Female Reproductive Issues Following Bariatric Surgery

1. Female Reproductive Issues Following Bariatric Surgery Joseph R. Wax, M.D. Professor of Obstetrics and Gynecology University of Vermont School of Medicine Maine Medical Center Portland, Maine

2. A Tale of Two Patients… • 25 year old G0 12 months after gastric bypass • Pre-conception care? • Pregnancy management? • 35 year old G3P1011 at 21 weeks with 2 days progressive abdominal pain. RYGB 18 months earlier. • Differential diagnosis? • Evaluation and treatment?

3. Goals • Describe commonly performed bariatric procedures and implications for female reproductive health • Review consequences of bariatric surgery with regard to preconception care • Describe complications of bariatric surgery in pregnancy and their management • Review pregnancy outcomes following bariatric surgery

4. Obesity in American Women (BMI > 25) (BMI > 30) 62% 33% (BMI > 40 or > 35 with comorbidity) 7% Ogden, C.L. JAMA 2006

5. Obesity-Related Morbidity

6. Obesity-Related Obstetrical Morbidity

7. Recent Trends in Bariatric Surgery • Almost 20-fold increase last decade • 2005 >100,000 • 2006 >200,000 • 5x as many procedures in women as men • >50% of all procedures in reproductive-aged women • Only effective treatment of morbid obesity CDC 2006

8. Bariatric Surgery – Prerequisites • Multidisciplinary care • Attempt non-surgical weight loss • Preoperative medical evaluation • Preconception consultation and care

9. Bariatric Procedures – Roux-en-Y Gastric Bypass • Restrictive and malabsorptive • Lose • 100 lb • 65-70% EBW • 35% BMI • 0.5% mortality • 5% operative morbidity Buchwald, H. Obes Surg 2002

10. Roux-en-Y Gastric BypassLaparoscopic vs. Open Simpfendorfer, C.H. Surg Clin N Am 2005

11. Bariatric Procedures – Laparoscopic Adjustable Gastric Banding • Restrictive • Lose • 50% EBW • 25% BMI • 0.1% mortality • 5% morbidity Buchwald, H. JACS 2005

12. Bariatric Procedures – Vertical Banded Gastroplasty • Restrictive • Efficacy, morbidity, mortality similar to LAGB Buchwald, H. Obes Surg 2002

13. Perioperative Reproductive Issues • Rapid weight loss over 12-18 months • Resolution of • PCOS • anovulation • irregular menses • Improved fertility and fecundity • Reliable contraception Teitelman, M. Obes Surg 2006 Bilenka, B. Acta Obstet Gynecol Scand 1995 Eid, G. M. Surg Obes Rel Dis 2005 Deitel, M. J Am Coll Nutr 1988

14. Gastric Bypass and Malabsorption • Supplements • ferrous sulfate or fumarate • B12 • 500-1000 µgm po qd or • 500-1000 µgm IM qm • folic acid • 400 µgm po qd • calcium citrate • 1200 mg po qd

15. Preconception Care • Avoid MVI with > 5000 IU vitamin A • Address other obesity-related comorbidities • hypertension • diabetes • obesity Rothman, K. M. NEJM 1995

16. Late Surgical Complications in Pregnancy – Bowel Obstruction • 6-8% pregnancies -Internal hernia -Intussusception -Volvulus • 9-25 months after RYGB • Delay in diagnosis or treatment → 2 maternal and 1 fetal death Wax, J.R. OG Survey 2007

17. Bowel Obstruction in Pregnancy • Nonspecific nature of abdominal complaints • Confusion with common obstetrical phenomena • Distracted from inciting event by 2° pancreatitis *Have low threshold to consult bariatric surgeon* * Have low threshold to explore pregnant patient for obstruction*

18. Internal Hernia in Pregnancy • Lesser sac into mesocolic tunnel • Petersen (below Roux limb) • Leaves of small bowel mesentery Karkala, N OG 2005

19. Intussusception in Pregnancy • 21 weeks’ gestation • RYGB 18 months earlier • Several days abdominal discomfort • Six hours constant pain • Suspected internal hernia Wax, J.R. Obes Surg 2007

20. Late Surgical Complications in Pregnancy – Malabsorption • Iron deficiency • usually mild, responsive to oral therapy • rare cases of needing parenteral iron • recommend trimesterly CBC • Folate and B12 • continue preconception supplements • recommend MSAFP and targeted ultrasound

21. Does Gastric Bypass Increase ONTD Risk? • 3 cases of ONTDs remote from RYGB (2-8 yrs) • no maternal vitamin supplements • 2 ↓B12, 1 ↓folate • Later studies • no ONTDs in 129 RYGB pregnancies • no increased risk of anomalies after bariatric surgery 15/289 cases vs. 6333/158,912 controls Sheiner, C.S. AJOG 2004 Haddow, J.E. Lancet 1986 Knudsen, L.B. Lancet 1986

22. Obesity Pregnancy RYGB Insulin Resistance Decreased fasting blood glucose Unfulfilled increased caloric intake Decreased caloric intake & absorption Pancreatic β cell hyperfunction Hyperinsulinemic Hypoglycemia Malabsorption and Carbohydrates

23. Hyperinsulinemic Hypoglycemia • Diagnosis • glucose < 55 mg/dL • insulin ≥ 3 mcU/mL • c-peptide ≥ 0.6 ng/mL • no sulfonylurea Halverson, J.D. Surgery 1982

24. Hyperinsulinemic Hypoglycemia • Affects approximately 4% pregnancies • Treatment = Dietary Modification • Avoid refined/simple sugars • Increase • protein • complex carbohydrates • Consume liquids well before and after meals • Consult bariatric nutritionist

25. Hyperinsulinemic Hypoglycemia in Pregnancy • 36-year old at 24 weeks • RYGB 39 months earlier • Lightheadedness, syncope • Postprandial glucose 34-57 mg/dL • Normal glucose, no symptoms after: • increase calories 1000 → 1500/day • increase protein 56g → 80g/day • avoid refined sugars Wax, J.R. Obes Surg 2007

26. Managing Dietary Failures • Rare, no reports in pregnancy • Reversal of bariatric procedure • Partial or total pancreatectomy

27. Dumping Syndrome • Affects small proportion of RYGB patients • Can be associated with postprandial hyperinsulinemic hypoglycemia • Precipitated by liquids, simple, refined sugars Vecht, J. Scand J Gastroent Suppl 1997 Hasler, W.L. Curr Treat Options Gast 2002 Ukleja, A. Nutr Clin Pract 2005

28. Rapid transit of nutrients to small intestine Osmotic fluid shifts Vasomotor Symptoms Abdominal Symptoms Dumping Syndrome – Early Phase (10-30 min) • palpitations • syncope • diaphoresis • flushing • headache • nausea • diarrhea • cramping • bloating

29. Reactive Hyperinsulinemic Hypoglycemia Vasomotor Symptoms Dumping Syndrome – Late Phase(1-3 hrs)

30. Dumping Syndrome – Treatment • Dietary Modification • Avoid refined/simple sugars • Increase • protein • complex carbohydrates • Consume liquids well before and after meals

31. Managing Dietary Failures • Rare, no reports in pregnancy • Medication • Acarbose (inhibits glucose absorption) • 25-50 mg after meals (TID) • S/E flatulence, diarrhea • category B • Octreotide (somatostatin analog) • 25-100 mcgm SQ 15-60 min before meals • category B

32. Dumping Syndrome – Implications for Pregnancy • Avoid glucose challenge test • Home glucose monitoring • 1-2 weeks at 26-28 weeks • treat if consistently elevated

33. Pregnancy Outcomes After Bariatric Surgery • Case reports and series • Case-control studies • small • subjects as own controls • women without bariatric surgery as controls • obese • non-obese • unspecified bariatric surgical procedure

34. Pregnancy after LAGB * vs. last presurgical pregnancy † vs. matched obese controls

35. Pregnancy After RYGB

36. Pregnancy After RYGB *adjusted for BMI at delivery Wax, J.R. et al Obes Surg 2008

37. Pregnancy After RYGB- Impact of Timing

38. Pregnancy After LAGB/RYGB

39. Bariatric Surgery and the Puerperium • Weight loss • limited descriptive data • rate similar to nonbariatric delivered patients and nonpregnant bariatric patients

40. Bariatric Surgery and Lactation • Not contraindicated • Ensure maternal B12 supplementation • several cases of neonatal B12 deficiency Grange, D.K. Pediatr Hematol Oncol 1994 Campbell, C.D. Haematologica 2005

41. Summary • Anatomic and physiologic changes associated with bariatric surgery have significant reproductive implications • Nutritional deficiencies generally mild and easily treated • Limited data suggest favorable pregnancy outcomes

42. Future Research • Pregnancy outcome • by specific bariatric procedure • account for • past pregnancy complications • persistent obesity • obesity-related comorbidities • congenital anomalies (ONTDs)

43. Guidelines for Care Wax, J.R. OG Survey 2007