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Pregnancy and Bariatric Surgery: What you need to know

Pregnancy and Bariatric Surgery

First Things First

Pregnancy and bariatric surgery: what do you need to know? First off: if you are a bariatric patient who is pregnant or wants to become pregnant, you’ve got to be connected with your bariatric team.  If you don’t have a bariatric team, please search out an experienced team in your local area.

How long after bariatric surgery should I wait to get pregnant?

Obviously, nutrition and vitamin levels are really important for growing a healthy baby throughout pregnancy, but the most important time is during the first 6 weeks of fetal development.  The right thing to do is to wait until about 18 months after surgery, then to work with your bariatric team to be sure your nutrition and vitamin levels are excellent, then think about getting pregnant.

How is fertility affected by bariatric surgery?

The next key point is that a woman’s fertility can be dramatically increased as she loses from an obese level toward a healthier weight.  In addition to decreasing PCOS, fertility in general is increased. So, even if your personal history has been that you can’t become pregnant, please don’t take that for granted and please use birth control!  Of course there’s a positive side to the improved fertility for many people.

The cautionary notes above, and most the rest of this blog, can apply equally to Sleeve or Gastric Bypass patients.

Is it safe to get pregnant after bariatric surgery?

Once we take care of nutrition and vitamin issues as above, the news about pregnancy after gastric bypass is very positive.  The background is that a woman who is in the grip of the Obesity Disease with pregnancy, has significantly elevated risk to her own health and to her baby’s health because of the obesity effects.  The good news is that, when a formerly obese woman becomes pregnant after having bariatric surgery, the pregnancy outcomes improve dramatically, becoming almost as favorable as the never-obese population.

In my own direct experience and my own patient population, I’ve seen almost 130 healthy babies born after bariatric surgery.

What are the risks?

The risks to pregnant women from the Obesity Disease are well-known.  Those risks include gestational diabetes, preeclampsia, and a higher rate of needing c-section with also a higher rate of c-section complications.  What’s less well known is that Obesity Disease for the pregnant mom can actually lead to baby having a predisposition in their own life of diabetes, obesity, hyperlipidemia, etc.  All these risks to mom and to baby have been shown in research studies to fall to normal-population levels after Mom loses weight.  This has been shown by comparing pregnancy and child outcomes in a large number of cases where moms with Obesity Disease had at least one baby before bariatric surgery and at least one baby after bariatric surgery.

When I mentioned a moment ago that the pregnancy outcomes are almost as favorable after bariatric surgery as for the never-obese population, the studies have shown that post-bariatric surgery moms have a slightly higher rate of premature delivery and their babies on average don’t weigh as much as the babies born to never-obese moms.  So far, the studies have not found any problem with other outcomes related to these variations.

Surprise babies?

Of course, many young women seek bariatric surgery with the goal of building a healthy family in the fullness of time.  Many women who suffer from the Obesity Disease have tried to get pregnant but have been unable to conceive.  For these women, as long as the fertility team is not finding any other problems, the chances of conception after weight loss are excellent.  In fact, a woman’s reproductive hormone balance (estrogen and all the associated hormones) may achieve a better balance after only a couple of months of weight loss; this can lead to surprise babies ahead of schedule.  Since it’s really not the best way to do things, we really recommend birth control even if your history has been that you can’t become pregnant.

Benefits of pregnancy after bariatric surgery

Not only do young women have more success with conceiving and delivering healthy babies, but they tell us that they feel more able to be active and engaged with their kids.  Thinking way down the road, women who have bariatric surgery are dramatically improving their chances of being around and being in good shape if/when grandbabies come along!

Weight changes with pregnancy

Women often have appropriate questions about the weight changes that may occur with pregnancy after bariatric surgery.  Many women have had the experience of gaining a huge amount of weight with a pregnancy and never being able to get that weight off.  What I’ve seen with my patients who have a pregnancy after bariatric surgery is that they gain an appropriate amount of weight coming from a moderate appropriate appetite increase.  So far, I’ve never seen a situation where mom had problems eating enough to grow a healthy baby, even in the few cases of an “oops” baby that started only a few months after the bariatric procedure.

Many women think that being pregnant means they have to “eat for two,” but keep in mind how tiny that second person is! The American College of Obstetrics & Gynecology recommends, ‘instead of eating for two, think of it as eating twice as healthy’.  We couldn’t agree more.  And remember, while your body needs a small increase in calories, those calories should still be healthful food options keeping in line with our nutrition guidelines. Click here for some delicious, healthful bariatric recipes (but be sure to mind any particular dietary changes recommended by your Ob/Gyn doctor).

Women seem mostly able to lose the pregnancy weight after delivery, although in my experience this seems to be an 80% thing rather than a 100% success rate.  There’s no avoiding the fact that pregnancy is pretty hard on a woman’s body, and for some women that sustained stress may push them out of metabolic balance in a lasting way.  And although it’s not a bariatric topic, I feel compelled to add that breastfeeding seems to help with weight loss as well as being healthier for the baby.

Common concerns

There are a couple of expected concerns or issues for women who are pregnant after bariatric surgery, and a couple of potential/unexpected concerns.

The expected concerns are around healthy fetal growth, about the right vitamins to take, and about monitoring/testing for gestational diabetes.  The unexpected concerns related to stresses that the pregnancy may create that lead to alterations or complications with the bariatric operation.  We’re going to take these in order:

  • Fetal growth – most obstetricians will plan a few extra fetal ultrasounds to monitor baby’s growth during pregnancy. Although the literature reports a slight trend toward smaller babies at delivery in post-bariatric moms, in my personal experience there has never been a concern about fetal growth deficiency.  There is also not a concern about fetal nutrition as long as mom has good nutrition; evolution has made the fetus a pretty effective “parasite,” so the fetus will get what it needs.  It’s easy to monitor mom’s nutrition, and we know both from theory and from experience that as long as we take care of mom the baby will do well too.  Happily, it’s very rare to need to do anything medical or artificial for mom’s nutrition.
  • Vitamins – it’s VERY important to take bariatric vitamins regularly before pregnancy, and to have levels tested to be sure everything is “up to par” before embarking on a pregnancy. During pregnancy, the Ob team will usually want the patient to change to prenatal vitamins instead of bariatric vitamins.  Much has been written about this topic and the literature is clear that bariatric vitamins are just as effective as prenatals in the setting of pregnancy, but on the other hand we know that our Obstetric colleagues function under very specific guidelines and they will mostly be happier if mom is taking prenatals.  I think the key principle is for mom to take one of these vitamin types on a very regular basis.
  • Monitoring for gestational diabetes – although the rate of gestational diabetes is MUCH lower in post-bariatric moms than in moms who suffer from the Obesity Disease, it’s still important to watch for this pregnancy complication. The traditional way of checking for gestational diabetes was for mom to drink a calibrated sugar drink, then to have her blood sugar response checked.   The problem in bariatric surgery moms (especially Gastric Bypass but also Sleeve) is that the sugar drink is very likely to cause a high blood sugar spike followed by a (potentially dangerous) blood sugar crash.  It’s basically a perfect recipe for serious dumping syndrome.  The good news is that the Ob guidelines have been updated to include alternative methods of checking for gestational diabetes, such as checking A1C levels by blood draw.
  • Gastric Bypass complication related to pregnancy = bowel obstruction. As most know, the re-routing of the intestine that’s accomplished during Gastric Bypass surgery creates a small but real potential for small bowel obstruction at some point in the future.  The bowel obstruction can be caused by a particular condition called an internal hernia, or by random scar adhesions.  Although it’s rare, the internal hernia form of bowel obstruction can be very serious and even life-threatening.  It seems to be the case that the natural growth of the uterus during pregnancy (pushing the intestine out of the way) may bring on bowel obstruction in a woman who was previously feeling well.  This is tricky because abdominal pain and nausea are not terribly uncommon in pregnancy.  The key message here is that you should go into pregnancy already having a solid connection with your bariatric team, so that if you have abdominal pain or nausea that your Ob team can’t fully diagnose or control, it will be easy to get the bariatric team involved for additional diagnosis and maybe treatment.
  • The Sleeve complication related to pregnancy is a new or worsened sensation of reflux/heartburn. This isn’t a big surprise, again because of the uterine growth and the increased abdominal pressure expected during pregnancy.  It seems that most of the reflux goes away after pregnancy, but not always.

I’m going to close by repeating the message that opened this blog:  pregnancy after bariatric surgery is more likely and can be a great thing, but it’s REALLY IMPORTANT to have your bariatric and your Ob team involved even before you become pregnant.  In that context, I’ve been honored to see many healthy babies and happy families.

Watch the video here: https://www.youtube.com/watch?v=4uonqP_ARag