Female Reproductive Issues Following Bariatric Surgery

Joseph R. Wax, M.D.

Professor of Obstetrics and Gynecology University of Vermont School of Medicine Maine Medical Center Portland, Maine

A Tale of Two Patients…

1.

2.

25 year old G 0 12 months after gastric bypass Pre-conception care?

Pregnancy management?

35 year old G earlier.

3 P 1011 at 21 weeks with 2 days progressive abdominal pain. RYGB 18 months Differential diagnosis?

Evaluation and treatment?

Goals

• • • • Describe commonly performed bariatric procedures and implications for female reproductive health Review consequences of bariatric surgery with regard to preconception care Describe complications of bariatric surgery in pregnancy and their management Review pregnancy outcomes following bariatric surgery

Obesity in American Women

Overweight or Obese

(BMI > 25)

62% Obese

(BMI > 30)

33% Extremely Obese

(BMI > 40 or > 35 with comorbidity)

7%

Ogden, C.L. JAMA 2006

Obesity-Related Morbidity

Hypertension Dyslipidemia Arthritis Sleep Apnea Diabetes CAD Stroke Gallbladder Cancer -colon -breast -endometrial * Second leading cause of death *

Obesity-Related Obstetrical Morbidity

Infertility Miscarriage Gestational diabetes Hypertension Macrosomia Cesarean Anesthesia Blood loss Wound Infection

Recent Trends in Bariatric Surgery

• • • • Almost 20-fold increase last decade – 2005 >100,000 – 2006 >200,000 5x as many procedures in women as men >50% of all procedures in reproductive-aged women

Only effective treatment of morbid obesity CDC 2006

Bariatric Surgery – Prerequisites

• • • • Multidisciplinary care Attempt non-surgical weight loss Preoperative medical evaluation

Preconception consultation and care

Bariatric Procedures – Roux-en-Y Gastric Bypass

• • • • Restrictive and malabsorptive Lose – 100 lb – 65-70% EBW – 35% BMI 0.5% mortality 5% operative morbidity

Buchwald, H. Obes Surg 2002

Advantages

Roux-en-Y Gastric Bypass Laparoscopic vs. Open Laparoscopic

Shorter hospital stay

Open

Tactile control of dissection Less post-operative discomfort Easier adhesiolysis Fewer wound complications Ability to use fine sutures Disadvantages Fewer cardiopulmonary complications Increased intra-abdominal complications Ease of performing ancillary procedures Fewer long-term complications Ventral hernia formation

Simpfendorfer, C.H. Surg Clin N Am 2005

Bariatric Procedures – Laparoscopic Adjustable Gastric Banding

• • • • Restrictive Lose – 50% EBW – 25% BMI 0.1% mortality 5% morbidity

Buchwald, H. JACS 2005

Bariatric Procedures –Vertical Banded Gastroplasty

• • Restrictive Efficacy, morbidity, mortality similar to LAGB

Buchwald, H. Obes Surg 2002

Perioperative Reproductive Issues

• • Rapid weight loss over 12-18 months – Resolution of • • • PCOS anovulation irregular menses – Improved fertility and fecundity

Reliable contraception Teitelman, M. Obes Surg 2006 Bilenka, B. Acta Obstet Gynecol Scand 1995 Eid, G. M. Surg Obes Rel Dis 2005 Deitel, M. J Am Coll Nutr 1988

Gastric Bypass and Malabsorption

• Supplements – – – – ferrous sulfate or fumarate B12 • 500-1000 µgm po qd or • 500-1000 µgm IM qm folic acid • 400 µgm po qd calcium citrate • 1200 mg po qd

Preconception Care

• • Avoid MVI with > 5000 IU vitamin A Address other obesity-related comorbidities – hypertension – diabetes – obesity

Rothman, K. M. NEJM 1995

Late Surgical Complications in Pregnancy – Bowel Obstruction

• 6-8% pregnancies -Internal hernia -Intussusception -Volvulus • • 9-25 months after RYGB Delay in diagnosis or treatment →

2 maternal and 1 fetal death

Wax, J.R. OG Survey 2007

Bowel Obstruction in Pregnancy

• • • Nonspecific nature of abdominal complaints Confusion with common obstetrical phenomena Distracted from inciting event by 2 ° pancreatitis * Have low threshold to consult bariatric surgeon * * Have low threshold to explore pregnant patient for obstruction *

Internal Hernia in Pregnancy

A.

B.

C.

Lesser sac into mesocolic tunnel Petersen (below Roux limb) Leaves of small bowel mesentery

Karkala, N OG 2005

Intussusception in Pregnancy

• • • • • 21 weeks’ gestation RYGB 18 months earlier Several days abdominal discomfort Six hours constant pain Suspected internal hernia

Wax, J.R. Obes Surg 2007

Late Surgical Complications in Pregnancy – Malabsorption

• • Iron deficiency – usually mild, responsive to oral therapy – rare cases of needing parenteral iron – recommend trimesterly CBC Folate and B12 – continue preconception supplements – recommend MSAFP and targeted ultrasound

• •

Does Gastric Bypass Increase ONTD Risk?

3 cases of ONTDs remote from RYGB (2-8 yrs) – – no maternal vitamin supplements 2 ↓ B12, 1 ↓ folate Later studies – – no ONTDs in 129 RYGB pregnancies no increased risk of anomalies after bariatric surgery 15/289 cases vs. 6333/158,912 controls

Sheiner, C.S. AJOG 2004 Haddow, J.E. Lancet 1986 Knudsen, L.B. Lancet 1986

Malabsorption and Carbohydrates

RYGB Decreased caloric intake & absorption Hyperinsulinemic Hypoglycemia Obesity Pregnancy Insulin Resistance Pancreatic β cell hyperfunction Decreased fasting blood glucose Unfulfilled increased caloric intake

Hyperinsulinemic Hypoglycemia

• Diagnosis –

glucose < 55 mg/dL

– insulin ≥ 3 mcU/mL – c-peptide ≥ 0.6 ng/mL – no sulfonylurea

Halverson, J.D. Surgery 1982

Hyperinsulinemic Hypoglycemia

• • • Affects approximately 4% pregnancies Treatment = Dietary Modification – – – Avoid refined/simple sugars Increase • protein • complex carbohydrates Consume liquids well before and after meals

Consult bariatric nutritionist

Hyperinsulinemic Hypoglycemia in Pregnancy

• • • • • 36-year old at 24 weeks RYGB 39 months earlier Lightheadedness, syncope Postprandial glucose 34-57 mg/dL Normal glucose, no symptoms after: – – increase calories 1000 → increase protein 56g → 1500/day 80g/day – avoid refined sugars

Wax, J.R. Obes Surg 2007

Managing Dietary Failures

• • • Rare, no reports in pregnancy Reversal of bariatric procedure Partial or total pancreatectomy

Dumping Syndrome

• • • Affects small proportion of RYGB patients Can be associated with postprandial hyperinsulinemic hypoglycemia Precipitated by liquids, simple, refined sugars

Vecht, J. Scand J Gastroent Suppl 1997 Hasler, W.L. Curr Treat Options Gast 2002 Ukleja, A. Nutr Clin Pract 2005

Dumping Syndrome – Early Phase (10-30 min)

Rapid transit of nutrients to small intestine Osmotic fluid shifts Vasomotor Symptoms • • • • • palpitations syncope diaphoresis flushing headache Abdominal Symptoms • • • • nausea diarrhea cramping bloating

Dumping Syndrome – Late Phase (1-3 hrs)

Reactive Hyperinsulinemic Hypoglycemia Vasomotor Symptoms

Dumping Syndrome –Treatment

• Dietary Modification – Avoid refined/simple sugars – Increase • • protein complex carbohydrates – Consume liquids well before and after meals

Managing Dietary Failures

• • Rare, no reports in pregnancy Medication – – Acarbose (inhibits glucose absorption) • 25-50 mg after meals (TID) • • S/E flatulence, diarrhea category B Octreotide (somatostatin analog) • 25-100 mcgm SQ 15-60 min before meals • category B

Dumping Syndrome – Implications for Pregnancy

•

Avoid glucose challenge test

– Home glucose monitoring • 1-2 weeks at 26-28 weeks • treat if consistently elevated

Pregnancy Outcomes After Bariatric Surgery

• • Case reports and series Case-control studies – small – subjects as own controls – women without bariatric surgery as controls • • obese non-obese – unspecified bariatric surgical procedure

Pregnancy after LAGB

Outcome Years SAB CS BW Wt gain DM Martin (n=23) 1990-5 2 (9%) 4 (22%) 3676g 0 (0) Weiss (n=7) 1996-2000 2 (28.6%) 2 (40%) 0 (0) HTN 0 (0) 0 (0) Band 0 (0) 2 (28.6%) * vs. last presurgical pregnancy † vs. matched obese controls Skull* (n=49) 1996-2003 0 0 ↓ ↓ ↓ 2 (4.1%) Dixon*† (n=79) 1995-2003 0 ↓ ↓ ↓ 0 (0)

Outcome SAB CS BW ≥ 4 kg < 2.5 kg Preterm Wt gain DM HTN

Pregnancy After RYGB

Printen (n=54) 2 (4.2%) 4 (8.7%) 1078-4230g 7 (18.4%) 7 (15.2%) Wittgrove (n=36) 0 ↓ 0 ↓ ↓ ↓ Richards (n=57) 0 0 ↓ ↓ ↓ 0 0 ↓ Patel (n=26) 0  0 0 0 0 0 0 0

Pregnancy After RYGB

Outcome Hypertension Crude OR (95% CI) 3.67 (1.36, 9.92) PPROM 0.33 (0.04, 2.77) Oligohydramnios 2.00 (0.65, 6.20) Gestational age > 41 wks *adjusted for BMI at delivery 0.50 (0.11, 2.36) Adjusted * OR (95% CI) 2.62 (0.66, 10.50) 0.24 (0.02, 3.38) 2.39 (0.66, 8.61) 0.57 (0.11, 2.97)

Wax, J.R. et al Obes Surg 2008

Pregnancy After RYGB- Impact of Timing

Outcome SAB CS BW Preterm Wt gain DM HTN Rand ( 10 early, 8 late) 0 Dao (21 early, 13 late) 0 0  0 0 0 Wax (20 early, 32 late) 0 0 0 0 0 0

Pregnancy After LAGB/RYGB

Less Compared to Pre-Surgical Pregnancy Similar Unclear Wt gain DM HTN BW ≥ 4kg CS BW Preterm SAB Growth restriction

Bariatric Surgery and the Puerperium

• Weight loss – limited descriptive data – rate similar to nonbariatric delivered patients and nonpregnant bariatric patients

Bariatric Surgery and Lactation

• • Not contraindicated Ensure maternal B12 supplementation – several cases of neonatal B12 deficiency

Grange, D.K. Pediatr Hematol Oncol 1994 Campbell, C.D. Haematologica 2005

Summary

• • • Anatomic and physiologic changes associated with bariatric surgery have significant reproductive implications Nutritional deficiencies generally mild and easily treated Limited data suggest favorable pregnancy outcomes

Future Research

• Pregnancy outcome – by specific bariatric procedure – account for • • • past pregnancy complications persistent obesity obesity-related comorbidities – congenital anomalies (ONTDs)

Preconception Pregnancy

Guidelines for Care

Reliable contraception through period of maximal weight loss Evaluate and treat comorbidities Evaluate and treat micronutrient deficiencies (B12, folate, iron) Meet with bariatric surgeon and nutritionist, preconception consultation with Ob/Gyn or Maternal-Fetal Medicine Folic acid, B12 and iron supplementation Folic acid, B12 and iron supplementation Second trimester MSAFP Consider monthly growth ultrasounds after 20 weeks Monitor for signs and symptoms of hypoglycemia Avoid NSAIDS if history of ulcer Puerperium Folic acid, B12 and iron supplementation Breast feeding compatible with bariatric surgery Notify pediatrician of maternal surgical history to enable monitoring for micronutrient deficiency (likely very low risk if mother taking prescribed supplements) Avoid NSAIDS if history of ulcer

Wax, J.R. OG Survey 2007