Knowledge, attitudes, and behaviors of women during pregnancy after bariatric surgery

Breastfeeding in metabolic and bariatric patients: a comprehensive guide for surgeons, patients, and the multidisciplinary team

Since nearly 40% of metabolic and bariatric surgery (MBS) patients are individuals with the ability to bear children, many may seek to become pregnant or may be currently lactating when seeking surgery. While many patients plan to breastfeed, MBS patients are at high risk for premature cessation of breastfeeding. Limited literature exists on the impact of MBS on lactation and there are no established guidelines to help clinicians support and educate MBS patients about breastfeeding. Herein, we aim to fill that gap by providing a comprehensive guide for bariatric surgeons, obstetricians, women's health providers, lactation consultants, registered dietitians, bariatric nurse coordinators, and advanced practice providers to support breastfeeding in patients with a history of MBS or who are considering MBS. We review physician-patient discussion points on how MBS impacts lactation, the micronutrient and caloric needs for this unique population, and data to support successful breastfeeding in post-MBS patients who are lactating regarding practical, anesthetic, and imaging considerations.

Pregnant women's experiences of nutrition care after previous bariatric surgery

PROBLEM

The rate of pregnancy following bariatric surgery is rising globally and is associated with health benefits but also increased risk of micronutrient deficiency, preterm birth and small for gestational age offspring. Bariatric surgery may limit women's ability to meet the nutrient demands of pregnancy, necessitating individualised nutrition therapy. However, little is known about women's experiences of, and preferences for nutrition-related care during pregnancy after bariatric surgery.

AIM

To describe women's experiences of pregnancy after bariatric surgery, focussing on nutrition-related care.

METHODS

This qualitative study interviewed women across Australia with a history of any bariatric surgery. Semi-structured telephone interviews were conducted after 36-weeks gestation and before childbirth. Data were analysed using reflexive thematic analysis.

FINDINGS

Thirteen women aged 26-37 participated. Three themes were generated: navigating healthcare, the personal toll of pregnancy after bariatric surgery, and women's agency. Despite a strong desire for specialised nutrition care, women encountered several barriers to accessing this. When care was available, it often did not meet women's needs due to healthcare professionals' limited understanding of the nutrition challenges faced in pregnancies following bariatric surgery. This compelled women to seek information outside their maternity care team and advocate for themselves during care.

DISCUSSION

These findings highlight the need to address barriers to accessing nutrition care for pregnant women following bariatric surgery. Improved understanding of pregnancy and post-operative symptoms may enable enhanced woman-centred care.

CONCLUSION

Greater awareness of bariatric surgery among all maternity care professionals is needed to improve opportunities for informed, shared decision-making with pregnant women.

Pregnancy post-bariatric surgery: Improved outcomes with telephonic nutritional management program

BACKGROUND

Pregnancies post-bariatric surgery are increasingly common. It is important to understand how to manage prenatal care in this high-risk population to optimize perinatal outcomes.

OBJECTIVE

To determine among pregnancies post-bariatric surgery whether participation in a telephonic nutritional management program was associated with improved perinatal outcomes and nutritional adequacy.

STUDY DESIGN

Retrospective cohort study of pregnancies post-bariatric surgery from 2012 to 2018. Participation in a telephonic management program with nutritional counseling, monitoring and nutritional supplement adjustment. Modified Poisson Regression estimated the relative risk using propensity score methods to account for baseline differences between the patients who participated in the program and patients who did not.

RESULTS

1575 pregnancies occurred post-bariatric surgery, of which 1142 (72.5 % of pregnancies) participated in the telephonic nutritional management program. Participants in the program were less likely than non-participants to have a preterm birth (aRR 0.48, 95 % CI 0.35-0.67), preeclampsia (aRR 0.43, 95 % CI (0.27-0.69)), gestational hypertension (aRR 0.62, 95 % CI 0.41-0.93), and to have neonates admitted to a Level 2 or 3 (aRR 0.61, 95 % CI0.39-0.94; aRR 0.66, 95 % CI 0.45-0.97, respectively), after adjusting for the propensity score to account for baseline differences. Risk of cesarean delivery, gestational weight gain, glucose intolerance and birthweight did not differ by participation. Among 593 pregnancies with nutritional labs available, participants in the telephonic program were less likely to have nutritional inadequacy in late pregnancy (aRR 0.91, 95 % CI 0.88-0.94).

CONCLUSION

Participation in a telephonic nutritional management program post-bariatric surgery was associated with improved perinatal outcomes and nutritional adequacy.

Experiences and information needs of women who become pregnant after bariatric surgery: An interpretive descriptive qualitative study

BACKGROUND

Obesity is known to negatively impact fertility and increase pregnancy related complications. Many women of childbearing age opt for bariatric surgery to lose weight in the preconception period. Physiological changes of bariatric surgery are associated with both benefits and risks for maternal and neonatal outcomes. How women understand these risks and experience pregnancy following bariatric surgery are largely unknown.

OBJECTIVE

To explore the information needs and experiences of Australian women who become pregnant following bariatric surgery.

DESIGN

An interpretive descriptive qualitative study of 11 Australian women with experiences of pregnancy following bariatric surgery participated in a private Facebook discussion group conducted in 2021. Women were recruited via targeted advertisements on social media.

RESULTS

Women identified several information gaps regarding the implications of having bariatric surgery for preconception, pregnancy, and postnatal periods. Family planning, pregnancy nutrition, and breastfeeding advice were key areas of information need. Women's experiences of pregnancy following bariatric surgery included attitudes of judgement and lack of knowledge from their healthcare providers.

CONCLUSIONS

Healthcare professionals caring for women who have had bariatric procedures need to ensure that all women are fully informed about the risks of becoming pregnant within the first 12-months post-surgery. They should also anticipate that despite recommendations, women will become pregnant earlier than advised, and can benefit from non-judgemental and supportive care to ensure risks of poor outcomes are minimised. The findings highlight that the provision of tailored resources and education for women and their healthcare teams are needed.

Perception and Practice of Bariatric Surgery and Reproductive Health in Women: a Cross-sectional Study of Chinese Bariatric Surgeons

BACKGROUND AND PURPOSE

Western studies have explored bariatric surgeons concerning their views on bariatric surgery (BS) and reproductive health, but Asian data were lacking. The aim of this study was to explore the perception and practice of bariatric surgeons on the reproductive health of female patients who underwent BS in China to better guide clinical practice and improve clinical outcomes.

METHOD

An online questionnaire of 31 questions developed by bariatric surgeons was collected by sending to one online communication group (WeChat group) whose members are Chinese bariatric surgeons.

RESULT

A total of 87 bariatric surgeons from mainland China were surveyed. Almost all (97.7%, 85/87) surgeons considered the reproductive health conversation for women who underwent BS to be important or very important. Only 1/4 of surgeons routinely discuss reproductive health-related issues with patients, and only 56% of doctors always ask patients for postoperative contraception. Less than 20% of bariatric surgeons have full knowledge of postoperative contraception, and nearly 40% of them believe that gynecologists should be responsible for providing contraception. More than 35% of bariatric surgeons have never been involved in the co-management of pregnancy in patients with a history of BS.

CONCLUSION

Although most bariatric surgeons are aware of the importance of female reproductive health, there is a large gap in the perception and clinical practice of bariatric surgeons in terms of reproductive health. It is necessary to further strengthen the education of bariatric surgeons and enhance multidisciplinary cooperation with gynecology, obstetrics, and other disciplines to bring better clinical outcomes.

Benefits and Risks of Bariatric Surgery on Women's Reproductive Health: a Narrative Review

Bariatric surgery (BS) is escalating as the most efficient and endurable therapy for severe obesity. Women's reproductive health is essential to women's quality of life and is receiving increasing attention. However, despite the high prevalence of BS among women, the effect of BS on reproductive health remains underemphasis. The purpose of this narrative review is to provide an overview of BS on women's reproductive health, including their reproductive health before, during, and after pregnancy. Although limited attention has been given, current evidence highlights the substantial implications of bariatric surgery on reproductive health and reminds us of the importance of adopting decision-making conversations about reproductive health before bariatric surgery.

Women's experiences of pregnancy and lactation after bariatric surgery: A scoping review

BACKGROUND

Obesity is a global public health problem, and in high income countries such as Australia, approximately 60 percent of women are overweight, and half of these women are classed in the obese range. A large proportion of women who are obese are of childbearing age and many are undergoing surgical weight loss procedures (bariatric surgery) before becoming pregnant.

OBJECTIVE

To collate and synthesize available literature regarding women's experiences of pregnancy and/or lactation following bariatric surgery.

DESIGN

A scoping review was undertaken of published research between 1990 and 2021, written in English, involving human participants, which described experiences of pregnancy and/or lactation after bariatric surgery.

RESULTS

From a total of 4673 abstracts identified using search terms and strings, only 5 items (4 published conference abstracts and one full paper) were identified. Women had little knowledge of how the bariatric surgery might impact pregnancy and only a minority received additional medical/nutrition care during pregnancy. Women wanted more information and support managing their pregnancies, and often received inconsistent advice. For some women experiences of conflict between eating well for the developing fetus and eating little to minimize weight gain or undo the weight loss they had achieved was reported.

CONCLUSIONS

Ensuring that both health care providers and women are informed about promoting a healthy pregnancy and lactation after bariatric surgery is paramount. More research is required to understand women's experiences and information needs to ensure advice and care is tailored to their specific needs.

Dietary supplements and bariatric surgery

Bariatric surgery or weight loss surgery has been in practice for achieving significant weight loss in patients who have failed to achieve weight loss after pharmacological interventions. The rising cases of obesity are a triggering factor for more bariatric surgeries worldwide. Interestingly, sustained weight loss achieved post-bariatric surgery offers metabolic advantages, and patients show improved glucose and lipid metabolisms. Bariatric surgery is directly linked to higher incidences of vitamin, mineral, and trace element deficiencies, thus making patients susceptible to anemia, osteoporosis, and cardiomyopathy. Reduced nutrient absorption capacity, dietary changes, dietary restriction, and altered gastrointestinal tract morphology are some reasons for nutritional deficiency observed in post-bariatric surgery procedures. Micro-and-macronutrient deficiency observed in patients during the postoperative phase requires continuous monitoring of nutritional parameters. Therefore, adequate multivitamin and mineral supplements become essential to prevent/overcome micronutrient deficiencies. Bariatric surgery also raises the risk of small for gestational age (SGA) babies. Hence, a 12 - 24 months gap is recommended between bariatric surgery and pregnancy to achieve desired weight loss targets. The topic of this review is the impact of bariatric surgery procedures on vitamin and mineral absorption and the role of dietary supplements in maintaining a healthy nutritional balance during the postoperative phase.

Maternal Nutritional Status and Pregnancy Outcomes Post-bariatric Surgery

Obesity in childbearing women leads to pregnancy-related complications such as gestational diabetes mellitus, pregnancy-associated hypertensive disorders, and macrosomia. Weight loss helps reduce these complications. Studies show bariatric surgery reduces obesity-related complications during and after pregnancy. However, bariatric surgery might be associated with adverse outcomes, such as low birth weight and small-for-gestational-age infants. In addition, several studies suggest pregnancy occurring less than a year post-bariatric surgery adversely affects pregnancy outcomes and causes micronutrients deficiency since the dramatic weight loss occurs in the first year. These adverse outcomes may lead to nutritional malabsorption, such as anemia and low vitamin B12 and folic acid levels. The review aims to overview obesity-related complications during pregnancy and the benefits and risks of bariatric surgery on pregnancy outcomes and maternal nutrition status.

Contraceptive counselling in 3 Canadian bariatric surgery clinics: a multicentre qualitative study of the experiences of patients and health care providers

BACKGROUND

Evidence suggests an increase in fertility and unintended pregnancy after bariatric surgery; contraceptive counselling, traditionally defined as a discussion of contraception options, is therefore an important facet of surgical planning. Our aim was to investigate patient experiences of contraceptive counselling, the attitudes of health care providers (HCPs) toward contraceptive counselling, and their perceptions of the facilitators and barriers to contraceptive counselling in bariatric surgery clinics.

METHODS

We conducted a qualitative study using semistructured interviews with patients and HCPs at publicly funded Canadian bariatric surgery clinics from May 2018 to February 2019. We recruited bariatric HCPs from across Canada using snowball sampling, and recruited patient participants from 3 Canadian bariatric surgery programs. Patient participants had to be at risk of pregnancy in the postoperative period, aged 18-45 years old and have completed all preoperative counselling. We included HCPs who delivered care in a publicly funded, hospital-affiliated bariatric surgery clinic in Canada. Team members analyzed transcripts thematically.

RESULTS

We completed 27 interviews (patient n = 16, HCP n = 11). Our analysis identified 3 separate themes: missing information in contraception counselling, making assumptions about who would benefit from counselling and strategies for improving contraception counselling. We found patients and HCPs wanted more resources on the safety and efficacy of contraceptive methods.

INTERPRETATION

Our study showed a need for structured contraceptive counselling in bariatric surgery clinics. Information resources that support patients and HCPs who provide counselling are needed.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

Extremely early pregnancy (<6 mo) after sleeve gastrectomy: maternal and perinatal outcomes

BACKGROUND

Data are scarce regarding outcomes of pregnancies occurring very early after bariatric surgery.

OBJECTIVES

We compared outcomes of pregnancies occurring extremely early (surgery-to-conception interval <6 mos) after laparoscopic sleeve gastrectomy (LSG) with those occurring later (≥6 mos postsurgery).

SETTING

A university hospital.

METHODS

We reviewed the records of all women who underwent LSG and delivered during 2006-2019.

RESULTS

Of 196 women, 23 (11.7%) became pregnant within 6 months of surgery. For these women, the median surgery-to-conception interval was 116 [interquartile range 76-161] days, compared with 903 [465-1377] days for the remaining cohort. Three (13.0%) women turned out postoperatively to be pregnant at the time of LSG. Compared with women who conceived later, the extremely early pregnancy group had lower gestational weight gain (median 4 versus 10 kg, P < .001), including negative gestational weight gain in 9 (39.1%) women. The proportion of small for gestational age (SGA) infants was higher among women who conceived within 6 months after surgery rather than later (26.1% versus 10.4%, P = .04). Other maternal and perinatal outcomes were similar between the groups. In multivariate analysis, conceiving within 6 months after LSG was the only independent factor associated with delivering a SGA infant (odds ratio [95% confidence interval]: 3.35 (1.12, 10.01), P = .03).

CONCLUSIONS

Pregnancy occurring in the first 6 months after LSG was independently associated with a higher rate of SGA infants. Delaying conception during the very early postoperative period is recommended. Providing adequate contraception and excluding the presence of early pregnancy at the time of surgery are of utmost importance.