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Management of Pregnancy Involving Obesity & Bariatric Surgery

Management of Pregnancy Involving Obesity & Bariatric Surgery. Dr. Dawn Boender PGY2. Overview. Obesity Review Obesity and Pregnancy Treatment of Obesity Managing Pregnancy Following Bariatric Surgery. Obesity Review 1. Obesity Review 1. >1/3 of adults (35.7%) are obese

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Management of Pregnancy Involving Obesity & Bariatric Surgery

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  1. Management of Pregnancy InvolvingObesity & Bariatric Surgery Dr. Dawn Boender PGY2

  2. Overview Obesity Review Obesity and Pregnancy Treatment of Obesity Managing Pregnancy Following Bariatric Surgery

  3. Obesity Review1

  4. Obesity Review1 • >1/3 of adults (35.7%) are obese • Non-Hispanic Blacks (49.5%) • Mexican Americans (40.4%) • All Hispanics (39.1%) • Non-Hispanic Whites (34.3%) • In 2008, obese individuals spent $1,429 more per year on health care • NOT an epidemic 2 • Endemic – condition that is habitually present

  5. Obesity Review • Comorbidities 2,3 • Type II Diabetes • Hyperlipidemia • Hypertension • Obstructive Sleep Apnea • Heart Disease • Stroke • Asthma • Musculoskeletal Problems • Cancer • Depression • Metabolic Syndrome • Gallbladder Disease • Liver Disease • DVT

  6. Obesity Review • Pregnancy Complications: 2,4 • Gestational DM • Hypertension • Preeclampsia • C/S Delivery • Postpartum Weight Retention • Prematurity • SAB & Stillbirth • Congenital Anomalies • Macrosomnia with Possible Birth Injury • Infections (pelvic, urinary, wound) • Postpartum Depression • Decreased Breastfeeding • Childhood Obesity

  7. Managing Obesity • Weight reduction programs 4 • Diet • Exercise • Behavior Modification • Pharmacotherapy • Referral for bariatric surgery 3 • BMI >40 • BMI >35 with Significant Comorbidities

  8. Approaching Patients 4 • Preconception Assessment and Counseling • Discuss risks • Encourage weight reduction • During pregnancy • Height, weight, BMI • Discuss goal weight gain • Offer nutrition counseling • Encourage exercise

  9. Approaching Patients Institute of Medicine Recommendations: 5 Additional guidelines for twin pregnancies IOM

  10. Approaching Patients 4 • Cesarean Section • Additional Resources: • Tables, Staff, Blood Products • Antibiotics • Subcutaneous Closure • Thromboprophylaxis • SCD • Unfractionated or LMW Heparin • Postpartum • Weight-Reduction Specialist

  11. Managing Obesity • Weight Reduction Programs • Diet • Exercise • Behavior Modification • Pharmacotherapy • Referral for Bariatric Surgery • BMI >40 • BMI >35 with Significant Comorbidities

  12. Review of Bariatric Surgery 3,6 Incidence increased 800% from 1998-2005 Average age 38.97 years Females 72.6% 50,000 Women Annually from 2003-2005 Mean Excess Weight Loss = 61.2%

  13. Review of Bariatric Surgeries 7 • Adjustable Gastric Banding 2 • Restrictive • Adjustable band 2 cm Below Gastroesophageal Junction

  14. Review of Bariatric Surgeries 7 • Roux-en-Y bypass 2,8 • Restrictive and Malabsorptive • 20-30 mL Pouch Formed • Gastroenterotomy • Stomach to Distal Jejunum • Enteroenterostomy • Anastomosis of 2 Parts of Intestine

  15. After Surgery • Obesity Decreases Fertility • Hyperinsulinemia2 • Oligo-ovulation and Anovulation9 • After Surgery:9 • Improves PCOS, Anovulation, and Menses • May Improve Fertility6 • Adolescents: Pregnancy rates after surgery doubles general adolescent population* • Consider non-oral modes of birth control* **Level B

  16. Non-pregnancy considerations • Contraception failure9 • Nutritional deficiencies8 • Most frequent: iron, Thiamin (Vit B1), folates (Vit B9),Vit D, Calcium, Protein, Vit B12 • Improve or resolve:2,3 • Diabetes • Hyperlipidemia • Hypertension • OSA • Wait to conceive: 12-24 months9 • Therapeutic medication monitoring • Up to 80% remain obese

  17. Pregnancy Outcomes • Decreased rates of:6,9 • Hypertension • Gestational Diabetes • Preeclampsia • Maternal Weight Gain • Premature Delivery (?) • Low Birth Weight (?) • Increases rate of: • Neural Tube Defects (noncompliance) • PPROM

  18. Pregnancy Recommendations • Three priorities: preventing iron, folic acid, and vit D/calcium deficiencies8 • Presenting Labs9 * • Protein (prealbumin) • Iron • Vit B12 • Folate • Vit D • Calcium • Trimester labs9 • CBC, iron, ferratin, calcium, Vit D * Level C

  19. Pregnancy Recommendations • Prenatal Vitamin • Additional Multivitamin • Vit A <5,000 IU • Postpartum survellience • Consult nutritionist* • Consult GI* • Band loosening • Alternative GDM screening* • Dumping syndrome • No NSAIDS postpartum • Therapeutic Drug levels** **Level B *Level C

  20. Pregnancy Recommendations • Nausea, Vomiting & Abdominal pain… harder to monitor! • Band loosening • 20 reports:6 • 14 bowel obstructions (internal hernias), 1 ulcer, 3 band events, 1 staple line stricture • 13-37wga (average 26 wga) • 5 neonates died • 3 maternal deaths • High index for suspicion9* *Level C

  21. Vitamin D Deficiency & Pregnancy10 • Deficiencies • Supplement 1200 mg Ca and 800 IU Vit D • Levels • >20 ng/mL (vs) • >32 ng/mL • Intake of 600 IU/day • PNV 400 IU/day • Vit D safe up to 1,000 -2,000 IU/day • Excess: neonatal tetany, IUGR, IUFD

  22. References Center for Disease Control Website. Available at: http://www.cdc.gov/obesity/data/adult.html. Accessed February 5, 2013. Cunningham, F.G. Et al. Williams obstetrics. 23rd ed. New York, NY: The McGraw-Hill Companies, Inc. 2010 Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-37. Obesity in pregnancy. Committee Opinion No 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:131;213-7. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academic Press; 2009.

  23. References Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M. Pregnancy and fertility following bariatric surgery. JAMA 2008;300:2286-96. Up To Date. Immages Roux-en-Y gastric bypass and Adjustable gastric band. Available at www.uptodate.com. Accessed February 5, 2013. Poitou Bernert C, Ciangura C, Coupaye M, Czernichow S, Bouillot JL, Basdevant A. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Bariatric surgery and pregnancy. ACOG Practice Bulletin No. 105. American College of Obstetricians and Gynecologists. Obstet Gyencol 2009;113:1405-13. Vitamin D: screening and supplementation during pregnancy. Committee Opinion No 459. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:197-98.

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