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

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Presentation on theme: "Bariatric Surgery and Pregnancy John Finney Bariatric Dietitian Doncaster Royal Infirmary."— Presentation transcript:

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 months (for BMI>50kg/m 2, 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

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

14  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 Post Operative Diet Following Bariatric Surgery

15  Stage 1  Liquid only (1 week)  Stage 2  Blended / Pureed textured diet Four Stages

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/m 2  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  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 Gestational Diabetes and Bariatric Surgery

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/m 2  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/m 2. Xs wt loss 88.2%

33 Patient 2 – Sleeve Gastrectomy  Pre op – 115.6kg (18st 2lb). BMI 48.1kg/m 2  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/m 2. XS wt loss 19.3%

34 Patient 3 – Gastric Bypass  Pre surgery wt 154.4kg (24st 4lb). BMI 53.8kg/m 2  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/m % xs wt loss

35

36  Contact Details  John Finney  Specialist Dietitian for Bariatric Surgery   #4110 /  Louise Parsons / Katie Kirk  Clinical Nurse Specialists for Bariatric Surgery  /  # 4294 /

37 References  Health Survey for England (HSE) (2012)  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  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): 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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