Nutritional Nutritional Deficiencies in Deficiencies in

Pregnant Patients Pregnant Patients who have undergone who have undergone

Bariatric SurgeryBariatric SurgeryVaishali Doshi, MDVaishali Doshi, MD

Assistant Professor of MedicineAssistant Professor of Medicine

Hematology/OncologyHematology/Oncology

University of Arkansas for University of Arkansas for Medical SciencesMedical Sciences

Gastric bypass and Gastric bypass and PregnancyPregnancy

Gastric bypass surgery for morbid obesity is Gastric bypass surgery for morbid obesity is considered an appropriate intervention when considered an appropriate intervention when other weight-loss measures have proven other weight-loss measures have proven unsuccessful. unsuccessful.

Weight loss often brings about improvement Weight loss often brings about improvement in overall health by lessening the effects of in overall health by lessening the effects of obesity-related comorbidities. obesity-related comorbidities.

In fact, the ability to become pregnant is In fact, the ability to become pregnant is enhanced, as weight loss often allows for a enhanced, as weight loss often allows for a normalization of sex hormones.normalization of sex hormones.

However, the nutrition challenges brought However, the nutrition challenges brought about by the surgery may have a profound about by the surgery may have a profound impact on maternal health and pregnancy impact on maternal health and pregnancy outcome. outcome.

OutlineOutline

Different procedures Different procedures Effects of surgery and nutritional Effects of surgery and nutritional

alterationsalterations Implications for pregnancy Implications for pregnancy

Major Categories Major Categories

Surgical procedures for morbid obesity Surgical procedures for morbid obesity may be classified according to the may be classified according to the digestive aftereffects brought about by digestive aftereffects brought about by the particular procedure. the particular procedure.

These categories include the These categories include the "restrictive" procedures "restrictive" procedures "restrictive-malabsorptive" procedures "restrictive-malabsorptive" procedures less common "malabsorptive" procedures. less common "malabsorptive" procedures.

Bariatric SurgeryBariatric Surgery

Nutritional needs Nutritional needs

1) vary depending on the degree of 1) vary depending on the degree of restriction and the degree of restriction and the degree of malabsorption caused by the surgery malabsorption caused by the surgery

2)specific area of the intestine is 2)specific area of the intestine is bypassed. bypassed.

Individual nutrients generally have a Individual nutrients generally have a specific site of absorption along the small specific site of absorption along the small intestine. intestine.

Restrictive proceduresRestrictive procedures

vertical banded gastroplasty (VBG), vertical banded gastroplasty (VBG), silicon ring vertical banded gastroplasty silicon ring vertical banded gastroplasty

(SRG)(SRG) adjustable silicone gastric banding (ASGB) adjustable silicone gastric banding (ASGB) weight loss simply by total volume of food weight loss simply by total volume of food

intake. intake.

Patients learn quickly that these surgeries Patients learn quickly that these surgeries require them to chew their food very well to require them to chew their food very well to

slow down the pace of eating slow down the pace of eating dramaticallydramatically

Vertical banded Vertical banded gastroplastygastroplasty

Restrictive proceduresRestrictive procedures

Food leaves the newly constructed pouch Food leaves the newly constructed pouch and empties directly into the original and empties directly into the original stomach for normal digestionstomach for normal digestion

It then moves through the entire It then moves through the entire duodenum and jejunum for normal duodenum and jejunum for normal absorption.absorption.

Malnutrition may occur as a result of Malnutrition may occur as a result of the necessity to limit food ingested ,thus the necessity to limit food ingested ,thus reducing caloric and nutrient intake.reducing caloric and nutrient intake.

Restrictive SurgeriesRestrictive Surgeries Generally, an adult multiple vitamin Generally, an adult multiple vitamin

and mineral supplement is sufficient and mineral supplement is sufficient after restrictive surgeries since there is after restrictive surgeries since there is no malabsorption of specific nutrients. no malabsorption of specific nutrients.

There is a significant decrease in the There is a significant decrease in the overall quantity of food intake and overall quantity of food intake and therefore a decrease in the quantity of therefore a decrease in the quantity of all micronutrients; a supplement all micronutrients; a supplement should bring intake up to the RDA should bring intake up to the RDA levels. levels.

RestrictiveRestrictive Restrictive-Restrictive-MalabsorbtiMalabsorbtionon

MalabsorbtiveMalabsorbtive

Vertical Vertical banded banded gastroplastygastroplasty

Roux-en Y Roux-en Y gastric gastric bypassbypass

Jejunoileal Jejunoileal bypassbypass

Adjustable Adjustable gastric gastric bandingbanding

BiliopancreatiBiliopancreatic diversionc diversion

Duodenal Duodenal switchswitch

Intragastric Intragastric balloonballoon

Horizontal Horizontal unreinforced unreinforced gastroplastygastroplasty

Roux-en-Y gastric bypassRoux-en-Y gastric bypass

RYGB RYGB

A small pouch is formed by stapling the A small pouch is formed by stapling the upper portion of the stomach across the upper portion of the stomach across the fundusfundus

The contents of the newly formed The contents of the newly formed stomach empty directly into the distal stomach empty directly into the distal jejunum via a constructed jejunum via a constructed gastrojejunostomy.gastrojejunostomy.

The remainder of the The remainder of the stomach,duodenam, proximal jejunum stomach,duodenam, proximal jejunum are completely bypassed are completely bypassed

RYGB RYGB

deficiencies of irondeficiencies of iron B12, folate, B12, folate, calcium. calcium. coppercopper

Iron Deficiency after Iron Deficiency after RYGBRYGB

Iron deficiency is common after RYGB Iron deficiency is common after RYGB due to decreased intake of adequate due to decreased intake of adequate quantities of meat and other iron rich quantities of meat and other iron rich foodsfoods

Anatomic changes resulting from the Anatomic changes resulting from the surgery prevent iron containing food surgery prevent iron containing food from being exposed to the acid from being exposed to the acid environment of the stomach, which is environment of the stomach, which is required for the release of iron from its required for the release of iron from its protein sourceprotein source

Iron Deficiency after Iron Deficiency after RYGBRYGB

Gastric acidity is essential for the Gastric acidity is essential for the reduction of iron from the ferric state reduction of iron from the ferric state to the ferrous state which is to the ferrous state which is necessary for absorptionnecessary for absorption

Iron is absorbed in the duodenum Iron is absorbed in the duodenum which is bypassed, some iron will be which is bypassed, some iron will be absorbed in the lower jejunum absorbed in the lower jejunum

Folate Deficiency after RYGBFolate Deficiency after RYGB

1)decreased intake of folate-rich foods. 1)decreased intake of folate-rich foods.

2) dietary folate bypasses the duodenum 2) dietary folate bypasses the duodenum which is the primary site of folate which is the primary site of folate absorption. absorption.

3) Folate absorption, however, can take 3) Folate absorption, however, can take place along the entire length of the place along the entire length of the small bowel with adaptation after surgery. small bowel with adaptation after surgery.

B12 absorption and deficiencyB12 absorption and deficiency

1)Intake of foods that are good sources of B12 are 1)Intake of foods that are good sources of B12 are consumed in very limited quantities; secondary, consumed in very limited quantities; secondary,

2) with a less acidic environment in the pouch as 2) with a less acidic environment in the pouch as compared to a normal stomach, it is difficult to release compared to a normal stomach, it is difficult to release protein-bound B12 from foods ingested. protein-bound B12 from foods ingested.

3) the unbound b12 is then joined to R binders 3) the unbound b12 is then joined to R binders The R binders are normally degraded in the duodenum The R binders are normally degraded in the duodenum

by pancreatic enzymesby pancreatic enzymes

4 )The absence of an acidic environment prevents the 4 )The absence of an acidic environment prevents the binding and subsequent release of b12 from food, binding and subsequent release of b12 from food,

B12 Absorption B12 Absorption

11 It then must pair up with intrinsic It then must pair up with intrinsic factor (IF) to form IF/B12 complexes factor (IF) to form IF/B12 complexes for absorption in the ileum. for absorption in the ileum.

22 A reduction in the availability of IF , A reduction in the availability of IF , (produced by parietal cells of (produced by parietal cells of stomach) combined with the stomach) combined with the decreased prescence of unbound Vit decreased prescence of unbound Vit B12 prevents formation of IF/B12 B12 prevents formation of IF/B12 complex resulting in malabsorbtion.complex resulting in malabsorbtion.

B12 SupplementationB12 Supplementation

Hyperhomocysteinemia is associated Hyperhomocysteinemia is associated with cardiac and neurological with cardiac and neurological abnormalitiesabnormalities

Long term supplementation of b12 Long term supplementation of b12 following bariatric surgeryfollowing bariatric surgery

Daily oral supplementation 350 ucg of Daily oral supplementation 350 ucg of b12 sublingualb12 sublingual

Occasionally oral supplementation is Occasionally oral supplementation is not adequate making monthly not adequate making monthly parenteral therapy a necessityparenteral therapy a necessity

Calcium deficiencyCalcium deficiency Calcium deficiency is common and metabolic bone disease Calcium deficiency is common and metabolic bone disease

represents a long-term potential risk associated with RYGB represents a long-term potential risk associated with RYGB surgery. surgery.

Calcium with VIT D is absorbed in the duodenumCalcium with VIT D is absorbed in the duodenum

Following RYGB ,the duodenum is bypassed, preventing Following RYGB ,the duodenum is bypassed, preventing access to the primary absorption site for calcium. access to the primary absorption site for calcium.

Patients who have undergone gastric bypass surgery Patients who have undergone gastric bypass surgery must rely on passive diffusion of dietary calcium along must rely on passive diffusion of dietary calcium along the length of the remaining intestinethe length of the remaining intestine

Typically, blood levels of calcium Typically, blood levels of calcium will be normal limits unless other will be normal limits unless other causes create abnormal levels.causes create abnormal levels.

calcium deficiency is insidious in calcium deficiency is insidious in nature an individual is potentially nature an individual is potentially releasing calcium from the bones releasing calcium from the bones constantly to maintain normal serum constantly to maintain normal serum calcium. calcium.

METABOLIC BONE DISEASEMETABOLIC BONE DISEASE

Over time metabolic bone disease Over time metabolic bone disease results. Oftentimes the individual is results. Oftentimes the individual is unaware of the problem until a bone unaware of the problem until a bone or a tooth breaks. At this point the or a tooth breaks. At this point the problem is significant. problem is significant.

Copper DeficiencyCopper Deficiency

Copper is an essential micronutrient that plays a vital role as a catalytic cofactor for a variety of metalloenzymes

Copper absorption occurs in the stomach and duodenum

Case reports of copper deficiency years after a gastric bypass

Copper DeficiencyCopper Deficiency

Copper deficiency is associated with iron deficiency

Copper is a part of hephaestin,which converts iron to its ferric form which is necessary for its transport by transferrin

Copper deficiency also causes a microcytic hypochromic anemia that is not responsive to iron supplementation

Micronutrient Micronutrient supplementationsupplementation

It is recommended that all patients following a It is recommended that all patients following a gastric bypass be given iron supplementation with gastric bypass be given iron supplementation with 40 to 65 mg of iron per day40 to 65 mg of iron per day

However women with an existing iron deficiency or However women with an existing iron deficiency or those who are menstruating may require higher those who are menstruating may require higher doses .doses .

Women having a restrictive only procedure ,where Women having a restrictive only procedure ,where digestive continuity is not disrupted, generally do digestive continuity is not disrupted, generally do not experience iron deficiency not experience iron deficiency

. .

Some prescription prenatal vitamin Some prescription prenatal vitamin supplements do contain this level of iron. supplements do contain this level of iron.

It is difficult to find an over-the-counter It is difficult to find an over-the-counter prenatal or a standard adult vitamin with this prenatal or a standard adult vitamin with this level of iron. level of iron.

If an over-the-counter prenatal vitamin is If an over-the-counter prenatal vitamin is selected, it is recommended that an iron selected, it is recommended that an iron supplement is added to total 40 to 60 mg of supplement is added to total 40 to 60 mg of iron per day. This generally prevents iron per day. This generally prevents deficiency in most individualsdeficiency in most individuals

Vitamin Supplementation post RYGBVitamin Supplementation post RYGB

Generally, individuals who take the sublingual B12 Generally, individuals who take the sublingual B12 very rarely develop sub optimal B12 levelsvery rarely develop sub optimal B12 levels

A very small percentage of individuals will still A very small percentage of individuals will still become B-12-deficient, despite oral therapybecome B-12-deficient, despite oral therapy

May require monthly injections on an ongoing basis. May require monthly injections on an ongoing basis.

Supplementation with prenatal vitamins containing 1 Supplementation with prenatal vitamins containing 1 mg of folicacid prior to and during pregnancy is mg of folicacid prior to and during pregnancy is sufficient to maintain adequate serunm levels and sufficient to maintain adequate serunm levels and reduce the risk for neural tube defectreduce the risk for neural tube defect

Calcium deficiency is common and can Calcium deficiency is common and can generally be prevented by consuming generally be prevented by consuming the correct form and amount of calcium. the correct form and amount of calcium.

Calcium citrate is the required form as it Calcium citrate is the required form as it does not require acid to break it down to does not require acid to break it down to be absorbed. be absorbed.

Most supplements contain calcium Most supplements contain calcium carbonate, which is not effective after carbonate, which is not effective after RYGB surgery.RYGB surgery.

Micronutrient supplementationMicronutrient supplementation

It is recommended to take 1200-1500 It is recommended to take 1200-1500 mg of calcium citrate per day. mg of calcium citrate per day.

Tums ® and other calcium carbonate Tums ® and other calcium carbonate supplements are not effective with supplements are not effective with reduced stomach acid. reduced stomach acid.

Periconceptual women Periconceptual women

Folic acid – 1 mgFolic acid – 1 mg Calcuim citrate -1200mg-1500mgCalcuim citrate -1200mg-1500mg Vit D Vit D B12 --- 350 ucg crystallineB12 --- 350 ucg crystalline Ferrous Iron 45-60 mg Ferrous Iron 45-60 mg

IMPLICATIONS FOR IMPLICATIONS FOR PREGNANCYPREGNANCY

PRECONCEPTIONPRECONCEPTION ANTENATALANTENATAL POST PARTUMPOST PARTUM

Preconception Preconception Preconception care is considered preventive Preconception care is considered preventive

carecare Most pregnancies are not planned and first Most pregnancies are not planned and first

prenatal visit occurs after the period of prenatal visit occurs after the period of organogenesis is completedorganogenesis is completed

Women of childbearing age who have Women of childbearing age who have undergone a bypass ,must continue taking undergone a bypass ,must continue taking vitamins so that a deficiency at pregnancy vitamins so that a deficiency at pregnancy onset can be avoidedonset can be avoided

Because anemia is not as common following Because anemia is not as common following restrictive bariatric procedures iron restrictive bariatric procedures iron supplementation is given only when necessary supplementation is given only when necessary

Labs at outsetLabs at outset

Serum iron, total iron binding Serum iron, total iron binding capacity, transferrin saturation, capacity, transferrin saturation, ferritinferritin

Vit b12, red cell folateVit b12, red cell folate Homocysteine and methyl malonic Homocysteine and methyl malonic

acidacid S calcuim S calcuim Copper levelCopper level

Antepartum Antepartum

If pregnancy was planned and If pregnancy was planned and preconception planning was obtained, preconception planning was obtained, the woman is advised to continue the woman is advised to continue taking the prescribed supplements and taking the prescribed supplements and a prenatal vitamin with iron is addeda prenatal vitamin with iron is added

If pregnancy was not planned early If pregnancy was not planned early evaluation and correction of nutritional evaluation and correction of nutritional status should be carried outstatus should be carried out

Anemia in PregnancyAnemia in Pregnancy Hyporegenerative ,reticulocytopenic anemiaHyporegenerative ,reticulocytopenic anemia To compensate for iron for fetal hemoglobin To compensate for iron for fetal hemoglobin

synthesis, to anticipate the losses due to synthesis, to anticipate the losses due to bleedingbleeding

Approximately 4 mg of iron needs to be Approximately 4 mg of iron needs to be absorbed dailyabsorbed daily

Total of 1000 mg of additional iron is needed Total of 1000 mg of additional iron is needed during the course of pregnancyduring the course of pregnancy

This amount is greater than the normal -500 This amount is greater than the normal -500 mg storage iron pool present in most womenmg storage iron pool present in most women

Iron deficient state with low ferritin levels Iron deficient state with low ferritin levels frequently occurs in the motherfrequently occurs in the mother

Deficiencies of iron, folate Deficiencies of iron, folate

Physiological anemia of Physiological anemia of pregnancypregnancy

Iron deficiency anemiaIron deficiency anemia

Oral iron (elemental of 200mg/day) Oral iron (elemental of 200mg/day) Ferrous sulphate tid ( 300 mg of ferrous Ferrous sulphate tid ( 300 mg of ferrous

sulphate =65 mg of elemental iron sulphate =65 mg of elemental iron Iron is best absorbed if given without Iron is best absorbed if given without

foodfood Side effects –constipation, Side effects –constipation,

diarrhoea,nauseau and abdominal pain diarrhoea,nauseau and abdominal pain If these limit compliance the medication If these limit compliance the medication

can be administered with food or the can be administered with food or the dose reduced by one halfdose reduced by one half

Oral Iron therapy Oral Iron therapy

Oral iron therapy usually corrects Oral iron therapy usually corrects the anemia within four to six the anemia within four to six weeks ,oral iron to be continued for weeks ,oral iron to be continued for 3-6 mths for body stores3-6 mths for body stores

Addition of VIT C ,to aid absorbtion Addition of VIT C ,to aid absorbtion have been tried with patients of have been tried with patients of gastric bypassgastric bypass

Ferrous products are effective, but Ferrous products are effective, but they are associated with more they are associated with more gastrointestinal side effects than gastrointestinal side effects than ferric products. ferric products.

Ferric products tend to have lower Ferric products tend to have lower absorption absorption

Parenteral Iron TherapyParenteral Iron Therapy

As patients with a gastric bypass have As patients with a gastric bypass have a true inability to absorb iron.a true inability to absorb iron.

Two forms are available- Two forms are available- Iron –dextran Iron –dextran Infusion at a single visitInfusion at a single visit

Iron dextran can cause severe allergic Iron dextran can cause severe allergic reactions including anaphylaxisreactions including anaphylaxis

pregnancy criteria - Cpregnancy criteria - C

FerrlecetFerrlecet

soduim ferric gluconate-ferrlecetsoduim ferric gluconate-ferrlecet Pregnancy criteria –BPregnancy criteria –B 125 MG/10 ML – Elemental iron125 MG/10 ML – Elemental iron Slowly as 2.1 mg/minSlowly as 2.1 mg/min Weekly dosingWeekly dosing

Response to oral iron can be assesed Response to oral iron can be assesed within 2-3 weeks, if no adequate within 2-3 weeks, if no adequate retic responseretic response

May consider Parenteral iron May consider Parenteral iron especially patients with RYGB especially patients with RYGB

Moniter with iron indices and Moniter with iron indices and ferritin every 2-3 mthsferritin every 2-3 mths

Vit B12 DEF Vit B12 DEF

Deficiency of VIT B12, B6 ,FOLIC ACID Deficiency of VIT B12, B6 ,FOLIC ACID results in elevated levels of homocysteineresults in elevated levels of homocysteine

The presence of hyperhomocysteinaemia may The presence of hyperhomocysteinaemia may be used as a marker in pregnancy to indicate be used as a marker in pregnancy to indicate the increased risk for thrombotic events and the increased risk for thrombotic events and early pregnancy loss early pregnancy loss

Vascular disease of placenta increases.Vascular disease of placenta increases. Important to maintain normal b vitamins and Important to maintain normal b vitamins and

folate levelsfolate levels Protect against recurrent early pregnancy lossProtect against recurrent early pregnancy loss

Complications Complications

maternal complications --- severe anemiamaternal complications --- severe anemia fetal complicationsfetal complications neural tube defectneural tube defect intrauterine growth restrictionintrauterine growth restriction failure to thrivefailure to thrive

Nutrient supplementation following Nutrient supplementation following Bariatric surgery and close supervision Bariatric surgery and close supervision before, during, and after pregnancy can before, during, and after pregnancy can help prevent nutrition-related complications help prevent nutrition-related complications and improve maternal and fetal health.and improve maternal and fetal health.