Devlieger o&p2013

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Devlieger o&p2013

  1. 1. Bariatric surgery and Pregnancy:a critical reviewRoland Devlieger, MD, PhDDepartment of obestetrics and gynaecologyUniversity hospitals KU Leuven, Belgium
  2. 2. Overview• Maternal obesity: management options• Bariatric surgery– Indications & procedures– Effects on fertility– Effects on pregnancy outcomes– Effects on later life• Clinical recommendations• Research gaps“Venus in front of the mirror”PP Rubens, 1613
  3. 3. Treatment of obesity
  4. 4. Treatment of obesity during pregnancyPhysicalactivity1Diet²MedicationObesity • No registerd safeproducts• Metformin?• Poor diet, especially in the obese• Intervention studies show benifit• Motivation and psychological factorsimportant• Reduced in pregnancy• Some PA contra-indicated• Intervention studies show some benefitPudevigne et al. 2006; ²Guelinckx et al. 2007;Rifas-Shiman et al. 2009; Thangaratinam et al, 2012; Bogaerts et al. 2012
  5. 5. Treatment of obesity before/between pregnanciesPhysicalactivity1Diet²MedicationObesityPudevigne et al. 2006; ²Guelinckx et al. 2007;Rifas-Shiman et al. 2009; Thangaratinam et al, 2012; Vinter et al, 2012; Bogaerts et al. 2012Bariatricsurgery-Is it safe?-Who should benefit?
  6. 6. Classification of BS proceduresLe Roux et al. Int J obesitas 2009Procedure type Restrictive procedures Malabsorptive procedures Mixed proceduresOperation examples Laparoscopic adjustablegastric banding (LAGB)Bilio-pancreatic diversion(BPD)Roux –en Y- gastric bypass(RYGB)Sleeve gastrectomy Bilio-pancreatic diversion withduodenal switch (BPD-DS)Vertical banded gastroplasty Jejuno-ileal bypassMechanism of weight loss Reduced food intake• Reduced gastric capacity• Early satietyReduced nutritient absorption• Small intestine bypassedReduced intake and uptakeSchematic examples LAGB BPD-DS RYGB
  7. 7. Mechanism of weight loss after BS• Complex• Reduced appetite: changes in gut hormons– Ghrelin, PYY, GLP-1• Effects on the reward system of the brain– Changes in food preferences– Neural pathways: Arcuate nucleus, DopamineRaghavendra et al, Obes Reviews 2012
  8. 8. Bariatric surgeryIndications• National Heart, Lung, and Blood Institute Expert Panel on the identification, evaluation, andtreatment of obesity for adults– bariatric surgery be an option for carefully selected patients with clinically severeobesity (BMI >40 or >35 with comorbid conditions) when less invasive methods ofweight loss have failed and the patient is at high risk for obesity-associated morbidityand mortality.• The American Gastroenterological Association (AGA) medical position statement on obesity– most effective approach for achieving long-term weight loss.– recommends surgery for patients with a BMI >40, or those with BMI >35 and 1 or moresevere obesity-related medical complication (eg, hypertension, heart failure, or sleepapnea) if they have been unable to achieve or maintain weight loss with conventionaltherapy, have acceptable operative risks, and are able to comply with long-termtreatment and follow-up.• American College of Preventive Medicine– policy statement on weight management counseling– recomments limiting surgical therapy for obesity to severely obese patients, defined asBMI >40.Pentin et al. 2005
  9. 9. Bariatric surgery Indications• Country-specific different reimbursement criteria• Most often used– Morbidly obese BMI > 40 kg/m²– BMI > 35 kg/m² with co-morbidities– Lifestyle interventions not succesfull– Operative risk acceptable• Commercial circuit
  10. 10. Trends in numbers of procedures worldwideBuchwald & Oien (2009)
  11. 11. Trends in percentages of procedures- Europe -0102030405060702003 2008 2011RYGBAGBSGBuchwald & Oien. Obes surg. 2013
  12. 12. Trends in percentages of procedures- USA/Canada -01020304050607080901002003 2008 2011RYGBAGBSGBuchwald & Oien. Obes surg. 2013
  13. 13. Bariatric surgery• USA 125.000 procedures per year• About 85 % → women of reproductive age1• An increasing number ofadolescents, predominantly female²-³1Samuel at al. 2006; ²Schilling et al. 2008; 3Pallati et al. 2012
  14. 14. Bariatric surgery in adolescentsPallati et al. 2012
  15. 15. Bariatric SurgeryEffects in a general population
  16. 16. Long term consequences of bariatric surgeryThe SOS-study• Swedish Obese Subject-study• Non-randomized, prospective controlled study 1987-2001• Study population: Obese Men and Women– Bariatric Surgery group (N=2 010)– Conventional treatment group (N= 2 037)• End points:– Primary: overall mortality– Secondary: myocardial infarction, stroke, cancer, self-reportedsleep apnea, hypertension, dyslipidemia, hyperuricemia
  17. 17. Sjöström et al. NEJM 2007Weight loss
  18. 18. Sjöström et al. JAMA 2012
  19. 19. Sjöström et al. Lancet Oncol 2009
  20. 20. SOS-study• Besides weight loss → improvement of co-morbidities (independently of the type ofsurgery)– Cardiovascular events– Recover from diabetes– Hypertension– Dyslipidemia– Obstructive sleep apnea– hyperuricemiaSjöström et al. N Engl J Med 2007
  21. 21. Cost-utility of BS for morbid obesity in FinlandMäklin et al. BJS 201133.870 vs. 50.495 Euro
  22. 22. Bariatric surgerycomplications• RYGB– Operative mortalities: 0.5 %1– Long-term: dumping, stomal stenosis, marginalulcers, staple line disruption, internal hernias²– Nutritional deficiencies: more common³• Vit B12, B1, C, folate, A, D and K• Calcium, iron, selenium, zinc and copper1Buchwald. 2005; ²Woodard. 2004; ³Shankar et al. Nutrition 2010; Stocker. Endocrinol Metab Clin North Am 2003
  23. 23. More recently:Increased prevalence after bariatric surgery of:• Substance abuse• Psychiatric disorders• Suicide deathsSuicide rate of 4.1/10,000 person-years (P = 0.03).Therefore, there is a great need to identify persons at risk andpost-operative psychological monitoring is recommended.Peterhänsel et al, Obes Rev 2013, King et al, JAMA 2012; Raghavendra et al, 2012
  24. 24. Bariatric surgeryEffects on fertility
  25. 25. Effects on fertility• In general, weight loss reverses the adverseeffects of obesityand adiposity on fertility• 50% anovulatory rate of women undergoing BSup to 71 % regained cyclicity of menstrual blood loss1• Most cohort studies or case control series →improvement in spontaneous pregnancy ratesafter BS1Teitelman et al. 2006
  26. 26. Effects on fertilityAbbreviations: FSH Follicular Stimulating Hormone, GnRH Gonadotropin Releasing Hormone, LH Lutenising Hormone, MISMüllerian Inhibiting Substance, SHBG Sex Hormone Binding Globuline.BARIATRIC SURGERYWEIGHT LOSSIMPROVED FERTILITYIMPROVED OVARIANFUNCTION↓MISIMPROVEDSELF IMAGEIMPROVEDSEXUAL ACTIVITY↓ADIPOSE TISSUE↓ESTRADIOL ↓INSULIN↑GnRH↑LH, FSH↑SHBG↓TESTOSTERONEDECREASEDCONTRACEPTIVEEFFICACY
  27. 27. Authors (reference) Sample size Design Summary of findingsBastounis et al. (38) 38 Prospective study Normalization of menstrual cycle irregularitiesRochester et al. (41) 25 Prospective study Partial recovery of luteal functionMerhi et al. (48) 18 Prospective study Drop in plasma BDNFManco et al. (49) 10 Prospective studyIncrease in free cortisol, FCI, and insulin sensitivity. Decrease in CBG and insulinsecretionChikunguwo et al. (51) 86 Prospective study Decrease in TSH. No change in free T4Moulin de Moraes et al. (52) 72 Prospective study Decrease in TSH. No change in free T4Eid et al. (66) 24 Historical cohort Spontaneous conception in 5 PCOS womenDeitel et al. (62) 30 Case series Spontaneous conception in 9 women and regulation of the menstrual cycleMartin et al. (64) 20 Clinical trial Spontaneous conception in 5 women. No obvious fetal or neonatal effectsBilenka et al. (63) 6 Retrospective study Spontaneous conception in 5 women and reduction in the risk of miscarriageFriedman et al. (89) 1,136 Retrospective study Reduction in the risk of miscarriage and decrease in pregnancy complicationsMarceau et al. (65) 783 Cross-sectional study Normalization of gestational weight changes and reduction of fetal macrosomiaSheiner et al. (67) 28 Historical cohortNo difference in obstetric characteristics, pregnancy outcome, or perinataloutcome. Higher rates of fertility treatmentsMerhi et al. (73) 16 Prospective study Drop in plasma MISGerrits et al. (39) 40 Prospective study Unintended pregnancies in 2 of 9 morbidly obese women despite OCP useVictor et al. (40) 7 Prospective study Lower plasma OCP metabolites levelsKinzl et al. (98) 82 Cross-sectional study Enhanced sexual functionCamps et al. (99) 94 Cross-sectional study Enhanced sexual functionHafner et al. (100) 83 Cross-sectional study Enhanced sexual functionMerhi et al. Fert Ster 2009
  28. 28. Bariatric surgery and contraception effectivenessAuthor Design N Surgery FindingsGerrits et al. 2003 Prospective study 40 Biliopancreatic diversion 2/9 unplanned pregnancies in OACusing groupWeiss et al. 2001 Descriptive study 215 LAGB No unplanned pregnanciesVictor et al. 1987 Prospective study 7 Jejuno-ileal bypass Lower OAC serum levelsAnderson et al. 1987 Pharmacokinetic 18 Jejuno-ileal bypass Obesity → reduces steroid levelsCiangura et al. 2011 Case series 3 RYGB Decreased ENG after implanonCiangura et al. 2011 Case series 44 mixed 92% had an IUD placed at time of BS→ high acceptanceNo results on safetyPaulen et al. Contraception 2007IncreasedfertilityIncreasedsexual activityUncertaincontraceptiveeffectivenessUnplannedpregnancies
  29. 29. Effects on pregnancy outcomesInterpretation of the available literature• Different types of surgery• Surgical vs. obstetric or neonatal literature• Varying designs, small study groups, different controlgroups
  30. 30. Reviews on the subject1) Pregnancy and Fertility following bariatric surgery: A systematic reviewJAMA 2008; 300:2286-2296Maggard MA, Yermilov I, Li Z, et al.2) Pregnancy after bariatric surgery: A comprehensive reviewArch Gynecol Obstet 2008; 277:381-388Karmon A, Sheiner E.3) Reproductive outcome after bariatric surgery: A critical reviewHuman Reproduction Update 2009; 15:189-201Guelinckx I, Devlieger R, Vansant G.4) Pregnancy after bariatric surgery: A reviewJournal of obesity 2011,Hezelgrave & Oteng-Ntim.
  31. 31. Bariatric surgery and preeclampsiaReference Procedure N %Skull et al. (2004) LAGB 49 vssame with 31 preoperative pregancies0.0 6.4 ↘Dixon et al. (2005) LAGB 79 vs1) pre-LAGB pregnancies2) Obese matched controls5.0 1) 28.02) 25.0↘Ducarme et al. (2007) LAGB 13 vs414 non LAGB obese0.0 3.1 ↘Patel et al. (2008) RYGB 25 vs188 non-obese39 obese2 severly obese=Lapolla et al. (2010) LAGB 83 vs1) 120 morbidly obese2) 858 normal weight27 vs27 pre-LAGB in same women34 morbidly obese vs45 post-LAGB no longer morbidly obsese12.07.414.71) 20.82) 2.314.811.1↘
  32. 32. Bariatric surgery and GDMReference Procedure N %Skull et al. (2004) LAGB 49 vssame with 31 preoperative pregnancies8.0 27.0 ↘Dixon et al. (2005) LAGB 79 vs1) pre-LAGB pregnancies2) Obese matched controls6.3 1) 15.02) 19.0↘Ducarme et al. (2007) LAGB 13 vs414 non LAGB obese0.0 22.1 ↘Patel et al. (2008) RYGB 25 vs188 non-obese39 obese2 severly obese=Lapolla et al. (2010) LAGB - 83 vs1) 120 morbidly obese2) 858 normal weight- 27 vs27 pre-LAGV in same women- 34 morbidly obese vs45 post-LAGB no longer morbidly obese6.07.411.81) 50.02) /7.42.2↘Lesko et al. (2012) Mixture 70 vs1) 140 (BMI within 6 points of averagepresurgery weight)2) 140 (BMI within 6 points of averageprepregnancy BMI)0 1) 16.42) 9.3↘
  33. 33. Bariatric surgery and macrosomiaReference Procedure N %Sheiner et al. (2004) Mixture 298 vs158 912 no BS9.4 4.6 ↗Marceau et al. (2004) BPD 251 vs1 577 before surgery7.7 34.8 ↘Dixon et al. (2005) LAGB 79 vs1) pre-LAGB pregnancies2) Obese matched controls11.4 17.7 ↘Ducarme et al. (2007) LAGB 13 vs414 non LAGB obese7.7 14.6 ↘Patel et al. (2008) RYGB 26 vs1) 188 non-obese2) 39 obese3) 2 severly obese↘Weintraub et al. (2008) Mixture 354 vs3013.2 7.6 ↘Lesko et al. (2012) Mixture 70 vs1) 140 (BMI within 6 points of averagepresurgery weight)2) 140 (BMI within 6 points of averageprepregnancy BMI)4.3 1) 18.12) 12.9↘
  34. 34. Bariatric surgery and C-sectionReference Procedure N %Sheiner et al. (2004) Mixture 298 vs158 912 no BS9.4 4.6 ↗Marceau et al. (2004) BPD 251 vs1 577 before surgery7.7 34.8 ↘Ducarme et al. (2007) LAGB 13 vs414 non LAGB obese7.7 14.6 ↘Patel et al. (2008) RYGB 26 vs188 non-obese39 obese2 severly obese12.4 15.2 =
  35. 35. Bariatric surgery and IUGRReference Procedure N %Sheiner et al. (2004) Mixture 298 vs158 912 no BS5.0 2.0 ↗Weintraub et al. (2008) Mixture 354 vs3013.9 2.3 ↗Santulli et al. (2010) RYGB 24 vs1) 120 normal BMI group2) 120 BMI matched control group4.2 1) 02) 0↗Kjaer et al, unpublished RYGB 286 vs 1070 matched controls 7.7 2.8 ↗
  36. 36. Bariatric surgery and prematurityReference Procedure N %Marceau et al. (2004) BPD 251 vs1 577 before surgery16.7 13.6 =Skull et al. (2004) LAGB 49 vs31 previous non-LAGB4 3 =Dixon et al. (2005) LAGB 79 first postoperative pregnancies vs1) 40 penultimate preoperative pregnancies2) 79 obese women, matched for parity, ageand BMI3) 61 000 community controls6.3 1) NR2) 12.73) 7.8=Ducarme et al. (2007) LAGB 13 vs414 obese7.7 7.1 =Patel et al. (2008) RYGB 25 vs1) 188 non-obese2) 39 obese3) 2 severly obese26.9 1) 20.22) 17.93) 25.9=Wax et al. (2008) GB 38 vs76 matched for age and prior CS26.3 22.4 =Lapolla et al. (2010) LAGB 83 vs1) 120 no LAGB obese2) 858 normal controls17.6 1) NS2) 3.6↗
  37. 37. Bariatric surgery and miscarriageReference Procedure N %Bilenka et al. (1995) VBG 14 vs18 pre-operative7 39 ↘Friedman et al. (1995) BPD 239 vs124 pre-operative28 21 ↘Marceau et al. (2004) BPD 251 vs1 577 before surgery21.6 26 =
  38. 38. Bariatric surgery and offspring obesityReference Procedure N Severe obesity%Smith et al, 2009 BPD 49 mothers111 Children 2.5-25y54 Before BS57 After BS11 35 ↘
  39. 39. SummaryComplication Effect of bariatric surgeryPre-eclampsia ↘Gestational diabetes ↘Macrosomia ↘Childhood obesity (↘)IUGR ↗Miscarriage =Prematurity =C-section =
  40. 40. Transgenerational effects of maternal obesity and the effect of BSObese motherMacrosomic BabyObese ChildObese adolescent SGA babyIncreased metabolic risk Increased metabolic riskPostnatal Overnutrition
  41. 41. Risk Factors for IUGR followingbariatric surgery• Insufficient weight gain (<IOM)• Persistent vomiting• Pregnancy during period of rapid weight loss• BPD>RYGB>LAGB
  42. 42. Bariatric surgery and pregnancy:(potential) risks• IUGR/SGA• Surgical complications• Nutritional deficiencies• Psychological problems and substance abuse
  43. 43. Surgical complications• Small bowel obstruction due to internal herniation, volvulus, leak, …• Not unfrequent (2-11%)Delay in diagnosis and treatment• Symptomatology frequent in pregnancy• Diagnostic procedures delayed in pregnancy• Changed anatomyHigh mortalityGuelinckx et al, 2009 ; Wax JR et al, 2013
  44. 44. Reference Type ofsurgeryInterval MaternalcomplicationFetalcomplicationLong-term outcomeWang et al. (2007) RYGB 2 months Internal hernia UncomplicatedWax et al. (2007a,b)RYGB 12 months Intussusception UncomplicatedBellanger et al.(2006)RYGB 24 months Small bowel obstruction UncomplicatedAhmed andO’Malley (2006)RYGB 8 months Internal hernia UncomplicatedBaker and Kothari(2005)RYGB 4 months Internal hernia UncomplicatedLoar et al. (2005) RYGB NA Small bowel volvulus Preterm delivery Maternal deathKakarla et al. (2005)RYGB 9 months Internal herniation Preterm delivery UncomplicatedKakarla et al. (2005)RYGB 30 months Small bowel herniation UncomplicatedCharles et al. (2005)RYGB 6 months Small bowel herniation UncomplicatedMoore et al. (2004) RYGB 18 months Small bowel herniation Maternal + fetal deathsGraubard et al.(1988)BPD 3 years Small bowel obstruction Fetal death Maternal + fetal deathsGuelinckx et al, Hum Reprod Update 2009
  45. 45. Renault KM et al, Acta Obstet Gynecol Scand 2012• Lap RYGB• 35 weeks: abdominal pain, nausea, vomiting,diarrhea• S/C and exploration• Maternal mortality 2 days post-caesarean• COD: Small bowel necrosis due to internalherniation with massive septic shockMaternal mortality in Denmark
  46. 46. Surgical complications:recommendations for care of women with history of RYGB• Increase awareness of patients and staff• Abdominal complaints should be considered SBOunless proven otherwise.• Usually surgical management required• Inspect entire small bowel in case of surgery or C-section for abdominal complaints• CT with contrast is preferred imaging methodWax JR AJOG 2013
  47. 47. Vitamin K deficient ICH: Cases UH LeuvenCase 1 Case 2 Case 3 Case 4 Case 5 Case 6Type of bariatric surgery Gastric banding Gastric banding Gastric banding Biliopancreatic diversion Duodenal switch Gastric bandingLaboratory values motherPT 46.8% (70–150%) Pseudo-BartterVitamin K 0.0008 nmol/L(0.8–5.3 nmol/L)PT 12 s (9.0-12.0)aPTT 29.3 s (24–31 s)K+ 2.29 mmol/L (3.5–5.1mmol/L)aPTT 29 s (24–31 s)f II 56% (70–130%)HCO3− 29.7 mmol/L (22–29 mmol/L)f II 56% (70–130%)f V 121% (70–130%)f VII 40% (70–130%) f VII 40% (70–130%)f IX 75 % (70–130%)f X 27% (70–130%) f X 27% (70–130%)Vitamin K1 0.2 nmol/L Vitamin K1 0.2 nmol/L(0.8–5.3 nmol/L) (0.8–5.3 nmol/L)Laboratory values infantsPT < 10% (70–100%) Pseudo-Bartter PT 16.8% (70–100%) PT 53% (70–100%) PT 75 s (70–100%)aPTT 121.2 s (24–38 s)K+ 2.42 mmol/L (3.5–5.1mmol/L)aPTT 93.4 s (24–38 s) aPTT 38 s (24–38 s) aPTT 121 s (24–38 s)Fibrinogen 1.29 g/L (2.00–3.80 g/L)Fibrinogen 0.93 g/L (2.00–3.80 g/L)f II 13% (70–130%)HCO3− 27.8 mmol/L (22–29 mmol/L)f II 18% (70–130%) f IIf V 78% (70–130%) f V 50% (70–130%)f VII 2.9% (70–130%) f VII 2.6% (70–130%)f VII 1-13%(70–130%)f IX 0.8% (70–130%) f IX 8% (70–130%) f IXf X 4.2% (70–130%) f X 13% (70–130%) f XNeonatal outcome Died Died Mental retardation Mental retardation Died DiedEerdekens A, Eur J Pediatr 2010;169(2):191-6Van Mieghem T, Obstet Gynecol 2008;112:434-6
  48. 48. *** **PABAS Study design• Prospective, multicenter trial• Inclusion: pregnant women with a history ofbariatric surgery– singleton pregnancy– ≤14+6 weeks GA– Informed consent• April 2009- Janary 2011
  49. 49. PABAS-study: aims• Life style during pregnancy• Diet: 7 days records, Healthy eating index (HEI)• Physical activity: Kaiser questionnaire• Nutritional deficiencies• Effects of tailored substitution• Comparison with contemporary controlsGuelinckx et al, 2009
  50. 50. Results:dietary habits, nutritient level, 1st trimesterDRIRestrictive categoryN =19Malabsorption categoryN =32P-valueEnergy intake (kcal/day) - 1915 ± 399 1794 ± 317 0.369Protein intake (E%) 9-10 15.2 ± 1.5 15.6 ± 2.3 0.544Carbohydrate intake (E%) > 55 48.5 ± 5.5 46.2 ± 3.9 0.196Fat intake (E%) 30-35 36.8 ± 4.7 38.2 ± 3.8 0.363Saturated fat intake (E%) < 10 14.0 ± 2.6 14.3 ± 2.1 0.732Dietary fibre (g/day) 30 17.8 ± 4.0 17.0 ± 5.0 0.623Calcium intake (mg/day) 1200 771 ± 296 686 ± 220 0.385Iron intake (mg/day) 10 10 ± 2 9 ± 2 0.171Fruits (pieces/day) 2-3 0.8 ± 0.4 0.8 ± 0.7 0.995Vegetables (g/day) 300 161 ± 54 132 ± 40 0.116Continues variables: ANOVA; Mean ± SD
  51. 51. Results: dietary habits0102030405060708090Restrictive cat. Malabsorption cat.Healthy Eating Index1st trimester2nd trimesterNo sign differenceaccording to repeated measures ANOVA with surgery group and trimesteras between- and within-subject variable respectively1st 1st2nd 2nd
  52. 52. 0102030405060708090100Vit A deficient Vit E deficient Vit D deficient < 7 µg/l Vit D 7-20 µg/l Vit K deficient1st trimesterResults: fat soluble vitamins
  53. 53. Proportion of patients with FS vitamin deficiency1st trimester2nd trimester3rd trimester0102030405060708090100Vit AVit EVit D < 7 µg/lVit D 7-20 µg/lVit KRestrictive types
  54. 54. 1st trimester2nd trimester3rd trimester0102030405060708090100Vit AVit EVit D < 7 µg/lVit D 7-20 µg/lVit KMalabsorption typesProportion of patients with FS vitamin deficiency
  55. 55. Results: Pregnancy outcomeRestrictivecategoryN =19MalabsorptioncategoryN =32Obese control categoryN = 32P-valueGWG 13.4 ± 7.2 13.2 ± 6.6 9.0 7.1 0.046Birth weight 3.4 ± 0.5 3.0 ± 0.6 3.4 0.5 0.007Macrosomia (%) 3 (16) 1 (3) 2 (6) nsIUGR 0 (0) 1 (3) 0 (0) nsChronic HT 0 (0) 0 (0) 8 (26) 0.001PIH 2 (12) 3 (13) 9 (29) 0.001PET 0 (0) 1 (3) 2 (6) nsGDM 1 4) 1 (3) 2 (6) nsIntestinal hernia 0 (0) 1 (3) 0 (0) nsMiscarriages 1 (4) (TOP NTD) 1 (3) 2 (6) nsICH 0 (0) 0 (0) 0 (0) ns
  56. 56. Nutritional deficienciesNutritional deficiencies Maternal complications Fetal/neonatalcomplicationsIron Anemia IUGRProteins Odema, weight loss IUGRVit B12 Anemia Pancytopenia,developmental delayFolic acid Anemia Neural tube defectsVit D Osteomalacia Hypocalcemia, ricketsVit A Microphthalmia, retinaldamageVit K Coagulation disorders Cerebral hemorrhage,IUDCalcium Hypocalcemia HypocalcemiaDevlieger & Guelinckx, Maternal obesity 2012
  57. 57. NTD after Bariatric surgery• Over 15 cases in the literature!• More frequent than in the obese?• Relation with folic acid deficiency?Pelizzo et al, Prenat Diagn 2013; Fonte et al, IASO-TOS 2013Case Age(y)GA(w)Defect FamilyHistoryDM AntiseizureMedicationMalnutritionFonte201327 20 Spine dysraphia withsacral bone agenesisno no no yesPelizzo201340 22 Spinal dysraphia withsacral bone agenesisno no no yes
  58. 58. Substance abuse in pregnancyBariatric procedureN = 54 (43.5%)Control groupN = 70 (56.5%)P-valueMaternal age 30.0 ± 4.8 29.1 ± 4.3 0.154BMI 28.3 ± 5.5 28.1 ±2.5 0.274Nulliparae 21 (39.6%) 32 (45.7%) 0.585Smoking 13 (24.5%) 4 (5.7%) 0.003Alcohol useTrimester 1Trimester 25 (9.4%)5 (9.4%)11 (15.7%)11 (15.7%)0.3050.950G. Jans et al, ECO 2013
  59. 59. Recommendations for clinical care• Preconception• Pregnancy– Early– Late• Postpartum periodDevlieger and Guelinckx, 2012
  60. 60. Preconception• Delay pregnancy until after period of rapid weight loss(1 year minimum)• Provide effective contraception• Involve lifestyle coach• Evaluate nutritional state, correct where necessary• Start folic acid (4mg)• Advice rapid pregnancy test if sec amenorrheaDevlieger and Guelinckx 2012
  61. 61. Clinical recommendationsFirst trimester• Involve lifestyle coach• Evaluate nutritional state, correct wherenecessary• Continue folic acid (4mg if obese) untill 12 weeks• Adjustable balloon: not systematically open, openif vomiting regularly (DD morning sickness) →active band managementDevlieger and Guelinckx 2012
  62. 62. Clinical recommendationsPregnancy• Advice GWG according to IOM guidelines for preconception BMI– Overweight: 7,0 to 11,5 kg (15 to 25 lbs)– Obesity: 5,0 to 9,0 kg (11 to 20 lbs)• Pay attention to symptoms of surgical complications• Detailed morphologic scanning at 12-20-30 weeks– Attention for growth, ossification, ICH• Screen for GDM– GCT-OGTT: dumping syndrome (50-95 %)– Fasting glucose– Day-profile• Re-evaluate nutritional deficiencies every trimesterDevlieger and Guelinckx 2012
  63. 63. Clinical recommendationsPostpartum• Advice and support breastfeeding?• Inform pediatrician• Follow-up and correction of nutritional deficiencies• Evaluate for signs of depression and alcohol abusus• Advice life-long coaching of lifestyleDevlieger and Guelinckx, 2012
  64. 64. Research Gaps Include:• Micronutrient deficiencies andsupplementation• Link with congenital malformations esp NTD• Breast feeding composition• Contraception efficacy• Timing of pregnancy after surgery• Long term effects on the offspringDevlieger and Guelinckx, 2012
  65. 65. AURORA study
  66. 66. • Design– Multicentric prospective cohort study• Study population– Women of reproductive age (18-45 yr)– Planning BS or had BS
  67. 67. Contact www.aurorastudy.orgroland.devlieger@uzleuven.be
  68. 68. Thank youGoele JansIsabelle GuelinckxAnnick BogaertsSarah BelSander GaljaardSarah PauwelsRivka TurcksinAnnelies MatheussenGuy MartensEvelien MartensGreet VansantAndre Van AsscheDirk TimmermanParticipating centres, care-givers and patientsStudiecentrumPerinatale Epidemiologie (SPE)

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