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Pregnancy After Bariatric Surgery Guidelines

Nutritional Screening And Supplementation

PREGNANCY | When Can I Become Pregnant After Weight Loss Surgery?

Postbariatric surgery patients should undergo close monitoring of their diet and nutrition from the preconception stage to the postnatal period. Preconception or at the first antenatal visit, patients should have their full blood count, ferritin, iron, vitamin B12, folate, thiamine, calcium, and vitamin D checked, with repeat testing at least once per trimester and during the post partum period if breastfeeding.42 The ASMBS, AACE, and TOS recommend that obstetrician management should be complemented with a multidisciplinary approach of bariatric dieticians, bariatric medical practitioners and bariatric surgeons.24,41

It is known that metabolic and nutritional changes occur after bariatric surgery due to reduced intake and alterations in digestive anatomy and physiology.42 The recommended nutritional supplementation following LAGB, LSG, RYGB, biliopancreatic diversion , and duodenal switch are summarised in Box 2. If oral supplementation is inadequate, particularly in cases of severe vomiting or decreased oral intake, parenteral supplementation of certain micronutrients, such as thiamine and vitamin B complexes, and iron should be considered.42,50 The recommended daily intake of these vitamins and minerals during the prenatal and perinatal periods for women with a history of bariatric surgery are summarised in Box 3.

French Study Group For Bariatric Surgery And Maternity Including All Listed Authors And Virginie Castera Md1 Rgis Coutant Md Phd2 Thierry Dupr Md3 Hubert Johanet Md4 Marie Pigeyre Md Phd5 Brigitte Rochereau Md6 Vronique Taillard Md7 Claudine Canale8 Anne

1Department of Endocrinology, St Joseph Hospital, Marseille, France

2Department of Pediatrics, Angers University Hospital, Angers, France

3Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Department of Biochemistry, Paris, France Société Française des Vitamines et Biofacteurs

4Clinique Turin, Paris, France

5Department of Nutrition, CHRU Lille, University Lille, Lille, France

6Antony, France

7Department of Nutrition, CHU Nimes, Nimes, France

8Collectif National des Associations dObèses

Other Foods And Drinks

Limit caffeine intake no more than 200mg per day. There is:

  • 100mg in a mug of instant coffee
  • 140mg in a mug of filter coffee
  • 75mg in a mug of tea
  • 40mg in a can of cola
  • 80mg in a 250ml can of energy drink
  • less than 25mg in a 50g bar of plain dark chocolate
  • less than 10mg in a 50g bar of plain milk chocolate

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Maternal And Reproductive Effects

  • Cesarean delivery | Operative morbidity
  • Indicated preterm birth
  • Be admitted earlier in labor
    • Require labor induction and additional oxytocin
    • Undergo longer labor
    • Miscarriage | Stillbirth
    • LGA and macrosomia | Childhood obesity
  • Impaired visualization of ultrasound images may compromise prenatal diagnosis but does not appear to compromise fetal weight estimations
  • Considerations For Patients With A Gastric Band

    Outcomes of pregnancy after bariatric surgery: results of a French ...

    If you have a gastric band and become pregnant you will need to contact the specialist bariatric nurse to discuss whether your band will need be adjusted during your pregnancy. If the band is not adjusted accordingly it may cause an increase in the symptoms of nausea, vomiting, intolerance to foods and abdominal pain. Please note excessive vomiting may increase the risk of band slippage.

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    Bariatric Surgery Can Help Improve Fertility And Pregnancy Outcomes In Several Ways

    Excess weight may trigger hormone imbalances that can affect a persons ovulation cycles and make it harder to get pregnant. It can also increase the chances for conditions that affect fertility, like polycystic ovary syndrome .

    Moving toward a healthier weight can help address these issues, such as promoting more predictable ovulation cycles and reducing insulin resistance, which causes blood sugar levels to rise and may cause irregular ovulation, or no ovulation at all. Some individuals may be able to achieve a healthier weight with lifestyle changes like diet and exercise. For others, undergoing bariatric surgery can lead to dramatic fertility improvements because it promotes increased weight loss at a faster rate.

    Once a person has conceived a child, being at a healthier weight can also help lead to better outcomes during pregnancy and delivery. For instance, theres a lower chance for problems like gestational diabetes, preterm birth, macrosomia , and stillbirth.

    When a pregnant person loses excess weight, their care team is also able to perform prenatal diagnostic procedures like ultrasounds more accurately. They may experience a shorter delivery time and be at less risk for postpartum complications like bleeding and infection, too.

    Breastfeeding After Having Bariatric Surgery

    Most women are concerned about whether they still can breastfeed after bariatric surgery or not. The answer is yes. Breastfeeding is recommended, however, specific attention to nutrition is still very important in this period.

    If you have any type of nutrition deficiencies, this will affect your milk since it will lack the necessary supplements for your babys growth.

    You can simply consult with your babys pediatrician, let them know about your bariatric surgery and your previous and current circumstances, and ask them to monitor your babys growth even more closely.

    If you have not reached your ideal weight before pregnancy and youre still a bit overweight, there is a probability of after giving birth your milk comes later than usual. In this case, just talk to your doctor and ask for some advice thatll streamline the breastfeeding process.

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    Recommendations For Pregnancy After Bariatric Surgery:

    • Pregnancy should be delayed by at least 1218 months due to adverse pregnancy outcomes associated with rapid weight loss. Based on ACOG guidelines, If pregnancy occurs before this recommended time frame, closer surveillance of maternal weight and nutritional status may be beneficial, and serial ultrasound monitoring of fetal growth should be considered.
    • Contraception should be prescribed after the surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption, and contraceptive devices such as intrauterine devices should be considered as first line therapy
    • After the surgery, women should undergo close monitoring for nutritional deficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. Protein, iron, folate, calcium, and vitamins B12 and D are the most common nutrient deficiencies after gastric bypass surgery. If no deficits are noted, a complete blood count and measurement of iron, ferritin, calcium, and vitamin D levels every trimester should be considered.
    • Bariatric surgeons, medical practitioners, dieticians, the patients usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.

    It Can Be Hard To Gain The Right Amount Of Weight

    Bariatric Surgery and pregnancy

    If you’ve gone through surgery in order to lose weight and likely experienced a change in how you feel about your body it can be challenging to see your belly growing rather than shrinking.

    Try to get comfortable with the idea that this is the time for you to gain, not lose weight. It’s important to gain an appropriate amount of weight to have as healthy a pregnancy as possible.

    After bariatric surgery, many women struggle to gain the right amount of weight during pregnancy. In one study, 24 percent of post-bariatric pregnant women had insufficient weight gain, 20 percent had adequate weight gain, and 56 percent had excessive weight gain. Predictably, more women with insufficient weight gain had SGA infants, and those with excessive weight gain had the highest prevalence of large-for-gestational age infants.

    Learn how much weight to gain during pregnancy, based on your pre-pregnancy BMI.

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    Can I Get Pregnant With An Intragastric Balloon In My Stomach

    In comparison with other types of bariatric surgery, the gastric balloon is much simpler and reversible. However, if youre planning to lose weight using a gastric balloon to increase fertility, it is better that you reach your ideal weight and then go for pregnancy.

    But sometimes, women get pregnant while having the balloon in their stomachs. This is not so problematic, but the removal of the balloon depends on its type. The 12-months balloons will be dissolved at the end of the year and there is no need for your doctor to remove them, but, the 6-month ones should be removed mostly by anesthesia, which is not suitable for pregnant women, thus not suggested.

    Recommended Birth Control For Pregnant Women After Bariatric Surgery

    If youve decided to listen to the first group of doctors, you need to prevent pregnancy as much as possible till at least 12 months after your operation.

    For sufficient contraception, your body needs a certain amount of hormones. Taking pills is a popular method among women, however, they cannot give you the necessary hormone and that is not something you can gamble on.

    Therefore, it is suggested that you take barrier methods. If you yourself are willing to make changes to your body in order to prevent pregnancy before your scheduled time, you can try female-controlled methods. If not, simply just ask your partner to use male condoms. This can all be arranged in an agreement between the two of you. But remember, itd be much better if you do not jeopardize your condition by taking oral medication and depending solely on them.

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    Nutritional Status Monitoring Multivitamins And Blood Tests

    Nutrient deficiencies can also occur in women who have undergone bariatric surgery, as a result of decreased food intake or food intolerances. Pregnancy can aggravate nutritional deficiencies however, women who have undergone a gastric bypass are at a high risk of deficiencies in micronutrients such as vitamin B12, iron, folate and fat-soluble vitamins. Women with previous bariatric surgery should have nutritional surveillance and screening for deficiencies during pregnancy. Protein, iron, folate, calcium, and vitamins B12 and D are the most common nutrient deficiencies after gastric bypass surgery and sometimes following sleeve gastrectomy. For pregnant women who have had bariatric surgery, screening for micronutrient deficiencies should be considered at the beginning of pregnancy and deficiencies should be treated accordingly. A complete blood screen including iron, ferritin, calcium, and vitamin D levels are recommended every trimester .

    Nutritional supplement

    Source: O’Kane et al

    Pregnancy In Postbariatric Surgery Patients

    Birth Control Guidelines for Bariatric Surgery

    Bariatric surgery with regards to fertility and pregnancy has both potential complications and benefits. A large prospective cohort study from Sweden showed that pregnancy in obesity was associated with increased rates of complications including the development of preeclampsia , fetal macrosomia , stillbirths and post partum haemorrhage compared with nonobese counterparts.36 There is also an increased risk of instrumental and caesarean deliveries, miscarriage, and development of neural tube defects in the maternal obesity group compared with their nonobese counterparts.37

    There is increasing evidence suggesting that bariatric surgery improves pregnancy outcomes. A systematic review from 2008 found three cohort studies showing a decrease in the rate of gestational diabetes mellitus and preeclampsia in patients who had undergone bariatric surgery compared with women with obesity who had not undergone surgery.9 Furthermore, bariatric surgery has also been shown to improve neonatal outcomes, specifically macrosomia 9 and large for gestational age infants .38

    However, it is important to note that there is an increased risk of a small for gestational age neonate in patients who undergo certain types of bariatric surgery before pregnancy, as a retrospective matchedcontrol cohort study found a significantly higher risk for SGA neonates in women following RYGB .39

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    Delaying Pregnancy After Bariatric Surgery

    A clinical practice guideline by the American Association of Clinical Endocrinology , The Obesity Society and the ASMBS recommends that pregnancy be delayed from 12 to 18 months after surgery due to the rapid and significant weight loss and nutritional insufficiencies which may lead to adverse pregnancy outcomes.25,26 Delaying pregnancy enables identification and correction of nutritional insufficiencies that may not be initially evident and allows the patient to achieve their full weightloss goals.27 Patients should be counselled appropriately by their surgeon and bariatric health care professional as part of routine preoperative management, as this time delay may have an impact on oocyte quality, which is known to decline in older women.28

    Nutritional Guidelines For Pregnancy After Bariatric Surgery

    The amount of nutrition your body delivers is for sure different before and after weight-loss surgery. By now you might be used to taking vitamins and mineral supplements every day in order not to lose your strength due to eating less than before the weight-loss surgery.

    You might be under the wrong impression that now that you are eating less, the fetus will not grow as much as it is supposed to. No worries because your baby takes what they need for growth from you. So, as long as you are healthy, theyre healthy.

    Even women who did not undergo a bariatric procedure could face problematic nutritional deficiencies during pregnancy. What you need to know is accurate information about the exact nutrition your body needs during this time, and of course, the necessary amount your body should be given on a daily basis.

    350 500 mcg 1000mcg
    Folic Acid
    Minimum level ==> 60 grams per day

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    Contraception And Preconception Counseling

    Contraception and preconception counseling should be provided for all women of reproductive age who are undergoing bariatric surgery. Counseling on the use of contraceptives is especially important in adolescents because pregnancy rates following bariatric surgery are twice those in the general adolescent population . The risk of oral contraceptive failure is increased after bariatric surgery, so nonoral administration should be considered.

    After bariatric surgery, a woman should wait 12 to 24 months before conceiving so that the fetus is not affected by rapid maternal weight loss and so that the patient can achieve her weight-loss goals. If pregnancy occurs before this recommended time frame, closer surveillance of maternal weight and nutritional status may be beneficial, and serial ultrasound monitoring of fetal growth should be considered.

    Gastric Bypass And Sleeve Gastrectomy

    Risks of bariatric surgery for women thinking about pregnancy

    Women who have undergone a gastric bypass or sleeve gastrectomy surgery may experience common pregnancy-related problems such as nausea, vomiting, and abdominal pain however, these symptoms can also mimic post-operative bariatric and gastrointestinal complications. Symptoms therefore require assessment and investigation by the bariatric surgical team to determine whether they are related to the surgery, and are a result of an internal hernia , reflux, aspiration or strictures.

    Dumping syndrome can occur after eating sugars, high-glycaemic carbohydrates and fats. It is more common after a gastric bypass but sometimes occurs following a sleeve gastrectomy. Symptoms include abdominal cramping, bloating, nausea, vomiting, and diarrhoea. Increased levels of insulin and hypoglycaemia can occur later, resulting in tachycardia, palpitations, anxiety, and sweating.

    Women who have had a gastric bypass and sleeve gastrectomy surgery are also at risk of malabsorption of oral medication due to a reduction in gastric acid. Therefore, slow- or modified-release preparations are not recommended and oral solutions or rapid-release preparations are preferred. Alternative preparations may therefore need to be considered and a medication review with the doctor is recommended. It is also imperative to monitor renal function before prescribing medications, especially if the pregnant woman reports vomiting. When prescribing medications, it is good practice to collaborate with the pharmacist.

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    The Best Time To Get Pregnant After Bariatric Surgery

    Most doctors recommend postponing pregnancy until at least 12 months after the surgery. The main reason for this recommendation is that obesity is associated with increased pregnancy complications, like gestational diabetes and preeclampsia . These problems do not vanish as soon as the surgery is done and are most likely to be treated at some point between 12 and 18 months after bariatric surgery.

    The other logic behind this idea is that after bariatric surgery youll start to lose weight. So, it is better to wait till your BMI stabilizes, and then you can get ready for pregnancy with ease of mind.

    However, as there are still some successful pregnancies right after the surgery, some experts believe there is no specific time, just do it whenever you feel ready!

    Regardless of the time of your pregnancy, it is wise to take everything into consideration. After all, pregnancy by itself brings about some abnormalities in your physical situation. You do not want to make it worse by not paying enough attention to your health and that of your baby.

    Will My Baby Have Any Side Effects Because Ive Had Bariatric Surgery

    If you still have this question, do not worry. All you need to do is to make sure you have appropriate eating habits and your body is delivered all the necessary nutrition, including vitamins and mineral supplementation.

    Also, to prevent any childhood obesity problems for your baby, have a balanced diet while pregnant and after that during the breastfeeding period.

    Focus on Healthy Weight Gain

    If youre not mentally ready for any kind of weight gain, then youre still not ready for a pregnancy. But if an unexpected one occurred, try to forget weight loss. However, it is important to control your weight in order not to gain excessive weight as it will affect both your mental and physical situation. So, try to focus on healthy weight gain instead.

    The American College of Obstetricians and Gynecologists published some numbers that indicate the ideal weight gain for women according to their BMI before pregnancy:

    30 < 1120 lbs

    If your body image irritates you as it might remind you of how you used to look, take it as a serious matter and visit a psychiatrist immediately.

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    You May Or May Not Need A C

    Some studies have reported higher cesarean rates among pregnant women who’ve had weight-loss surgery than among the general population. But this may be partly because women who undergo bariatric surgery are often older and more likely to be obese than women in the general population both risk factors for cesarean delivery.

    Other studies have found that women who’ve had bariatric surgery aren’t more likely to need a c-section, compared to obese women who haven’t had weight-loss surgery.

    Talk with your doctor about the likelihood of a cesarean ahead of time. Does your provider consider you at high risk for a c-section, and if so, why? Ask about your provider’s c-section rate and philosophy about c-sections in general. During labor, what might cause your provider to recommend a c-section?

    Also, you may be able to reduce your odds of having a c-section by following your doctor’s weight-gain recommendations, exercising during pregnancy, and taking childbirth preparation classes. You can also consider hiring a doula for support.

    Learn more:

    ACOG. 2009 . ACOG practice bulletin no. 105: Bariatric surgery and pregnancy. Obstetrics & Gynecology 11: 1405-1413. I have a pdf of the full version.

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