Approach to the care of the pregnant patient after bariatric surgery: A Bariatric Surgeon’s Perspective

Daniel Skubleny1, Noah J Switzer2, Richdeep Gill3, Daniel Birch2, Shahzeer Karmali2, Chirstopher de Gara2. 1Faculty of Medicine and Dentistry, University of Alberta, 2University of Alberta, 3University of Calgary

INTRODUCTION: We present a review of the literature on the pregnant patient with a prior history of bariatric surgery, highlighting 4 common presentations: internal hernia, gallstone disease, nutrient deficiency and management of the laparoscopic adjustable gastric band (LAGB). Bariatric surgery is now a common procedure among reproductive age women. Although bariatric surgery improves pregnancy outcomes for both mother and fetus when compared to non-bariatric obese controls, it has been shown to be associated with unique physiologic and surgical complications during pregnancy.

METHODS AND PROCEDURES: A literature search of electronic databases PUBMED, MEDLINE, EMBASE, SCOPUS and Web of Science using keywords and phrases relating to bariatric surgery and pregnancy and internal hernia or nutrition or gallstone disease or vomiting was conducted. English articles of all publication types published from 1995-2015 were considered for review.

RESULTS: Failure to identify complications associated with internal hernia, gallstone disease, nutritional deficiency and the laparoscopic adjustable gastric band can have detrimental consequences to both mother and fetus. The possibility of internal hernia must be considered in the pregnant woman with abdominal pain and obstructive symptoms. Radiologic imaging is often low yield and early surgical intervention is associated with improved outcome. Clinical observation and diagnosis with subsequent laparoscopy/laparotomy is an effective and safe treatment. If possible, early surgical intervention for gallstone disease during pregnancy is optimal due to procedural safety and higher risk of adverse events and miscarriage with delayed treatment. Bariatric surgery is associated with numerous nutrient deficiencies including folic acid, Vitamins A, D, K and B12 and iron and can cause adverse fetal events. Physicians must engage in close but logical monitoring of nutrient deficiency and provide supplementation if necessary. The LAGB should remain inflated except in the event of symptomatic nausea and vomiting or if the patient is not gaining appropriate weight.

CONCLUSION: Special considerations must be made in the approach to the pregnant patient after bariatric surgery. Our recommendation for these patients is to ensure close multidisciplinary follow up during pregnancy to assess maternal nutritional status and weight gain. In the event of suspected internal hernia or gallstone disease consultation of a general or bariatric surgeon should be sought and if indicated, surgical intervention should not be delayed.

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