How To Have a Healthy Pregnancy as a WLS Post-Op
May 18, 2016With nearly triple the incidence of worldwide obesity since 1910 plaguing the current world population, significant medical strides have been made to alleviate morbid obesity. Of the many bariatric procedures available today, the Vertical Sleeve Gastrectomy (VSG) is one of the premier procedures to treat morbid obesity. The Sleeve Gastrectomy involves the removal of nearly 85% of the stomach, shaping the remaining stomach into a sleeve-like pouch.
The Roux-en-Y Gastric Bypass (RNY) is another “gold standard” procedure for bariatric surgery. The RNY involves the formation of an egg-sized gastric pouch and connection of this pouch to a 120-150cm segment of the small intestine as a Roux limb. According to the U.S. Centers for Disease Control and Prevention, the number of patients receiving gastric sleeve and/or bypass procedures has increased 12-fold since 1996. The purpose of this article is to analyze specific risks and benefits concerning pregnancy after weight loss surgery from the lens of these two “gold standard” weight loss procedures.
Benefits to Pregnancy as a WLS Post-Op
Naturally, after undergoing weight-loss surgery, the immediate benefits to patients that adhere to nutrition and exercise guidelines is a drastic reduction in body fat and their overall Body Mass Index (BMI).
Yet from the primary benefit of weight loss, there are many secondary benefits to post-operative pregnancy. Many ask, “Will weight-loss surgery affect my chances of becoming pregnant?” The answer simply put is YES, and in a very profound way.
In fact, women with infertility issues linked to obesity can benefit from restoration of the normal ovulatory cycle after years, or even decades, of irregular periods(1). Additionally, weight loss surgery has even been reported to boost fertility in females diagnosed with polycystic ovarian syndrome (PCOS), with cases documenting a complete resolution of their PCOS symptoms(2).
To put the potency of fertility after weight-loss surgery into perspective, some patients can conceive as early as one month postoperatively, even after years of sexual activity without contraception. Consequently, an increase in the volume of patients receiving weight-loss procedures annually, paired with a surge in fertility post-operatively, and lack of contraception proves to be the common recipe for the cliché claim “Oops! I wasn’t planning on getting pregnant”.
Timing of Pregnancy After WLS
As a general guideline, physicians recommend that patients refrain from conceiving for a minimum of 18 months post weight loss surgery. To many, this recommendation seems extreme because of a lack of understanding for risks of pregnancy within this sensitive 18-month period. After weight-loss surgery, the body changes on a fundamental metabolic level that can pose a potential threat of maternal nutritional deficiency. These deficits, when combined with an additional requirement of a growing baby, can cause significant malnutrition to both the mother and child.
After weight loss surgery, the body changes on a fundamental metabolic level that can pose a potential threat of maternal nutritional deficiency. These deficits, when combined with an additional requirement of a growing baby, can cause significant malnutrition to both the mother and child. Malnutrition during pregnancy among weight loss patients conceiving within the 18 month period has shown an overall decreased size of infant birth weight(3).
The suggested 18-month period is based on the amount of time for projected stability of the mother’s weight, dubbed as the plateau period. For some patients, this plateau may not be experienced until after 18 months, while others may reach a plateau within 12 months. It is important to note that weight stability is the first and best marker before attempting to conceive to ensure a healthy pregnancy.
Reduce Your Chances of Complications
As an example, let’s say that you did not adhere to the medically advised 18 months no conception rule, and are concerned by “What do I do now?” “How can reduce my chance of complications?” Let's first outline the markers for complications after weight-loss surgery and cross-reference them with the changes and requirements needed for a healthy pregnancy.
As previously mentioned, malnutrition is a potential risk for mothers conceiving within the sensitive 18-month postoperative period. Generally, weight loss patients are instructed to maintain a high protein (60-70 grams) low carbohydrate diet post-operatively with an average 1,500 calorie intake.
Some skeptics have suggested that a high protein diet during pregnancy can cause developmental disorders. Rest assured this is not supported scientifically in the literature. On the contrary, many studies suggest that an increased protein intake (75-100grams) during pregnancy promotes fetal tissue development necessary for the sustained healthy growth of an infant to full term(4). Diet is an important point of contingency when analyzing the success of sustained weight loss during pregnancy.
Obstetricians generally recommend a minimum caloric intake of around 1,700 calories. Yet, with weight-loss patients, the 200-calorie deficit from the bariatric diet versus the recommended pregnancy diet can be retrieved from a mother’s fat reserve. If after evaluation, your obstetrician detects symptoms of malnutrition then an increase in calories is warranted to accommodate and support the growing fetus.
Aside from basic nutritional requirements during pregnancy, there are key vitamin and mineral deficiencies after weight loss surgery that should be monitored closely during pregnancy.
| Common Vitamin and Mineral Deficiencies with WLS | Common Vitamins & Minerals Essential to a Healthy Pregnancy |
| Vitamin A | Vitamin A |
| Vitamin C | Vitamin C |
| Vitamin D | Vitamin D |
| Vitamin E | Not specifically listed |
| Vitamin B1 | Vitamin B1 |
| Folate | Folate |
| Vitamin B6 | Vitamin B6 |
| Vitamin B12 | Vitamin B12 |
| Iron | Iron |
| Calcium | Calcium |
| Copper | Not specifically listed |
| Zinc | Zinc(5) |
Common vitamin and mineral deficiencies experienced after gastric bypass are more common and gastric sleeve are less common.
Generally, obstetricians recommend continued use of a bariatric multi-vitamin as they usually contain all the essential vitamins and minerals required for a healthy pregnancy.
It is important to note that excessive dosing of Vitamin A may be harmful to the developing fetus. If this is the case, your obstetrician may recommend a prenatal multi-vitamin to replace your bariatric multi-vitamin.
How Does Exercise Affect Pregnancy?
Diet and vitamin supplementation are two essential prongs for a healthy pregnancy, but what about exercise? Some patients take pregnancy as an excuse to put a halt to their regular exercise regimen. Although high levels of stress have been reported to cause complications during pregnancy, low impact, low-stress exercises (such as swimming) can significantly improve a mother’s quality of life. Exercise is a helpful tool during pregnancy to ensure a slow weight gain till full-term and sustained weight loss post delivery.
Psychologically, many mothers who had bariatric surgery have a hard time accepting the fact that they have to gain weight during pregnancy. Many patients will ask, “How much weight should I be expecting to gain during pregnancy?” As a general rule of thumb, women with a BMI of 19.8-26 are recommended to gain 25-35 pounds, while women with BMI’s of 26.1-29 are expected to gain at least 15 pounds during pregnancy(6). Do not be discouraged! This is a period of your life where weight gain is encouraged!
Healthy Pregnancy and Baby After WLS
Pregnancy after bariatric surgery can seem like a trivial difference. But what many bariatric patients may not realize is that undergoing pregnancy while still in the obese body weight range can actually lead to far more complications than a pregnancy with reduced body weight after weight loss surgery. Several studies indicate marked improvements in conditions such as gestational diabetes, hypertension, preeclampsia, and inability to breastfeed with weight loss surgery prior to pregnancy.
Several studies indicate marked improvements in conditions such as gestational diabetes, hypertension, preeclampsia, and inability to breastfeed with weight loss surgery prior to pregnancy. In all cases, the risk of contracting any one of these conditions is severely heightened with obese pregnancies(7). In addition, your children have a higher chance of growing up to be obese themselves if they are conceived while you are still in the obese body weight range. Children born to mothers post-weight loss surgery are more likely to not struggle with obesity as they themselves grow into adolescence and adulthood(8).
The main take home message for bariatric patients who are worried about the overall risks pregnancy is: You are in a much better position now than you think you were prior to weight loss surgery!
Be determined and focus on the end goal of a healthy pregnancy. As Hartigan says, “Giving birth and being born brings us into the essence of creation, where the human spirit is courageous and bold and the body, a miracle of wisdom.”
References
- Legro, Richard S. et al. “Effects of Gastric Bypass Surgery on Female Reproductive Function.” The Journal of Clinical Endocrinology and Metabolism12 (2012): 4540–4548. PMC. Web. 2 May 2016.
- Malik, Shaveta M, and Michael L Traub. “Defining the Role of Bariatric Surgery in Polycystic Ovarian Syndrome Patients.” World Journal of Diabetes4 (2012): 71–79. PMC. Web. 2 May 2016.
- Pelizzo, Gloria et al. “Malnutrition in Pregnancy Following Bariatric Surgery: Three Clinical Cases of Fetal Neural Defects.” Nutrition Journal13 (2014): 59.PMC. Web. 2 May 2016.
- Brett, Kendra Elizabeth et al. “Maternal–Fetal Nutrient Transport in Pregnancy Pathologies: The Role of the Placenta.” International Journal of Molecular Sciences9 (2014): 16153–16185. PMC. Web. 2 May 2016.
- Gadgil, Meghana D. et al. “Laboratory Testing for and Diagnosis of Nutritional Deficiencies in Pregnancy Before and After Bariatric Surgery.” Journal of Women’s Health2 (2014): 129–137. PMC. Web. 2 May 2016.
- Kaska, Lukasz et al. “Nutrition and Pregnancy after Bariatric Surgery.” ISRN Obesity2013 (2013): 492060. PMC. Web. 2 May 2016
- Kominiarek, Michelle A. “Preparing for and Managing a Pregnancy After Bariatric Surgery.” Seminars in Perinatology6 (2011): 356–361. PMC. Web. 2 May 2016
- Barisione M et al. “Body weight at developmental age in siblings born to mothers before and after surgically induced weight loss”. Surg Obes Rel Dis (2012);8(4):387-91
 | ABOUT THE AUTHOR Dr. Sadek is a board-certified, fellowship-trained robotic and laparoscopic general surgeon with a specialization in minimally invasive bariatric and foregut surgery. A clinical assistant Professor of surgery at Rutgers RWJ Medical School and the Director of bariatric surgery program at RWJ Barnabas University Hospital, as well as the system wide chief of minimally invasive and bariatric surgery at Robert Wood Johnson Barnabas Healthcare system. Dr. Sadek has founded and established one of the largest, safest, state-of-the-art bariatric surgery programs in the northeast. |
 | ABOUT THE AUTHOR Andrew M. Wassef is surgical research investigator with a focus on minimally invasive bariatric & metabolic surgery. In collaboration with Advanced Surgical & Bariatrics, Rutgers University, Robert Wood Johnson Medical School and Princeton University he has designed and is presently conducting several IRB and basic science studies focusing solely on bariatric surgery. With the potential breadth of knowledge gained from these studies he hopes to shed some light on the etiology of co-morbid condition as well the biochemical, psychological and neurological pathways associated with the progression of obesity. |
