Nutrition Considerations for the Postoperative Pregnant Patient

W hat kinds of vitamin changes should my postoperative patient make if she is planning pregnancy or if she becomes pregnant?

Before getting pregnant, a postoperative patient should have her blood drawn to check common postop deficiencies, including the B vitamins (B12, folic acid, B1, B6), calcium and vitamin D, an iron panel including ferritin, and prealbumin. Nutritional deficiencies should be corrected preconception if possible. If a patient is already pregnant, special consideration should be taken with the following nutrients: iron, folic acid, vitamin A, protein, vitamin B12, calcium, and vitamin D (Table 1).

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Table 1.

Supplement Recommendations for Pregnant Postoperative Patients

	Nutrient considerations
Preconception	Monitor for and correct calcium, vitamin D, vitamin B12, folic acid, vitamin B1, and vitamin B6 deficiencies if present
During pregnancy	Iron: oral supplementation or iron infusion if indicated
	Calcium: 1,200–1,500 mg calcium citrate in TID dosing
	Vitamin D: monitor and correct deficiency
	Vitamin B12: monitor and correct deficiency
	Vitamin A: daily intake should not exceed 10,000 IU
	Protein: Goal of 1.1 grams per kilogram of prepregnancy weight

Iron deficiency is common in both malabsorptive bariatric procedures (more than 50% of patients ¹ ) as well as during pregnancy (23% in the general population ² ), making this unique population more susceptible to anemia. For those patients who do not respond to oral iron supplementation, referrals to hematology for possible iron infusions should be considered. Folic acid is important to prevent neural tube defects, but evidence at this time does not suggest the bariatric patient will be at increased risk for fetal birth defects. ³ That being said, 16.1% of pregnant bypass patients developed folic acid deficiencies. ⁴ Therefore, supplementation of 1,000 μg should be recommended. Prenatal vitamins should not contain more than 10,000 IU of vitamin A to prevent the risk of birth defects such as cranium, heart, and spinal cord. ⁵ Patients should be instructed to eat high quality sources of protein at every meal and snack to meet the additional requirements for synthesis of maternal and fetal tissue. Patients should aim for 1.1 grams of protein per kilogram of their prepregnancy weight ⁶ to meet these needs. Vitamin B12 should be monitored for those patients with malabsorptive procedures and supplemented in accordance with prepregnancy recommendations. Vitamin D is important for immune function and brain development ⁷ during pregnancy. Postoperative patients who remain obese will have higher vitamin D requirements as vitamin D becomes immobilized within fat cells. Depending on blood levels, at least 1,000 IU should be taken daily, and prescription doses of 50,000 IU weekly should be given for clinical deficiencies. Due to maternal bone turnover, pregnant patients should be advised to supplement with an additional 1,200–1,500 mg calcium citrate beyond the prenatal or multivitamin taken in three doses. With special attention to vitamins, the bariatric patient can maintain a safe and healthy pregnancy.

Nausea and vomiting can be a challenge for a post-bariatric patient during her pregnancy. Do you have any tips for mitigating these symptoms?

Nausea and vomiting can be a problem for many pregnant women as well as for the bariatric patient. Nausea can become more severe with dehydration and low blood sugars, so eating and drinking on a schedule is important. These women should aim for a minimum of 64 ounces of noncaffeinated fluid daily and start the day off with a breakfast balanced with complex carbohydrates and protein, such as fresh fruit mixed with cottage cheese or Greek yogurt. It is recommended that pregnant women eat breakfast within 1 hour of waking or as soon as they get out of bed if they are very prone to nausea. If solid foods are not an option due to the nausea, a protein shake with half a frozen banana or some frozen berries may be easier to ingest.

Pregnant postop women should follow breakfast with a similar carb/protein combination every 3–4 hours to prevent low blood sugars. If strong smells exacerbate nausea, good options include cold foods such as tuna, low fat chicken salad, or having someone else prepare the food or protein shake. If protein from shakes is nauseating, substitute plain Greek yogurt for 23 grams protein per 1 cup serving. Pregnant women should take a full 30 minutes to eat and should not drink fluids with meals to prevent overfullness. Additionally, 1 gram dosages of ginger improve vomiting prevention for most, ⁸ and taking vitamins with food or before bed can help prevent nausea associated with swallowing pills.

Tips for preventing nausea and vomiting during pregnancy:

• Drink at least 64 ounces of fluid daily.

• Eat a balanced meal every 3–4 hours. Every meal should have carbohydrates and protein (e.g., Greek yogurt with fruit).

• Eat breakfast within 1 hour of waking up.

• Meals should last 30 minutes.

• If smells make nausea worse, try eating cold foods.

• Drink ginger tea.

• Take vitamins with food or before bed.