and
nonpregnant bariatric patients
Bariatric Surgery and Lactation
• Not contraindicated
• Ensure maternal B12 supplementation
– several cases of neonatal B12 deficiency
Grange, D.K. Pediatr Hematol Oncol 1994
Campbell, C.D. Haematologica 2005
Summary
• Anatomic and physiologic changes associated
with bariatric surgery have significant
reproductive implications
• Nutritional deficiencies generally mild and easily
treated
• Limited data suggest favorable pregnancy
outcomes
Future Research
• Pregnancy outcome
– by specific bariatric procedure
– account for
• past pregnancy complications
• persistent obesity
• obesity-related comorbidities
– congenital anomalies (ONTDs)
Guidelines for Care
Preconception Reliable contraception through period of maximal weight loss
Evaluate and treat comorbidities
Evaluate and treat micronutrient deficiencies (B12, folate, iron)
Meet with bariatric surgeon and nutritionist, preconception consultation
with Ob/Gyn or Maternal-Fetal Medicine
Folic acid, B12 and iron supplementation
Pregnancy
Folic acid, B12 and iron supplementation
Second trimester MSAFP
Consider monthly growth ultrasounds after 20 weeks
Monitor for signs and symptoms of hypoglycemia
Avoid NSAIDS if history of ulcer
Puerperium
Folic acid, B12 and iron supplementation
Breast feeding compatible with bariatric surgery
Notify pediatrician of maternal surgical history to enable monitoring for
micronutrient deficiency (likely very low risk if mother taking
prescribed supplements)
Wax, J.R. OG Survey 2007
Avoid NSAIDS if history of ulcer