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Bariatric Surgery and Pregnancy

Bariatric Surgery and Pregnancy. John Finney Bariatric Dietitian Doncaster Royal Infirmary. Discussion Points. Obesity in Pregnancy Bariatric Surgery Gastric Bypass Gastric Band Sleeve Gastrectomy Post op diet Bariatric Surgery and Pregnancy Recommendations Areas of Limited Evidence

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Bariatric Surgery and Pregnancy

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  1. Bariatric Surgery and Pregnancy John Finney Bariatric Dietitian Doncaster Royal Infirmary

  2. Discussion Points • Obesity in Pregnancy • Bariatric Surgery • Gastric Bypass • Gastric Band • Sleeve Gastrectomy • Post op diet • Bariatric Surgery and Pregnancy • Recommendations • Areas of Limited Evidence • Gestational Diabetes • Case studies

  3. Obesity • Global epidemic (WHO, 2000) • Obesity rates in the UK continue to rise (HSE, 2012) • Obesity prevalence in women of reproductive age 24.2% and expected to rise (Ono, 2005)

  4. Obesity • Bariatric surgery is an effective tool for treating obesity (Shah, 2006) • Many co-morbidities can improve following weight loss surgery (Perry, 2008) • Significantly more women than men have bariatric surgery • Many of these women are of a reproductive age

  5. Obesity in Pregnancy • Prior to conception associated with infertility • Increases risks in pregnancy • Maternal death • Gestational diabetes • Pre eclampsia • Hypertension • And many more ………

  6. Criteria for Referral • New Clinical Commissioning Policy • Published April 2013 • NICE guidance (2006) • BMI >40kg/m² • Or 35-40kg/m² with other significant disease • Obesity present for at least 5 years • Complied with a local specialist MDT obesity service weight loss programme for 12-24 months (for BMI>50kg/m2, minimum period is 6/12)

  7. Keyhole Surgery

  8. Gastric Bypass Surgery Gastric Bypass

  9. Gastric Bypass Complications Leak from the joins Narrowing or blockage Nutritional deficiencies

  10. Gastric Band Surgery Gastric Band

  11. Gastric Band Complications Band slippage Band erosion Infection Port disconnection Band leakage

  12. Sleeve Gastrectomy Sleeve Gastrectomy

  13. Sleeve Gastrectomy Complications Staple line leak/bleed Narrowing or blockage Nutritional deficiencies

  14. Post Operative Diet Following Bariatric Surgery • Post surgery staged process • to allow the body to get used to the operation • let swelling decrease • Not put excessive pressure on joins / dislodge bands • Individual time spent at each stage depends on procedure and the patient is progressing • Important not to rush through the stages, it will take longer in the end

  15. Post Operative Diet Following Bariatric Surgery Stage 1 Liquid only (1 week) • Four Stages • Stage 2 • Blended / Pureed textured diet

  16. Post Operative Diet Following Bariatric Surgery Stage 3 Soft diet • Four Stages • Stage 4 • Normal textured diet

  17. Pre Op Guidance for Post Op Success Regular meals Control snacking Healthy choices – long term small portions Speed – important to eat slowly – 15 – 20 minutes to eat a meal Chewing – chew well, 20 – 30 times Drinking and eating – avoid Fizzy drinks – reduce and avoid Physical activity

  18. Vitamin and Mineral Supplements

  19. % Excess Weight Loss Overall

  20. Co-morbidity Improvements

  21. Effects of Bariatric Surgery on Pregnancy • Lack of evidence in controlled trials • Varying evidence amongst papers • However, research tends to suggest, patients having undergone bariatric surgery and lost significant weight have improved outcomes and there is no increased risk to the mother or infant

  22. Recommendations • Varying practice nationally at surgery centres • Patients should contact centre where had surgery if possible, and if necessary referred back there • Patients within 2 years of surgery (NHS) will generally still be under the surgery team’s care • Ante natal team should be encouraged to communicate with the surgery centre

  23. Recommendations • Patients are advised not to become pregnant within 18 months of surgery (ACOG, 2005) • Rapid weight loss in this phase • Potential for greater risk of nutritional deficiencies • Anecdotally – patients in the earlier phases of their weight loss journey fair poorer in terms of weight loss • Oral contraception may not be as effective (gastric bypass) • Patients do become pregnant earlier than advised!

  24. Recommendations • All patients should be taking multivitamin and mineral supplements – need to ensure they take a pregnancy safe one • BMI>30 kg/m2 • folic acid 5mg • Vitamin D (10mcg/d) (nb. May already be taking vitamin D supplement depending on surgery) • Gastric Bypass / Sleeve Gastrectomy – continue with Vitamin B12 injections • Gastric Bypass – continue with Adcal D3 bd and ferrous sulphate tds

  25. Recommendations • Diet as per normal advice in pregnancy • regular meals • healthy food choices (Patients will be aware of limitations within diet) • portions will generally be smaller • Food safety advice in pregnancy • Micronutrient monitoring

  26. Bariatric Issues in Pregnancy • Weight loss / maintenance / gain • Micronutrient issues • Iron • Calcium / Vit D • Dietary habits / restrictions • + the effect of pregnancy on appetite / cravings

  27. Areas of Limited Evidence • Monitoring • Regular, depending on stage of surgery and pregnancy • Scans? Some papers suggest more frequent? • Band adjusting • Varying suggestions around the country full deflation vs. monitoring of symptoms and weight • Gestational diabetes

  28. Gestational Diabetes and Bariatric Surgery • Patients with BMI>30 are at risk of developing gestational diabetes • Normal test is GTT • However, in RYGB – contraindicated due to potential for dumping syndrome and false readings • Alternative testing required

  29. Gestational Diabetes and Bariatric Surgery • No best practice guidance • Suggestion • Fasting blood glucose and HbA1c at booking – if readings in the diabetes range – early review and treatment • If normal and no hx of T2 DM prior to bariatric surgery, then ~26 weeks – fasting glucose and post prandial glucose (1-2 hours?) for approximately 1/52. Then referral to antenatal team if appropriate • Liaise with surgical team and diabetes team

  30. Useful Resources • Tommy’s Guide (2013) – Managing obesity in pregnant women: an online guide for health professionals • NICE (2010) Weight Management before, during and after pregnancy

  31. Our Experience … • 3 patients have become pregnant within 2 years • 2 RYGB • 1 Sleeve Gastrectomy • All 3 have given birth and reported that babies are progressing well

  32. Patient 1 – Gastric Bypass • Pre op – 140.6kg (22st 11lb), BMI – 50.4kg/m2 • Reported as compliant post op. Got pregnant approx 9/12 post RYBG. Wt approx 90kg • Lost further 6kg through pregnancy – did stabilise • Developed gestational DM (put on insulin) and had vit D deficiency • Were concerns at 35/40 pregnancy that foetus had stopped growing • Uncomplicated birth 3/12 ago • Now 18/12 post RYGB wt 78.1 kg (12 4lb), BMI 28kg/m2. Xs wt loss 88.2%

  33. Patient 2 – Sleeve Gastrectomy • Pre op – 115.6kg (18st 2lb). BMI 48.1kg/m2 • Compliance issues post op – non attender, did not appear to be following advice • Pregnant approx 10/12 post sleeve • Wt difficult to asses – approx 100kg (15st 11lb) • Gained wt during pregnancy, ? Amount – at least 9kg • Therefore, overall % xs weight loss – approx 11.5% • Complicated birth. Now 24/24 post sleeve, wt 105kg (16st 7lb). BMI 43.7kg/m2. XS wt loss 19.3%

  34. Patient 3 – Gastric Bypass • Pre surgery wt 154.4kg (24st 4lb). BMI 53.8kg/m2 • Compliant post op. Got pregnant 8/12 post RYGB. Had miscarriage at around 12 weeks • Got pregnant again 13/12 post RYGB. Wt approx 99.4kg (15st 9lb) 66% xs wt loss • Continued with generally good compliance. • Wt decreased approx 9kg but had slight regain. Remained controlled. Had vit D deficiency • Uncomplicated birth • Attended clinic 24/12 post RYGB for discharge. Wt 77kg (12st 2lb). BMI 27 kg/m2. 93.3% xs wt loss

  35. Contact Details • John Finney • Specialist Dietitian for Bariatric Surgery • John.finney@dbh.nhs.uk • #4110 / 07766070570 • Louise Parsons / Katie Kirk • Clinical Nurse Specialists for Bariatric Surgery • Louise.parsons@dbh.nhs.uk / katie.kirk@dbh.nhs.uk • # 4294 / 07766070570

  36. References • Health Survey for England (HSE) (2012) http://www.hscic.gov.uk/catalogue/PUB13218 • Heslehurst, N., Brown, A. (2010) Managing obesity in pregnant women: an online guide for health professionals. Tommy’s • National Institute for Clinical Excellence (2006) Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. Department of Health • National Institute for Clinical Excellence (2010) Weight Management Before, During and After Pregnancy. Department of Health • NHS Commissioning Board Clinical Reference Group for Severe and Complex Obesity (2013) Clinical Commissioning Policy: Complex and Specialised Obesity Surgery. NHS Commisioning Board • Ono, Y., Guthold, R., Strong, K. (2005) WHO Global Comparable Estimates http://apps.who.int/infobase • Perry CD, Hutter MM, Smith DB, Newhouse JP, McNeil BJ. (2008) Ann Surg. Jan;247(1):21-7. Survival and changes in comorbidities after bariatric surgery • Shah M, Simha V, Garg A. (2006)J Clin Endocrinol Metab. Nov;91(11):4223-31. Epub 2006 Sep 5. Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. • World Health Organisation (2000) Obesity; Preventing and Managing the Global Epidemic. Geneva: WHO

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