Transcript Doctor, Why Am I Fat?

Pregnancy and Morbid Obesity
Obesity and Pregnancy Health Summit
October 18, 2011
Michael D. Trahan, MD, FACS
Martha Jefferson Surgical Associates
Martha Jefferson Bariatric Care Center
Objectives
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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
Weight (lbs)
120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300
5'0"
Height
5'2"
5'4"
5'6"
5'8"
5'10"
6'0"
6'2"
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
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Polycystic ovary
Infertility
Cancer
Stress incontinence
Social
Sexual dysfunction
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PIH
Gest diabetes
DVT
Macrosomia
Low birth weight
Spontaneous ab
IUGR
C section rate
Hormones
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Low levels of circulating sex hormonebinding globulin
– Strongly binds testosterone
– Weakly binds estradiol
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Peripheral aromatization of androgens in
adipocytes
 High levels of androgens and estrogens
Hormones
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Hirsutism
 Irregular cyclesinfertility
 Mammary and endometrial hyperplasia
 Higher cancer risk
Cleland WH. Endocrinology 1983.
Obstetric complications
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Pregnancy induced hypertension
– 12% vs 4.8%
Gestational diabetes
– 9.5% vs 2.3%
Preterm labor
– 5.5% vs 3.3%
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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
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79 morbidly obese women of >1200 patients over
10 years
 IVF cancellation rate: 25% vs 11%
 Higher BMI correlated with longer need for
gonadotropin stimulation
 Fertilization rate and number of embryos no
different
Dokras A. Obstet Gynecol 2006
Delivery Complications
Cedergren MI. Obstet Gynecol 2004.
Neonatal outcomes
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Cedergran, MI. Obstet Gynecol 2004.
How can we lose weight?
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Low carbohydrate diet
 Low fat diet
 Low calorie diet
 Exercise
 Medications (Phen-fen, Amphetamines,
Orlistat, Prozac, Wellbutrin)
 Behavior modification and hypnosis
All have something in common
They don’t work very well for very long
 3-5% of people succeed in long term weight
loss by diet and exercise alone
 They don’t cure the comorbidities
 Most meds are approved only for short-term
use
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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
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Open
Laparoscopic
Not the “Easy way out”
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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”
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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
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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
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Expected within reason (46 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
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.
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.
Postoperative changes
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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.
Pregnancy following gastric bypass
for morbid obesity
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49 pregnancies in 36 women
– 36 singleton (3 twin, 2 triplet, 1 elective Ab, 7
–
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–
–
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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
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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
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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
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Maternal weight gain
– 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
* p<0.05
Dixon, et al. Obstet Gynecol 2005
Nutritional needs
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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
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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
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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
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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!