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CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Bariatric Surgery and Pregnancy: Nutritional Management Pre Post? Andrea Langley RD MSc. CDE

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CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Objectives Overview of Obesity and Pregnancy Types of Bariatric Surgery Nutrition and Bariatric Surgery Case Study Recommendations for Pregnancy post Bariatric Surgery

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Obesity in Pregnancy Prevalence ranges from 10-35% 1 29% of U.S. women of childbearing age were obese 8% were morbidly obese (BMI 40) 2 11-21% of Canadian women were obese 3 Weight gain recommendations for women with BMI 30 is 11-20lbs 1 Kominiarek, MA. Obstet Gynecol Clin N Am 2010; 37: 305-320 2 Artal R et al. Obstetrics andGynecology 2010; 115(1): 152 3 Statistics Canada. 2005. http://www.statcan.gc.ca/pub/82-620-m/2005001/article/adults-adultes/8060-eng.htm.

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Obesity in Pregnancy Associated with increased risk of stillbirth and intrauterine fetal death Greater risk for preterm labour, miscarriage and fetal chromosomal anomolies Higher rates of: GDM, gestational hypertension, pre-eclampsia and caesarian section

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Roux-en-Y Gastric Bypass Restrictive and malabsorptive procedure Restricts stomach volume Requires lifelong vitamin and mineral supplementation http://www.nlm.nih.gov/medlineplus/ency/imagepages/19268.htm

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Roux-en-Y Gastric Bypass Wt. loss of ~65% excess weight in 1 year Rapid onset of feeling full; satiety while eating Benefits: Nutritional deficiencies (B12, zinc, calcium, fat-soluble vitamins, thiamine, folate, iron) Dumping syndrome (w/ sugary foods) Anastomotic leakage, stricture or ulcer Risks:

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Biliopancreatic Diversion w/Duodenal Switch Half of the stomach is permanently removed Stomach is then connected to distal part of the SI Remainder of SI connected to the end of small bowel Requires lifelong vitamin and mineral supplementation http://www.nlm.nih.gov/medlineplus/ency/imagepages/19500.htm

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Biliopancreatic Diversion Duodenal Switch Pylorus is intact and may prevent dumping syndrome Stomach pouch is larger than other bariatric sx, so larger portions can be consumed Benefits: Frequent soft BMs (up to 4-6/day) Frequent passing of foul-smelling gas Gas pains and bloating Hair loss Intolerance of certain foods Side effects: Fat soluble vitamins, iron, folate, B12 Greater risk of nutritional deficiencies

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Nutrient Absorption Duodenum Calcium, phosphorus, magnesium, pantothenate, B6, C, zinc, chromium, molydenum, manganese, iron, copper, selenium, thiamine, riboflavin, niacin, biotin, folate, A, D, E, K lipids, monosaccharides, amino acids Jejunum C, folate, D, B12, K, magnesium Bile acids and salts Ileum Sodium, chloride, potassium, K, biotin, water Short chain fatty acids

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Causes of Nutrient Deficiencies after Bariatric Surgery ie. intolerances to red meat Decreased intake of certain foods May result in B12 deficiency Decreased gastric acid secretion Duodenum and jejunum Bypass of nutrient absorption sites

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Recommended Supplements for Bariatric Surgery Patients Kusher RF and Cummings S. Medical Management of patients after bariatric surgery. UpToDate 2012: 1-38. SupplementDoseNote Multivitamin/mineral with iron1-2/day Calcium1200-1500mg (elemental)/day Preferably citrate form, divided dose Vitamin D800 IU/day Iron40-65mg (elemental) if premenopausal 18-27mg (elemental) for other women B12500-1000mcg/d or 1000mcg IM/month

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Recommended Diet Guidelines Post-Bariatric Surgery Avoid grazing which may lead to higher calorie intake 3 meals and 1-2 planned snacks BPD-DS patients may need 1.5g/kg/d due to malabsorption Aim for at least 60g protein May cause dumping syndrome esp. after RYGB Limit simple carbohydratesSeparate fluids and solids

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Recommended Laboratory Tests CBC Lipid profile Electrolytes Glucose Iron studies, ferritin Folate Albumin Vitamin B12 Bilirubin Aminotransferases Alk Phos 25-hydroxyvitamin D PTH Thiamin Recommended at 3 mo, 6 mo and annually after Kusher RF and Cummings S. Medical Management of patients after bariatric surgery. UpToDate 2012: 1- 38.

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Pregnancy Following Bariatric Surgery Recommended to wait 12-18months post-surgery Peak weight loss occurs between 12-18months Not associated with adverse perinatal outcomes Lower risk of GDM, gestational HTN and macrosomia Assess for nutritional deficiencies pre-pregnancy May need parenteral forms if labs do not improve

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Pregnancy Following Bariatric Surgery Discuss contraception as fertility may improve If dumping syndrome, use an alternative to the OGCT 24-28 weeks, test BG fasting and pc meals for 1 week 1 Counsel on risks of obesity in pregnancy One study demonstrated 41% obese 2 after surgery 1 Kominiarek, MA. Semin Perinatol 2011. 35: 356-361. 2Lapolla et al. Obes Surg 2010. 20: 1251-1257.

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Case Study 32 y.o. female, G 7 T 0 P 4 A 2 L 3, referred at 14 weeks G.A. re: pregnancy post BPD w/DS Followed from Oct. 2009- Feb. 2010 Known from pregnancy in 2007 Lost 150 lbs with surgery; prev. BMI 51 No regular follow-up with surgeon (in Michigan)

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Case Study PMHx Bipolar (off meds), other mental health issues PTSD Biliopancreatic diversion w/duodenal switch Meds OTC X-strength Ranitidine (150mg 3-4/d) Vitamins: PNV calcium citrate (2x 500mg) time-released vitamin C 1000mg liquid iron 20ml (? elemental) water-soluble vitamin D

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Case Study Anthropometrics: Ht 1.6m Pre-pregnancy wt. 58.1kg BMI 22.7 Current wt. 64kg at 15 weeks Activity: No regular activity Complaints: Bloating after meals Vomiting after every meal, but subsiding now Heartburn Feels terrible, dizziness, SOB occ. blurred vision with eating

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Case Study Obstetrical Hx: Followed in 2007 pregnancy TPN for ~6 weeks (at her insistence) Dx: IFG and reports of hypoglycemia Polyhydramnios Previous pregnancies: 1995 baby born at 26 wks - died at 1 month 1998 female, 34 weeks 7lbs 2002 boy, 29 weeks 3 lbs; has CP (? GDM) 2007- boy, 33 weeks 4 lb 7oz, IFG/polyhydramnios

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Case Study contd Diet: Consumes 3 meals and 1-2 snacks/day. Carbohydrates vary from 10-60g at meals Consuming protein powder with soy milk most days Eating meat/chicken 1-2 x /day High GI foods Financial: on CPP but recently lost benefits Applying for ODSP Social: Relationship with partner of last child and current Lives with her 3 children

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Case Study Labs: DateTestValueReference Range Oct. 4/09Hgb Hct 108g/L 0.33 115-160g/L 0.34-0.48 Sept. 14/09Ferritin B12 11.1g/L 257pmol/L 35-291g/L (

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Case Study Assessment : Significant weight gain at 15 weeks Inadequate protein intake -needs ~90g/day Insufficient dietary/supplementary iron No vitamin/mineral panel in the last year Need PTH or albumin to assess calcium status ? Cause for blurred vision food choices,BGs?

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Case Study Plan at 14 weeks : Carbohydrate controlled diet 45g CHO at meals and 30g CHO at snacks TID Controlled wt. gain of 0.5-1lb/week Aim for 90-100g protein/day

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Case Study Plan at 14 weeks: Recommend vitamin/mineral status PTH, vit D, B 1, B 12, folate, zinc, vit A, selenium, copper May benefit from ferrous fumerate BID Provides 200mg elemental iron Suggested testing BG when vision blurred May benefit from early OGCT

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Case Study Admitted to antenatal Dec. 27, 2009 for TPTL and shortened cervix None of the recommendations from October for vitamins or labs were done Dec. 15 th labs ferritin (10.3), B 12 (112) and Hgb (97) Recommended B 12 and triferex (150mg elemental) B 12 ordered Dec. 30 th (2 nd admission)

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Case Study Jan 4 th Vitamin C 500mg, Ca Carbonate 1250mg and vitamin D 1000mg were ordered at RD request Jan 5 th OGTT results 3.2/8.3/2.9 reactive hypoglycemia Controlled carbohydrate diet ordered in hospital Weekly BG fasting and 1hr pcb Ferrous gluconate changed to Triferex Jan 11 th labs: Ca 1.85 (ref. 2.12-2.62), vitamin D 25 (75-225) Fasting 3.7, 1hr pcB 4.5 not symptomatic Spoke to bariatric surgeon re: labs and vitamin needs

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Recommendations from Bariatric Surgeon : Pregnancy Aim for B12 >500 and ferritin at high end of N If protein low, order TP, alb, pre-alb If iron low, 150mg TID elemental or IV iron 2-3 x/week, then 1x/week for 3-4 weeks Vitamin D need water soluble 2000 IU TID If low, drisdol (50 000 IU) x 6 months Repeat labs in 2 months; if still low at 6 mo - BID

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Recommendations from Bariatric Surgeon : Pregnancy If vitamin A low, need water soluble A and D TID (do not need separate vitamin D) Ca citrate 3000mg/day May require rocaltrol or calcitrol 0.5mcg/d x 6 months Pancreatic enzymes 20mg TID Regular B vitamin Complex carb, high protein for reactive hypo

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Case Study Jan 18 th : Vitamin D 1000IU changed to Drisdol 50 000IU Ca carbonate 1250mg changed to Ca citrate 1500mg TID Received 1 dose IV iron, to be repeated in 1 week Pancreatic enzymes 20mg TID to aid digestion

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Case Study Jan 25 th : Ordered glucerna at HS snack TestValueReference Range B12245pmol/L181-672pmol/L Ferritin243g/L35-291g/L Prealbumin0.17g/L0.18-0.45g/L Hgb86g/L115-160g/L Hct0.280.34-0.48 Vitamin A1.1mol/L1.2-2.8mol/L Protein57g/L60-80g/L

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Case Study Feb 2 nd : Beta carotene 25 000 IU ordered (3750g RAE) Non-toxic as compared to preformed vitamin A Feb 24 th : Zinc 8.7umol/L (N 9.8umol/L) 175mg zinc gluconate ordered on discharge

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Case Study BG records: DateFasting1hr pcB1hr pcL1hr pcS Feb 1/103.14.2 Feb 2/103.44.85.23.1 Feb 3/103.54.8 Feb 17/107.9

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Case Study Delivered Feb. 21 4lb 7oz at 34 weeks Baby in NICU, trying to breastfeed Total wt. gain ~28lbs (had polyhydramnios) Received a total of 3 treatments of IV iron Discharge meds: seroquel 25mg pantoloc 40mg pancrealipase TID vitamin C 500mg B carotene 25 000 IU Ca citrate 1500mg TID vit D 50 000 IU zinc gluconate 175mg triferex 150mg

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Case Study Postpartum received call from pt 1 hr pc BG 11 and 3 elevated BGs 2 hrs pc Reported she was low in Vitamin A, D, ferritin, B 12, zinc Recommendations: Continue vitamin D and f/u BW 2-3 months Change beta carotene to water soluble A + D and reassess in 2-3 months Continue zinc supplement and repeat 2-3 months Change to ferrous fumerate 300mg BID Try testing ac meal or 2 hr pc or ? A 1C

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Case Study April 14, 2010 patient seen by outpatient hematology Changed from Triferex to ferrous gluconate 300mg OD Provides 36mg elemental

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Case Study October 2010 seen by Outpatient Nutrition Counselling postpartum for nutritional deficiencies Current supplements: Vitamin D 50 000IU - zinc gluconate 175mg Beta carotene (same dose likely) - B complex Calcium 1200mg (? type) - multivitamin/mineral Ferrous gluconate 300mg BID (72mg elemental) Plans to d/c beta carotene and start preformed vitamin A (water soluble)

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Case Study Diet: consuming 3 meals and 1-2 snacks Aims for high protein (actual intake 55-60g/d) Anthropometrics: ht 160cm wt. 64kg BMI 25 Labs: DateTestValueRef Range April 10Ferritin Hgb Albumin Creatinine B12 Protein 34g/L 119g/L 40g/L 42mol/L 477pmol/L 59g/L 35-291g/L 115-160g/L 35-50g/L 55-115mol/L 181-672pmol/L 60-80g/L Sept 10Ferritin Hgb B12 Vitamin D Calcium 28g/L 111g/L 315pmol/L 44nmol/L 2.2mmol/L 35-291g/L 115-160g/L 181-672pmol/L 75-225nmol/L 2.12- 2.62mmol/L

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Case Study Recommendations Increase protein by including high pro smoothie Need vitamin A labs prior to starting preformed A Outdoor activity to assist with increased vitamin D Need labs for vitamin A, zinc, PTH Switch to ferrous fumerate to increase elemental

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Planning a Pregnancy - Recommendations Post Sx. Discuss contraceptive use d/t increased fertility Review risks on obesity in pregnancy (if obese) Aim for 3 meals and 1-2 planned snacks Conduct a vitamin/mineral panel Adequate supplementation prior to pregnancy Consider alternative to OGCT during pregnancy

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References Karmon, A and Sheiner, E. Pregnancy after bariatric surgery. Arch Gynecol Obstet. 2008; 277: 381-388. ACOG Practice Bulletin. Bariatric Surgery and Pregnancy. 2009; 105: 1405- 1413. Grazia Dalfa, M et al. Pregnancy and foetal outcome after bariatric surgery. Journal of Maternal-Fetal and Neotatal Medicine. 2012; Early online 1-7. Ziegler, O et al. Medical follow up after bariatric surgery. Diabetes and Metabolism. 2009; 35: 544-557. Hezelgrave, N.L. and Oteng-Ntim, E. Pregnancy after Bariatric Surgery. J Obes. 2011. Online 2011 July 14. Ouyang, DW. UpToDate 2012. Counseling women about fertility and pregnancy after bariatric surgery. Kominiarek, M.A. Preparing for and managing a pregnancy after bariatric surgery. Semin Perinatol. 2011; 35: 356-361. Kominiarek, M.A. Pregnancy after bariatric surgery. Obstet Gyneol Clin N Am. 2010; 37: 305-320. Kushner, RF and Cummings, S. Medical Management of patients after bariatric surgery. UpToDate 2012.

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Thank You