Pregnancy and Neonatal O utcome after Bariatric S urgery

1. Pregnancy and Neonatal Outcome after Bariatric Surgery Dr Amal Ayed Specialist in Obstetrics and Gynecology (MRCOG) MSc Obstetrics and Gynecology Ultrasound (UK) Fetal Medicine Subspecialist Ministry of Health Farwaniya Hospital Kuwait

2. Objectives • Maternal and fetal risks in obese women • Types of bariatric surgery procedures • Advantages , limitations of Bariatric surgeries in relation to maternal and fetal outcome. • Management of pregnancy following bariatric surgery • Conclusion • Recommendations

3. Maternal obesity is associated with increased risk of all the following except: A -Emergency caesarean section B- Induced labour C- Antepartum hemorrhage D- Thromboembolism

4. Pregnancy after bariatric Surgery is associated with decreased risk of all the following except: A- Preterm labour B- Pre-eclampsia C- Gestational diabetes D- Fetal macrosomia

5. Introduction • Maternal obesity has become one of the most commonly occurring risk factors in obstetric practice. • Obesity in pregnancy is usually defined as a body mass index (BMI) of 30 kg/m2 or more at the first antenatal consultation. • UK CMACE (2006–2008) reported 47% of mothers who died from direct causes were either overweight or obese, as were 50% of women who died from indirect causes. Centre for Maternal and Child Enquiries(CMACE).Maternal Obesity in the UK: Findings from National Project. London:CMACE,2010.

6.  Maternal and Fetal risks in Obese women Rahat Khan.2013 .Review .TOG.

7. 9th International Scientific Meeting of Royal College of Obstetricians and Gynecologists - Joint Meeting with the Hellenic Obstetric & Gynaecological Society 28-30 September 2011, Megaron Athens International Conference Centre, Athens, Greece.Effect of obesity on pregnancy.2011 .

8. Maternal and Fetal risks in Obese women • Total of 8876 • Obese women (42%) were at the highest risk of : - Induced labour (46.6% vs 27.4%) - Emergency caesarean delivery (35.1% vs 19.6%) - 6 times risk of pre-eclampsia - 4 times risk of post partum hemorrhage - large baby >4000gm - Fetal anomalies ( NTD and cardiac defect) • Same risk of delivering preterm baby as a woman with normal BMI (12.5% vs 12.4%). • No statistically significant association between maternal BMI and antepartum hemorrhage (P=0.40) or stillbirth (P = 0.7). (P < 0.001)

9. NICE recommends Bariatric surgery as an option in morbidly obese patients (BMI >40 kg/m2) where lifestyle and/or medications have been found to be ineffective. • Obstetricians, surgeons and primary care clinicians will be required to address questions posed by their patients regarding the safety of pregnancy after weight loss surgery. NICE Guidelines [CG189] Published date: November 2014

10. Bariatric Surgery Procedures Mal-absorbed Restrictive Mal-absorbed Restrictive

11. Bariatric Surgery Procedures Khan R, et al. 2015

12. Bariatric Surgery Procedures • The number of bariatric surgical procedures is increasing in most of the Western and Eastern countries • Laparoscopic Roux-en-Y gastric bypass (mal-absorptive) surgery and laparoscopic gastric banding (restrictive procedures) are the most frequently used procedures. • Mal-absorptive surgery results in life-long anatomic and physiologic changes and may thus cause more safety concerns in pregnancy compared to the restrictive procedures.

13. Maternal Outcome after Bariatric Surgery LAGB = laparoscopic adjustable gastric binding RYGB = Roux-en-Y gastric bypass BPD = biliopancreatic diversion Chilelli NC, Burlina S, Dalfrà MG, Lapolla A (2014). J Obes Weight Loss Ther 4: 210.

14. Maternal Outcome after Bariatric Surgeries A. Positive outcomes: • ↑infertility • ↓weight gain during pregnancy • ↓ gestational diabetes and fetal macrosomia • ↓ preeclampsia • No significant differences were recorded for cesarean, postpartum hemorrhage. • Lack of robust evidence to demonstrate a significant effect of bariatric surgery on miscarriage rate . B. Adverse outcome: - Surgical and Metabolic complications

15. Maternal complications during pregnancy Chilelli NC, Burlina S, Dalfrà MG, Lapolla A (2014) .J Obes Weight Loss Ther 4: 210.

16. Fetal Outcome after Bariatric Surgery BPD, biliopancreatic diversion; BW, birth weight; IUGR, intrauterine growth restriction; LAGB, laparoscopic adjustable gastric banding; LGA, large for gestational age; Macrosomia, birth weight ≥ 4000 g; nr, not reported; RYGB, Roux-en-Y gastric bypass; SGA, small for gestational age. Maria Grazia Dalfrà.2012

17. Roos N, et al. 2013.BMJ

18. Fetal Outcome after Bariatric Surgery • Increased rate of intrauterine growth restriction . • Overall risk of spontaneous or induced preterm birth before 32 weeks is increased . • Number of observational studies have highlighted the importance of further research into the potential increase in congenital malformations following bariatric surgery. • Lacks good evidence to support improved perinatal outcomes following pregnancy post bariatric surgery, although there is little evidence to suggest adverse outcomes.

19. Management of pregnancy following Bariatric Surgery A. Pre-conception • Contraceptive counselling –delay pregnancy for 12-18 months after surgery. • Follow-up with nutritionist/dietitian to monitor nutritional status and weight gain. • Folic acid, vitamin B12, calcium and iron supplementation. B. Antenatal care • Multidisciplinary setting to optimise pregnancy outcome. • Early antenatal consultation. • Offer emotional support.

20. Management of pregnancy following Bariatric Surgery • Determine baseline nutritional status . • Regular blood tests . • Weigh the individual at every visit to monitor gestational weight gain. • GTT to detect gestational diabetes mellitus. • Ultrasound for fetal anomalies and growth . • If slight suspicion of intestinal obstruction, perform clinical examination and imaging studies. Surgical exploration may be required. • Assess for thromboprophylaxis.

21. Management of pregnancy following Bariatric Surgery C. Intrapartum • Bariatric surgery is not an indication for C section. • It is important to anticipate problems and effectively prepare equipment and personnel. • Fetal scalp monitoring may be required. D. Postpartum • Adequate pain control, early mobilisation, thromboprophylaxis, physiotherapy. • Encourage breast feeding. • Follow up with nutritionist to ensure a healthy diet and to guide further weight loss, if required. • Women considering body contouring surgery postbariatric surgery should wait until they have completed their family as future pregnancies can reverse the effects of cosmetic surgery.

22. Conclusion • Women who have had bariatric surgery generally tolerate pregnancy well. • Multidisciplinary team for healthy maternal and neonatal outcome. • key to a healthy pregnancy after weight-loss surgery is paying attention to nutrition. • Bariatric surgery is associated with reduced risks of gestational diabetes and large-for-gestational-age infants but increased small-for-gestational-age infants, a shorter length of gestation, and potentially an increased risk of stillbirth or neonatal death.

23. Recommendations • Pregnancy after bariatric surgeries is safer with fewer complications than pregnancy in morbidly obese women. • Delaying conception for at least 18 months after bariatric surgeries. • Optimum nutrient supplement including 5 mg folic acid • Pregnant women with a history of bariatric surgery should be regarded as a risk group and be counselled about the increased risk of preterm birth and intrauterine growth restriction • Follow up with nutrition and surgeons to prevent nutrition and surgical complications

24. Research Gap • Effect of bariatric surgery on miscarriage rate . • Effect of bariatric surgery on fetal malformation( NTD)

25. Maternal obesity is associated with increased risk of all the following except: A -Emergency caesarean section B- Induced labour C- Antepartum hemorrhage D- Thromboembolism

26. Pregnancy after bariatric Surgery is associated with decreased risk of all the following except: A- Preterm labour B- Pre-eclampsia C- Gestational diabetes D- Fetal macrosomia

27. Thank You.

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