The number of bariatric surgeries performed in the United States has risen exponentially. Given that the majority of patients are female and of reproductive age, it is important for clinicians who manage women’s health issues to be aware of the surgery, its long term goals, and the potential effect on future pregnancies. Weight-loss surgery, also known as bariatric surgery, is a significant intervention for individuals struggling with severe obesity. With the rise in obesity rates, more women of reproductive age are undergoing these procedures, making it crucial to understand the impact of weight-loss surgery on pregnancy. This article provides a comprehensive overview of the risks and considerations for women who become pregnant after bariatric surgery, offering guidance on how to ensure a healthy pregnancy and outcome.
What is Weight-Loss (Bariatric) Surgery?
Bariatric surgery is designed to help individuals lose weight by making the stomach smaller. This type of surgery is only used for people who are very overweight and have not been able to lose weight with diet and exercise. Some types of surgery also change the connection between your stomach and intestines. This surgery is typically recommended for individuals with a body mass index (BMI) > 40 kg/m2 or a BMI > 35 kg/m2 with other co-morbid conditions. Bariatric surgery promotes weight loss via restriction (limits the amount of food ingested), malabsorption (bypasses parts of the small intestine) or a combination of both.
Having weight-loss surgery is a big step. After surgery, you'll need to make new, lifelong changes in how you eat and drink.
Common Types of Bariatric Surgery
In the United States, the most common procedures performed today are the Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD). These can be performed either via laparoscopy or laparotomy.
Roux-en-Y Gastric Bypass (RYGB): This combined procedure divides the stomach and creates a gastric pouch that holds <30 mL (restrictive portion). The jejunum is then divided distal to the ligament of Treitz with the distal segment anastomosed to the gastric pouch.
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Adjustable Gastric Banding (AGB): In this restrictive surgery, an inflatable band is placed below the gastroesophageal junction and connected with a tube to an injection port, leaving a gastric pouch of 50 mL. Some weight-loss surgery teams may adjust your gastric band if you are pregnant, by removing fluid from it, and you may gain weight as a result.
Sleeve Gastrectomy (VSG): A type of weight-loss surgery where part of the stomach is removed, making it much smaller and shaped like a sleeve or tube.
How Weight-Loss Surgery Affects Pregnancy
If you had weight-loss surgery, experts suggest waiting for 1 to 2 years after the surgery to get pregnant. This surgery helps people lose a lot of weight quickly. Getting pregnant too soon after surgery could mean that a growing baby might not get needed nutrients. Because the greatest weight loss occurs in the first 12-18 months after surgery, this has prompted several societies and authors to recommend waiting at least 12 months prior to conception. This is based on the theory that a pregnancy occurring during a period of malnutrition could lead to adverse outcomes such as low birth weight or malformations. Several studies have compared outcomes between pregnancies conceived early (i.e. < 12 months after surgery) vs. late (i.e. >12 or >18 months after surgery. These studies have not found significant differences in perinatal outcomes between the two time periods.
Benefits of Weight-Loss Surgery Before Pregnancy
Weight-loss surgery before pregnancy can offer several benefits:
Improved Fertility: Help you get pregnant if obesity was the reason you had trouble getting pregnant. Infertility problems, one of the obesity related co-morbidities, commonly improve after weight loss from bariatric surgery procedures.
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Reduced Pregnancy Complications: Lower your chance of some pregnancy problems. These include high blood pressure and gestational diabetes.
Healthier Weight Gain: Reduce how much weight you gain during pregnancy.
Lower Risk of Cesarean Section: It might also reduce your risk of needing a caesarean section (C-section).
Potential Risks and Considerations
Despite the benefits, pregnancy after bariatric surgery requires careful management due to potential risks:
Nutritional Deficiencies: Weight-loss surgery can make it hard for your body to absorb some nutrients, such as folic acid, calcium, vitamin B12, and iron. Perhaps the greatest concern for a pregnancy after bariatric surgery is maternal nutrition. In general, anemia is a common complication after RYGB surgery and iron deficiency is a common etiology for this. Nutritional deficiencies are also common in pregnancies after bariatric surgery. For these reasons, ensuring appropriate maternal nutrition before and after delivery takes precedence in prenatal care.
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Dumping Syndrome: Dumping syndrome can occur after ingestion of refined sugars and high-glycemic carbohydrates in patients who have had gastric bypass surgery. Symptoms include abdominal cramping, bloating, nausea, vomiting, and diarrhea. Women with dumping syndrome may not tolerate the 50-g glucose solution typically administered to screen for gestational diabetes.
Surgical Complications: The literature continues to describe case reports of surgical complications during pregnancies after bariatric surgery including adhesions, internal hernias, small intestine ischemia, and band slippage. Unfortunately there are no preventive measures to avoid these complications and they are known to occur in a small percentage of patients after bariatric surgery.
Prenatal Care After Weight-Loss Surgery
In most ways, your prenatal care will be the same as for other pregnancies. But there are a few differences. You may need to keep seeing the doctor who did your surgery. This is to make sure that you aren’t having any delayed problems from the surgery.
Key Components of Prenatal Care
Multidisciplinary Team: The bariatric team is multidisciplinary and includes surgeons, psychologists, nutritionists, nurses, patient educators, endocrinologists, and cardiologists. Similar to management in preparation for and after bariatric surgery, the approach during pregnancy should continue to be multidisciplinary with an emphasis on consultations from the nutritionist and surgeon. You must let your midwife and consultant know about your weight-loss surgery.
Nutritional Guidance: A dietitian may work with you to make sure you're getting the nutrition you need and to help you plan meals. Your weight-loss surgery team can give you guidance on your diet and the supplements you’re taking to make sure you’re on the right track. Your midwifery team also needs to know what diet advice you’ve been given by your weight-loss surgery team, so don’t forget to tell them.
Vitamin and Mineral Supplementation: You may need to take extra vitamins and minerals. You will need vitamin and mineral supplements if you get pregnant after any type of weight-loss surgery. You may also need regular blood tests to check your nutrient levels during each trimester. Talk to your healthcare team about what vitamin and mineral supplements you will need and how your blood levels will be monitored during pregnancy.
Specific Nutritional Recommendations
Folic Acid: All pregnant women and birthing people are advised to take 400mcg of folic acid every day until they are 12 weeks pregnant. Folic acid can help prevent birth defects known as neural tube defects, including spina bifida.
Iron: Empiric iron supplementation is recommended.
Calcium: Calcium carbonate is available in chewable forms but should be taken with meals to enhance absorption. Calcium citrate preparations are preferred in bariatric surgery patients because they are better absorbed when gastric acid production is diminished.
Monitoring and Testing
Periodic clinical and biochemical monitoring is recommended after malabsorptive types of bariatric surgery even if patients tolerate their diet well without vomiting or diarrhea. This is so that subclinical nutritional deficiencies can be detected prior to the development of overt deficiencies. Testing includes a complete blood count, glucose, electrolytes, and creatinine every 3 months for the first year after surgery and tests for nutritional deficiencies (albumin, iron, vitamin B12, folate, calcium, and vitamin D) every 6 months in the first year and then repeated yearly. In pregnancy, one option is to perform these tests once a trimester if the levels are normal. Contact your weight-loss surgery team for guidance and to arrange other types of tests or monitoring.
Managing Gestational Diabetes Screening
If you had bypass surgery, you are not advised to have an OGTT as there is a risk of having a reaction called ‘dumping syndrome’. As such, an alternative method to the 50g glucola for gestational diabetes screening is recommended.
Maintaining a Healthy Pregnancy
Making healthy choices can help you have a healthy pregnancy after weight-loss surgery. Here are two of the most important things you can do.
Diet and Nutrition
Eating well is crucial. Talk with your doctor, midwife, or a dietitian about what to eat and when and how much you can eat after surgery. Keeping a food diary may help you keep track of the types and amounts of food you eat. It is natural to gain some weight when you are pregnant. This is because your baby is growing and surrounded by amniotic fluid and placenta. Chat with your midwife and weight-loss surgery team about how you feel so they can support and advise you.
You may worry that if you eat less after surgery, you won’t be getting enough food to support your baby’s development. But this is unlikely because your baby takes what they need for growth from you. You do not need to eat any extra food in the first 2 trimesters of pregnancy. How you eat is likely to differ from before you had surgery. You may be used to taking vitamin and mineral supplements every day. Ask them about anything that worries you and follow their advice on healthy eating.
If it has been 18 months or more since your surgery, and your weight is now stable, you may need to look after your weight in the same way as the average person does.
Although nausea and/or sickness in early pregnancy are common, vomiting in pregnancy following weight-loss surgery should be checked out.
Physical Activity
Be active. Swimming and walking are good choices. If you weren't very active before you were pregnant, talk to your doctor or midwife about how you can slowly get more active.
Emotional Well-being
Some people may have a hard time with the idea of gaining weight for pregnancy after losing all that weight. I worked so hard to lose weight that, although I was thrilled to be pregnant, I was also scared that my body would be out of control again. Pregnancy can cause weird and wonderful changes to your body. Talk to your doctor or midwife if this bothers you.
Labor and Delivery Considerations
Bariatric surgery should not affect the management of labor and delivery. Although rates of cesarean delivery are higher in women who have had bariatric surgery, it is not an indication for cesarean delivery.
Breastfeeding
Many of my pregnant patients ask whether it's OK to breastfeed their baby. I tell them that breastfeeding is encouraged and that their ability to do so isn't usually affected by their surgery.
Special Considerations for Obese Patients
If you have a BMI over 30, you will be monitored more carefully by your midwifery team because there is a higher risk of pregnancy related complications, such as increased blood pressure, gestational diabetes and blood clots.