conception after bariatric surgery is a high-risk case that needs close monitoring by a team of obstetricians, bariatric surgeons, nutritionists, and sonologists.

1. PREGNANCY AFTER
BARIATRIC SURGERY
Dr. PUSHP LATA SANKHWAR
MBBS , MS , FICS , FICOG, MNAMS
Professor
Dept. of Obgyn, KGMU, Lko

2. Learning Objectives-
Prevalence Of Obesity
Problem Of Pregnancy with obesity
Bariatric Surgery & Its Outcome
Important recommendations 2019.

3. Obesity is the new
worldwide Epidemic
• These trends have been noticed across all races, age
groups, and nations.
• Largest increase has been seen in young adolescents
and young women
BACKGROUND

4. ABOUBAKRELNASHAR

5. OBESITY
“AN EMERGING MENACE”
1. > 1 Billion are Overweight
2.Of which 135 million are Indians (2023)
3. 26% of nonpregnant women ages 20 – 39
are overweight/obese (4 to 37%)
W
H
O

6. WORLD OBESITY ATLAS- 2023
Prevalence of obesity in various parts of the world. (BMI> 25)
FEMALE TO MALE % RATIO OF OVERWEIGHT (2020 data)
Southeast Asia- 8/4
Africa- 18/7
Europe- 28/26
Mediterranean region- 30/20
America- 37/32

7. In INDIA …..NFHS – 5 (2019-21)
Overweight Female Male
India (overall) 23% 22.1% (NFHS-5)
Punjab 44 35
Delhi 41 37
UP 31 25
Uttarakhand 39 31
India (Obese) 19.7% (Female) 19.3% (Male)
Gujrat 30 25

8. Obesity and Pregnancy rates
Maheshwari et al, 2007 : 37 papers for effects of obesity on ART- 12 papers actually included
BMI > 25 vs < 25 : Lower pregnancy rates

9. The BMI (kg/m2) classification published by both the World Health
Organization (WHO) and the National Institute for Health and Clinical
Excellence (NICE): *

10. INTRODUCTION
Bariatric surgery is one option for weight loss in
patients with a body mass index (BMI) of at least 40
kg per m2, or in those with a BMI of at least 35 kg per
m2 who have comorbidities.
Two approaches to bariatric surgery: restrictive or
malabsorptive surgeries.
The most common restrictive procedure is adjustable
gastric banding, and the most common
restrictive/malabsorptive procedure is the Roux-en-Y
gastric bypass.

11. Rapid weight loss is typical after either procedure,
resulting in improvement of polycystic ovary syndrome,
anovulation, and irregular menses, thus leading to higher
fertility rates.
 However, bariatric surgery should NOT be considered a
treatment for infertility.

12. As the prevalence of adult obesity increases, physicians are
more often caring for patients who have undergone or who
are considering bariatric surgery.
 Counseling and treating women who become pregnant
after bariatric surgery presents unique challenges.
Although outcomes are generally good, nutritional and
surgical complications can arise.

13. MAY I DARE TO DREAM?

14. YES , POSSIBLE
BUT ,
FIRST
LET’S LOOK AT
THE PROBLEMS OF PREGNANCY WITH OBESITY

15. Miscarriage
Pre-
eclampsia
(3-4 times)
Gestational
Diabetes
(3times)
Thrombo-
embolism
PREGNANCY
RISKS

16. Dys-functional
labour
Shoulder
Dystocia
Anaesthetic
Complications
Technical
difficulties (IV
access,.....)
Higher CS
Rate
(1.5 times)
LABOUR
RISKS

17. Thrombo-
embolism
Depression
Post-partum
Haemorrhage
(4 times)
Lower
Breast
Feeding Rate
Wound
Infection
POST-PARTUM
RISKS

18. NICU
Admission
(1.5
times)
Stillbirth
(2 times)
Neonatal
Death
Complications
Later in Life
Congenital
Anomalies
Fetal & Neonatal
Risks Risks

19. So,
Women are recommended
to reduce weight
before pregnancy
-by diet and exercise (prefer),
-medication
 -and for morbid obesity may opt for bariatric surgery

20. 1. Laparoscopic adjustable gastric banding
(LAGB)
2. Vertical banded gastroplasty (VBG)
3. Laparoscopic ROUX-en-Y gastric bypass
4. Biliopancreatic diversion (BPD)&
biliopancreatic diversion with duodenal
switch (DS)

21. Bariatric Surgery
A serious approach to serious problem
Safety of operation in
India
In Good Hands
is as Safe as
Lap Chole

23. Post Bariatric surgery pregnancies are
generally safe
Work in
collaboration with
the Bariatric surgery
team to manage

25. It is medically advised to wait 12 to 24 months post-
surgery before conceiving to mitigate potential fetal
complications and achieve optimal weight-loss
outcomes.
* If pregnancy occurs earlier, vigilant medical
monitoring of maternal weight, nutritional status, and
serial ultrasound assessments for fetal growth are
recommended

26. Latest recommendations-2019
• The American College of Obstetricians and Gynecologists
(ACOG) recently reviewed.
• AND also Green Top guidelines available on pregnancy
after bariatric surgery.

27. Contraception and Preconception
Counseling
•Bariatric surgery patients, especially adolescents, require thorough
contraception and preconception counseling.
•Adolescents undergoing bariatric surgery face a heightened
postoperative pregnancy risk, double that of the general population.
•The elevated risk of oral contraceptive failure post-bariatric surgery
necessitates consideration of non-oral alternatives-
Especially LARC as preferred choice

28. PERICONCEPTION PERIOD-
•Prepregnancy multivitamin and mineral supplement to ensure total daily dosing from all
supplements, eg, Table 3 (level 4).
•Folic acid 0.4 mg daily during preconception and first trimester, 4‐5 mg if obese
• or diabetic (level 4).
•Convert Vitamin A to beta‐ carotene form (level 2+). Add oral dose of vitamin K
• weekly if deficiency is noted with coagulation defect (level 2−).
•Vitamin B12 supplementation (1 mg IM
• 3 monthly) (level 4). Oral supplementation can be attempted, but reduced absorption is to
be expected (level 4).
•Supplement vitamin D to keep levels above 50 nmol/L, and serum PTH within normal
levels (level 4). Add calcium as needed (level 4).
•Additional supplementation should be given if deficiency is identified.

29. ANTENATAL PERIOD-
• Nutrient deficiencies can also occur after restrictive
surgical procedures, such as adjustable gastric
banding, because of decreased food intake or food
intolerances.
• There is no consensus as such on the treatment of
pregnant women who have had this procedure, but
early consultation with a bariatric surgeon is
recommended.

30. Antenatal Period
• Careful drug administration because of the risk of malabsorption
• Extended-release preparations are not recommended; oral
solutions or rapid-release preparations are preferred.
• Nonsteroidal anti-inflammatory drugs should be used with
caution during the postpartum period to avoid gastric ulceration.
• When prescribing medications for which the drug level is critical,
physicians may need to test drug levels to ensure a therapeutic
effect.

31. In 1st trimester- Serum indices to be checked
•Every 3 months:
• full blood count,
• iron profile
•serum ferritin,
•serum folate
• serum vitamin B12 or
transcobalamin (level 2−),
• serum vitamin A (level 2−).
Every 6 months:
• prothrombin time, INR, and
serum vitamin K1 concentration
(level 2+),
• serum protein and albumin
(level 2−),
• serum vitamin D with calcium,
phosphate, magnesium, and
PTH (level 4),
• renal function and liver
function tests (level 4),
• serum vitamin E

32. 2nd and 3rd Trimester-
 Energy requirements should be individualized on the basis of prepregnancy
BMI, GWG, and physical activity level, with limitations on energy dense
foods if excessive GWG is identified (level 2)
 Early or late dumping—eliminate rapidly absorbed carbohydrates. Substitute
with protein and low GI alternatives, six smaller meals. Use liquids 30 min
after meals and lay down after eating (level 2−).
 Avoid caffeinated or alcoholic beverages (level 4)
 consider changing eating frequency and portion size (level 4).
 Artificial nutrition support may be indicated in cases of severe malnutrition
during pregnancy, with initiation and choice of feeding route determined by
local nutrition support protocols (level 4)

33. Labor & Delivery
• H/o of Bariatric
surgery should
not change course
of labor &
delivery
• C-section rates
are slightly higher
in these patients

34. While breast feeding-
 Every 3 months :
 Full blood count, serum ferritin, and iron studies including
transferrin saturation (level 2−), serum folate, and
 serum vitamin B12 (level 2−), serum vitamin A (level 2−),
 serum vitamin D with calcium, phosphate, magnesium, and PTH
(level 4).
Every 6 months-
 PT/INR, and serum vitamin K1 concentration (level 2+),
 serum protein and albumin (level 2−),
 renal function test

35. TAKE HOME MESSAGE

36.  It’saTeamwork
 Requiresthoroughevaluation
 Early consultation with a bariatric surgeon is critical to
determine whether the symptoms are related to the surgery.
 Meticulous monitoring during pregnancy and labor.
 Avoid pregnancy during the initial weight loss phase (1-2 year)

37. Nutritional Status Monitoring
• Evaluation at the beginning of pregnancy- for deficiencies in micro-
nutrients should be considered and treatment should be initiated if
any deficits are present.
Protein, iron, folate, calcium, and vitamins B12 and D are the most
common nutrient deficiencies after gastric bypass surgery.
Life-long vitamin supplementation is advised.
• Every trimester evaluation even if no deficits are noted, -
- A complete blood count and measurement of iron, ferritin, calcium, and
vitamin D levels

38. Antenatal Period
• Complications include-
• malabsorption,
• band slipping,
• erosion,
• and internal hernia.
• Dumping syndrome
can occur after ingestion of refined sugars and high-glycemic
carbohydrates -- Symptoms include abdominal cramping, bloating, nausea,
vomiting, and diarrhea.

39. Weight loss is one of the corner stone to
achieve a healthy pregnancy and child birth

41. ⦿ CMACE/RCOG Joint Guideline. Management of Women with Obesity in Pregnancy March 2010
⦿ CMACE release: National enquiry into maternal obesity – Implications for women, babies and the
NHS
⦿ Obesity and Reproductive Health - study group statement .Consensus views arising from the 53rd
Study Group: Obesity and Reproductive Health
⦿ Effect of overweight and obesity on assisted reproductive technology—a systematic review
2007. Published by Oxford University Press on behalf of the European Society of Human
Reproduction and Embryology.
⦿ Fertility: assessment and treatment for people with fertility problems Clinical Guideline 11
February 2004 Developed by the National Collaborating Centre for Women’s and Children’s Health
(NICE)
⦿ The Impact of Obesity on PCOS and Reproductive Health. Review article: Obesity in pregnancy
,Review article: The short- and long-term implications of maternal obesity on the mother and her
offspring ,Review article: The impact of obesity on reproduction in women with polycystic ovary
syndrome .The BJOG October edition (Volume 113, number 10)
⦿ THE ROLE OF BARIATRIC SURGERY IN THE MANAGEMENT OF FEMALE FERTILITY Scientific
Advisory Committee Opinion Paper 17 March 2010
⦿ National Institute for Health and Clinical Excellence. Obesity. Guidance on the prevention,
identification, assessment and management of overweight and obesity in adults and children.
London: National Institute for Health and Clinical Excellence (NICE), 2006.
⦿ World Health Organization. Obesity: Preventing and managing the global epidemic. Geneva: World
Health Organization, 2000.
⦿ Green-Top Guideline No. 37. Reducing the risk of thrombosis and embolism during pregnancy and
puerperium. London: Royal College of Obstetricians and Gynaecologists, 2009.
⦿ The Pre-eclampsia Community Guideline Development Group. Pre-eclampsia Community Guideline
(PRECOG). Middlesex:Action on Pre-Eclampsia (APEC), 2004
and
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