Editorial
JOURNAL OF WOMEN’S HEALTH Volume 23, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4719
Optimizing Micronutrients in Pregnancies Following Bariatric Surgery Melinda Maggard-Gibbons, MD, MSHS
T
he majority of patients undergoing bariatric surgery are women of reproductive age, 18–45 years old. Severe obesity is associated with worse pregnancy outcomes compared with normal weight individuals, and a number of large studies suggest that surgically induced weight loss may improve both maternal and fetal outcomes—such as reduced gestational diabetes and better fetal weight. A recent study comparing pre-surgery pregnancies with first and second subsequent post-surgery pregnancies provides further convincing evidence in this regard.1 The study by Gadgil et al. provides a unique look at receipt of preconception and pregnancy micronutrient testing in a relatively substantial sample of insured patients who underwent bariatric procedures across multiple states.2 Bariatric surgery patients, regardless of the type of procedure, are at a higher risk of nutritional deficiencies than the general population. Not surprisingly, testing was higher in the post-surgery group (testing for vitamin B12 was 2% pre-surgery versus 51% post-surgery), but was much lower than recommended by national guidelines.3,4,5 As the study sample reflects practices from 2002 to 2008, it is unknown if greater attention to both preconception and pregnancy micronutrient testing has occurred more recently. Because testing rates were low, the true prevalence of micronutrient deficiencies is not known in this study. Likewise, the clinical rationale for why some patients were tested and others were not or whether patients were receiving ongoing supplementation is not known. Additionally, certain subgroups may be at even higher risk of micronutrient deficiencies, based on presence of patient characteristics like insulin-dependent diabetes or current body mass index. While testing is important, the full story needs to provide the results and subsequent management. Surgically induced weight loss may lead to improvement in fertility, which obese patients may struggle with more than normal weight individuals. Post-surgery, patients need to be counseled on the need for contraception as well as the importance of pre-conception optimal nutrition and receipt of folic acid. The study highlights the need for broad implementation of guidelines for micronutrient testing, and the appropriate management of identified deficiencies, in post-bariatric surgery women who are considering pregnancy. Fortunately, rates of poor maternal and fetal outcomes related to nutritional deficiencies in post-surgery patients appear to be rare. However, these adverse events can be devastating, such as fetal neural tube defects or low birth-weight neonates, and yet are poten-
tially preventable. Practice guidelines need to be tailored to individual procedure types, such as Roux en Y gastric bypass, gastric sleeve, and laparoscopic adjustable gastric band. Additional studies are warranted to identify subgroups in this population that may be of even higher risk for these nutrient deficiencies. The challenge for widespread adherence is how to reach the obstetricians, family medicine providers, and midwives who care for these unique patients in their practices. Disclosure Statement
No competing financial interests exist. References
1. Amsalem D, Aricha-Tamir B, Levi I, Shai D, Sheiner E. Obstetric outcomes after restrictive bariatric surgery: What happens after 2 consecutive pregnancies? Surg Obes Relat Dis 2013; Sep 19. pii: S1550-7289(13)00295-5. doi: 10 .1016/j.soard.2013.08.016. 2. Gadgil MD, Chang HY, Richards TM, et al. Laboratory testing for and diagnosis of nutritional deficiencies in pregnancy before and after bariatric surgery. J Womens Health 2013; Oct 8. [Epub ahead of print] 3. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009;113:1405–1413. 4. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 549: obesity in pregnancy. Obstet Gynecol 2013;121:213–217. 5. Mechanick JI, Youdim A, Jones DB, et al; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic and Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Obesity (Silver Spring) 2013;21:S1–S27.
Address correspondence to: Melinda Maggard-Gibbons, MD, MSHS Department of Surgery University of California, Los Angeles Medical Center 10833 Leconte Los Angeles, CA 90095 E-mail: [email protected]
Department of Surgery, University of California, Los Angeles Medical Center, Los Angeles, California.
107
JOURNAL OF WOMEN’S HEALTH Volume 23, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.4719
Optimizing Micronutrients in Pregnancies Following Bariatric Surgery Melinda Maggard-Gibbons, MD, MSHS
T
he majority of patients undergoing bariatric surgery are women of reproductive age, 18–45 years old. Severe obesity is associated with worse pregnancy outcomes compared with normal weight individuals, and a number of large studies suggest that surgically induced weight loss may improve both maternal and fetal outcomes—such as reduced gestational diabetes and better fetal weight. A recent study comparing pre-surgery pregnancies with first and second subsequent post-surgery pregnancies provides further convincing evidence in this regard.1 The study by Gadgil et al. provides a unique look at receipt of preconception and pregnancy micronutrient testing in a relatively substantial sample of insured patients who underwent bariatric procedures across multiple states.2 Bariatric surgery patients, regardless of the type of procedure, are at a higher risk of nutritional deficiencies than the general population. Not surprisingly, testing was higher in the post-surgery group (testing for vitamin B12 was 2% pre-surgery versus 51% post-surgery), but was much lower than recommended by national guidelines.3,4,5 As the study sample reflects practices from 2002 to 2008, it is unknown if greater attention to both preconception and pregnancy micronutrient testing has occurred more recently. Because testing rates were low, the true prevalence of micronutrient deficiencies is not known in this study. Likewise, the clinical rationale for why some patients were tested and others were not or whether patients were receiving ongoing supplementation is not known. Additionally, certain subgroups may be at even higher risk of micronutrient deficiencies, based on presence of patient characteristics like insulin-dependent diabetes or current body mass index. While testing is important, the full story needs to provide the results and subsequent management. Surgically induced weight loss may lead to improvement in fertility, which obese patients may struggle with more than normal weight individuals. Post-surgery, patients need to be counseled on the need for contraception as well as the importance of pre-conception optimal nutrition and receipt of folic acid. The study highlights the need for broad implementation of guidelines for micronutrient testing, and the appropriate management of identified deficiencies, in post-bariatric surgery women who are considering pregnancy. Fortunately, rates of poor maternal and fetal outcomes related to nutritional deficiencies in post-surgery patients appear to be rare. However, these adverse events can be devastating, such as fetal neural tube defects or low birth-weight neonates, and yet are poten-
tially preventable. Practice guidelines need to be tailored to individual procedure types, such as Roux en Y gastric bypass, gastric sleeve, and laparoscopic adjustable gastric band. Additional studies are warranted to identify subgroups in this population that may be of even higher risk for these nutrient deficiencies. The challenge for widespread adherence is how to reach the obstetricians, family medicine providers, and midwives who care for these unique patients in their practices. Disclosure Statement
No competing financial interests exist. References
1. Amsalem D, Aricha-Tamir B, Levi I, Shai D, Sheiner E. Obstetric outcomes after restrictive bariatric surgery: What happens after 2 consecutive pregnancies? Surg Obes Relat Dis 2013; Sep 19. pii: S1550-7289(13)00295-5. doi: 10 .1016/j.soard.2013.08.016. 2. Gadgil MD, Chang HY, Richards TM, et al. Laboratory testing for and diagnosis of nutritional deficiencies in pregnancy before and after bariatric surgery. J Womens Health 2013; Oct 8. [Epub ahead of print] 3. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009;113:1405–1413. 4. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 549: obesity in pregnancy. Obstet Gynecol 2013;121:213–217. 5. Mechanick JI, Youdim A, Jones DB, et al; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic and Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Obesity (Silver Spring) 2013;21:S1–S27.
Address correspondence to: Melinda Maggard-Gibbons, MD, MSHS Department of Surgery University of California, Los Angeles Medical Center 10833 Leconte Los Angeles, CA 90095 E-mail: [email protected]
Department of Surgery, University of California, Los Angeles Medical Center, Los Angeles, California.
107
