Most literature on other pregnancy outcomes after bariatric surgery supports the concept that risk in pregnancy is not significantly increased after bariatric surgery. However, the published articles usually have small numbers largest to date is deliveries after bariatric surgery and varying control groups including obese women without prior bariatric surgery 30 , 31 vs.
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Cesarean delivery data are conflicting but the overall trend is that of increased cesareans after bariatric surgery. For example, more than two-thirds of 39 pregnancies conceived after bariatric surgery in a single center were delivered by cesarean. The findings may be related to a care-giver bias and should also be interpreted in the context of the increasing cesarean section rate nationwide. An improvement in obesity related co-morbidities during a pregnancy after bariatric surgery is not surprising assuming that weight loss has occurred.
However, the impact on neonatal outcomes is less clear as the presence of nutritional deficiencies and anatomical changes might impact placental and fetal development and manifest as abnormal fetal growth or congenital abnormalities. Reports of infant birth weight should be interpreted with caution. In general, there is a trend for more small for gestational age SGA infants and fewer large for gestational age LGA infants with a lower mean birth weight in pregnancies after bariatric surgery. However, the findings often did not reach statistical significance 31 , 37 and the reported occurrences of SGA were still lower than what would be expected in the normal population.
However, it is possible that the reported changes in birth weight profiles represent a redistribution to the normal population.
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Further study is needed to determine the long-term consequences of a pregnancy after bariatric surgery. Although the numbers are limited, bariatric surgery does not alter perinatal mortality or congenital malformations. Many patients are still obese after bariatric surgery.
Similar to management in preparation for and after bariatric surgery, the approach during pregnancy should continue to be multidisciplinary with an emphasis on consultations from the nutritionist and surgeon. Patient education regarding nutrition and clinical management to prevent and detect nutritional deficiencies is key.
There are several case reports of unexpected vitamin deficiencies i. The etiology for deficiencies vary from decreased intake of certain foods due to intolerance i. There is no standard approach to screening and treating deficiencies during a pregnancy after bariatric surgery. As such, the approach mirrors what is recommended for the non-pregnant bariatric population. These guidelines also differ according to the type of bariatric procedure with a closer surveillance of nutrient deficiencies after malabsorptive i. Selective nutritional deficiencies are less common after AGB.
The following recommendations are evidence-based recommendations for the nutritional management of the post-bariatric surgery patient from a task force of the American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. For the non-pregnant population, at least 60g of protein daily are required.
The recommendations also state that a daily long-term vitamin and mineral supplement be considered, with malabsorptive procedures RYGB, gastric sleeve, BPD requiring more replacement. Furthermore, according to best practice guidelines, a daily multivitamin and calcium with vitamin D is recommended for all bariatric surgery patients. Calcium citrate preparations are preferred in bariatric surgery patients because they are better absorbed when gastric acid production is diminished.
As such, empiric iron supplementation is recommended. Modified guidelines from Mechanick et al for supplementation in the pregnant population are summarized in Table 1. Recent guidelines for non-pregnant patients after bariatric surgery have also been suggested by The Endocrine Society. The goals for nutrition and supplementation along with laboratory monitoring are similar.
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Periodic clinical and biochemical monitoring is recommended after malabsorptive types of bariatric surgery even if patients tolerate their diet well without vomiting or diarrhea. This is so that subclinical nutritional deficiencies can be detected prior to the development of overt deficiencies. Testing includes a complete blood count, glucose, electrolytes, and creatinine every 3 months for the first year after surgery and tests for nutritional deficiencies albumin, iron, vitamin B 12 , folate, calcium, and vitamin D every 6 months in the first year and then repeated yearly.
Restrictive procedures such as the AGB may also require testing and supplementation if there is decreased intake or poor tolerance to certain foods or food groups. Modified guidelines for laboratory testing in the pregnant population are summarized in Table 1. In pregnancy, one option is to perform these tests once a trimester if the levels are normal.
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Abnormal levels or persistent deficiencies despite supplementation would require additional testing and management in consultation with the bariatric surgery team. One of the routine recommendations after bariatric surgery is to minimize or eliminate the intake of simple carbohydrate-dense foods and beverages after RYGB as these can precipitate dumping syndrome a group of symptoms including abdominal pain, cramping, nausea, diarrhea, lightheadedness, flushing, tachycardia, and syncope.
It is thought that these symptoms occur as a result of gut peptides released when food bypasses the stomach and enters the small intestine directly. One example includes home glucose monitoring with fasting and post-prandial values during one week in the week period. For pregnancies after AGB, one of the issues that arises is how to manage the band.
Common practice is to deflate the band either prior to or early in the pregnancy to lessen complications such as band migration and nausea and vomiting in pregnancy. The literature continues to describe case reports of surgical complications during pregnancies after bariatric surgery including adhesions, internal hernias, small intestine ischemia, and band slippage. Two maternal deaths, attributed to a delay in diagnosis and management of complications, have been reported.
Abdominal pain in a bariatric surgery patient is considered an emergent condition, regardless of a pregnancy. Other common complaints during pregnancy such as nausea and vomiting should be carefully evaluated. Table 2 summarizes the recommendations for prenatal care in a pregnancy after bariatric surgery. Pregnancy outcomes after bariatric surgery tend to approach those of the general obstetrical population. Special considerations are necessary in the management of a pregnancy after bariatric surgery.
Further research should consider a greater role for bariatric surgery in improved pregnancy outcomes along with the long-term impact on offspring. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
National Center for Biotechnology Information , U. Author manuscript; available in PMC Dec 1. Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at Semin Perinatol. See other articles in PMC that cite the published article.
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Find a partner who supports your efforts to achieve a healthy lifestyle. Challenge and support each other. Stay true to yourself. You have probably changed a lot in your weight loss journey. Figure out what is important to you in a partner and stay true to this. This will be your guidepost for helping you find the right person. And they end up unhappy. I mean this in a literal and a figurative sense. Know that your spirituality can always guide you if you want it to—whether that means sitting quietly in your house, doing yoga, or going to Church. And always have faith that the right person WILL come along and accept you for who you are—inside and out.
A person who does not think she is good enough to be loved, very often has a low sense of self-worth. This lack of self-worth comes from a lack of self-love.