Casco Bay Surgery

Bariatric Surgery Program
Guidelines for Preconception and Prenatal Care Following Gastric Bypass Surgery

Maine Medical Center
Division of Maternal-Fetal Medicine
887 Congress Street, Suite 200
Portland, ME  04102

Background

Morbid obesity represents a serious medical condition that may cause or contribute to additional disorders such as diabetes, hypertension, and hypercholesterolemia, among others. Gastric bypass surgery may be part of an overall weight control program in women of reproductive age. Pre-existing medical conditions or physiologic changes following surgery may have clinically significant consequences for women contemplating pregnancy after gastric bypass.

Purpose

These guidelines are intended to foster a team approach to the gastric bypass patient contemplating pregnancy or already pregnant. Preconception and prenatal concerns are outlined, including recommendations for care.

Return of Ovulatory Function

Comment

Due to rapid weight loss immediately following surgery, previously anovulatory and infertile women may quickly regain ovulatory function and fertility.

Recommendation

1. Reliable contraception should be employed for at least 18 months following surgery, the period of maximal weight loss.

2. Patient should be referred to her primary care provider or obstetrician/gynecologist peri-operatively for this care.

Preconception Care for Pre-Existing Conditions

Comment

Pre-existing medical conditions such as hypertension and diabetes incur maternal and fetal risk through direct pathophysiological effects or indirectly through teratogenicity of medications used in their treatment.

Recommendations

1. Preconception perinatal consultation

2. Review of medical records and current medications.

3. Review maternal-fetal issues regarding pregnancy after bariatric surgery.

4. Establish pre and post-conception care plan.

Nutritional Deficiencies Following Surgery

Comment

Folic acid, B₁₂ and iron deficiency anemia are not uncommon following surgery. Folic acid deficiency may be associated with an increased risk of fetal open neural tube defects (ONTD’s). Offspring of women following bariatric surgery may also experience an increased frequency of fetal ONTD’s.

Recommendations         

1. Folic acid supplements of at least 400 mcg/day orally 1 month prior to and 12 weeks after conception. Consider increasing this dose to 4 mg orally daily.

2. Iron and B₁₂ supplements as indicated based on red blood cell indices, serum B₁₂, iron, or ferritin levels. Prenatal vitamins usually include 30-90 mg elemental iron and 0.8-1.0 mg folic acid. Additional supplements should take the form of the specific nutrient requiring supplementation. Multiple vitamin pills incur the risk of excessive intake of other nutrients. Consultation of the Maine Bariatric Surgery nutritionist may be of assistance.

3. Vitamin B₁₂ can be administered 500 mcg orally daily or 1000 mcg IM monthly.

4. Avoid more than twice the recommended daily allowance of fat-soluble vitamins A, D, E, and K. Vitamin A in doses of > 5,000 IU/day may be teratogenic.

5. Counsel patient in regards to parenteral hyperalimentation if inadequate caloric intake orally.

Potential Increased Risk for Fetal ONTD’s

 Recommendations

1.  Folic acid supplementation (see above).

2.  Maternal serum alpha-fetoprotein screen 15-21 weeks.

3. Targeted fetal ultrasound 18-20 weeks.

Suboptimal Fetal Growth vs. Supranormal Growth

Comment

Conception during the period of maximal weight loss may increase the risk of intrauterine growth restriction. Maternal nutritional deficiencies and anemia may add to this risk. On the other hand, obesity in pregnancy can lead to increased frequency of macrosomia and cesarean delivery.

Recommendations

1. Monthly growth ultrasound beginning at 24 weeks gestation.

2. Preconception and ongoing nutritional evaluation by Maine Bariatric Surgery nutritionist.

3. Correction of nutritional deficiencies.      

Maternal Dumping Syndrome

Comment

High sugar content can cause cramps, diarrhea, nausea, light-headedness, and palpitations.

Recommendations

1. Avoid one and three hour glucose challenge testing.

2. Instead, perform 1 week of checking fasting and two-hour postprandial finger sticks. Target ranges of < 90 mg/dL for fasting and < 120 mg/dL for postprandials, and manage accordingly.

Labor and Delivery

Comment

 Obesity is associated with an increased risk of cesarean delivery and postoperative morbidity.

Recommendations

1. Timing and mode of delivery is based on obstetrical indications.

2. Consider antibiotic prophylaxis at cesarean, deep venous thrombosis prophylaxis perioperatively for obese patients.

Breastfeeding

Comment

Lactation is compatible with gastric bypass surgery.

Recommendations  

Notify pediatrician of maternal surgical history due to potential risk of neonatal megaloblastic anemia.

Postpartum Weight Loss

Comment

Weight loss after delivery follows the same pattern as in women without a history of bariatric surgery.

Recommendations

Counsel patient accordingly.

References

1. American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 5^th ed. Washington, D.C. 2002.

2. www.cascobaysurgery.com.

3. Wills CE. Gastric bypass for morbid obesity. J. Med Assoc. Ga. 1981; 70: 725-7.
   Printen KJ, Scott D. Pregnancy following gastric bypass for the treatment of morbid obesity. Amer Surgeon 1982; 48: 363-5.

4. Haddow JE, Hill LE, Kloza EM, Thanhauser D. Neural tube defects after gastric bypass. Lancet 1986; 1330.
   Richards DS, Miller DK, Goodman GN. Pregnancy after gastric bypass for morbid obesity. J Reprod Med 1987; 32: 172-6.

5. Chapman R, Chapman K. Pregnancy occurring in a morbidly obese woman who had undergone gastric stapling. J. Royal Soc Med 1991; 84: 503-4.

6. Grange DK, Finlay JL. Nutritional vitamin B₁₂ deficiency in a breast-fed infant following maternal gastric bypass. Ped Hematol Oncol 1994; 11: 311-8.

7. Gurewitsch ED, Smith-Levitin M, Mack J. Pregnancy following gastric bypass surgery for morbid obesity. Obstet Gynecol 1996; 88: 658-61.

8. Wittgrove AC, Jester L, Wittgrove P, Clark W. Pregnancy following gastric bypass for morbid obesity. Obesity Surgery 1998; 8: 461-4.

9. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000; 95: 927-30.
   Kral JG, Brolin RE, Buchwald H, Pories WJ, Sarr MG, Sugarman HJ, Wolfe BM. Research considerations in obesity surgery. Obesity Research 2002; 10: 63-4.
   

The Bariatric Surgery Center
12 Andover Road
Portland, Maine 04102
(207)-761-5612
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