Bariatric Surgery in Women: A Boon Needs Special Care During Pregnancy

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Glucose Abnormalities and Inappropriate Weight Gain Predict Negative Pregnancy Outcomes After Gastric Bypass Surgery

PURPOSE

Pregnancy after gastric bypass (RYGB) surgery remains at high risk for gestational diabetes mellitus, prematurity, and small for gestational age infants (SGA). Our objective was to describe the interstitial glucose (IG) profiles and weight changes during such pregnancies, and the association of these factors with adverse pregnancy outcomes.

MATERIAL AND METHODS

One hundred twenty two pregnancies were analyzed in a monocentric retrospective study. IG profiles were evaluated by continuous glucose monitoring for 4 days. Maternal (hypertension, hospitalizations, and caesarean section) and neonatal outcomes (prematurity, weight for gestational age, hospitalizations, and malformations) were recorded. A logistic stepwise regression model assessed the influence of weight gain and impaired IG on pregnancy outcomes.

RESULTS

Pregnancies occurred 33 (SD 21 months) after surgery. 73% of the women had IG abnormalities (55% with an increased % of time >140 mg/dl and 69% with an increased % of time <60 mg/dl). Five (4%) children were large for gestational age (LGA), 24 (20%) were SGA and 16 (13%) were born prematurely. There were 3 malformations but no stillbirth. LGA was associated with a high % of time >140 mg/dl and an excessive maternal weight gain. Prematurity was associated with a high % of time <60 mg/dl and an insufficient maternal weight gain. In the multivariate analysis, inappropriate weight gain explained LGA and prematurity independently. SGA was associated with a shorter % of time <60 mg/dl.

CONCLUSION

The relationship between IG abnormalities and/or maternal weight gain and neonatal outcomes in pregnancies after RYGB, suggests a careful monitoring of these parameters.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.

Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper.

A Review of Obstetrical Outcomes and Complications in Pregnant Women after Bariatric Surgery

Bariatric surgery (BS) is a novel treatment for weight reduction with longer lasting health benefits. This review aimed to summarise the available evidence regarding the fetomaternal outcomes and the most common challenges and complications in pregnancies following BS. Google Scholar (Google LLC, Mountain View, California, USA) and PubMed® (National Library of Medicine, Bethesda, Maryland, USA) databases were searched for articles published until December 2018. A total of 64 articles were included in this review and results showed that BS mitigates the risk of gestational diabetes mellitus, hypertensive disorders in pregnancy and fetal macrosomia. However, it can also have detrimental effects on fetomaternal health. There is paucity of data regarding small for gestational age intrauterine growth restriction, premature rupture of membranes and long-term effects on the children born to women who underwent BS.

Management of Pregnant Women after Bariatric Surgery

The prevalence of obesity is growing worldwide, and strategies to overcome this epidemic need to be developed urgently. Bariatric surgery is a very effective treatment option to reduce excess weight and often performed in women of reproductive age. Weight loss influences fertility positively and can resolve hormonal imbalance. So far, guidelines suggest conceiving after losing maximum weight and thus recommend conception at least 12-24 months after surgery. As limited data of these suggestions exist, further evidence is urgently needed as well for weight gain in pregnancy. Oral glucose tolerance tests for the diagnosis of gestational diabetes mellitus (GDM) should not be performed after bariatric procedures due to potential hypoglycaemic adverse events and high variability of glucose levels after glucose load. This challenges the utility of the usual diagnostic criteria for GDM in accurate prediction of complications. Furthermore, recommendations on essential nutrient supplementation in pregnancy and lactation in women after bariatric surgery are scarce. In addition, nutritional deficiencies or daily intake recommendations in pregnant women after bariatric surgery are not well investigated. This review summarizes current evidence, proposes clinical recommendations in pregnant women after bariatric surgery, and highlights areas of lack of evidence and the resulting urgent need for more clinical investigations.