Transcript Gastric Bypass Implications and Complications in Pregnancy

Weight-Loss Surgery
for Obesity:
Implications and
Complications in Fertility and
Pregnancy
Leslie McLemore, MD
June 18th 2010
Definition and Epidemiology of Obesity
Effect of Obesity on Fertility and Pregnancy
Bariatric Surgery
•Indications
•Types of Procedures
Effects of Bariatric Surgery
•Fertility
•Pregnancy
How to counsel/manage patients
•Preconception
•Antepartum
Obesity
Normal
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2008
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1990
1999
2008
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
20
07
20
05
20
03
20
01
19
99
-2
00
8
-2
00
6
-2
00
4
-2
00
2
-2
00
0
Percent of Women
Age 20-39
Obesity in Women
Age 20-39
40%
35%
30%
25%
20%
15%
10%
5%
0%
BMI>40
BMI>35
BMI>30
Obesity by Race
60
Percent of Women
Age 20-39
50
40
All
30
White
Black
20
Mexican
American
10
0
19
9
0
9-2
00
20
0
0
1-2
02
20
0
0
3-2
04
20
0
0
5-2
06
20
0
0
7-2
08
Definition and Epidemiology of Obesity
Effect of Obesity on Fertility and Pregnancy
Bariatric Surgery
•Indications
•Types of Procedures
Effects of Bariatric Surgery
•Fertility
•Pregnancy
How to counsel/manage patients
•Preconception
•Antepartum
Obesity and Fertility

BMI >23.9 associated with subfertility
(Nurses Health Study 1994)

BMI >27 RR 3.1 of anovulatory subfertility
(Grodstein et al. 1994)

Prolonged time to pregnancy in women
with BMI >25 (Hassan & Killick 2004)
Obesity and Fertility

Hormonal
Leptin/Insulin

Ovulatory/Ovarian

Endometrial

Psychosocial
Brewer and Balen 2010 Reproduction
Obesity and Pregnancy
Complication
Risk with
Obesity
Type of Study
O’Brien et al.
2008
Pre-Eclampsia
Risk doubled
with each 5-7
kg/m2 increase
Gestational
Diabetes
OR 3.01 (2.34-3.87) Systematic
Review
Meta-analysis
Torloni et al.
2009
Cesarean
Delivery
OR 2.26 (2.04-2.51) Systematic
Review
OR 2.23 (2.07-2.42) Meta-analysis
Poobalan et al.
2009
Emergency C/S
Systematic
Review
Reference
Obesity and Pregnancy
Complication
Risk with Obesity
Instrumented
Delivery
OR 1.17 (1.13-1.21)
Hemorrhage
Infection
NICU admission
OR 1.20 (1.16-1.24)
OR 3.33 (2.74-4.06)
OR 1.38 (1.16-1.64)
Congenital
anomalies
NTD
CV anomalies
Cleft lip/palate
Anorectal
atresia
Hydrocephaly
Limb reduction
OR 1.87 (1.62-2.15)
1.30 (1.12-1.51)
1.20 (1.03-1.47)
1.48 (1.12-1.97)
1.68 (1.19-2.36)
1.34 (1.03-1.73)
Type of Study
Reference
Meta-analysis
Heslehurst et al.
2008
Systematic
Review
Meta-analysis
Stothard et al. 2009
Definition and Epidemiology of Obesity
Effect of Obesity on Fertility and Pregnancy
Bariatric Surgery
•Indications
•Types of Procedures
Effects of Bariatric Surgery
•Fertility
•Pregnancy
How to counsel/manage patients
•Preconception
•Antepartum
Indications for Bariatric
Surgery





BMI > 40
BMI ≥ 35 with comorbidity (diabetes, heart
disease, sleep apnea)
Overweight for more than five years
Unsuccessful, serious attempts to lose
weight
Be willing to make changes in their eating
habits and lifestyle
Who Gets Bariatric Surgery?

83% Female

60% White

78% Private
Insurance
Pratt et al. 2009 Surg Endosc
Types of Bariatric Surgery

Restrictive




Malabsorptive



Adjustable gastric banding*
Vertical banded gastroplasty
Sleeve gastrectomy
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch
Restrictive/Malabsorptive

Roux-en-Y*
* Performed at UW
Adjustable Gastric Banding
Vertical Banded Gastroplasty
Sleeve Gastrectomy
Biliopancreatic Diversion
Biliopancreatic Diversion with
Duodenal Switch
Roux-en-Y
Complications of Bariatric
Surgery







Ventral hernia
Gall stone disease
Stricture
Band slippage
Pouch enlargement
Small bowel
obstruction
Nutritional
deficiencies









Band erosion
Leaks
Wound infection
Stomal stenosis
Staple line failure
Esophageal dilation
Vomiting
Diarrhea
Internal hernia
Complications of Bariatric
Surgery

Phase 1 (0-6 wks): bleeding, staple line
leak, perforation, obstruction, infections

Phase 2 (7-12 wks): psychological (effects
of eating patterns), vomiting, dumping

Phase 3 (>12 wks): cholelithiasis, small
bowel obstruction
Definition and Epidemiology of Obesity
Effect of Obesity on Fertility and Pregnancy
Bariatric Surgery
•Indications
•Types of Procedures
Effects of Bariatric Surgery
•Fertility
•Pregnancy
How to counsel/manage patients
•Preconception
•Antepartum
Does Bariatric Surgery Improve
Fertility?
IMPAIRS
IMPROVES
Merhi 2009 Fertility and Sterility
Does Bariatric Surgery Improve
Fertility?
Study
Surgery
Weight loss
Pregnancy
Eid et al 2005
Roux-en-Y
57% ↓
5/24
Deitel et al 1988 Not specified
≥ 50%
9/30
Bilenka et al
1995
Marceau et al
2004
VBG
Mean 36kg
5/6
BPD
Mean 42kg
15/32
Martin et al
2000
Sheiner et al
2006
AGB
Mean
5/5
10.6kg
Increased use of infertility treatments in
patients with bariatric surgery
Pregnancy Outcomes




Lack of consistent
data
Lack of controlled
studies
Matched cohort
studies suggest less
GDM/HTN/Pre-E
C/S rate the same or
increased
Maggard et al 2008 JAMA
Pregnancy Outcomes
Procedure
Control
Outcome
Result
LAGB
Consecutive
pregnancies
BMI >30
Gastric
Bypass
Non-surgery
GDM
Pre-E
PIH
IOL
PIH
0 vs. 22%
0 vs. 3.1%
No difference
No difference
68 vs. 26%
Previous
pregnancy
GDM
PIH
C-section
0 vs. 24%
0 vs. 41%
No difference
Community
GDM
Pre-E
C-section
9.4 vs. 5%
No difference
25 vs. 12%
Mixed
Neonatal outcomes

Congenital anomalies


Lower mean birth
weight


= to general
population
Compared to obese
women
No increase in
perinatal death
Maggard et al 2008 JAMA
Definition and Epidemiology of Obesity
Effect of Obesity on Fertility and Pregnancy
Bariatric Surgery
•Indications
•Types of Procedures
Effects of Bariatric Surgery
•Fertility
•Pregnancy
How to counsel/manage patients
•Preconception
•Antepartum
Counseling
Is pregnancy desired?
NO
Yes
Contraception
Preconception
Contraception
Preconception Counseling

Current morbidities?

Time from surgery?

Compliance with
supplements?
Antepartum Management

Nutrition assessment and
supplementation

Weight gain recommendations

Diabetes screening

Medication absorption

Complications

Fetal surveillance
Nutrition
Consumption
Stomach acid
Absorption
Bloomberg et al. 2005 Obesity Surgery
• Iron
• Calcium
• Thiamine
• Folic Acid
• Vitamins A, D, K
Recommendations for Weight
Gain
Diabetes Screening
50g, 1hr GTT
For bariatric surgery patients:
≥140
100g, 3hr GTT
Fasting: less than 95 mg/dL
1 hour: less than 180 mg/dL
2 hour: less than 155 mg/dL
3 hour: less than 140 mg/dL
Home glucose monitoring Fasting & 2 hr post-prandial x
1wk
Medications

NSAIDs: Preterm labor/short cervix


↑ risk of ulcer
Antibiotics: PPROM, UTI, pyelonephritis
↓ absorption
 Avoid extended release formulations

Complications Requiring
Surgery

Cholelithiasis

Persistent nausea
and vomiting, weight
loss

Internal hernias
Complications Requiring
Surgery
Fetal Surveillance

No guidelines

Consider for:


Nutritional concerns
Inaccurate fundal
height
Conclusions

Increase in obese population = increase in
number of bariatric surgeries

Reproductive-age women are the largest
population of bariatric surgery patients

Appropriate contraceptive counseling is
necessary.
Conclusions

Pregnancy after bariatric surgery is safe.

Consult with nutritionist.

Early consultation with bariatric surgeon for
patients with adjustable band.

High index of suspicion for internal hernia with
complaint of abdominal pain.
References
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Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin clin Nutr Metab
Care. 2004;7:569-575
Baeten JM, Bukusi EA, Lambe M. Pregnancy Complications and Outcomes Among Overweight
and Obese Nulliparous Women. Am J Public Health. 2001;91:46-440
Beckman LM, Beckman TR, Earthman CP. Changes in Gastrointestinal Hormones and Leptin
after Roux-en-Y Gastric Bypass Procedure: A Review. J Am Deit Assoc. 2010;110:571-584
Bloomberg RD, Fleishman A, Nalle J, et al. Nutritional Deficiencies following Bariatric Surgery:
What Have We Learned? Obes Surg 2005;15:145-154
Brewer CJ, Balen AH. The adverse effects of obesity on conception and implantation.
Reproduction 2010 (Ahead of print, manuscript REP-09-0568)
Chu SY, Kim SY, Schmid CH et al. Maternal obesity and risk of cesarean delivery: a metaanalysis. Obesity reviews 2007;8:385-394
Colquitt JL, Picot JL, Clegg AJ. Surgery for obesity. Cochrane Database of Systematic Reviews
2009, Issue 2. Art. No.:CD003641
Coustan DR. A 40-year-old Woman With Diabetes Contemplating Pregnancy After Gastric Bypass
Surgery. JAMA 2008;299(21):2550-2557
Edmiston CE, Krepel C, Kelly H, et al. Perioperative antibiotic prophylaxis in the gastric byass
patient: Do we achieve therapeutic levels? Surgery 2004;136:738-747
Eerdekens A, Debeer A, Van Hoey G, et al. Maternal bariatric surgery: adverse outcomes in
neonates. Eur J Pediatr 2010;169:191-196
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middle trimester pregnancy resulting in fetal loss: risk of internal hernia never ends. Surgery for
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References (cont.)
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Faintuch J, Dias MCG, et al. Pregnancy Nutritional Indices and Birth Weight After Roux-en-Y
Gastric Bypass. Obes Surg 2009;19:583-589
Gagne DJ, DeVoogd K, Rutkoski JD, et al. Laparoscopic repair of internal hernia during
pregnancy after Roux-en-Y gastric bypass. Surgery for Obesity and Related Diseases 2010;6:8892
Gosman GG, King WC, Schrope B, et al. Reproductive health of women electing bariatric
surgery. Fertility and Sterility 2009 (Article in Press)
Heslehurst N, Simpson H, Ells LJ. The impact of maternal BMI status on pregnancy Obesity
reviews 2008;9:635-683
Lier HO, Biringer E, Stubhaug B, et al. Psychiatric Disorders and Participation I re- and
Postoperative Counseling Groups in Bariatric Surgery Patients. Obes Surg 2010 (online
publication)
Magee SR, Shih G, Hume A. Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery. JABFM 2007;20:310-313
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Merhi ZO. Impact of bariatric surgery on female reproduction. Fertility and Sterility 2009;92:15011507
Metwally M, Ong KJ, Ledger WL, et al. Does high body mass index increase the risk of
miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence.
Fertility and Sterility 2008;90(3):714-726
Moliterno JA, DiLuna ML, Sood S, et al. Gastric Bypass: a risk factor for neural tube defects? J
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References (cont.)
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O’Brien TE, Ray JG, Chan WS. Maternal Body mass Index and the Risk of Preeclampsia: A
Systematic Overview. Epidemiology 2003;14:368-374
Pardela M, Wiewiora M, Sitkiewicz T, Wylezol M. The Progress in Bariatric Surgery. Journal of
Physiology and Pharmacology 2005;56:Supp6, 35-44
Poobalan AS, Aucott LS, Gurung T, et al. Obesity as an independent risk factor for elective and
emergency caesarean delivery in nulliparous women – systematic review and meta-analysis of
cohort studies. Obesity reviews 2009;10:28-35
Scheen AJ, De Flines J, De Roover A, Paquot N. Bariatric surgery in patients with Type 2
diabetes: benefits, risks, indications and perspectives. Diabetes and Metabolism 2009;35:537543
Sheiner E, Balaban E, Dreiher J, et al. Pregnancy Outcome in Patients Following Different Types
of Bariatric Surgeries. Obes Surg 2009;19:1286-1292
Stothard KJ, Tennant PWG, Bell R, Rankin J. Maternal Overweight and Obesity and the Risk of
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QUESTIONS?