Pregnancy and bariatric surgery - TOG article

Question 1

How long should patients wait to get pregnant following bariatric surgery?

Answer 1

12-18 months due to rapid weight loss and when nutritional deficiencies/electrolyte imbalance arises

Though evidence not different/conclusive re: outcomes

Question 2

How many women who died of direct causes and indirect causes in 2006-2008 were overweight or obese?

Answer 2

Direct - 47%
Indirect - 50%

(Overall 49%)

Question 3

What is the prevalence of obesity in women of reproductive age?

Answer 3

28%

Question 4

What are the top 5 maternal and fetal risks in obese women by odds ratio?

Answer 4

Thromboembolism - 9.7
GDM - 3.6
Spontaneous abortion - 3.5
Shoulder dystocia - 3.14
Stillbirth - 2.79

Question 5

When does NICE recommend bariatric surgery?

Answer 5

BMI >40 where lifestyle and/or medications have been found to be ineffective

Question 6

What types of bariatric surgery are there?

Answer 6

Restrictive 
- *Laparoscopic adjustable gastric banding
- Silastic ring
- Vertical-banded gastroplasty
- Sleeve gastrectomy
Malabsorptive
- Biliopancreatic diversion
- Jejunoileal bypass
Mixed
- *Roux en Y gastric bypass 

• • lower complication rates. 5%

Question 7

How many require fertility treatment following bariatric surgery?

Answer 7

6.7%

Question 8

Which nutritional deficiencies are seen following surgery (particularly malabsorptive)?

Answer 8

B12* and folate* 
Plasma protein levels
Iron*
Calcium*
Fat soluble vitamins
- *supplements required

Also - dumping syndrome with excessive carb diet or GTT

Deficiency exacerbated by nausea and vomiting

Question 9

What is the ideal gestational weight gain in pregnancy?

Answer 9

7-11kg

Question 10

What are the surgical complications during pregnancy?

Answer 10

Band slippage and migration => vomiting
Band leakage 24%
Gastric prolapse 4% (needing removal at laparotomy)
Intestinal hernia (8%) and obstruction; perforation and death
Consider diagnosis when having pain and vomiting

Question 11

How many women following surgery complete 37/40 and have uncomplicated pregnancies?

Answer 11

76 and 79% respectively

Question 12

What are the OR for PET and chronic hypertension following surgery?

Answer 12

0.2 and 0.4 respectively

Question 13

How should women be screened for GDM following bariatric surgery?

Answer 13

Fasting and 2 hr post prandial BMs at home for a week at 26-28/40

Question 14

Does bariatric surgery reduce the rate of Caesarean?

Answer 14

No - ?caregiver bias

Infection risk

Question 15

How does morbid obesity contribute to a reduction in breastfeeding?

Answer 15

Positional difficulties
Reduced prolactin response to suckling
Malabsorption in mum may affect energy content of milk ?PN growth affected (nutritional supplements to continue)

Question 16

What are the perinatal outcomes following surgery?

Answer 16

?Higher incidence of spontaneous miscarriage
No difference in perinatal mortality rates or preterm births
?Reduced birthweight
Congenital malformations higher - diaphragmatic herina, intestinal obstruction, recal atresia (0.4%), NTDs (0.8%)
?PROM

Question 17

How many women undergo plastic surgery following bariatric surgery?

Answer 17

12%

Advise to wait until after family complete

Question 18

Which type of surgery has shown low plasma levels or the COCP?

Answer 18

Jejuno-ileal bypass surgery

Question 19

How many women may require parenteral nutrition following biliopancreatic diversion?

Answer 19

21%

Question 20

What are the antenatal considerations in management following surgery?

Answer 20

MDT
Nutritional status and supplementation
Weight every visit to monitor gestational weight gain
Anaesthetic and paediatric alerts
Fasting/2hr BMs at 26-28/40
Screen for NTDs and serial growth scans
Consider diagnosis of intestinal obstruction when presenting with pain and vomiting
Assess for LMWH

Question 21

What is the mortality rate of bariatric surgery?

Answer 21

0.1-1.1% mortality

Question 22

What long term weight loss can be achieved with bariatric surgery?

Answer 22

14-25%