Obesity represents a dangerous public health concern all over
the universe. The World Health Organization suggests that, by
2015, approximately 2.3 billion adults will be overweight and more
than 700 million will be obese [1]. Prevalence of obesity continues
to rise and obesity has become the second leading cause of death
in the West [2]. Obesity is associated with numerous comorbidities
affecting virtually every organ system, including hypertension, type
II diabetes mellitus, coronary artery disease, dyslipidemia, certain
cancers, and ultimately increased mortality [3]. Obese women of
reproductive age are a specific group at risk for a host of obesityrelated
reproductive and obstetric complications, such as infertility,
early miscarriage, gestational hypertension and diabetes mellitus,
pre-eclampsia, preterm birth, and intrauterine fetal demise [4].
Bariatric surgery has been recently proven to decrease mortality
in postoperative patients when compared to obese controls and is,
thus, a promising weapon in the fight against obesity [5]. Over 80
%of bariatric surgical patients are women with obesity in their
reproductive years [6]. Obesity adversely affects fertility; the rapid
weight loss following bariatric surgery can increase fecundity.
To combat reproductive complications of obesity, the American
College of Obstetrics and Gynecology advocates weight loss prior
to conception and acknowledges bariatric surgery as preliminarily
promising in prepregnancy obesity treatment [7]. Bariatric surgery
has become a cornerstone in the management of morbid obesity
and is safely recommended for obese women of childbearing age
[8].
Figure 1: Procedures of Bariatric Surgery.
Procedures for bariatric surgery are traditionally categorized
into three groups (Figure 1). The aim of the first group of
procedures is to restrict energy intake by reducing gastric capacity.
This includes the laparoscopic adjustable gastric band (LAGB).
The Roux-en-Y gastric bypass (RYGB) is another type, which
combines food restriction with a certain degree of malabsorption
by shortening the length of the intestinal tract. The third group
includes vertical sleeve gastrectomy (VSG). The Laparoscopic
Sleeve Gastrectomy is performed by removing approximately 80
percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana and the fourth type is biliopancreatic
diversion. The most performed procedures today are the LAGB and
the RYGB [9].
Restrictive approaches like vertical banded gastroplasty and
laparoscopic adjustable gastric banding are designed to restrict
caloric intake, whereas primarily malabsorptive procedures such as
Biliopancreatic diversion with or without duodenal switch promote
weight loss by decreasing nutrient absorption [10]. Reports of
pregnancy after bariatric surgery demonstrated concerning
complications related to poor maternal nutritional status, including
anemia, neural tube defects, and intrauterine growth retardation
[11]. In addition, a case of gastrointestinal bleeding after vertical
banded gastroplasty and reports of fatal bowel obstruction
secondary to internal intestinal herniation after Roux-en-Y gastric
bypass caused further alarm among both bariatric surgeons and
obstetricians alike [12].
Reproductive Management after Bariatric Surgery
a) Operation-to-birth intervals of less than 2 years were
associated with higher risks for prematurity [13] because women
after bariatric surgery suffer from nutritional deficiencies may be
rather grave and may involve the developing foetus [14].
b) Reliable contraception after the operation. During this
period there is a need for the use of reliable contraception. As there
is a risk for malabsorption of hormones taken orally, the combined
and progestogen-only pills are contraindicated, and displaced
by non-oral hormonal contraception or non-hormonal methods,
including intrauterine devices and condoms [15].
c) Nutritional monitoring and supplementation tailored to
the type of bariatric operation performed with a specific focus on
keying out and treating deficiencies in iron, folic acid, B12, calcium,
and vitamin D both pre- and post-conception.
d) Recommendations during pregnancy: one standard prenatal
vitamin daily, which may include or should be supplemented with
the following 400 μg folate daily for all reproductive-aged women
50-100 mg elemental iron daily for menstruating and pregnant
women 1,000 mg calcium daily for all postoperative patients, 60 g
of dietary protein daily for pregnant patients.
e) Low threshold for suspicion of intestinal obstruction during
pregnancy. Image via CT scan and surgical exploration as needed.
f) Close follow up of weight changes during gestation and
postpartum cooperation with high-risk obstetrical colleagues in
patient management.