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The role of bariatric surgery in the management

Despite the fact that bariatric surgery does not reduce absolute BMI to within normal range in most patients, studies suggest it improves some important markers of fertility including hyper-insulinemia and ovulation in polycystic ovary syndrome.
Moreover, maternal outcomes and morbidity in pregnancy are better than for women who are similarly obese and are comparable with that of the general population.
Obese women who have weight loss surgery before becoming pregnant have a lower risk of pregnancy-related health problems and their children are less likely to be born with complications.
Life-long vitamin supplementation is advised.
It is advised against falling pregnant during the initial weight loss phase (1 year)

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The role of bariatric surgery in the management

  1. 1. Wafaa B. Basta Specialist Gynaecology & Obstetrics at Mataria Teaching Hospital MBBch., MSc ., Egyptian Fellowship, MRCOG ERC MEMBER EFSS 16th Annual international Conference MARIOTT ZAMALEK CAIRO 8th 2011
  2. 2.  What are the degrees of obesity ?  How far is the impact of obesity on fertility & reproduction ?  How strong is the evidence supporting weight loss?  What are the bariatric surgeries?  To whom bariatric surgery should be offered ?  What are the effect of bariatric surgery on fertility & obesity co-morbidities ?  Pregnancy &labour clinical considrations after bariatric surgery.
  3. 3.  One of the most serious public health problems of the 21st century.  Obesity is a leading preventable cause of death worldwide.
  4. 4. Genetics Behavior Environment
  5. 5. a person’s weight in kilograms square of height in metres (kg/m2).
  6. 6. * <18.5 : Underweight * 18.5-24.9 : Normal/Healthy * 25.0-29.9 : Overweight (pre-obese) * 30.0-34.9 : Obese (Class I) * 35.0-39.9 : Obese (Class II) * ≥40 Obese ( Class III = morbid obesity) o Waist –hip ratio correlates more with the metabolic disorder.
  7. 7. **In1997 the WHO formally recognized obesity as a global epidemic. **At 2008, The WHO claimed that 1.5 billion individuals over the age of 20 are considered obese. **Obesity rates are rising worldwide.
  8. 8.  Data from the Demographic and Health Surveys show that:  In 1992, mothers with young children had a mean (BMI) of 26.9.  By 2005, rise to a mean BMI of 30.1, with nearly half of Egyptian women of reproductive age classified as obese. WHO study (Musaiger 2004)
  9. 9.  Obesity is associated with reduced fertility primarily as a result of oligo-ovulation and an-ovulation .  In one study of 500 women, there was a 30% reduction in rate of conception with each 0.1 point increase in waist–hip ratio. Fat and female fecundity: prospective study of effect of body fat distribution on conception rates. BMJ 1993;306:484–7.
  10. 10.  Compared with normal weight women with PCOS, those obese women with PCO are characterised by: * Worsened hyper-androgenic state. * Worsened metabolic state. * Poorer menses. * Poorer ovulatory performance. * Poorer pregnancy rates. • Obese women with PCOS often report extreme difficulty in loosing weight .
  11. 11.  Compared with women with a BMI of 25 kg/m2 or less, women with a BMI ≥ 25 kg/m2 have: * A lower chance of pregnancy following IVF. * Require higher dose of gonado-trophins . * More days of ovarian stimulation. * Have an increased miscarriage rate.
  12. 12.  There is insufficient evidence on the effect of BMI on: * Live birth, * Cycle cancellation, * Oocyte recovery , * Ovarian hyper-stimulation syndrome.  Further studies are needed to investigate the true impact of weight on the outcome of ART.
  13. 13. Pregnancy complications: • Miscarriage • PE • TE • Gestational diabetes Labour risks: • Dys-functional labour • Labour induction • Higher CS rates • Shoulder dystocia • Anaesthetic complications Post-partum risks: • PPH • TE • Wound infection • Failure to lactate Fetal & neonatal complications: • SB (2.1 -4.3 fold) • NND • NICU admission • Congenital anomalies(NTD, cardiac) • Later in life(childhood obesity, diabetes, growth abnormalities) O B E S I T Y
  14. 14. Maternal Death Confidential Enquiry into Maternal and Child Health’s report UK 2003–2005 Taken all together
  15. 15.  women seeking fertility advice with a BMI above 29 kg/m2 should be informed that:  They will take longer time to conceive.  ART is less likely to be effective at this BMI.  Losing weight in a structured group programme of exercise and dietary advice is likely to increase their chances of conceiving. National Institute for Clinical Excellence. Fertility: Assessment and Treatment for People with Fertility Problems. Clinical Guideline 11. London: NICE; 2004
  16. 16.  Fertility treatment should be deferred in women who are morbidly obese, until they have lost weight to below a BMI of 35 kg/m2, although in those with more time (under 37 years with normal ovarian reserve) a weight reduction to less than 30 kg/m2 is preferable. Balen AH, Anderson RA. Impact of obesity on female reproductive health: British Fertility Society, Policy and Practice Guidelines. Hum Fertil (Camb) 2007;10:195–206.
  17. 17.  Women who are obese, increased their chances of getting pregnant and reduced their risk of pregnancy complications by having bariatric surgery and the outcomes after delivery for both mother and child were acceptable, provided that adequate nutrition and vitamin supplementation was maintained. The US Agency for Healthcare Research and Quality: a technology assessment on weight-loss surgery and pregnancy, commissioned by the American College of Obstetricians and Gynecologists
  18. 18. Weight loss Non-surgical Behavioral changesDiet Exercise Pharmacotherapy Bariatric surgery
  19. 19. Traditional methods of weight loss are less successful than bariatric surgery to induce successful long-term weight loss.!!!!!!!!
  20. 20.  First performed in the 1960s.  Women : men ratio = 3:1  70% of these women fall within childbearing age.  15–30% weight loss, sustained in the long- term.  Effectiveness acknowledged by NICE (in the UK) and FDA (in the USA).  Low rate of complications.
  21. 21.  Within current guidelines, bariatric surgery is considered 1st, line treatment in adults with a BMI above 50kg/m2.  It is considered for patients with:  BMI above 40kg/m2  BMI above 35kg/m2 + obesity co-morbidity
  22. 22.  Restrictive Procedures  Vertical banded gastro-plasty ( VBGP )  Laparoscopic adjustable gastric banding (LAGB)  Mal-absorptive Procedures  Bilio-pancreatic diversion ( BPD )  Bilio-pancreatic diversion with duodenal switch (BPD- DS)  Combined Procedures  Laparoscopic Roux-en-Y gastric bypass (RYGB )
  23. 23. -adjustable silicone band is placed around the upper part of the stomach to create a small upper- stomach pouch . - limits hunger - promote early feeling of satiety -Can be performed by laparotomy Common complications : band slipping, erosion the port site becoming infected.
  24. 24. • Restrictive procedure • staples are used to create a smaller stomach pouch. • Complication: • Stomal narrowing with persistent vomiting • Staple line leak • Band erosion • Wound infection or hernia
  25. 25. A small stomach pouch is isolated from the rest of the stomach with staples and empties directly into the lower portion of the jejunum. Delaying mixing of food with bile and pancreatic juices. The result is an early sense of satiety . Can be performed by laparotomy.  Complications Anastomotic leak with peritonitis DVT Internal hernias creates a roux limb ( or straight limb) connected to the gastric pouch and the “Y” portion is down- stream as the entero-enterostomy
  26. 26.  Mal-absorptive procedure which reduce nutrient absorption by bypassing a large portion of the small intestine.  Three segments  Alimentary tract  Biliary tract  Common channel - -Complications: - steatorrhoea - protein malnutrition -Anastomotic leak -Deep-vein thrombosis -Internal hernia.
  27. 27.  The aims of Bariatric surgery in morbidly obese are to:  Normalise metabolic & psych-social development  Enhance fertility  Improve the outcome of pregnancy  Improve the weight & metabolic development of offspring.
  28. 28. Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26
  29. 29. Diabetes Completely resolved 76.8 % Hyper-lipidaemia improved 70 % Hypertension resolved 61 % Sleep apnoea Resolved 86 % Psychiatric morbidity improved 88 % Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery:a systematic review and meta-analysis. J Am Med Assoc 2004;292:1724–37.
  30. 30.  Improved pregnancy rates  Improved PCO markers affecting fertility.  Possible decreased miscarriage rates  Reduced pregnancy related co- morbidity(gestational diabetes, hypertension, average weight gain )  Improved fetal complication(congenital anomalies,macrosomia )
  31. 31.  The effect of weight loss through bariatric surgery on fertility and childbirth outcomes has not yet been fully elucidated.
  32. 32.  Case series suggest improvement in the ability to conceive after bariatric surgery . -Dixon JB, Dixon ME, O’Brien PE. Pregnancy after Lap-Band surgery:management of the band to achieve healthy weight outcomes. Obes Surg 2001;11:59–65. -Marceau P, Kaufman D, Biron S, Hould FS, Lebel S, Marceau S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004;14:318–24. -Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000;95:927–30.
  33. 33.  but studies which document improvements in fertility after bariatric surgery are hampered by a lack of power to determine statistical significance. -Bilenka B, Ben-Shlomo I, Cozacov C, Gold CH, Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand 1995;74;42–4. -Deitel M, Stone E, Kassam HA, Wilk EJ, Sutherland DJ. Gynecologic–obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988;7:147–53. -
  34. 34.  Bariatric surgery improves the markers of PCO which influence fertility, such as  Anovulation,  Hirsutism,  Hormonal changes,  Insulin resistance,  Sexual activity .  However, bariatric surgery should not be considered a treatment for infertility . Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual patterns. Obes Surg 2006;16:1457–63.
  35. 35.  The effect of bariatric surgery on miscarriage rates is difficult to evaluate because of small numbers in studies .  Two retrospective studies record changes ,One found no difference in miscarriage rates pre- and postoperatively (21.6% compared with 26% )1 and another recorded a reduction (17% compared with 11%),2 . 1-Marceau P, Kaufman D, Biron S, Hould FS, Lebel S, Marceau S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004;14:318–24. 2- Friedman D, Cuneo S, Valenzano M, Marinari GM, Adami GF, Gianetta E, et al. Pregnancies in an 18-year follow–up after biliopancreatic diversion. Obes Surg 1995;5:308–313.
  36. 36. postoperative pregnancies (LAGB) Community levels women who were similarly obese Pregnancy induced hypertension 10% 10% 38% Gestational diabetes 6.3% 5.5% 19% Dixon JB, Dixon ME, O’Brien PE. Birth outcomes in obese women after lagb A prospective cohort study Obstet Gynecol 2005;106:965–72.
  37. 37.  Compared with the general population:  The No. of congenital anomalies, not increased .  The No. of perinatal death, not increased.  A trend towards lower mean birth weight:  More SGA infants.  Decreased macrosomia .
  38. 38.  Contraception  Timing of pregnancy  Nutritional dificiency  Drug absorption
  39. 39.  Recommendation is to wait 12-24 months after bariatric surgery before conceiving so that: 1) The fetus is not exposed to a rapid maternal weight loss environment . 2) The patient can achieve full weight loss goals . 3) Any operative complications should have appeared.
  40. 40.  Increased risk of oral contraception failure with mal-absorption .  Non-oral rout should be considered .
  41. 41.  The most common nutritional deficiencies are of protein, iron, vitamin B12,folate, vitamin D. and calcium.  Evaluate for micronutrient deficiencies at the beginning of pregnancy .  If there is a proven deficit, then treat & monitor.  In the absence of a deficiency, monitor the blood count, iron, ferritin, calcium, and vitamin D levels every trimester .
  42. 42.  It is not known if women require higher dose of folic acid ( greater than 0.4mg/d)  The daily recommendation for protein intake of 60g is the same regardless of bariatric surgery status .  Caloric and protein restriction during pregnancy may impair fetal growth so, there is no recommendation for caloric restriction during pregnancy.
  43. 43.  Fluid from the gastric band is removed or lessened during a pregnancy allowing for less gastric constriction and an increase in oral intake & relieve nausea and vomiting during the first trimester . 
  44. 44.  Delay in the diagnosis of bariatric-related operative complications including intestinal obstruction and GI hemorrhage -----There should be a high index of suspicion for gastrointestinal surgical complication.  Exploratory surgery during pregnancy may be required to treat these complications .  Maternal deaths have been reported .
  45. 45.  Dumping syndrome: hyper-insulinemia and hypoglycemia due to rapid empty of the stomach into the small intestine.  Patients with dumping syndrome may not tolerate the 75g GTT.  Alternative measures to screen for gestational diabetes is home glucose monitoring ( fasting and 2-hours PP blood sugar) for approximately 1 week during the 24-28 weeks of gestational .
  46. 46.  Absorptive surface of the intestine Extended-release preparations not recommended .  Smaller gastric pouch caution against using non steroidal anti-inflammatory drugs postpartum to avoid gastric ulceration .  In using medications in which a therapeutic drug level is critical testing drug levels may be necessary to ensure a therapeutic effect.
  47. 47.  Does not alter the course of labor and delivery.  Cesarean delivery rates are higher after bariatric surgery, as high as 62% .  Bariatric surgery itself should not be considered an indication for a cesarean delivery.
  48. 48.  Obesity has many deleterious effects for women of reproductive age.  Obese women are more likely to encounter fertility problems & miscarriage.  Maternal& foetal mortality and morbidity is significantly elevated for obese women due to complications in pregnancy labour and postpartum period .
  49. 49.  The management of obesity requires a multidisciplinary approach.  Stepwise programmes with realistic time- related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.  Weight loss interventions do not appear to be common practice among fertility centres& pre-pregnancy clinics in spite of clear evidence as to the benefits.
  50. 50.  Obese women who have weight loss surgery before becoming pregnant have a lower risk of pregnancy-related health problems and their children are less likely to be born with complications.  Life-long vitamin supplementation is advised.  It is advised against falling pregnant during the initial weight loss phase (1 year)
  51. 51.  Despite the fact that bariatric surgery does not reduce absolute BMI to within normal range in most patients, studies suggest it improves some important markers of fertility including hyper- insulinemia and ovulation in polycystic ovary syndrome.  Moreover, maternal outcomes and morbidity in pregnancy are better than for women who are similarly obese and are comparable with that of the general population.  Long-term cardiac and metabolic outcomes for infants born following bariatric procedures are also improved.
  52. 52.  Pregnancy is better to be delayed for 1-2 years after bariatric surgery.  During pregnancy adequate nutrition and vitamin supplementation should be maintained,  Caution should be exercised when determining eligibility for in vitro fertilisation in women who have undergone bariatric surgery.
  53. 53.  Prevention of childhood obesity is a priority. In particular, barriers to physical activity in girls and young women should be addressed.
  54. 54.  CMACE/RCOG Joint Guideline. Management of Women with Obesity in Pregnancy March 2010  CMACE release: National enquiry into maternal obesity – Implications for women, babies and the NHS  Obesity and Reproductive Health - study group statement .Consensus views arising from the 53rd Study Group: Obesity and Reproductive Health  Effect of overweight and obesity on assisted reproductive technology—a systematic review 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.  Fertility: assessment and treatment for people with fertility problems Clinical Guideline 11 February 2004 Developed by the National Collaborating Centre for Women’s and Children’s Health (NICE)  The Impact of Obesity on PCOS and Reproductive Health. Review article: Obesity in pregnancy ,Review article: The short- and long-term implications of maternal obesity on the mother and her offspring ,Review article: The impact of obesity on reproduction in women with polycystic ovary syndrome .The BJOG October edition (Volume 113, number 10)  THE ROLE OF BARIATRIC SURGERY IN THE MANAGEMENT OF FEMALE FERTILITY Scientific Advisory Committee Opinion Paper 17 March 2010  National Institute for Health and Clinical Excellence. Obesity. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. London: National Institute for Health and Clinical Excellence (NICE), 2006.  World Health Organization. Obesity: Preventing and managing the global epidemic. Geneva: World Health Organization, 2000.  Green-Top Guideline No. 37. Reducing the risk of thrombosis and embolism during pregnancy and puerperium. London: Royal College of Obstetricians and Gynaecologists, 2009.  The Pre-eclampsia Community Guideline Development Group. Pre-eclampsia Community Guideline (PRECOG). Middlesex: Action on Pre-Eclampsia (APEC), 2004