Transcript Bariatric Surgery and Pregnancy Nutritional Management

Bariatric Surgery and Pregnancy:
Nutritional Management
Pre
Post?
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Andrea Langley RD MSc. CDE
Objectives
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Overview of Obesity and Pregnancy
Types of Bariatric Surgery
Nutrition and Bariatric Surgery
Case Study
Recommendations for Pregnancy post Bariatric
Surgery
CARING FOR THE BODY, MIND & SPIRIT SINCE 1869
Obesity in Pregnancy
 Prevalence ranges from 10-35%
 29% of U.S. women of childbearing age were
obese
 8% were morbidly obese (BMI ≥ 40)
 11-21% of Canadian women were obese
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 Weight gain recommendations for women with
BMI ≥ 30 is 11-20lbs
1 Kominiarek,
MA. Obstet Gynecol Clin N Am 2010; 37: 305-320
Artal R et al. Obstetrics andGynecology 2010; 115(1): 152
3Statistics Canada. 2005. http://www.statcan.gc.ca/pub/82-620-m/2005001/article/adults-adultes/8060-eng.htm.
2
Obesity in Pregnancy
 Associated with increased risk of stillbirth and
intrauterine fetal death
 Greater risk for preterm labour, miscarriage and
fetal chromosomal anomolies
 Higher rates of:
 GDM, gestational hypertension, pre-eclampsia and
caesarian section
Roux-en-Y Gastric Bypass
 Restrictive and malabsorptive procedure
 Restricts stomach volume
 Requires lifelong vitamin and mineral
supplementation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19268.htm
Roux-en-Y Gastric Bypass
Benefits:
• Wt. loss of ~65% excess weight in 1 year
• Rapid onset of feeling full; satiety while eating
Risks:
• Nutritional deficiencies (B12, zinc, calcium, fatsoluble vitamins, thiamine, folate, iron)
• Dumping syndrome (w/ sugary foods)
• Anastomotic leakage, stricture or ulcer
Biliopancreatic Diversion
w/Duodenal Switch
 Half of the stomach is permanently removed
 Stomach is then connected to distal part of the SI
 Remainder of SI connected to the end of small
bowel
 Requires lifelong vitamin and mineral
supplementation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19500.htm
Biliopancreatic Diversion –
Duodenal Switch
Benefits:
• Pylorus is intact and may prevent dumping syndrome
• Stomach pouch is larger than other bariatric sx, so larger
portions can be consumed
Side effects:
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Frequent soft BM’s (up to 4-6/day)
Frequent passing of foul-smelling gas
Gas pains and bloating
Hair loss
Intolerance of certain foods
Greater risk of nutritional deficiencies
• Fat soluble vitamins, iron, folate, B12
Nutrient Absorption
Duodenum
Calcium, phosphorus, magnesium, pantothenate, B6,
C, zinc, chromium, molydenum, manganese, iron,
copper, selenium, thiamine, riboflavin, niacin, biotin,
folate, A, D, E, K
lipids, monosaccharides, amino acids
Jejunum
C, folate, D, B12, K, magnesium
Bile acids and salts
Ileum
Sodium, chloride, potassium, K, biotin, water
Short chain fatty acids
Causes of Nutrient Deficiencies
after Bariatric Surgery
Decreased intake
of certain foods
• ie. intolerances to red meat
Decreased gastric
acid secretion
• May result in B12 deficiency
Bypass of nutrient
absorption sites
• Duodenum and jejunum
Recommended Supplements for
Bariatric Surgery Patients
Supplement
Dose
Multivitamin/mineral with iron
1-2/day
Calcium
1200-1500mg
(elemental)/day
Vitamin D
800 IU/day
Iron
40-65mg (elemental)
if premenopausal
B12
500-1000mcg/d or
1000mcg IM/month
Note
Preferably citrate form,
divided dose
18-27mg (elemental) for
other women
Kusher RF and Cummings S. Medical Management of patients after bariatric surgery. UpToDate 2012: 1-38.
Recommended Diet Guidelines
Post-Bariatric Surgery
3 meals and 1-2 planned snacks
• Avoid grazing which may lead to higher calorie intake
Aim for at least 60g protein
• BPD-DS patients may need 1.5g/kg/d due to malabsorption
Limit simple carbohydrates
• May cause dumping syndrome –esp. after RYGB
Separate fluids and solids
Recommended Laboratory
Tests
Recommended at 3 mo, 6 mo and annually after
 CBC
 Vitamin B12
 Lipid profile
 Bilirubin
 Electrolytes
 Aminotransferases
 Glucose
 Alk Phos
 Iron studies, ferritin
 25-hydroxyvitamin D
 Folate
 PTH
 Albumin
 Thiamin
Kusher RF and Cummings S. Medical Management of patients after bariatric surgery. UpToDate 2012: 138.
Pregnancy Following Bariatric
Surgery
 Recommended to wait 12-18months post-surgery
 Peak weight loss occurs between 12-18months
 Not associated with adverse perinatal outcomes
 Lower risk of GDM, gestational HTN and macrosomia
 Assess for nutritional deficiencies pre-pregnancy
 May need parenteral forms if labs do not improve
Pregnancy Following Bariatric
Surgery
 Discuss contraception as fertility may improve
 If dumping syndrome, use an alternative to the
OGCT
 24-28 weeks, test BG fasting and pc meals for 1 week1
 Counsel on risks of obesity in pregnancy
 One study demonstrated 41% obese2 after surgery
1 Kominiarek, MA. Semin Perinatol 2011. 35: 356-361.
2Lapolla et al. Obes Surg 2010. 20: 1251-1257.
Case Study
 32 y.o. female , G7T0P4A2L3, referred at 14 weeks G.A.
re: pregnancy post BPD w/DS
 Followed from Oct. 2009- Feb. 2010
 Known from pregnancy in 2007
 Lost 150 lbs with surgery; prev. BMI 51
 No regular follow-up with surgeon (in Michigan)
Case Study
PMHx
• Bipolar (off meds), other mental health issues
• PTSD
• Biliopancreatic diversion w/duodenal switch
Meds
• OTC X-strength Ranitidine (150mg 3-4/d)
Vitamins:
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PNV
calcium citrate (2x 500mg)
time-released vitamin C 1000mg
liquid iron 20ml (? elemental)
water-soluble vitamin D
Case Study
Anthropometrics:
• Ht 1.6m Pre-pregnancy wt. 58.1kg
• BMI 22.7 Current wt. 64kg at 15 weeks
Activity:
• No regular activity
Complaints:
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Bloating after meals
Vomiting after every meal, but subsiding now
Heartburn
‘Feels terrible’, dizziness, SOB
occ. blurred vision with eating
Case Study
Obstetrical Hx: Followed in 2007 pregnancy
• TPN for ~6 weeks (at her insistence)
• Dx: IFG and reports of hypoglycemia
• Polyhydramnios
Previous pregnancies:
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1995 – baby born at 26 wks - died at 1 month
1998 – female, 34 weeks 7lbs
2002 – boy, 29 weeks 3 ½ lbs; has CP (? GDM)
2007- boy, 33 weeks 4 lb 7oz, IFG/polyhydramnios
Case Study – cont’d
Diet: Consumes 3 meals and 1-2 snacks/day.
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Carbohydrates vary from 10-60g at meals
Consuming protein powder with soy milk ‘most days’
Eating meat/chicken 1-2 x /day
High GI foods
Financial: on CPP but recently lost benefits
• Applying for ODSP
Social:
• Relationship with partner of last child and current
• Lives with her 3 children
Case Study
Labs:
Date
Test
Value
Reference
Range
Oct. 4/09
Hgb
Hct
108g/L
0.33
115-160g/L
0.34-0.48
Sept. 14/09
Ferritin
11.1µg/L
B12
257pmol/L
35-291µg/L
(<10 – deficient)
181-672pmol/L
Ca
Creatinine
2.05mmol/L
41umol/L
2.12-2.62mmol/L
55-115umol/L
Sept. 2/09
Case Study
Assessment:
 Significant weight gain at 15 weeks
 Inadequate protein intake -needs ~90g/day
 Insufficient dietary/supplementary iron
 No vitamin/mineral panel in the last year
 Need PTH or albumin to assess calcium
status
 ? Cause for blurred vision – food
choices,BG’s?
Case Study
Plan at 14 weeks:
 Carbohydrate controlled diet
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45g CHO at meals and 30g CHO at snacks TID
 Controlled wt. gain of 0.5-1lb/week
 Aim for 90-100g protein/day
Case Study
Plan at 14 weeks:
 Recommend vitamin/mineral status
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PTH, vit D, B1, B12, folate, zinc, vit A, selenium, copper
 May benefit from ferrous fumerate BID
 Provides 200mg elemental iron
 Suggested testing BG when vision blurred
 May benefit from early OGCT
Case Study
 Admitted to antenatal Dec. 27, 2009 for TPTL and
shortened cervix
 None of the recommendations from October for
vitamins or labs were done
 Dec. 15th labs – ferritin (10.3), B12 (112) and Hgb (97)
 Recommended B12 and triferex (150mg elemental)
 B 12 ordered Dec. 30th (2nd admission)
Case Study
Jan 4th
Jan 5th
Jan 11th
labs:
• Vitamin C 500mg, Ca Carbonate 1250mg and vitamin D
1000mg were ordered at RD request
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OGTT results 3.2/8.3/2.9 – reactive hypoglycemia
Controlled carbohydrate diet ordered in hospital
Weekly BG fasting and 1hr pcb
Ferrous gluconate changed to Triferex
• Ca 1.85 (ref. 2.12-2.62), vitamin D 25 (75-225)
• Fasting 3.7, 1hr pcB 4.5 – not symptomatic
• Spoke to bariatric surgeon re: labs and vitamin needs
Recommendations from
Bariatric Surgeon : Pregnancy
 Aim for B12 >500 and ferritin at high end of N
 If protein low, order TP, alb, pre-alb
 If iron low, 150mg TID elemental or IV iron 2-3
x/week, then 1x/week for 3-4 weeks
 Vitamin D – need water soluble 2000 IU TID
 If low, drisdol (50 000 IU) x 6 months
 Repeat labs in 2 months; if still low at 6 mo - BID
Recommendations from
Bariatric Surgeon : Pregnancy
 If vitamin A low, need water soluble A and D TID (do
not need separate vitamin D)
 Ca citrate 3000mg/day
 May require rocaltrol or calcitrol 0.5mcg/d x 6 months
 Pancreatic enzymes 20mg TID
 Regular B vitamin
 Complex carb, high protein for reactive hypo
Case Study
Jan 18th:
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Vitamin D 1000IU changed to Drisdol 50 000IU
Ca carbonate 1250mg changed to Ca citrate 1500mg TID
Received 1 dose IV iron, to be repeated in 1 week
Pancreatic enzymes 20mg TID to aid digestion
Case Study
Jan 25th:
Test
Value
Reference Range
B12
245pmol/L
181-672pmol/L
Ferritin
243µg/L
35-291µg/L
Prealbumin
0.17g/L
0.18-0.45g/L
Hgb
86g/L
115-160g/L
Hct
0.28
0.34-0.48
Vitamin A
1.1µmol/L
1.2-2.8µmol/L
Protein
57g/L
60-80g/L
 Ordered glucerna at HS snack
Case Study
Feb 2nd :
Feb 24th:
• Beta carotene 25 000 IU ordered (3750µg RAE)
• Non-toxic as compared to preformed vitamin
A
• Zinc 8.7umol/L (N 9.8umol/L)
• 175mg zinc gluconate ordered on discharge
Case Study
BG records:
Date
Fasting
Feb 1/10
3.1
Feb 2/10
3.4
4.8
Feb 3/10
3.5
4.8
Feb 17/10
1hr pcB
1hr pcL
1hr pcS
4.2
5.2
3.1
7.9
Case Study
Delivered Feb. 21 – 4lb 7oz
at 34 weeks
• Baby in NICU, trying to
breastfeed
• Total wt. gain ~28lbs (had
polyhydramnios)
• Received a total of 3
treatments of IV iron
Discharge meds:
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seroquel 25mg
pantoloc 40mg
pancrealipase TID
vitamin C 500mg
B carotene 25 000 IU
Ca citrate 1500mg TID
vit D 50 000 IU
zinc gluconate 175mg
triferex 150mg
Case Study
 Postpartum – received call from pt
 1 hr pc BG 11 and 3 elevated BG’s 2 hrs pc
 Reported she was low in Vitamin A, D, ferritin, B12, zinc
 Recommendations:
 Continue vitamin D and f/u BW 2-3 months
 Change beta carotene to water soluble A + D and
reassess in 2-3 months
 Continue zinc supplement and repeat 2-3 months
 Change to ferrous fumerate 300mg BID
 Try testing ac meal or 2 hr pc or ? A1C
Case Study
 April 14, 2010 – patient seen by outpatient
hematology
 Changed from Triferex to ferrous gluconate
300mg OD
 Provides 36mg elemental
Case Study
 October 2010 – seen by Outpatient Nutrition Counselling
postpartum for nutritional deficiencies
Current supplements:
 Vitamin D 50 000IU
- zinc gluconate 175mg
 Beta carotene (same dose likely) - B complex
 Calcium 1200mg (? type)
- multivitamin/mineral
 Ferrous gluconate 300mg BID (72mg elemental)
 Plans to d/c beta carotene and start preformed vitamin A
(water soluble)
Case Study
Diet: consuming 3 meals and 1-2 snacks
 Aims for ‘high protein’ (actual intake 55-60g/d)
Anthropometrics: ht 160cm wt. 64kg BMI 25
Labs:
Date
Test
Value
Ref Range
April ‘10
Ferritin
Hgb
Albumin
Creatinine
B12
Protein
34µg/L
119g/L
40g/L
42µmol/L
477pmol/L
59g/L
35-291µg/L
115-160g/L
35-50g/L
55-115µmol/L
181-672pmol/L
60-80g/L
Sept ‘10
Ferritin
Hgb
B12
Vitamin D
Calcium
28µg/L
111g/L
315pmol/L
44nmol/L
2.2mmol/L
35-291µg/L
115-160g/L
181-672pmol/L
75-225nmol/L
2.122.62mmol/L
Case Study
Recommendations
 Increase protein by including high pro smoothie
 Need vitamin A labs prior to starting preformed A
 Outdoor activity to assist with increased vitamin
D
 Need labs for vitamin A, zinc, PTH
 Switch to ferrous fumerate to increase elemental
Planning a Pregnancy Recommendations Post Sx.
 Discuss contraceptive use d/t increased fertility
 Review risks on obesity in pregnancy (if obese)
 Aim for 3 meals and 1-2 planned snacks
 Conduct a vitamin/mineral panel
 Adequate supplementation prior to pregnancy
 Consider alternative to OGCT during pregnancy
References
 Karmon, A and Sheiner, E. Pregnancy after bariatric surgery. Arch Gynecol
Obstet. 2008; 277: 381-388.
 ACOG Practice Bulletin. Bariatric Surgery and Pregnancy. 2009; 105: 14051413.
 Grazia Dalfa, M et al. Pregnancy and foetal outcome after bariatric surgery.
Journal of Maternal-Fetal and Neotatal Medicine. 2012; Early online 1-7.
 Ziegler, O et al. Medical follow up after bariatric surgery. Diabetes and
Metabolism. 2009; 35: 544-557.
 Hezelgrave, N.L. and Oteng-Ntim, E. Pregnancy after Bariatric Surgery. J Obes.
2011. Online 2011 July 14.
 Ouyang, DW. UpToDate 2012. Counseling women about fertility and pregnancy
after bariatric surgery.
 Kominiarek, M.A. Preparing for and managing a pregnancy after bariatric
surgery. Semin Perinatol. 2011; 35: 356-361.
 Kominiarek, M.A. Pregnancy after bariatric surgery. Obstet Gyneol Clin N Am.
2010; 37: 305-320.
 Kushner, RF and Cummings, S. Medical Management of patients after bariatric
surgery. UpToDate 2012.
Thank You