Pregnancy and Morbid Obesity

Obesity and Pregnancy Health SummitOctober 18, 2011

Michael D. Trahan, MD, FACSMartha Jefferson Surgical Associates

Martha Jefferson Bariatric Care Center

Objectives

Review the implications of morbid obesity on women’s health

Discuss the impact of morbid obesity on pregnancy and childbirth

Clarify the treatment options for morbid obesity including bariatric surgery

Body mass index

5'4"

Hei

gh

t

Weight (lbs)

5'2"

5'0"

5'10"

5'8"

5'6"

6'0"

6'2"

120 130 150 160 170 180 190 200 210 220 230 240 250140 260 270 280 290 300

6'4"

Obesity related comorbidities

Type 2 Diabetes

Hypertension

Heart disease

High cholesterol

Reflux disease

Sleep Apnea

Venous stasis disease

Cancer

Degenerative joint disease

Infertility

Pseudotumor cerebri

Incontinence

Psychosocial problems

Injuries

Gynecologic/obstetric comorbidities

Polycystic ovaryInfertilityCancerStress incontinenceSocialSexual dysfunction

PIHGest diabetesDVTMacrosomiaLow birth weightSpontaneous abIUGRC section rate

Hormones

Low levels of circulating sex hormone-binding globulin– Strongly binds testosterone– Weakly binds estradiol

Peripheral aromatization of androgens in adipocytes

High levels of androgens and estrogens

Hormones

HirsutismIrregular cyclesinfertilityMammary and endometrial hyperplasiaHigher cancer risk

Cleland WH. Endocrinology 1983.

Obstetric complications Pregnancy induced hypertension

– 12% vs 4.8% Gestational diabetes

– 9.5% vs 2.3% Preterm labor

– 5.5% vs 3.3%

Intrauterine growth retardation– 0.8% vs 1.1%

Macrosomia (>4000 g)– 15% vs 8.3%

C-section– 47% vs 21%

Weiss JL. Am J Obstet Gynecol 2004.

Infertility treatment

79 morbidly obese women of >1200 patients over 10 years

IVF cancellation rate: 25% vs 11%Higher BMI correlated with longer need for

gonadotropin stimulationFertilization rate and number of embryos

no different

Dokras A. Obstet Gynecol 2006

Delivery Complications

Cedergren MI. Obstet Gynecol 2004.

Neonatal outcomes

Cedergran, MI. Obstet Gynecol 2004.

How can we lose weight?Low carbohydrate dietLow fat dietLow calorie dietExerciseMedications (Phen-fen, Amphetamines,

Orlistat, Prozac, Wellbutrin)Behavior modification and hypnosis

All have something in common

They don’t work very well for very long3-5% of people succeed in long term weight

loss by diet and exercise aloneThey don’t cure the comorbiditiesMost meds are approved only for short-term

use

Candidates for Bariatric Surgery

BMI ≥ 40 (maybe as low as 35 or even 30 in some circumstances)

Age over 18 Limited comorbidities No substance abuse – alcohol, drugs, tobacco Psychologically stable Strong social support system Realistic outlook on lifestyle modifications Stomach operations (weight loss surgery, reflux or ulcer

operations) 400 pound weight limit

Open Laparoscopic

Not the “Easy way out”

The operation alone is not the key to successful weight loss.

The new anatomic configuration or device is best thought of as a tool for weight loss.

Tools do not do the work for us; they have to be used in the correct situation and with the correct technique to achieve the desired goal.

Not the “Easy way out”

Patients must be committed to life-long, often difficult, alterations in their diets and lifestyles

Bariatric surgery is associated with many serious risks which can be life-threatening

Can be expensive

Surgical Options

Purely Restrictive– Vertical Banded Gastroplasty– Laparoscopic Adjustable Gastric Banding

(Lap-Band®, Realize®)– Sleeve Gastrectomy

Purely Malabsorptive– Jejunoileal Bypass (not done anymore)

Combination– Roux-en-y Gastric Bypass– Biliopancreatic diversion– Duodenal Switch

Lap-Band® or Gastric Bypass

The Gastric Bypass Tool

Small pouch– Cannot physically hold very

much– Stretch receptors provide

feeling of fullness at small volumes

– Can be enlarged over time Expected within reason (4-

6 ounces) Habitually overeating

The Band Tool

Small pouch

The Gastric Bypass Tool (cont)

The narrow opening– Prevents the rapid

emptying of the small pouch to provide longer satisfaction

– This function can be overridden by a mostly liquid diet or by drinking liquids with meals

The Band Tool

Narrow opening

- Adjustable diameter

The Gastric Bypass Tool (cont)

Avoid carbohydrates– About 40% of gastric

bypass patients get dumping syndrome

– Deterrent to eating high carbohydrate foods

The tool (cont)

Malabsorption– Not thought to be a major

component of the weight loss potential of the tool

– Calcium must be supplemented

– Multivitamin must be taken by everyone

– Iron and/or B12 supplement may be necessary

Gastric bypass video

Lap-Band® Video

Realize® Video

Comparing Weight Loss Results

Reference: 1. O’Brien P, McPhail T, Chaston T, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006:16;1032-40.

Laparoscopic adjustable gastric banding (LAGB) provides effective weight loss after 3 years, comparable to that seen with standard gastric

bypass1

*LAGB using the LAP-BAND® System and another adjustable gastric band. Comparison is based on pooled data from 43 peer-reviewed reports involving at least 100 patients at entry and providing at least 3 years postoperative data.

Postoperative changes

After loss of 50% excess weight Regulation of menstrual cycle in 95%-100% Decrease hirsutism Decrease free test., androstenedione, and DHEA Stress incontinence 61% preop to 12% postop Loss of insulin resistance

Deitel M. Am Coll Nutr 1988.

Escobar-Morreale HF. J Clin Endo Metab 2005.

Pregnancy following gastric bypass for morbid obesity

49 pregnancies in 36 women– 36 singleton (3 twin, 2 triplet, 1 elective Ab, 7

spontaneous Ab)– 0 HTN– 1 GD– 13 C section– 4 preterm– 2 Macrosomia

Wittgrove AC. Obes Surg 1998.

Pregnancy following gastric bypass for morbid obesity

17 had been pregnant before surgery– Preterm: 3 vs 2– HTN: 7 vs 0– GD: 4 vs 0– C-S: 6 vs 6– Macrosomia: 7 vs 1– Weight gain: 20.4 kg vs 12.7 kg

Wittgrove AC. Obes Surg 1998.

Birth Outcomes in Obese Women After Laparoscopic Gastric Banding

79 women from 1,382 patients who had a first pregnancy after a Lap-Band

Compared these to the 40 pregnancies in the same group before surgery

Looked at birth weight, PIH, GD, neonatal outcomes

Dixon, et al. Obstet Gynecol 2005

Birth Outcomes in Obese Women After Laparoscopic Gastric Banding

Maternal weight gain * p<0.05

– 9.6 kg in Band patients*– 14.4 kg pre-op patients*

PIH– 45% vs 10%*

GD– 15% vs 6.3%

Preeclampsia– 28% vs 5%*

Neonatal outcomes no different than community

Dixon, et al. Obstet Gynecol 2005

Nutritional needs

All postoperative patients should wait until weight stabilizes (12-18 months) before pregnancy

We recommend secure form of contraception for 2 years At some point that infertile patient starts to ovulate again The Band can be adjusted to manage weight during

pregnancy

Nutritional needs

All patients take daily MVI and calcium citrate Attention to Iron, B12, Folate, Calcium Follow levels and supplement accordingly With gastric bypass the duodenum is bypassed:

supplement iron orally, rarely parenterally B12 supplements available sublingual, nasal, parenteral Calcium deficiency can be manifest by elevated alk phos

and parathyroid hormone

Summary

Morbid obesity results androgen and estrogen excess. Morbid obesity increases the risk of a number of

complications of pregnancy and childbirth. Bariatric surgery results in significant weight loss,

improvement in comorbidities, and reduction in obstetrical complications

Weight counseling should be a routine part of women’s health care and preconception planning

Summary

Bariatric surgery results in significant weight loss, improvement in comorbidities, and reduction in obstetrical complications

Weight counseling should be a routine part of women’s health care and preconception planning

Thanks for Coming!