Abstract
Introduction
Methods
A review of the literature using PubMed was conducted in August 2013. Search topics included pregnancy after bariatric surgery, adverse effects of bariatric surgery on pregnancy, and care of pregnant bariatric surgery patients. Web site searches included the same terms using the Google search engine. Journal articles were selected on relevance to the nutritional and medical management of women who become pregnant after bariatric surgery. This list includes official guidelines and both comprehensive review articles and randomized controlled trials concerning maternal and infant complications in the population of interest.
Bibliographic Findings
Major themes
• Appropriate weight gain, by Institute of Medicine (IOM) recommendations, is often challenging due to decreased consumption and nausea/vomiting. A focus on adequate protein intake is especially important.
• The likelihood of nutrient deficiencies depends upon the procedure performed (in ascending order):
○ Adjustable gastric banding ○ Vertical sleeve gastrectomy ○ Roux-en-Y gastric bypass ○ Bilio-pancreatic diversion.
• Screen for key nutrients (iron, folate, vitamin B12, vitamin D, and calcium) every 6 months during the first year after bariatric surgery, and annually thereafter.
• Supplement with a daily multivitamin plus additional iron (50–100 μg total per day), calcium (1,500–2,000 mg/day), vitamin D (2,000 IU), and vitamin B12 (1,000 μg/month IM).
• Pregnancy should be delayed until 12–18 months after a malabsorptive procedure to avoid the period of greatest weight loss.
Published guidelines
Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009;17:S1–70, v.
American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009;113:1405–1413. Available at www.guideline.gov/content.aspx?id=14683. Accessed August 1, 2013.
Web sites
ACOG Committee Opinion on Obesity in Pregnancy (Bariatric Surgery Section). Available at www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Obesity_in_Pregnancy. Accessed August 1, 2013.
Available at www.brighamandwomens.org/Patients_Visitors/pcs/nutrition/services/healtheweightforwomen/special_topics/Pregnancy_After_WeightLoss_Surgery.aspx?subID=submenu10. Accessed August 1, 2013.
Journal articles
Kominiarek MA. Preparing for and managing a pregnancy after bariatric surgery. Semin Perinatol 2011;35:356–361.
Bal BS, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol 2012;8:544–556.
Blume CA, Boni CC, Casagrande DS, Rizzolli J, Padoin AV, Mottin CC. Nutritional profile of patients before and after Roux-en-Y gastric bypass: 3-year follow-up. Obes Surg 2012;22:1676–1685.
Faintuch J, Dias MC, de Souza Fazio E, et al. Pregnancy nutritional indices and birth weight after Roux-en-Y gastric bypass. Obes Surg 2009;19:583–589.
Guelinckx I, Devlieger R, Donceel P, et al. Lifestyle after bariatric surgery: a multicenter, prospective cohort study in pregnant women. Obes Surg 2012;22:1456–1464.
Kjaer MM, Lauenborg J, Breum BM, Nilas L. The risk of adverse pregnancy outcome after bariatric surgery: a nationwide register-based matched cohort study. Am J Obstet Gynecol 2013;208:464.e1–464.e5.
Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am 2010;39:109–124.
Kominiarek MA. Preparing for and managing a pregnancy after bariatric surgery. Semin Perinatol 2011;35:356–361.
Lesko J, Peaceman A. Pregnancy outcomes in women after bariatric surgery compared with obese and morbidly obese controls. Obstet Gynecol 2012;119:547–554.
Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008;300:2286–2296.
Magdaleno R Jr, Pereira BG, Chaim EA, Turato ER. Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges. Arch Gynecol Obstet 2012;285:559–566.
Nomura RM, Dias MC, Igai AM, Paiva LV, Zugaib M. Anemia during pregnancy after silastic ring Roux-en-Y gastric bypass: Influence of time to conception. Obes Surg 2011;21:479–484.
Poitou Bernert C, Ciangura C, Coupaye M, Czernichow S, Bouillot JL, Basdevant A. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab 2007;33:13–24.
Ruz M, Carrasco F, Rojas P, et al. Iron absorption and iron status are reduced after Roux-en-Y gastric bypass. Am J Clin Nutr 2009;90:527–532.
Schweitzer DH, Posthuma EF. Prevention of vitamin and mineral deficiencies after bariatric surgery: evidence and algorithms. Obes Surg 2008;18:1485–1488.
Shankar P, Boylan M, Sriram K. Micronutrient deficiencies after bariatric surgery. Nutrition 2010;26:1031–1037.
Sheiner E, Edri A, Balaban E, Levi I, Aricha-Tamir B. Pregnancy outcome of patients who conceive during or after the first year following bariatric surgery. Am J Obstet Gynecol 2011;204:50.e1–50.e6.
Sheiner E, Levy A, Silverberg D, et al. Pregnancy after bariatric surgery is not associated with adverse perinatal outcome. Am J Obstet Gynecol 2004;190:1335–1340.
Vargas-Ruiz AG, Hernandez-Rivera G, Herrera MF. Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2008;18:288–293.
Wax JR, Cartin A, Wolff R, Lepich S, Pinette MG, Blackstone J. Pregnancy following gastric bypass for morbid obesity: effect of surgery-to-conception interval on maternal and neonatal outcomes. Obes Surg 2008;18:1517–1521.
Weintraub AY, Levy A, Levi I, Mazor M, Wiznitzer A, Sheiner E. Effect of bariatric surgery on pregnancy outcome. Int J Gynaecol Obstet 2008;103:246–251.
Weiss HG, Nehoda H, Labeck B, Hourmont K, Marth C, Aigner F. Pregnancies after adjustable gastric banding. Obes Surg 2001;11:303–306.
Xanthakos SA. Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009;56:1105–1121.
Ziegler O, Sirveaux MA, Brunaud L, Reibel N, Quilliot D. Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. Diabetes Metab 2009;35:544–557.
Conclusions
Pregnancy after bariatric surgery can provide immense benefits of sustained weight loss and may reduce maternal and perinatal complications of obesity. However, there are special considerations for this population. A vigilant team approach, with special attention to the nutritional requirements of this high-risk population can minimize adverse effects and promote a healthy pregnancy and delivery.