Introduction:
Obesity rates are increasing in both developing and developed countries. According to the World Health Organization (WHO) report, ten percent of the world population is obese, an approximately threefold increase since 1975. Obesity is known as a major risk factor in developing numerous chronic conditions, including diabetes, cardiovascular disease, musculoskeletal disorders, and various types of cancers.
Management of obesity is mainly focused on lifestyle modifications with appropriate diet and exercise under the guidance of nutrition professionals. However, with the recent advancements in medical science, obesity treatments focus on medical and surgical interventions like bariatric surgical procedures, pharmacotherapy, and endoscopic bariatric procedures. Nowadays, there is an increase in women having pregnancy post-bariatric surgery. It can lead to new challenges in pregnancy like malnutrition, micronutrient deficiencies, higher risk of protein deficiency. It happens due to increased mothers and newborns' demand.
How Is Bariatric Surgery Done?
Bariatric surgeries are weight loss surgeries performed in obese women to get rid of excess fat deposition in the body. Previously, the Roux-en-Y gastric bypass (RYGB) was the most widely used procedure. The other techniques are sleeve gastrectomy and the adjustable gastric band.
In RYGB surgery, a small pouch is created at the gastric fundus, which restricts the food intake. The stomach’s main body and the length of the duodenum and jejunum are bypassed, hence creating an element of malabsorption. The sleeve gastrectomy is a restrictive procedure that involves surgical removal of the greater curvature of the stomach. The recent advancement in bariatric surgery is single anastomosis gastric bypass which reduces the complexity of the previously used gastric bypass surgery. Some other types of bariatric surgery are biliopancreatic diversion (BPD) and duodenal switch (DS), which cause significant malabsorption, and therefore are less commonly performed.
What Are Bariatric Surgery Pregnancy Risks?
Bariatric surgery is effective for weight loss. However, there are bariatric surgery pregnancy risks. It introduces specific considerations during pregnancy. Nutritional deficiencies are a major concern after bariatric surgery. Nutrition malabsorption, such as deficiency of folic acid, iron, and calcium may lead to an increase in the risk of maternal anemia and neural tube defects in the fetus. Due to rapid weight loss, the stored toxins are released into the bloodstream. It causes several risks to the developing fetus. After bariatric surgery, the hormonal changes affect fertility and cause several complications, such as gestational diabetes.
During pregnancy, there is a need for close monitoring, medical supervision, and nutritional supplementation to address associated risks. Adequate prenatal care and screenings are required for associated complications.
What Are The Nutritional Concerns for Pregnant Women?
During pregnancy, there is a need for optimal nutrition for both maternal health and fetal development. The essential nutritional concerns for pregnant women are described below:
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Folic acid is required to prevent birth defects.
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Iron is to support the growing fetus and to prevent mother anemia.
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Calcium for bone development.
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Vitamin D for calcium absorption and bone development.
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Iodine for thyroid function.
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Vitamin A.
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Hydration.
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Omega-3 fatty acids.
Can Bariatric Surgery Be Performed Before or After Pregnancy?
Pregnancy following bariatric surgery is commonly reported these days as there is an increase in the number of obese women undergoing this surgery to overcome obesity. However, there is a drastic increase in the number of bariatric surgeries to get rid of obesity and hence an increased pregnancy rate post-bariatric surgery. Still, it is advisable to postpone pregnancy for at least a year after bariatric surgery.
The women seeking pregnancy after bariatric surgery need comprehensive care before conception along with appropriate antenatal care to achieve the best outcomes. Adequate nutrition is of utmost importance in pregnancy, which is more crucial after bariatric surgery. It requires proper monitoring and management under nutritional specialists to avoid any associated complications. Close monitoring is needed to check deficiencies during each trimester.
When Is It Recommended to Conceive After Bariatric Surgery?
The weight loss caused by bariatric surgery leads to an improvement in the ovulation rate. However, these changes could be hazardous for the developing fetus if a woman conceives immediately after bariatric surgery. Some studies claim that no significant difference in the weight of babies was observed if a woman becomes pregnant in the same year after bariatric surgery or after a year following bariatric surgery. The American Association of Clinical Endocrinologists, the Obesity Society, and American Metabolic And Bariatric Surgery recommend avoiding conceptions for 12 to 18 months after bariatric surgery.
The type of bariatric surgery is one other important factor that needs to be considered if pregnancy is planned after bariatric surgery. Small for gestational age (SGA) was more reported in women who underwent Roux-en-Y gastric bypass (RYGB) or adjustable gastric banding. A small for gestational age baby (SGA) is a condition when the estimated weight of the infant or birth weight is less than 10th centile for the gestational age. Hence it is important to wait 12 to 18 months before planning pregnancy. It is suggested to check the supplementation and the level of nutrients before attempting to conceive if the period of surgery and pregnancy is longer.
What Is the Recommended Method of Delivery for a Mother After Bariatric Surgery?
There is no suggested mode of delivery for women undergoing bariatric surgery. Vaginal delivery is indicated in women following bariatric surgery unless any underlying medical condition is present at the time of delivery. Some studies suggest that there is a reduction in the number of cesarean deliveries followed by bariatric surgery. Also, there is a subsequent decrease in neonatal intensive care unit admission.
How Does Bariatric Surgery Affect Breastfeeding?
Bariatric surgery provides women with a healthier weight and reduces comorbid conditions with an increase in fertility rates, along with improved pregnancy outcomes when compared to obese women. Breastfeeding is known to have numerous health benefits for both infants and mothers.
Many studies were conducted to study the impact of bariatric surgery on breastfeeding.
However, there is very little evidence that has been reported suggesting the same. However, some studies suggest that breast milk does not lack any essential nutrients and does not possess any long-term effects if adequate nutrition is provided to the mothers. It is of utmost importance that the mother's nutrient intake should be properly monitored to prevent any deficiencies in the mother's body during the lactation phase.
The observational studies conducted on the infants lack the appropriate design and sample size. Hence, more comprehensive studies are needed in the future to determine the effect of bariatric surgery on an infant's health. Until now, it is recommended to continue appropriate nutritional supplementation during the lactation phase and to continue breastfeeding for at least six months after delivery.
Conclusion:
Pregnancy after bariatric surgery is considered to be one of the high-risk pregnancies. It requires multidisciplinary follow-up to ensure an optimal outcome for the mother and infants. It is important that all its subsequent effects, monitoring, nutritional requirements, and possible associated complications should be discussed properly with the patients. However, it would be best to postpone pregnancy for a year or two after undergoing bariatric surgery.
