Pregnancy and Morbid Obesity

1. Pregnancy and Morbid Obesity Obesity and Pregnancy Health Summit October 18, 2011 Michael D. Trahan, MD, FACS Martha Jefferson Surgical Associates Martha Jefferson Bariatric Care Center

2. Objectives • Review the implications of morbid obesity on women’s health • Discuss the impact of morbid obesity on pregnancy and childbirth • Clarify the treatment options for morbid obesity including bariatric surgery

3. Weight (lbs) 260 270 280 290 300 190 200 210 220 230 240 250 120 130 140 150 160 170 180 5'0" 5'2" 5'4" Height 5'6" 5'8" 5'10" 6'0" 6'2" 6'4" Body mass index

4. Type 2 Diabetes Hypertension Heart disease High cholesterol Reflux disease Sleep Apnea Venous stasis disease Cancer Degenerative joint disease Infertility Pseudotumor cerebri Incontinence Psychosocial problems Injuries Obesity related comorbidities

5. Polycystic ovary Infertility Cancer Stress incontinence Social Sexual dysfunction PIH Gest diabetes DVT Macrosomia Low birth weight Spontaneous ab IUGR C section rate Gynecologic/obstetric comorbidities

6. Hormones • Low levels of circulating sex hormone-binding globulin • Strongly binds testosterone • Weakly binds estradiol • Peripheral aromatization of androgens in adipocytes • High levels of androgens and estrogens

7. Hirsutism Irregular cyclesinfertility Mammary and endometrial hyperplasia Higher cancer risk Cleland WH. Endocrinology 1983. Hormones

8. Pregnancy induced hypertension 12% vs 4.8% Gestational diabetes 9.5% vs 2.3% Preterm labor 5.5% vs 3.3% Intrauterine growth retardation 0.8% vs 1.1% Macrosomia (>4000 g) 15% vs 8.3% C-section 47% vs 21% Weiss JL. Am J Obstet Gynecol 2004. Obstetric complications

9. 79 morbidly obese women of >1200 patients over 10 years IVF cancellation rate: 25% vs 11% Higher BMI correlated with longer need for gonadotropin stimulation Fertilization rate and number of embryos no different Dokras A. Obstet Gynecol 2006 Infertility treatment

10. Delivery Complications Cedergren MI. Obstet Gynecol 2004.

11. Neonatal outcomes • Cedergran, MI. Obstet Gynecol 2004.

12. How can we lose weight? • Low carbohydrate diet • Low fat diet • Low calorie diet • Exercise • Medications (Phen-fen, Amphetamines, Orlistat, Prozac, Wellbutrin) • Behavior modification and hypnosis

13. All have something in common • They don’t work very well for very long • 3-5% of people succeed in long term weight loss by diet and exercise alone • They don’t cure the comorbidities • Most meds are approved only for short-term use

14. Candidates for Bariatric Surgery • BMI ≥ 40 (maybe as low as 35 or even 30 in some circumstances) • Age over 18 • Limited comorbidities • No substance abuse – alcohol, drugs, tobacco • Psychologically stable • Strong social support system • Realistic outlook on lifestyle modifications • Stomach operations (weight loss surgery, reflux or ulcer operations) • 400 pound weight limit

15. Open Laparoscopic

16. Not the “Easy way out” • The operation alone is not the key to successful weight loss. • The new anatomic configuration or device is best thought of as a tool for weight loss. • Tools do not do the work for us; they have to be used in the correct situation and with the correct technique to achieve the desired goal.

17. Not the “Easy way out” • Patients must be committed to life-long, often difficult, alterations in their diets and lifestyles • Bariatric surgery is associated with many serious risks which can be life-threatening • Can be expensive

18. Surgical Options • Purely Restrictive • Vertical Banded Gastroplasty • Laparoscopic Adjustable Gastric Banding (Lap-Band®, Realize®) • Sleeve Gastrectomy • Purely Malabsorptive • Jejunoileal Bypass (not done anymore) • Combination • Roux-en-y Gastric Bypass • Biliopancreatic diversion • Duodenal Switch

19. Lap-Band® or Gastric Bypass

20. The Gastric Bypass Tool Small pouch • Cannot physically hold very much • Stretch receptors provide feeling of fullness at small volumes • Can be enlarged over time • Expected within reason (4-6 ounces) • Habitually overeating

21. The Band Tool Small pouch

22. The Gastric Bypass Tool (cont) The narrow opening • Prevents the rapid emptying of the small pouch to provide longer satisfaction • This function can be overridden by a mostly liquid diet or by drinking liquids with meals

23. The Band Tool Narrow opening - Adjustable diameter

24. The Gastric Bypass Tool (cont) Avoid carbohydrates • About 40% of gastric bypass patients get dumping syndrome • Deterrent to eating high carbohydrate foods

25. The tool (cont) Malabsorption • Not thought to be a major component of the weight loss potential of the tool • Calcium must be supplemented • Multivitamin must be taken by everyone • Iron and/or B12 supplement may be necessary

26. Gastric bypass video

27. Lap-Band® Video

28. Realize® Video

29. Comparing Weight Loss Results Laparoscopic adjustable gastric banding (LAGB) provides effective weight loss after 3 years, comparable to that seen with standard gastric bypass1 *LAGB using the LAP-BAND® System and another adjustable gastric band. Comparison is based on pooled data from 43 peer-reviewed reports involving at least 100 patients at entry and providing at least 3 years postoperative data. Reference: 1. O’Brien P, McPhail T, Chaston T, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006:16;1032-40.

30. After loss of 50% excess weight Regulation of menstrual cycle in 95%-100% Decrease hirsutism Decrease free test., androstenedione, and DHEA Stress incontinence 61% preop to 12% postop Loss of insulin resistance Deitel M. Am Coll Nutr 1988. Escobar-Morreale HF. J Clin Endo Metab 2005. Postoperative changes

31. 49 pregnancies in 36 women 36 singleton (3 twin, 2 triplet, 1 elective Ab, 7 spontaneous Ab) 0 HTN 1 GD 13 C section 4 preterm 2 Macrosomia Wittgrove AC. Obes Surg 1998. Pregnancy following gastric bypass for morbid obesity

32. Pregnancy following gastric bypass for morbid obesity • 17 had been pregnant before surgery • Preterm: 3 vs 2 • HTN: 7 vs 0 • GD: 4 vs 0 • C-S: 6 vs 6 • Macrosomia: 7 vs 1 • Weight gain: 20.4 kg vs 12.7 kg Wittgrove AC. Obes Surg 1998.

33. 79 women from 1,382 patients who had a first pregnancy after a Lap-Band Compared these to the 40 pregnancies in the same group before surgery Looked at birth weight, PIH, GD, neonatal outcomes Dixon, et al. Obstet Gynecol 2005 Birth Outcomes in Obese Women After Laparoscopic Gastric Banding

34. Birth Outcomes in Obese Women After Laparoscopic Gastric Banding • Maternal weight gain * p<0.05 • 9.6 kg in Band patients* • 14.4 kg pre-op patients* • PIH • 45% vs 10%* • GD • 15% vs 6.3% • Preeclampsia • 28% vs 5%* • Neonatal outcomes no different than community Dixon, et al. Obstet Gynecol 2005

35. Nutritional needs • All postoperative patients should wait until weight stabilizes (12-18 months) before pregnancy • We recommend secure form of contraception for 2 years • At some point that infertile patient starts to ovulate again • The Band can be adjusted to manage weight during pregnancy

36. Nutritional needs • All patients take daily MVI and calcium citrate • Attention to Iron, B12, Folate, Calcium • Follow levels and supplement accordingly • With gastric bypass the duodenum is bypassed: supplement iron orally, rarely parenterally • B12 supplements available sublingual, nasal, parenteral • Calcium deficiency can be manifest by elevated alk phos and parathyroid hormone

37. Summary • Morbid obesity results androgen and estrogen excess. • Morbid obesity increases the risk of a number of complications of pregnancy and childbirth. • Bariatric surgery results in significant weight loss, improvement in comorbidities, and reduction in obstetrical complications • Weight counseling should be a routine part of women’s health care and preconception planning

38. Summary • Bariatric surgery results in significant weight loss, improvement in comorbidities, and reduction in obstetrical complications • Weight counseling should be a routine part of women’s health care and preconception planning

39. Thanks for Coming!