Bariatric Surgery: Reproductive Implications

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1 Disclosures Bariatric Surgery: Reproductive Implications I have no significant financial disclosures Lauren A. Miller MD MPH February 22, 2018 O bjectives State of the obesity problem Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2015 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before Medical complications of obesity Types of bariatric surgery Risks / benefits of bariatric surgery Preconception considerations Pregnancy management Complications *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. 1

2 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016 In which of the following groups isbariatric surgery most commonly performed? Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before Males age >50 years A Females age > 50 years B Females age years C Males age years D *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. Start the presentation to see livecontent Still no live content? Install the app or get help at PollEv.com/app Bariatric Surgery 80% of bariatric surgery is performed on women of childbearing age in the US 1 Medical Complications ofobesity Insulin resistance / Type 2 diabetes Chronic hypertension Obstructive sleep apnea Osteoarthritis Chronic pain, falls / injuries Psychologic problems, depression 2

3 Reproductive Complications of Obesity Infertility PCOS Endometrial Cancer Breast Cancer Gestational Diabetes Pre-Eclampsia Cesarean section Fetal anomalies Bariatric Surgery Basics Limit capacity of stomach Delay gastric emptying Limit absorption Modify appetite and satiety via neuroendocrine changes 2-3 Bariatric Menu Roux-en-Y (RYGB) Adjustable Gastric Band: Lap-Band Biliopancreatic Diversion Sleeve Gastrectomy Roux-en-Y Open Roux-en-Y Gastric Bypass Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 5, Laparoscopic Roux-en-Y Gastric Bypass Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 6,

4 Roux-en-Y Roux-en-Y Pros High weight loss 70-80% Excess body weight (EBW) 3,4 Neuroendocrine alterations à Lasting weight loss Cons Malabsorption Longer surgery Higher surgical risk 18 Open Roux-en-Y Gastric Bypass Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 5, Open Roux-en-Y Gastric Bypass Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 5, Adjustable Band Adjustable Band Pros Cons Adjustable Low surgical risk No malabsorption No neuroendocrine change 3 Weight loss only modest 3 Increased risk of reoperation 18 Laparoscopic Adjustable Gastric Banding Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 7,

5 Biliopancreatic Diversion Biliopancreatic Diversion Pros Cons Normal eating capacity High weight loss % EBW Significant malabsorption Protein malnutrition Severe anemia Fat-soluble vitamin deficiencies Persistent diarrhea Mortality 1% Morbidity 20-25% 3,4 Biliopancreatic Diversion Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 3, Sleeve Gastrectomy Sleeve Gastrectomy Pros Cons Mod-High weight loss 40-60% EBW 21 At 5 years? Comparable to RYGB 22 More effective than Lap- Band at 2 years 22 May be less effective than RYGB Less common procedure; less insurance coverage Sleeve Gastrectomy Buchwald, Henry, MD, PhD, Buchwald's Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Chapter 10,

6 Type 2 Diabetes Do not conceive until weight loss is stabilized? ACOG months 8 Bariatric Surgeons 2 years We conclude there is scant evidence of pregnancy outcomes upon which to make recommendations about how long to delay pregnancy following surgery 9 Maintain care with Surgeon and Nutritionist! Retinopathy rapid progression Diabetic nephropathy Creatinine >1.5md/dl may worsen to ESRD risk hypertensive disorders (50%) placental insufficiency RR 2 risk still birth Chronic HTN (10-20% diabetics) risk pre-eclampsia risk placental insufficiency stillbirth Diabetic Ketoacidosis risk of fetal mortality (10-35%) risk of maternal death Coronary Artery Disease risk of MI and death Fetal Anomalies (6-12%) HbA1c 10% = 20-25% anomaly rate Cardiac, CNS, Spina Bifida, Sacral agenesis; cardiomyopathy Spontaneous Abortion Stillbirth Macrosomia Shoulder Dystocia Preterm Labor Cesarean section Hypoglycemia as neonate Obesity, HTN, DM in offspring Type 2 Diabetes Bariatric surgery results in higher rates of shortterm and long-term diabetes remission and prevention of incident diabetes than does conventional therapy for obesity Gestational Diabetes Lap-Band 10 Pre-surgery 15% 6.3% 19% Gastric Bypass 11 Pre-surgery 11% 2.7% Any bariatric surgery in Sweden % 6.8% 6

7 Pre-eclampsia Lap-Band 10 Pre-surgery Pre-E = 28% Pre-E = 5% Pre-E = 25% ghtn+ = 45% ghtn+ = 10% ghtn+ = 38% Gastric Bypass 11 Pre-surgery ghtn = 19% ghtn = 0% Preterm Birth Lap-Band 10 Pre-surgery NR 6.3% Any bariatric surgery in Sweden % NS Any bariatric surgery in Washington %* RR % 7.5% Gen Population 8.6% Fetal Risk of Maternal Obesity Fetal anomalies ONTD Macrosomia Shoulder dystocia Stillbirth Long term childhood hypertension, diabetes, obesity, metabolic syndrome SGA / Low Birthweight Lap-Band 10 Pre-surgery NR 6.3% 8.9% Gastric Bypass 11 Pre-surgery 30.4% 5.5% Any bariatric surgery in Sweden %* Any bariatric surgery in Washington %* RR % Gen Population 8.9% 7

8 LGA / Macrosomia Stillbirth Lap-Band 10 Pre-surgery NR 11.4% 17.7% Any bariatric surgery in Sweden LGA8.6%* Any bariatric surgery in Washington %* RR % Gen Population 8.7% Any bariatric surgery in Sweden Still birth or neonatal death 1.7% Any bariatric surgery in Washington % NS Gen Population 1.5% 1% NS Cesarean Section rates No difference Pre vs. Post-surg 9 Infection Wound dehiscence Pregnancy Monitoring Gestational Diabetes Screening: - Regular 1 hour OGTT if able (1 st and 2 nd tri) - 1 week fasting and 1 hour PP BG checks per trimester 8

9 Nutrition When adhering to vitamin supplementation recommendation nutritional deficiencies are rare for most bariatric surgeries 9 Screen for deficiencies q-trimester Biliopancreatic diversion procedure are at higher risk of deficiencies and needing parenteral nutritional support 9 Nutritional Deficiencies B 12 (Cobalamin) Intrinsic factor produced in pylorus (stomach) 50% will have a deficiency 23 Measure Serum B12 level Subclinical disease measure serum methymalonic acid 1000mcg daily after surgery PO insufficient à B12 Injections, q1-3 months 23 ** May have implication for breastfeed newborn B 12 levels 3,5 Nutritional Deficiencies Nutritional Deficiencies Folate Rates of deficiency are very low after bariatric surgery Folate is absorbed throughout the small bowel and enteral bacteria produce folate If concern technically need to check erythrocyte folate levels, not serum folate All should be taking mcg daily At preconception meeting increase to 4-5g/day 23 Ca 2+ / Vitamin D 1500mg Calcium recommended in pregnancy & post-bartiatric surgery 800 IU or more Vitamin D daily 23 Calcium citrate or gluconate may be better absorbed than calcium carbonate owing to diminished gastric acid in the smaller pouch 3 Remind patient to separate intake of their iron and calcium supplements by at least 2 hours! 9

10 Nutritional Deficiencies Nutritional Deficiencies Vitamin A, E, K Rare to have deficiencies if taking daily multivitamin * if Biliopancreatic diversion à need to monitor levels Zinc, Copper, Selienium Multivitamin 23 Iron Absorbed in the Duodenum / Jejunum 50% post-surgery have deficiency 100mg daily elemental iron 23 Thiamine (B1) proximal small intestines Deficiencies seen with extreme vomiting 3,6,23 IV 100mg/d if admitted with hyperemesis Check iron studies pre-pregnancy and q3 months during pregnancy if normal Check monthly if additional treatment required Nutritional Deficiencies Special Consideration Protein Need 60g/day Hypoalbuminemia Edema is severe if very low levels Avoidance of NSAIDs Due to risk of gastric irritation Aspirin for pre-e prevention? Reflux Discuss with their bariatric surgeon Prevent esophageal injury, gastric ulceration 10

11 Emergencies Internal Herniation Small bowel obstruction (9%) 7 Pouch rupture Anastomotic leaks Devascularization complications Midgut volvulus from adhesions Gastric ulceration / perforation SCAN Patient!!! Ref 7,9 References Questions? 1. Shinogle JA, Owings MF, Kozak LJ: Gastric bypass as treatment for obesity: trends, characteristics, and complications. Obes Res 2005, 13: Bariatric Surgery, edited by Nadey S. Hakim, et al., Imperial College Press, ProQuest Ebook Central, 3. Landsberger, E. J. and E. D. Gurewitsch (2007). "Reproductive implications of bariatric surgery: Preand postoperative considerations for extremely obese women of childbearing age." Current Diabetes Reports 7(4): Buchwald H, Avidor Y, Braunwald E, et al.: Bariatric surgery: a systematic review and meta-analysis. JAMA 2004, 292: Grange DK, Finlay JL: Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass. Pediatr Hematol Oncol 1994, 11: Chiossi G, Neri I, Cavazzuti M, et al.: Hyperemesis gravidarum complicated by Wernicke encephalopathy: background; case report; and review of the literature. Obstet Gynecol Surv 2006, 61: Capella RF, Iannace VA, Capella JF: Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg 2006,203: American College of Obstetricians and Gynecologists: ACOG Committee Opinion number 315, September Obesity in pregnancy. Obstet Gynecol 2005, 106:

12 9. Maggard M, et.al. Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy. Evidence Report/Technology Assessment No (Prepared by the Southern California Evidence-based Practice Center under Contract No ). Rockville, MD: Agency for Healthcare Research and Quality. November Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol 2005;106(5 Pt 1): Wittgrove AC, Jester L, Wittgrove P, et al. Pregnancy following gastric bypass for morbid obesity. Obes Surg 1998;8(4):461-4; discussion Johansson, K., et al. (2015). "Outcomes of Pregnancy after Bariatric Surgery." New England Journal of Medicine 372(9): Mingrone G, Panunzi S, De GaetanoA, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012; 366: Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medicaltherapy in obese patients with diabetes. mn Engl J Med 2012; 366: Sjöström L, Lindroos AK, Peltonen M,et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351: Sjöström L, Peltonen M, Jacobson P, et. al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 2014; 311: Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects N Engl J Med 2012; 367: Bariatric Surgical Procedures for Obese and Morbidly Obese Patients: A Review of Comparative Clinical and Cost- Effectiveness, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2014 Apr 24. Available from: Kominiarek, M. A., et al. "American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society." Surgery for Obesity and Related Diseases 13(5): Feichtinger, M., et al. (2017). "Altered glucose profiles and risk for hypoglycaemia during oral glucose tolerance testing in pregnancies after gastric bypass surgery." Diabetologia 60(1): Diamantis, T., et al. (2014). "Review of long-term weight loss results after laparoscopic sleeve gastrectomy." Surgery for Obesity and Related Diseases 10(1): Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3): , discussion Slater, C., et al. (2017). "Nutrition in Pregnancy Following Bariatric Surgery." Nutrients 9(12):