Female Reproductive Issues Following Bariatric Surgery

1
Female Reproductive Issues Following Bariatric
Surgery

• Joseph R. Wax, M.D.
• Professor of Obstetrics and Gynecology
• University of Vermont School of Medicine
• Maine Medical Center
• Portland, Maine

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A Tale of Two Patients

• 25 year old G0 12 months after gastric bypass
• Pre-conception care?
• Pregnancy management?
• 35 year old G3P1011 at 21 weeks with 2 days
  progressive abdominal pain. RYGB 18 months
  earlier.
• Differential diagnosis?
• Evaluation and treatment?

3
Goals

• 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

4
Obesity in American Women
(BMI gt 25)
(BMI gt 30)
62
33
(BMI gt 40 or gt 35 with comorbidity)
7
Ogden, C.L. JAMA 2006
5
Obesity-Related Morbidity
Hypertension Arthritis
Dyslipidemia Sleep Apnea
Diabetes Cancer
CAD -colon
Stroke -breast
Gallbladder -endometrial
Second leading cause of death Second leading cause of death
6
Obesity-Related Obstetrical Morbidity
Infertility Cesarean
Miscarriage Anesthesia
Gestational diabetes Blood loss
Hypertension Wound Infection
Macrosomia
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Recent Trends in Bariatric Surgery

• Almost 20-fold increase last decade
• 2005 gt100,000
• 2006 gt200,000
• 5x as many procedures in women as men
• gt50 of all procedures in reproductive-aged women
• Only effective treatment of morbid obesity

CDC 2006
8
Bariatric Surgery Prerequisites

• Multidisciplinary care
• Attempt non-surgical weight loss
• Preoperative medical evaluation
• Preconception consultation and care

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Bariatric Procedures Roux-en-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
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Roux-en-Y Gastric BypassLaparoscopic vs. Open
Laparoscopic Open
Advantages 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
Disadvantages Increased intra-abdominal complications Ventral hernia formation
Simpfendorfer, C.H. Surg Clin N Am 2005
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Bariatric Procedures Laparoscopic Adjustable
Gastric Banding

• Restrictive
• Lose
• 50 EBW
• 25 BMI
• 0.1 mortality
• 5 morbidity

Buchwald, H. JACS 2005
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Bariatric Procedures Vertical Banded
Gastroplasty

• Restrictive
• Efficacy, morbidity, mortality similar to LAGB

Buchwald, H. Obes Surg 2002
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Perioperative Reproductive Issues

• Rapid weight loss over 12-18 months
• Resolution of
• PCOS
• anovulation
• irregular menses
• Improved fertility and fecundity
• Reliable contraception

Teitelman, M. Obes Surg 2006
Bilenka, B. Acta Obstet Gynecol Scand 1995 Eid,
G. M. Surg Obes Rel Dis 2005 Deitel, M. J
Am Coll Nutr 1988
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Gastric Bypass and Malabsorption

• 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

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Preconception Care

• Avoid MVI with gt 5000 IU vitamin A
• Address other obesity-related comorbidities
• hypertension
• diabetes
• obesity

Rothman, K. M. NEJM 1995
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Late Surgical Complications in Pregnancy Bowel
Obstruction

• 6-8 pregnancies
• -Internal hernia
• -Intussusception
• -Volvulus
• 9-25 months after RYGB
• Delay in diagnosis or treatment ?

2 maternal and 1 fetal death
Wax, J.R. OG Survey 2007
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Bowel Obstruction in Pregnancy

• Nonspecific nature of abdominal complaints
• Confusion with common obstetrical phenomena
• Distracted from inciting event by 2 pancreatitis
• Have low threshold to consult bariatric
  surgeon
• Have low threshold to explore pregnant patient
  for obstruction

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Internal Hernia in Pregnancy

1. Lesser sac into mesocolic tunnel
2. Petersen (below Roux limb)
3. Leaves of small bowel mesentery

Karkala, N OG 2005
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Intussusception in Pregnancy

• 21 weeks gestation
• RYGB 18 months earlier
• Several days abdominal discomfort
• Six hours constant pain
• Suspected internal hernia

Wax, J.R. Obes Surg 2007
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Late Surgical Complications in Pregnancy
Malabsorption

• 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

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Does Gastric Bypass 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
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Malabsorption and Carbohydrates
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Hyperinsulinemic Hypoglycemia

• Diagnosis
• glucose lt 55 mg/dL
• insulin 3 mcU/mL
• c-peptide 0.6 ng/mL
• no sulfonylurea

Halverson, J.D. Surgery 1982
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Hyperinsulinemic Hypoglycemia

• Affects approximately 4 pregnancies
• Treatment Dietary Modification
• Avoid refined/simple sugars
• Increase
• protein
• complex carbohydrates
• Consume liquids well before and after meals
• Consult bariatric nutritionist

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Hyperinsulinemic Hypoglycemia in Pregnancy

• 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
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Managing Dietary Failures

• Rare, no reports in pregnancy
• Reversal of bariatric procedure
• Partial or total pancreatectomy

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Dumping 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
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Dumping Syndrome Early Phase (10-30 min)

• palpitations
• syncope
• diaphoresis
• flushing
• headache

• nausea
• diarrhea
• cramping
• bloating

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Dumping Syndrome Late Phase(1-3 hrs)
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Dumping Syndrome Treatment

• Dietary Modification
• Avoid refined/simple sugars
• Increase
• protein
• complex carbohydrates
• Consume liquids well before and after meals

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Managing Dietary Failures

• 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

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Dumping Syndrome Implications for Pregnancy

• Avoid glucose challenge test
• Home glucose monitoring
• 1-2 weeks at 26-28 weeks
• treat if consistently elevated

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Pregnancy Outcomes After 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

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Pregnancy after LAGB
Outcome Martin (n23) Weiss (n7) Skull (n49) Dixon (n79)
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. matched
obese controls
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Pregnancy After RYGB
Outcome Printen (n54) Wittgrove (n36) Richards (n57) Patel (n26)
SAB 2 (4.2) - - 0
CS 4 (8.7) 0 0 ?
BW 1078-4230g - ? 0
4 kg - ? ? 0
lt 2.5 kg 7 (18.4) - 0 0
Preterm 7 (15.2) 0 0 0
Wt gain - ? ? 0
DM - ? 0 0
HTN - ? ? 0
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Pregnancy After RYGB
Outcome Crude OR (95 CI) Adjusted OR (95 CI)
Hypertension 3.67 (1.36, 9.92) 2.62 (0.66, 10.50)
PPROM 0.33 (0.04, 2.77) 0.24 (0.02, 3.38)
Oligohydramnios 2.00 (0.65, 6.20) 2.39 (0.66, 8.61)
Gestational age gt 41 wks 0.50 (0.11, 2.36) 0.57 (0.11, 2.97)
adjusted for BMI at delivery
Wax, J.R. et al Obes Surg 2008
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Pregnancy After RYGB- Impact of 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
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Pregnancy After LAGB/RYGB
Compared to Pre-Surgical Pregnancy Compared to Pre-Surgical Pregnancy Compared to Pre-Surgical Pregnancy
Less Similar Unclear
Wt gain CS SAB
DM BW Growth restriction
HTN Preterm
BW 4kg
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Bariatric Surgery and the Puerperium

• Weight loss
• limited descriptive data
• rate similar to nonbariatric delivered patients
  and nonpregnant bariatric patients

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Bariatric Surgery and Lactation

• Not contraindicated
• Ensure maternal B12 supplementation
• several cases of neonatal B12 deficiency

Grange, D.K. Pediatr Hematol Oncol 1994 Campbell,
C.D. Haematologica 2005
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Summary

• 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

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Future Research

• Pregnancy outcome
• by specific bariatric procedure
• account for
• past pregnancy complications
• persistent obesity
• obesity-related comorbidities
• congenital anomalies (ONTDs)

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Guidelines for Care
Preconception Reliable contraception through period of maximal weight loss Evaluate and treat comorbidities Evaluate and treat micronutrient deficiencies (B12, folate, iron) Meet with bariatric surgeon and nutritionist, preconception consultation with Ob/Gyn or Maternal-Fetal Medicine Folic acid, B12 and iron supplementation
Pregnancy Folic acid, B12 and iron supplementation Second trimester MSAFP Consider monthly growth ultrasounds after 20 weeks Monitor for signs and symptoms of hypoglycemia Avoid NSAIDS if history of ulcer
Puerperium Folic acid, B12 and iron supplementation Breast feeding compatible with bariatric surgery Notify 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