Obesity and Pregnancy ||
Bariatric Surgery ||
Dumping Syndrome ||
Maternal Outcomes || Maternal Complications || Neonatal Complications ||
Nursing Considerations || Recommendations || References and Resources
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The problem of obesity in this country has reached epidemic proportions. Obesity is defined as > 200 pounds (90kg) and a BMI of > 30. It is the most common medical condition affecting the health of our women and children with ever increasing incidences of co-morbidities such as gestational diabetes, hypertension, preeclampsia, macrosomia, neural tube defects, intrapartum anesthesia problems, late fetal death, emergency cesarean section, wound complications, and endometriosis. It is estimated to be affecting approximately 6-10% of all pregnancies, with up to 3% being massively obese (> 300 pounds).
Who’s having surgery? Approximately 83% of all weight loss surgeries are being performed on women of childbearing age defined as women between the ages of 18 and 514,6. These numbers are ever increasing in the younger adult population.
There are currently two surgical procedures most commonly being performed for weight loss. The adjustable gastric band (AGB) is considered to be a restrictive surgery. It limits the amount of food entering the stomach and slows the rate of food passage through the digestive tract. A silicone band is placed at the top of the stomach’s fundus to decrease the size of the stomach creating a pouch. Sterile water can be added or removed from the band to adjust the pouch size and allow for emptying. The procedure is less invasive, has a shorter length of hospital stay, and is reversible. Disadvantages include foreign body reaction, band slippage, and erosion, and risk for leakage and infection. This procedure is gaining popularity and is recommended for women of childbearing age planning to have children.
The second procedure is the combined restrictive/malabsorptive procedure called the Roux-en-Y (RNY). It limits food intake by creating a separate pouch at the stomach’s fundus and creates a bypass for the rest of the stomach, duodenum, and proximal jejunum. It is Y-shaped, hence the name. It excludes most of the small intestine resulting in less absorption of calories and nutrients. It is the most common and most successful procedure performed with optimal long-term weight loss. It has significantly improved co-morbidities associated with severe obesity such a hypertension, type 2 diabetes, osteoarthritis, and sleep apnea, just to name a few. Disadvantages include longer length of hospital stay, risk for nutritional deficiencies, stomal stenosis, obstruction, leakage, hernia, and “dumping syndrome”.
Dumping syndrome can be both an advantage and disadvantage as it deters from consuming sugary foods, but has uncomfortable side effects. Dumping syndrome is caused by foods that are high in sugar moving quickly from the stomach into the small intestine. This causes an osmotic load pulling water into the small intestine. It decreases circulating blood volume and increases the insulin response. This results in a host of symptoms including tachycardia (ie: rapid heart rate), hypoglycemia (ie: low blood sugar levels), nausea, vomiting, sweating, abdominal pain, diarrhea, and bloating.
With the gastric band procedure, there have been a few studies that have shown promising outcomes for women during pregnancy. A study by Skull, et al. (2004) looked at 49 laparoscopic adjustable gastric band (LAGB) patients versus previous non-LAGB procedure patients. Patients had decreased weight gain with no effect on fetal weight or neonatal complications and a significant decrease in the incidence of gestational diabetes (GDM) (8% vs 27%) and hypertension (8% vs 22.5%). A second study by Dixon, et al. (2005) compared 79 consecutive first pregnancies at greater than 20 weeks gestation with a mean weight gain significantly lower than those pre-LAGB. There were no differences in birth weights. The incidence of pregnancy induced hypertension (PIH) and GDM were significantly less than the obese group. Neonatal outcomes were consistent with community outcomes. Band adjustments were made on a few of these patients and they had more favorable outcomes. A third study by Martin, et al. (2000) looked at 359 obese women of childbearing age (18-51) with 20 who conceived and resulted in 23 pregnancies. Eighteen pregnancies were full term with no reports of diabetes, hypertension, neural tube defects, eclampsia, and normal fetal weights. Five women continued to lose weight without adverse fetal or neonatal effects.
With the RNY procedure, women with successful pregnancies also faired well. A study by Wittgrove, et al. (1998) looked at 49 pregnancies among 36 women with 17 of these women having pregnancies before their RNY procedure. These women served as their own controls. The 17 patients prior to RNY with 23 pregnancies had higher rates of hypertension and DM. A higher rate of macrosomia (ie: excessive birth weight) occurred, with 7 of 23 having a birth weight > 4000 grams during their pregnancies. These same patients had no incidence of hypertension or DM during their pregnancies after RNY. There was one of 18 babies with a birth weight > 4000 grams. A few other studies (Sheiner, et al. 2004; Richards, et al. 1987) have also shown improved outcomes and no statistical differences regarding pregnancy outcomes with respect to birth weight, hypertension, GDM, oligohydramnios (ie: a lower than normal amount of amniotic fluid), labor induction, labor dystocia, shoulder dystocia, perinatal death, congenital malformations, and large for gestational age.
Bariatric surgery is considered a safe procedure with favorable effects on pregnancy outcome; however, there have been case reports of complications occurring following bariatric surgery. Band erosion was reported by Ramirez and Turrentine (1995) following gastric banding. Weismann, et al. (1995) reported a case following gastric bypass with severe electrolyte imbalance resulting in a neonatal death at 34 days of life. Two cases of bowel obstruction have been reported by Kakarla, et al. (2005) and Moore, et al. (2004) with the latter resulting in a maternal and fetal death following gastric bypass.
Nutritional deficiencies following the RNY procedure range from vitamin B12, vitamin B1, iron, folic acid, and calcium. The middle and pyloric portions of the stomach contain parietal cells which are sources of hydrochloric acid and intrinsic factor. Hydrochloric acid helps to break down food and release vitamin B12. Vitamin B12 needs the intrinsic factor for absorption. This portion of the stomach is removed, thereby affecting rates of absorption. Portions of the small intestine are also bypassed where a significant amount of vitamins and nutrients are unable to be absorbed. Vitamin and mineral deficiencies can lead to a myriad of problems ranging from anemia, decreased immune function, weakness, fatigue, neural tube defects, and bone fractures.
There have been a few case studies reported in the literature that have shown vitamin B12 deficiencies in the newborn. Vitamin B12 is normally passed through to the fetus during pregnancy and then post-delivery through breast milk. Maternal serum vitamin B12 levels should be 150-800 pg/mL. Normal breastmilk levels should be 2670-13,110 pg/mL. The first case was a symptomatic newborn exclusively breastfeeding for the previous 10 months. The mother had low serum and breastmilk levels of vitamin B12. She had a previous gastrojejunostomy 2 years prior to pregnancy. Both were treated with intramuscular injections of vitamin B12. The second case study was an asymptomatic newborn diagnosed with vitamin B12 deficiency based on an abnormal newborn screen. This mother was also exclusively breastfeeding. She had gastric bypass prior to pregnancy and had stopped taking her prenatal vitamins due to side effects. Both were treated with intramuscular injections of vitamin B12.
There are many nursing recommendations that can be communicated with patients at different times during their life course. A pregnancy should be planned when the patient is in excellent health after the initial rapid weight loss phase. Patients should follow the daily nutritional recommendations set forth by their bariatric surgeon. Once pregnancy has occurred, early prenatal care in the first trimester is a must. Avoiding the glucose tolerance test can prevent dumping syndrome. During labor, recognizing the signs and symptoms of bowel obstruction can lead to appropriate medical interventions. Finally, appropriate care and education for the mother and her family regarding breastfeeding, maintenance of adequate nutrition, and warning signs and symptoms for the newborn will prevent morbidity and mortality. An interdisciplinary team approach is beneficial in ensuring a healthy outcome for both mother and baby. Please refer to box 1 for a suggested list of recommendations.
(1) AORN Bariatric Surgery Guideline. (2005) Standards, Recommended Practices, and Guidelines, 55-73.
(2) Campbell, C.D., Ganesh, J., & Ficicioglu, C. (2005) Two newborns with nutritional vitamin B12 deficiency: challenges in newborn screening for B12 deficiency. Haematologica/The hematology journal. http://www.haematologica.org/online/2005/ECR45/ E-case haematologica, 90 (ECR).
(3) Catalano, P.M. (2007) Management of obesity in pregnancy. Obstetrics & Gynecology, 109, 2, part 1, 419-433.
(4) Cesario, S.K. (2003) Obesity in pregnancy what every nurse needs to know. AWHONN Lifelines, 7, 2, 118-125.
(5) Dixon, J.B., Dixon, M.E., & O’Brien, P.E. (2005) Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstetrics & Gynecology, 106, no. 5, part 1, 965-972.
(6) Edwards, J.E. (2005) Pregnancy after bariatric surgery. AWHONN Lifelines, 9, 5, 388-393.
(7) Ehrenberg, H.M. & Johnson, N. (2005) Obesity, weight loss surgery and pregnancy risk and recommendations. Obesity Help Magazine, 5, 58-60.
(8) Elliot, K. (2003) Nutritional considerations after bariatric surgery. Critical Care Nursing Quarterly, 26, 2, 133-138.
(9) Fountain, R.A., King, J., & Blackwelder, L. (2007) Successful pregnancy following partial pancreatectomy after complications from a laparoscopic adjustable gastric banding. JOGNN, 36, 5, 457-463.
(10) Grange, D.K. & Finlay, J.L. (1994) Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass. Pediatric Hematology and Oncology, 11, 311-318.
(11) Gurewitsch, E.D., Smith-Levitin, M. & Mack, J. (1996) Pregnancy following gastric bypass for morbid obesity. Obstetrics and Gynecology, 88, 658-661.
(12) Hall, L.F. & Neubert, A.G. (2005) Obesity and pregnancy. Obstetrical and Gynecological Survey, 60, 4, 253-260.
(13) Herrera, B. (2005) Pregnancy after weight loss surgery : can it be healthy. Midwifery Today, p 33. www.midwiferytoday.com
(14) Kakarla, N., Dailey, C., Marino, T., Shikora, S.A. & Chelmow, D. (2005) Pregnancy after gastric bypass surgery and internal hernia formation. Obstetrics and Gynecology, 105, 1195-1198.
(15) Lourdes, St George, Daniel Lin (2005) Malabsorption in pregnancy after biliopancreatic diversion for morbid obesity. MJA, 182, 6, 308.
(16) Marceau, P., Kaufman, D., Biron, S., Hould, F-S., Lebel, S., Marceau, S., & Kral, J.G. (2004) Outcome of pregnancies after biliopancreatic diversion. Obesity Surgery, 14, 318-324.
(17) Martin, L.F., Finigan, K.M. & Nolan, T.E. (2000) Pregnancy after adjustable gastric banding. Obstetrics & Gynecology, 95, 927-930.
(18) Moore, K.A. Ouyang, D.W. & Whang, E.E. (2004) Maternal and fetal deaths after gastric bypass surgery for morbid obesity. NEJM, 357, 7, 721-722.
(19) Morin, K.H. & Reilly, L. (2007) Caring for obese pregnant women. JOGNN, 36, 5, 482-489.
(20) Ramirez, M.M. & Turrentine, M.A. (1995) Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical banded gastroplasty. American J of Obstet Gynecol. 173, 1630-1631.
(21) Richards, D.S., Miller, D.K., & Goodman, G.N. (1987) Pregnancy after gastric bypass for morbid obesity. The Journal of Reproductive Medicine, 32, 3, 172-176.
(22) Scopinaro, N., Gianetta, E., Adami, G.F., Friedman, D., Traverso, E., Marinari, G.M., Cuneo, S., Vitale, B., Ballari, F., Colombini, M., Baschieri, G., & Bachi, V. (1996) Biliopancreatic diversion for obesity at 18 years. Surgery, 119, 261-268.
(23) Sheiner, E., Levy, A., Silverberg, D., Menes, T.S., Levy, I., Katz, M., & Mazor, M., (2004) Pregnancy after bariatric surgery is not associated with adverse perinatal outcome. American Journal of Obstetrics & Gynecology, 190, 1335-1340.
(24) Skull, A.J, Slater, G.H., Duncombe, J.E., & Fielding, G.A. (2004) Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes. Obesity Surgery, 14, 230-235.
(25) Weiss, H.G., Nehoda, H., Labeck, B., Hourmont, K., Marth, C., & Aigner, F. (2001) Pregnancies after adjustable gastric banding. Obesity Surgery, 11, 303-306.
(26) Weiss, J.L. & Malone, F.D. (2001) Caring for obese obstetric patients. Contemporary OB/Gyn; 6:12-26.
(27) Weissman, A., Hagay, Z., Schachter, M. & Dreazen, E. (1995) Severe maternal and fetal electrolyte imbalance in pregnancy after gastric bypass surgery for morbid obesity. The Journal of Reproductive Medicine, 40, 813-816.
(28) Wittgrove, A.C., Jester, L., Wittgrove, P., & Clark, G.W. (1998) Pregnancy following gastric bypass for morbid obesity. Obesity Surgery; 8: 461-464.
(29) Woodard, C.B. (2004) Pregnancy following bariatric surgery. JPNN, 18, 4, 329-340.