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