Female Female Reproductive Issues Reproductive Issues Following Bariatric Following Bariatric
SurgerySurgery
Joseph R. Wax, M.D.Professor of Obstetrics and Gynecology
University of Vermont School of Medicine
Maine Medical CenterPortland, Maine
A Tale of Two A Tale of Two Patients… 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?
GoalsGoals
• 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 Obesity in American WomenWomen
Overweight or Obese Obese
Extremely Obese
62% 33%
7%
(BMI > 25) (BMI > 30)
(BMI > 40 or > 35 with comorbidity)
Ogden, C.L. JAMA 2006
Obesity-Related Obesity-Related MorbidityMorbidity
Hypertension ArthritisDyslipidemia Sleep ApneaDiabetes CancerCAD -colonStroke -breastGallbladder -
endometrial
**Second leading cause of deathSecond leading cause of death**
Obesity-Related Obesity-Related Obstetrical MorbidityObstetrical Morbidity
Infertility CesareanMiscarriage AnesthesiaGestational diabetes
Blood loss
Hypertension Wound Infection
Macrosomia
Recent Trends in Bariatric Recent Trends in Bariatric SurgerySurgery
• 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 Only effective treatment of morbid obesityobesity
CDC 2006
Bariatric Surgery – Bariatric Surgery – PrerequisitesPrerequisites
• Multidisciplinary care• Attempt non-surgical weight
loss• Preoperative medical evaluation• Preconception consultation and Preconception consultation and
carecare
Bariatric Procedures – Roux-Bariatric Procedures – Roux-en-Y Gastric Bypassen-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 BypassRoux-en-Y Gastric BypassLaparoscopic vs. OpenLaparoscopic vs. Open
Laparoscopic Laparoscopic
OpenOpen
AdvantagesAdvantages
Shorter hospital stay
Tactile control of dissection
Less post-operative discomfort
Easier adhesiolysis
Fewer wound complications
Ability to use fine sutures
Fewer cardiopulmonary complications
Ease of performing ancillary procedures
Fewer long-term complications
DisadvantaDisadvantagesges
Increased intra-abdominal complications
Ventral hernia formation
Simpfendorfer, C.H. Surg Clin N Am 2005
Bariatric Procedures – Bariatric Procedures – Laparoscopic Adjustable Laparoscopic Adjustable
Gastric BandingGastric Banding
• Restrictive• Lose
– 50% EBW– 25% BMI
• 0.1% mortality• 5% morbidity
Buchwald, H. JACS 2005
Bariatric Procedures – Bariatric Procedures – Vertical Banded Vertical Banded
GastroplastyGastroplasty
• Restrictive• Efficacy,
morbidity, mortality similar to LAGB
Buchwald, H. Obes Surg 2002
Perioperative Reproductive Perioperative Reproductive IssuesIssues
• Rapid weight loss over 12-18 months– Resolution of
• PCOS• anovulation• irregular menses
– Improved fertility and fecundity
• Reliable Reliable contraceptioncontraception
Teitelman, M. Obes Surg 2006 Bilenka, B. Acta Obstet Gynecol Scand 1995Eid, G. M. Surg Obes Rel Dis 2005 Deitel, M. J Am Coll Nutr 1988
Gastric Bypass and Gastric Bypass and MalabsorptionMalabsorption
• 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 CarePreconception Care
• Avoid MVI with > 5000 IU vitamin A• Address other obesity-related
comorbidities– hypertension– diabetes– obesity
Rothman, K. M. NEJM 1995
Late Surgical Complications Late Surgical Complications in Pregnancy – Bowel in Pregnancy – Bowel
ObstructionObstruction• 6-8% pregnancies
-Internal hernia-Intussusception-Volvulus
• 9-25 months after RYGB• Delay in diagnosis or treatment →
2 2 maternalmaternal
andand1 fetal1 fetaldeathdeath
Wax, J.R. OG Survey 2007
Bowel Obstruction in Bowel Obstruction in PregnancyPregnancy
• Nonspecific nature of abdominal complaints• Confusion with common obstetrical
phenomena• Distracted from inciting event by 2°
pancreatitis* Have low threshold to consult bariatric Have low threshold to consult bariatric
surgeonsurgeon**
** Have low threshold to explore pregnant Have low threshold to explore pregnant patient for obstructionpatient for obstruction**
Internal Hernia in Internal Hernia in PregnancyPregnancy
A. Lesser sac into mesocolic tunnel
B. Petersen (below Roux limb)
C. Leaves of small bowel mesentery
Karkala, N OG 2005
Intussusception in Intussusception in PregnancyPregnancy
• 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 Late Surgical Complications in Pregnancy – in Pregnancy – MalabsorptionMalabsorption
• 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 Does Gastric Bypass Increase ONTD Risk?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
Sheiner, C.S. AJOG 2004 Haddow, J.E. Lancet 1986 Knudsen, L.B. Lancet 1986
Malabsorption and Malabsorption and CarbohydratesCarbohydrates
RYGB
Decreasedcaloric intake& absorption
HyperinsulinemicHypoglycemia
Pregnancy
Decreasedfasting blood
glucose
Unfulfilled increased
caloric intake
Obesity
Insulin Resistance
Pancreatic β cellhyperfunction
Hyperinsulinemic Hyperinsulinemic HypoglycemiaHypoglycemia
• Diagnosis– glucose < 55
mg/dL– insulin ≥ 3 mcU/mL– c-peptide ≥ 0.6
ng/mL– no sulfonylurea
Halverson, J.D. Surgery 1982
Hyperinsulinemic Hyperinsulinemic HypoglycemiaHypoglycemia
• Affects approximately 4% pregnancies
• Treatment = Dietary Modification– Avoid refined/simple sugars– Increase
• protein• complex carbohydrates
– Consume liquids well before and after meals
• Consult bariatric nutritionistConsult bariatric nutritionist
Hyperinsulinemic Hyperinsulinemic Hypoglycemia in Hypoglycemia in
PregnancyPregnancy• 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 Managing Dietary FailuresFailures
• Rare, no reports in pregnancy• Reversal of bariatric procedure• Partial or total pancreatectomy
Dumping SyndromeDumping 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 – Dumping Syndrome – Early Phase (10-30 min)Early Phase (10-30 min)
Rapid transit of nutrientsto small intestine
Osmotic fluid shifts
Vasomotor Symptoms Abdominal Symptoms
• palpitationspalpitations• syncopesyncope• diaphoresisdiaphoresis• flushingflushing• headacheheadache
• nauseanausea• diarrheadiarrhea• crampingcramping• bloatingbloating
Dumping Syndrome – Late Dumping Syndrome – Late PhasePhase
(1-3 hrs)(1-3 hrs)
ReactiveHyperinsulinemic Hypoglycemia
Vasomotor Symptoms
Dumping Syndrome – Dumping Syndrome – TreatmentTreatment
• Dietary Modification– Avoid refined/simple sugars– Increase
• protein• complex carbohydrates
– Consume liquids well before and after meals
Managing Dietary Managing Dietary FailuresFailures
• 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 – Dumping Syndrome – Implications for Implications for
PregnancyPregnancy
• Avoid glucose challenge test– Home glucose monitoring
•1-2 weeks at 26-28 weeks•treat if consistently elevated
Pregnancy Outcomes Pregnancy Outcomes After Bariatric SurgeryAfter 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 LAGBPregnancy after LAGB
OutcomOutcomee
MartinMartin(n=23)(n=23)
WeissWeiss(n=7)(n=7)
Skull*Skull*(n=49)(n=49)
Dixon*Dixon*††(n=79)(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
Wt gain - - ↓ ↓
DM 0 (0) 0 (0) ↓ ↓
HTN 0 (0) 0 (0) ↓ ↓
Band 0 (0) 2 (28.6%) 2 (4.1%) 0 (0)* vs. last presurgical pregnancy* vs. last presurgical pregnancy† † vs. matched obese controlsvs. matched obese controls
Pregnancy After RYGBPregnancy After RYGB
OutcomeOutcomePrintenPrinten(n=54)(n=54)
WittgrovWittgrovee
(n=36)(n=36)
RichardsRichards(n=57)(n=57)
PatelPatel(n=26)(n=26)
SAB 2 (4.2%) - - 0
CS 4 (8.7%) 0 0 BW 1078-
4230g- ↓ 0
≥ 4 kg - ↓ ↓ 0< 2.5 kg
7 (18.4%) - 0 0
Preterm 7 (15.2%) 0 0 0
Wt gain - ↓ ↓ 0
DM - ↓ 0 0
HTN - ↓ ↓ 0
Pregnancy After RYGBPregnancy After RYGB
OutcomeOutcome Crude OR (95% Crude OR (95% CI)CI)
Adjusted * OR Adjusted * OR (95% CI)(95% CI)
HypertensionHypertension 3.67 (1.36, 9.92) 2.62 (0.66, 10.50)
PPROMPPROM 0.33 (0.04, 2.77) 0.24 (0.02, 3.38)
OligohydramniOligohydramniosos
2.00 (0.65, 6.20) 2.39 (0.66, 8.61)
Gestational Gestational age age >> 41 41
wkswks0.50 (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 Pregnancy After RYGB- Impact of Timingof Timing
Outcome
Rand( 10 early, 8 late)
Dao(21 early, 13 late)
Wax(20 early, 32 late)
SAB - 0 -CS 0 0 0
BW - 0 0
Preterm
- 0 0
Wt gain - 0
DM - - 0
HTN - 0 0
Pregnancy After Pregnancy After LAGB/RYGBLAGB/RYGB
Compared to Pre-Surgical PregnancyCompared to Pre-Surgical Pregnancy
LessLess SimilarSimilar UnclearUnclear
Wt gain CS SAB
DM BW Growth restriction
HTN Preterm
BW ≥ 4kg
Bariatric Surgery and Bariatric Surgery and the Puerperiumthe Puerperium
• Weight loss– limited descriptive data– rate similar to nonbariatric delivered
patients and nonpregnant bariatric patients
Bariatric Surgery and Bariatric Surgery and LactationLactation
• Not contraindicated• Ensure maternal B12
supplementation– several cases of neonatal B12
deficiency
Grange, D.K. Pediatr Hematol Oncol 1994
Campbell, C.D. Haematologica 2005
SummarySummary
• 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 ResearchFuture Research
• Pregnancy outcome– by specific bariatric procedure– account for
• past pregnancy complications• persistent obesity• obesity-related comorbidities
– congenital anomalies (ONTDs)
Guidelines for CareGuidelines for CarePreconception
Reliable contraception through period of maximal weight lossEvaluate and treat comorbiditiesEvaluate and treat micronutrient deficiencies (B12, folate, iron)Meet with bariatric surgeon and nutritionist, preconception consultation with Ob/Gyn or Maternal-Fetal MedicineFolic acid, B12 and iron supplementation
Pregnancy Folic acid, B12 and iron supplementationSecond trimester MSAFPConsider monthly growth ultrasounds after 20 weeksMonitor for signs and symptoms of hypoglycemiaAvoid NSAIDS if history of ulcer
Puerperium
Folic acid, B12 and iron supplementationBreast feeding compatible with bariatric surgeryNotify pediatrician of maternal surgical history to enable monitoring for micronutrient deficiency (likely very low risk if mother taking prescribed supplements) Avoid NSAIDS if history of ulcer
Wax, J.R. OG Survey 2007