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Devlieger o&p2013
1. Bariatric surgery and Pregnancy:
a critical review
Roland Devlieger, MD, PhD
Department of obestetrics and gynaecology
University hospitals KU Leuven, Belgium
2. Overview
• Maternal obesity: management options
• Bariatric surgery
– Indications & procedures
– Effects on fertility
– Effects on pregnancy outcomes
– Effects on later life
• Clinical recommendations
• Research gaps
“Venus in front of the mirror”
PP Rubens, 1613
4. Treatment of obesity during pregnancy
Physical
activity1
Diet²
MedicationObesity • No registerd safe
products
• Metformin?
• Poor diet, especially in the obese
• Intervention studies show benifit
• Motivation and psychological factors
important
• Reduced in pregnancy
• Some PA contra-indicated
• Intervention studies show some benefit
Pudevigne et al. 2006; ²Guelinckx et al. 2007;Rifas-Shiman et al. 2009; Thangaratinam et al, 2012; Bogaerts et al. 2012
5. Treatment of obesity before/between pregnancies
Physical
activity1
Diet²
MedicationObesity
Pudevigne et al. 2006; ²Guelinckx et al. 2007;Rifas-Shiman et al. 2009; Thangaratinam et al, 2012; Vinter et al, 2012; Bogaerts et al. 2012
Bariatric
surgery
-Is it safe?
-Who should benefit?
6. Classification of BS procedures
Le Roux et al. Int J obesitas 2009
Procedure type Restrictive procedures Malabsorptive procedures Mixed procedures
Operation examples Laparoscopic adjustable
gastric banding (LAGB)
Bilio-pancreatic diversion
(BPD)
Roux –en Y- gastric bypass
(RYGB)
Sleeve gastrectomy Bilio-pancreatic diversion with
duodenal switch (BPD-DS)
Vertical banded gastroplasty Jejuno-ileal bypass
Mechanism of weight loss Reduced food intake
• Reduced gastric capacity
• Early satiety
Reduced nutritient absorption
• Small intestine bypassed
Reduced intake and uptake
Schematic examples LAGB BPD-DS RYGB
7. Mechanism of weight loss after BS
• Complex
• Reduced appetite: changes in gut hormons
– Ghrelin, PYY, GLP-1
• Effects on the reward system of the brain
– Changes in food preferences
– Neural pathways: Arcuate nucleus, Dopamine
Raghavendra et al, Obes Reviews 2012
8. Bariatric surgery
Indications
• National Heart, Lung, and Blood Institute Expert Panel on the identification, evaluation, and
treatment of obesity for adults
– bariatric surgery be an option for carefully selected patients with clinically severe
obesity (BMI >40 or >35 with comorbid conditions) when less invasive methods of
weight loss have failed and the patient is at high risk for obesity-associated morbidity
and mortality.
• The American Gastroenterological Association (AGA) medical position statement on obesity
– most effective approach for achieving long-term weight loss.
– recommends surgery for patients with a BMI >40, or those with BMI >35 and 1 or more
severe obesity-related medical complication (eg, hypertension, heart failure, or sleep
apnea) if they have been unable to achieve or maintain weight loss with conventional
therapy, have acceptable operative risks, and are able to comply with long-term
treatment and follow-up.
• American College of Preventive Medicine
– policy statement on weight management counseling
– recomments limiting surgical therapy for obesity to severely obese patients, defined as
BMI >40.
Pentin et al. 2005
9. Bariatric surgery Indications
• Country-specific different reimbursement criteria
• Most often used
– Morbidly obese BMI > 40 kg/m²
– BMI > 35 kg/m² with co-morbidities
– Lifestyle interventions not succesfull
– Operative risk acceptable
• Commercial circuit
13. Bariatric surgery
• USA 125.000 procedures per year
• About 85 % → women of reproductive age1
• An increasing number of
adolescents, predominantly female²-³
1Samuel at al. 2006; ²Schilling et al. 2008; 3Pallati et al. 2012
16. Long term consequences of bariatric surgery
The SOS-study
• Swedish Obese Subject-study
• Non-randomized, prospective controlled study 1987-2001
• Study population: Obese Men and Women
– Bariatric Surgery group (N=2 010)
– Conventional treatment group (N= 2 037)
• End points:
– Primary: overall mortality
– Secondary: myocardial infarction, stroke, cancer, self-reported
sleep apnea, hypertension, dyslipidemia, hyperuricemia
20. SOS-study
• Besides weight loss → improvement of co-
morbidities (independently of the type of
surgery)
– Cardiovascular events
– Recover from diabetes
– Hypertension
– Dyslipidemia
– Obstructive sleep apnea
– hyperuricemia
Sjöström et al. N Engl J Med 2007
21. Cost-utility of BS for morbid obesity in Finland
Mäklin et al. BJS 2011
33.870 vs. 50.495 Euro
22. Bariatric surgery
complications
• RYGB
– Operative mortalities: 0.5 %1
– Long-term: dumping, stomal stenosis, marginal
ulcers, staple line disruption, internal hernias²
– Nutritional deficiencies: more common³
• Vit B12, B1, C, folate, A, D and K
• Calcium, iron, selenium, zinc and copper
1Buchwald. 2005; ²Woodard. 2004; ³Shankar et al. Nutrition 2010; Stocker. Endocrinol Metab Clin North Am 2003
23. More recently:
Increased prevalence after bariatric surgery of:
• Substance abuse
• Psychiatric disorders
• Suicide deaths
Suicide rate of 4.1/10,000 person-years (P = 0.03).
Therefore, there is a great need to identify persons at risk and
post-operative psychological monitoring is recommended.
Peterhänsel et al, Obes Rev 2013, King et al, JAMA 2012; Raghavendra et al, 2012
25. Effects on fertility
• In general, weight loss reverses the adverse
effects of obesityand adiposity on fertility
• 50% anovulatory rate of women undergoing BS
up to 71 % regained cyclicity of menstrual blood loss1
• Most cohort studies or case control series →
improvement in spontaneous pregnancy rates
after BS1
Teitelman et al. 2006
26. Effects on fertility
Abbreviations: FSH Follicular Stimulating Hormone, GnRH Gonadotropin Releasing Hormone, LH Lutenising Hormone, MIS
Müllerian Inhibiting Substance, SHBG Sex Hormone Binding Globuline.
BARIATRIC SURGERY
WEIGHT LOSS
IMPROVED FERTILITY
IMPROVED OVARIAN
FUNCTION
↓MIS
IMPROVED
SELF IMAGE
IMPROVED
SEXUAL ACTIVITY
↓ADIPOSE TISSUE
↓ESTRADIOL ↓INSULIN
↑GnRH
↑LH, FSH
↑SHBG
↓TESTOSTERONE
DECREASED
CONTRACEPTIVE
EFFICACY
27. Authors (reference) Sample size Design Summary of findings
Bastounis et al. (38) 38 Prospective study Normalization of menstrual cycle irregularities
Rochester et al. (41) 25 Prospective study Partial recovery of luteal function
Merhi et al. (48) 18 Prospective study Drop in plasma BDNF
Manco et al. (49) 10 Prospective study
Increase in free cortisol, FCI, and insulin sensitivity. Decrease in CBG and insulin
secretion
Chikunguwo et al. (51) 86 Prospective study Decrease in TSH. No change in free T4
Moulin de Moraes et al. (52) 72 Prospective study Decrease in TSH. No change in free T4
Eid et al. (66) 24 Historical cohort Spontaneous conception in 5 PCOS women
Deitel et al. (62) 30 Case series Spontaneous conception in 9 women and regulation of the menstrual cycle
Martin et al. (64) 20 Clinical trial Spontaneous conception in 5 women. No obvious fetal or neonatal effects
Bilenka et al. (63) 6 Retrospective study Spontaneous conception in 5 women and reduction in the risk of miscarriage
Friedman et al. (89) 1,136 Retrospective study Reduction in the risk of miscarriage and decrease in pregnancy complications
Marceau et al. (65) 783 Cross-sectional study Normalization of gestational weight changes and reduction of fetal macrosomia
Sheiner et al. (67) 28 Historical cohort
No difference in obstetric characteristics, pregnancy outcome, or perinatal
outcome. Higher rates of fertility treatments
Merhi et al. (73) 16 Prospective study Drop in plasma MIS
Gerrits et al. (39) 40 Prospective study Unintended pregnancies in 2 of 9 morbidly obese women despite OCP use
Victor et al. (40) 7 Prospective study Lower plasma OCP metabolites levels
Kinzl et al. (98) 82 Cross-sectional study Enhanced sexual function
Camps et al. (99) 94 Cross-sectional study Enhanced sexual function
Hafner et al. (100) 83 Cross-sectional study Enhanced sexual function
Merhi et al. Fert Ster 2009
28. Bariatric surgery and contraception effectiveness
Author Design N Surgery Findings
Gerrits et al. 2003 Prospective study 40 Biliopancreatic diversion 2/9 unplanned pregnancies in OAC
using group
Weiss et al. 2001 Descriptive study 215 LAGB No unplanned pregnancies
Victor et al. 1987 Prospective study 7 Jejuno-ileal bypass Lower OAC serum levels
Anderson et al. 1987 Pharmacokinetic 18 Jejuno-ileal bypass Obesity → reduces steroid levels
Ciangura et al. 2011 Case series 3 RYGB Decreased ENG after implanon
Ciangura et al. 2011 Case series 44 mixed 92% had an IUD placed at time of BS
→ high acceptance
No results on safety
Paulen et al. Contraception 2007
Increased
fertility
Increased
sexual activity
Uncertain
contraceptive
effectiveness
Unplanned
pregnancies
29. Effects on pregnancy outcomes
Interpretation of the available literature
• Different types of surgery
• Surgical vs. obstetric or neonatal literature
• Varying designs, small study groups, different control
groups
30. Reviews on the subject
1) Pregnancy and Fertility following bariatric surgery: A systematic review
JAMA 2008; 300:2286-2296
Maggard MA, Yermilov I, Li Z, et al.
2) Pregnancy after bariatric surgery: A comprehensive review
Arch Gynecol Obstet 2008; 277:381-388
Karmon A, Sheiner E.
3) Reproductive outcome after bariatric surgery: A critical review
Human Reproduction Update 2009; 15:189-201
Guelinckx I, Devlieger R, Vansant G.
4) Pregnancy after bariatric surgery: A review
Journal of obesity 2011,
Hezelgrave & Oteng-Ntim.
31. Bariatric surgery and preeclampsia
Reference Procedure N %
Skull et al. (2004) LAGB 49 vs
same with 31 preoperative pregancies
0.0 6.4 ↘
Dixon et al. (2005) LAGB 79 vs
1) pre-LAGB pregnancies
2) Obese matched controls
5.0 1) 28.0
2) 25.0
↘
Ducarme et al. (2007) LAGB 13 vs
414 non LAGB obese
0.0 3.1 ↘
Patel et al. (2008) RYGB 25 vs
188 non-obese
39 obese
2 severly obese
=
Lapolla et al. (2010) LAGB 83 vs
1) 120 morbidly obese
2) 858 normal weight
27 vs
27 pre-LAGB in same women
34 morbidly obese vs
45 post-LAGB no longer morbidly obsese
12.0
7.4
14.7
1) 20.8
2) 2.3
14.8
11.1
↘
32. Bariatric surgery and GDM
Reference Procedure N %
Skull et al. (2004) LAGB 49 vs
same with 31 preoperative pregnancies
8.0 27.0 ↘
Dixon et al. (2005) LAGB 79 vs
1) pre-LAGB pregnancies
2) Obese matched controls
6.3 1) 15.0
2) 19.0
↘
Ducarme et al. (2007) LAGB 13 vs
414 non LAGB obese
0.0 22.1 ↘
Patel et al. (2008) RYGB 25 vs
188 non-obese
39 obese
2 severly obese
=
Lapolla et al. (2010) LAGB - 83 vs
1) 120 morbidly obese
2) 858 normal weight
- 27 vs
27 pre-LAGV in same women
- 34 morbidly obese vs
45 post-LAGB no longer morbidly obese
6.0
7.4
11.8
1) 50.0
2) /
7.4
2.2
↘
Lesko et al. (2012) Mixture 70 vs
1) 140 (BMI within 6 points of average
presurgery weight)
2) 140 (BMI within 6 points of average
prepregnancy BMI)
0 1) 16.4
2) 9.3
↘
33. Bariatric surgery and macrosomia
Reference Procedure N %
Sheiner et al. (2004) Mixture 298 vs
158 912 no BS
9.4 4.6 ↗
Marceau et al. (2004) BPD 251 vs
1 577 before surgery
7.7 34.8 ↘
Dixon et al. (2005) LAGB 79 vs
1) pre-LAGB pregnancies
2) Obese matched controls
11.4 17.7 ↘
Ducarme et al. (2007) LAGB 13 vs
414 non LAGB obese
7.7 14.6 ↘
Patel et al. (2008) RYGB 26 vs
1) 188 non-obese
2) 39 obese
3) 2 severly obese
↘
Weintraub et al. (2008) Mixture 354 vs
301
3.2 7.6 ↘
Lesko et al. (2012) Mixture 70 vs
1) 140 (BMI within 6 points of average
presurgery weight)
2) 140 (BMI within 6 points of average
prepregnancy BMI)
4.3 1) 18.1
2) 12.9
↘
34. Bariatric surgery and C-section
Reference Procedure N %
Sheiner et al. (2004) Mixture 298 vs
158 912 no BS
9.4 4.6 ↗
Marceau et al. (2004) BPD 251 vs
1 577 before surgery
7.7 34.8 ↘
Ducarme et al. (2007) LAGB 13 vs
414 non LAGB obese
7.7 14.6 ↘
Patel et al. (2008) RYGB 26 vs
188 non-obese
39 obese
2 severly obese
12.4 15.2 =
35. Bariatric surgery and IUGR
Reference Procedure N %
Sheiner et al. (2004) Mixture 298 vs
158 912 no BS
5.0 2.0 ↗
Weintraub et al. (2008) Mixture 354 vs
301
3.9 2.3 ↗
Santulli et al. (2010) RYGB 24 vs
1) 120 normal BMI group
2) 120 BMI matched control group
4.2 1) 0
2) 0
↗
Kjaer et al, unpublished RYGB 286 vs 1070 matched controls 7.7 2.8 ↗
36. Bariatric surgery and prematurity
Reference Procedure N %
Marceau et al. (2004) BPD 251 vs
1 577 before surgery
16.7 13.6 =
Skull et al. (2004) LAGB 49 vs
31 previous non-LAGB
4 3 =
Dixon et al. (2005) LAGB 79 first postoperative pregnancies vs
1) 40 penultimate preoperative pregnancies
2) 79 obese women, matched for parity, age
and BMI
3) 61 000 community controls
6.3 1) NR
2) 12.7
3) 7.8
=
Ducarme et al. (2007) LAGB 13 vs
414 obese
7.7 7.1 =
Patel et al. (2008) RYGB 25 vs
1) 188 non-obese
2) 39 obese
3) 2 severly obese
26.9 1) 20.2
2) 17.9
3) 25.9
=
Wax et al. (2008) GB 38 vs
76 matched for age and prior CS
26.3 22.4 =
Lapolla et al. (2010) LAGB 83 vs
1) 120 no LAGB obese
2) 858 normal controls
17.6 1) NS
2) 3.6
↗
37. Bariatric surgery and miscarriage
Reference Procedure N %
Bilenka et al. (1995) VBG 14 vs
18 pre-operative
7 39 ↘
Friedman et al. (1995) BPD 239 vs
124 pre-operative
28 21 ↘
Marceau et al. (2004) BPD 251 vs
1 577 before surgery
21.6 26 =
38. Bariatric surgery and offspring obesity
Reference Procedure N Severe obesity
%
Smith et al, 2009 BPD 49 mothers
111 Children 2.5-25y
54 Before BS
57 After BS
11 35 ↘
40. Transgenerational effects of maternal obesity and the effect of BS
Obese mother
Macrosomic Baby
Obese Child
Obese adolescent SGA baby
Increased metabolic risk Increased metabolic risk
Postnatal Overnutrition
41. Risk Factors for IUGR following
bariatric surgery
• Insufficient weight gain (<IOM)
• Persistent vomiting
• Pregnancy during period of rapid weight loss
• BPD>RYGB>LAGB
42. Bariatric surgery and pregnancy:
(potential) risks
• IUGR/SGA
• Surgical complications
• Nutritional deficiencies
• Psychological problems and substance abuse
43. Surgical complications
• Small bowel obstruction due to internal herniation, volvulus, leak, …
• Not unfrequent (2-11%)
Delay in diagnosis and treatment
• Symptomatology frequent in pregnancy
• Diagnostic procedures delayed in pregnancy
• Changed anatomy
High mortality
Guelinckx et al, 2009 ; Wax JR et al, 2013
44. Reference Type of
surgery
Interval Maternal
complication
Fetal
complication
Long-term outcome
Wang et al. (2007) RYGB 2 months Internal hernia Uncomplicated
Wax et al. (2007a,
b)
RYGB 12 months Intussusception Uncomplicated
Bellanger et al.
(2006)
RYGB 24 months Small bowel obstruction Uncomplicated
Ahmed and
O’Malley (2006)
RYGB 8 months Internal hernia Uncomplicated
Baker and Kothari
(2005)
RYGB 4 months Internal hernia Uncomplicated
Loar et al. (2005) RYGB NA Small bowel volvulus Preterm delivery Maternal death
Kakarla et al. (2005)RYGB 9 months Internal herniation Preterm delivery Uncomplicated
Kakarla et al. (2005)RYGB 30 months Small bowel herniation Uncomplicated
Charles et al. (2005)RYGB 6 months Small bowel herniation Uncomplicated
Moore et al. (2004) RYGB 18 months Small bowel herniation Maternal + fetal deaths
Graubard et al.
(1988)
BPD 3 years Small bowel obstruction Fetal death Maternal + fetal deaths
Guelinckx et al, Hum Reprod Update 2009
45. Renault KM et al, Acta Obstet Gynecol Scand 2012
• Lap RYGB
• 35 weeks: abdominal pain, nausea, vomiting,
diarrhea
• S/C and exploration
• Maternal mortality 2 days post-caesarean
• COD: Small bowel necrosis due to internal
herniation with massive septic shock
Maternal mortality in Denmark
46. Surgical complications:
recommendations for care of women with history of RYGB
• Increase awareness of patients and staff
• Abdominal complaints should be considered SBO
unless proven otherwise.
• Usually surgical management required
• Inspect entire small bowel in case of surgery or C-
section for abdominal complaints
• CT with contrast is preferred imaging method
Wax JR AJOG 2013
47.
48.
49.
50. Vitamin K deficient ICH: Cases UH Leuven
Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Type of bariatric surgery Gastric banding Gastric banding Gastric banding Biliopancreatic diversion Duodenal switch Gastric banding
Laboratory values mother
PT 46.8% (70–150%) Pseudo-Bartter
Vitamin K 0.0008 nmol/L
(0.8–5.3 nmol/L)
PT 12 s (9.0-12.0)
aPTT 29.3 s (24–31 s)
K+ 2.29 mmol/L (3.5–5.1
mmol/L)
aPTT 29 s (24–31 s)
f II 56% (70–130%)
HCO3
− 29.7 mmol/L (22–
29 mmol/L)
f II 56% (70–130%)
f V 121% (70–130%)
f VII 40% (70–130%) f VII 40% (70–130%)
f IX 75 % (70–130%)
f X 27% (70–130%) f X 27% (70–130%)
Vitamin K1 0.2 nmol/L Vitamin K1 0.2 nmol/L
(0.8–5.3 nmol/L) (0.8–5.3 nmol/L)
Laboratory values infants
PT < 10% (70–100%) Pseudo-Bartter PT 16.8% (70–100%) PT 53% (70–100%) PT 75 s (70–100%)
aPTT 121.2 s (24–38 s)
K+ 2.42 mmol/L (3.5–5.1
mmol/L)
aPTT 93.4 s (24–38 s) aPTT 38 s (24–38 s) aPTT 121 s (24–38 s)
Fibrinogen 1.29 g/L (2.00–
3.80 g/L)
Fibrinogen 0.93 g/L (2.00–
3.80 g/L)
f II 13% (70–130%)
HCO3
− 27.8 mmol/L (22–
29 mmol/L)
f II 18% (70–130%) f II
f V 78% (70–130%) f V 50% (70–130%)
f VII 2.9% (70–130%) f VII 2.6% (70–130%)
f VII 1-13%
(70–130%)
f IX 0.8% (70–130%) f IX 8% (70–130%) f IX
f X 4.2% (70–130%) f X 13% (70–130%) f X
Neonatal outcome Died Died Mental retardation Mental retardation Died Died
Eerdekens A, Eur J Pediatr 2010;169(2):191-6
Van Mieghem T, Obstet Gynecol 2008;112:434-6
51. *
*
* *
*
PABAS Study design
• Prospective, multicenter trial
• Inclusion: pregnant women with a history of
bariatric surgery
– singleton pregnancy
– ≤14+6 weeks GA
– Informed consent
• April 2009- Janary 2011
52. PABAS-study: aims
• Life style during pregnancy
• Diet: 7 days records, Healthy eating index (HEI)
• Physical activity: Kaiser questionnaire
• Nutritional deficiencies
• Effects of tailored substitution
• Comparison with contemporary controls
Guelinckx et al, 2009
54. Results: dietary habits
0
10
20
30
40
50
60
70
80
90
Restrictive cat. Malabsorption cat.
Healthy Eating Index
1st trimester
2nd trimester
No sign difference
according to repeated measures ANOVA with surgery group and trimester
as between- and within-subject variable respectively
1st 1st2nd 2nd
56. Proportion of patients with FS vitamin deficiency
1st trimester
2nd trimester
3rd trimester
0
10
20
30
40
50
60
70
80
90
100
Vit A
Vit E
Vit D < 7 µg/l
Vit D 7-20 µg/l
Vit K
Restrictive types
57. 1st trimester
2nd trimester
3rd trimester
0
10
20
30
40
50
60
70
80
90
100
Vit A
Vit E
Vit D < 7 µg/l
Vit D 7-20 µg/l
Vit K
Malabsorption types
Proportion of patients with FS vitamin deficiency
59. Nutritional deficiencies
Nutritional deficiencies Maternal complications Fetal/neonatal
complications
Iron Anemia IUGR
Proteins Odema, weight loss IUGR
Vit B12 Anemia Pancytopenia,
developmental delay
Folic acid Anemia Neural tube defects
Vit D Osteomalacia Hypocalcemia, rickets
Vit A Microphthalmia, retinal
damage
Vit K Coagulation disorders Cerebral hemorrhage,
IUD
Calcium Hypocalcemia Hypocalcemia
Devlieger & Guelinckx, Maternal obesity 2012
60. NTD after Bariatric surgery
• Over 15 cases in the literature!
• More frequent than in the obese?
• Relation with folic acid deficiency?
Pelizzo et al, Prenat Diagn 2013; Fonte et al, IASO-TOS 2013
Case Age
(y)
GA
(w)
Defect Family
History
DM Antiseizure
Medication
Malnutrition
Fonte
2013
27 20 Spine dysraphia with
sacral bone agenesis
no no no yes
Pelizzo
2013
40 22 Spinal dysraphia with
sacral bone agenesis
no no no yes
61. Substance abuse in pregnancy
Bariatric procedure
N = 54 (43.5%)
Control group
N = 70 (56.5%)
P-value
Maternal age 30.0 ± 4.8 29.1 ± 4.3 0.154
BMI 28.3 ± 5.5 28.1 ±2.5 0.274
Nulliparae 21 (39.6%) 32 (45.7%) 0.585
Smoking 13 (24.5%) 4 (5.7%) 0.003
Alcohol use
Trimester 1
Trimester 2
5 (9.4%)
5 (9.4%)
11 (15.7%)
11 (15.7%)
0.305
0.950
G. Jans et al, ECO 2013
62. Recommendations for clinical care
• Preconception
• Pregnancy
– Early
– Late
• Postpartum period
Devlieger and Guelinckx, 2012
63. Preconception
• Delay pregnancy until after period of rapid weight loss
(1 year minimum)
• Provide effective contraception
• Involve lifestyle coach
• Evaluate nutritional state, correct where necessary
• Start folic acid (4mg)
• Advice rapid pregnancy test if sec amenorrhea
Devlieger and Guelinckx 2012
64. Clinical recommendations
First trimester
• Involve lifestyle coach
• Evaluate nutritional state, correct where
necessary
• Continue folic acid (4mg if obese) untill 12 weeks
• Adjustable balloon: not systematically open, open
if vomiting regularly (DD morning sickness) →
active band management
Devlieger and Guelinckx 2012
65. Clinical recommendations
Pregnancy
• Advice GWG according to IOM guidelines for preconception BMI
– Overweight: 7,0 to 11,5 kg (15 to 25 lbs)
– Obesity: 5,0 to 9,0 kg (11 to 20 lbs)
• Pay attention to symptoms of surgical complications
• Detailed morphologic scanning at 12-20-30 weeks
– Attention for growth, ossification, ICH
• Screen for GDM
– GCT-OGTT: dumping syndrome (50-95 %)
– Fasting glucose
– Day-profile
• Re-evaluate nutritional deficiencies every trimester
Devlieger and Guelinckx 2012
66. Clinical recommendations
Postpartum
• Advice and support breastfeeding?
• Inform pediatrician
• Follow-up and correction of nutritional deficiencies
• Evaluate for signs of depression and alcohol abusus
• Advice life-long coaching of lifestyle
Devlieger and Guelinckx, 2012
67. Research Gaps Include:
• Micronutrient deficiencies and
supplementation
• Link with congenital malformations esp NTD
• Breast feeding composition
• Contraception efficacy
• Timing of pregnancy after surgery
• Long term effects on the offspring
Devlieger and Guelinckx, 2012
74. Thank you
Goele Jans
Isabelle Guelinckx
Annick Bogaerts
Sarah Bel
Sander Galjaard
Sarah Pauwels
Rivka Turcksin
Annelies Matheussen
Guy Martens
Evelien Martens
Greet Vansant
Andre Van Assche
Dirk Timmerman
Participating centres, care-givers and patients
Studiecentrum
Perinatale Epidemiologie (SPE)
