Bariatric Surgery and

pregnancy
Background
• Defined as a BMI of 30 and more
• Maternal obesity in the united states 10-36%
• Increasing with decades
Maternal effects of obesity on pregnancy
• Reduced fertility as a result of oligo or anovulation , and less likely to
respond to ovulation induction
• Increased risk of Gestational Diabetes
• Preeclampsia
• Cesarean delivery
• Infectious morbidity
• OR : problem with anesthesia , increased operating time , increased blood
loss
• Venous thromboembolism
• Less successful VBAC
• Higher preterm birth but not due to preterm labor
Fetal and Neonatal effects of obesity in
pregnancy
• Congenital abnormality , growth abnormalities , miscarriage , stillbirth
e.g neural tube defects , cardiac defects , facial clefting
• Impaired visualization of ultrasound images of these abnormalities,
but no problem in weight estimation
• Increase in LGA
• Still birth 2.1-4.3 fold greater in obese compared with normal
• Increase in childhood obesity
Bariatric surgery
• BMI 40 OR More , or 35 + other comorbidities
• Restrictive approach – gastric banding
• Malabsorptive approach – Roux en Y
Effect of surgery on future fertility
• Rapid weight loss  improvement of PCOS , anovulation , irregular
menses, higher fertility rates
• Should not be considered a treatment for infertility
• Compromised absorption of OCP  unintended pregnancy
• Difficult to evaluate effect of miscarriage
Effect on Maternal morbidity and mortality
• Rate of hypertension /preeclampsia is decreased
• Rate of diabetes is decreased
• Average weight gain also decreased
• PPROM increased only in one study in the rest unchanged
• One study reported increase in c-section but this is because most
have had prior history of c-section
Effect on fetal morbidity
• No increase in perinatal death
• There is a decrease in LGA
• And maternal weight after bariatric surgery is the predictor of
macosomia
Clinical Considerations and Recommendations
How should contraception and preconception be
approached in patients after bariatric surgery
• Increase in pregnancy rates after bariatric surgery
• High rate of failure of OCP because of malabsorption
• Use non-oral contraception forms
• Waiting 12-24 month after bariatric surgery before conceiving , so
that the fetus is not in a rapid weight loss environment and so that
the mom has time to achieve weight loss goals
Addressing nutritional status during pregnancy in
women who have had bariatric surgery
• Protein , iron , vitamin B12 , FOLATE , Vit D , calcium deficiencies
• Evaluate these at the beginning of pregnancy
• Supplement with oral forms but if no improvement then try parentral
forms
• Not known whether they require higher doses than the standard folic
acid dose
• Protein intake should be 60g regardless of bariatric surgery status
• Even if remains overweight should not go for caloric restriction or
protein restriction because there is evidence of impaired fetal growth
Addressing nutritional status during pregnancy in
women who have had bariatric surgery
• Several studies suggested that women who become pregnant after
bariatric surgery should take prenatal vitamin in addition to a
multivitamin.
• Excess vitamin A consumption is associated with birth defect
• Close surveillance postpartum , cases of nutritional deficiencies in
infants who are breastfed by women who had undergone bariatric
procedures
Special considerations in the antenatal period
• Anastomotic leaks
• Bowl obstruction
• Internal hernia
• Ventral Hernia
• Band erosion
• Band migration
Dumping syndrome
• Related to the ingestion of refined sugars or high glycemic
carbohydrates that stomach rapidly empties into the small intestine
• Fluid shifts from the intravascular compartment into the bowel lumen
and result in small bowel distention
• Symptoms : abdominal cramps, bloating , nausea , vomiting and
diarrhea.
• Hyperinsulinemia and consequent hypoglycemia
• Tachycardia , palpitations , anxiety , diaphoresis
• May not tolerate 50 g OGTT , can do 1hr and 2 hr charting at home at
that week
Medications and absorption
• Roux en Y  absorptive surface of the intestine is decresed 
decreased time for absorption
• Extended release preparation are not recommended
• Rapid release formulations are preferred
• NSAIDs shld be avoided postpartum– avoid ulceration ( small gastric
pouch)
• Testing drug level may be necessary
Are there special considerations during labor and
delivery for women who have had bariatric
surgery
• There is an increased rate of cesarean delivery even when controlling
for counfounder
• Unknown why this is
• There is no physiologic reason for performing more cesarean
deliveries in women who have had bariatric surgeries
• Bariatric surgery should not alter the course of labor and delivery
• However many remain obese and are admitted earlier in labor and
need induction and more oxytocin and have longer labor