- Email: [email protected]
Managing Malnourishment in Pregnancy after Bariatric Surgery
CASE REPORTS
Managing Malnourishment in Pregnancy after Bariatric Surgery Rachel K. Harrison, MD;1 Charles Berkelhammer, MD;2 Victor Suarez, MD;3 Helen H. Kay, MD3 1
Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL
2
Department of Gastroenterology, Advocate Christ Medical Center, Oak Lawn, IL
3
Department of Maternal Fetal Medicine, Advocate Christ Medical Center, Oak Lawn, IL
Abstract Background: Little information exists to guide monitoring and treatment of malnourishment during pregnancy after bariatric surgery. Here we present a case with severe deficiencies and recommendations for testing and treatment. Case: Our patient underwent a duodenal switch procedure resulting in significant weight loss and numerous deficiencies. She then experienced a neonatal demise with multiple congenital abnormalities, including diaphragmatic hernia, possibly related to severe vitamin A deficiency. After high doses of oral and parenteral replacement, pancreatic enzymes, and total parenteral nutrition, she delivered an anatomically normal but growthrestricted neonate in a subsequent pregnancy. Conclusion: Bariatric procedures may result in nutritional deficiencies that affect pregnancy outcome. Women with severe deficiencies require pre-pregnancy counselling, monitoring, aggressive treatment, and a multidisciplinary approach to care.
Résumé Contexte : Il n’existe que peu de données pour guider le suivi et le traitement de la malnutrition pendant la grossesse à la suite d’une chirurgie bariatrique. Nous présentons ici un cas caractérisé par de graves carences nutritionnelles ainsi que des recommandations aux fins de dépistage et de traitement. Cas : Notre patiente a subi une permutation duodénale qui a entraîné une importante perte de poids et de nombreuses carences nutritionnelles. Sa grossesse s’est soldée par le décès du fœtus, qui présentait plusieurs anomalies congénitales, dont une hernie diaphragmatique, possiblement attribuables à une grave carence en vitamine A. La patiente a par la suite reçu de grandes doses de produits de remplacement par voies orale et parentérale et d’enzymes pancréatiques, et a été alimentée par nutrition parentérale totale avant de donner naissance à un bébé ne présentant aucune anomalie anatomique, à l’exception d’un retard de croissance.
de la grossesse. Avant de tomber enceintes, les femmes présentant de graves carences ont besoin d’être conseillées, suivies et traitées de façon intensive au moyen d’une approche de soins multidisciplinaire. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.06.019
INTRODUCTION
O
bese women generally experience an improvement in overall health after bariatric surgery, with benefits extending to pregnancy.1,2 These benefits include weight loss, decreased rates of diabetes and hypertension, and improvement in cardiovascular health.3 In pregnancy, rates of preeclampsia, gestational diabetes, and LGA infants decline,1,2 but the risks of SGA infants and shorter gestation increase for these women compared to BMI-matched control groups.2,4 Additionally, some investigators have demonstrated a trend toward stillbirth or neonatal death.2
Key Words: Bariatric surgery, pregnancy, malnourishment, vitamin deficiency
From 2003 to 2005, 49% of all bariatric procedures were performed on women of child-bearing potential.1 Despite the benefits, malnutrition due to malabsorption of essential vitamins and nutrients is a common complication. The type of bariatric procedure performed further determines which nutrients will be most affected and how severe the effect will be. Therefore, in those patients who have not completed child-bearing, it is important to keep in mind the type of bariatric surgery and the impact of bariatric surgery on the health of the patient and on her future pregnancies.
Corresponding Author: Dr. Rachel K. Harrison, University of Illinois at Chicago, Department of Obstetrics and Gynecology, Chicago, IL. [email protected]
CASE
Conclusion : Les chirurgies bariatriques peuvent être à l’origine de carences nutritionnelles ayant des effets défavorables sur l’issue
Competing interests: None declared. Received on March 11, 2017 Accepted on June 9, 2017
Our patient had undergone a duodenal switch procedure at age 21, after which she lost 215 pounds to reach her current weight of 155 pounds. She had two early spontaneous abortions and ■■ JOGC ■■ 2017 • 1
CASE REPORTS
Table. Serum nutrient levels in second pregnancy Nutrient
10 weeks
Calcium ionized Copper
24 weeks
33 weeks
1.20 81
35 weeks
1.16 79
Folate
17.3
Irona
Vitamin E-α
80–155 µg/dL
2 mg daily
>5.4 ng/mL
1 mg daily
50–170 µg/dL
100 mg IV weekly PRN
86 1.9
2.4
1.6–2.4 mg/dL
70 mg daily
0.13
0.16
0.25
0.32
0.3–1.2 mg/L
18,000 IU daily PO (PNV), 100,000 IU weekly IM PRN
300
326
211–911 pg/mL
12 µg daily
10.0
18.7
10.2
9.5
30–100 ng/mL
50,000 IU daily
4
5.3
5.9
6.0–23.0 mg/L
1200 IU daily
2.6
Vitamin B12 Vitamin D 250-H
Supplement, highest dose given 2400 mg daily
27
Magnesium Vitamin A
Normal range 1.17–1.31 mmol/L
Vitamin E-γ
0.2
0.3
0.3–3.2 mg/L
1200 IU daily
Vitamin K
0.21
0.43
0.2
0.22–4.88 nmol/L
700 µg daily (PNV) + 5 mg IM per month, 10 mg SQ weekly PRN
34
33
43
70–120 µg/dL
150 mg daily
Zinc
PRN: as needed; PO: by mouth; PNV: prenatal vitamin; SQ; subcutaneous injection. a
Blank cells indicate the nutrient was not measured at GA.
in her third pregnancy was transferred to us at 22 weeks due to fetal diaphragmatic hernia. She was profoundly deficient in many vitamins and micronutrients, including vitamin A deficiency resulting in night blindness. Intrauterine growth restriction was also identified. At 31 weeks, she experienced preterm premature rupture of membranes with chorioamnionitis and delivered. The neonate weighed 1630 g with Apgar scores of 2/4/7 but shortly after passed away due to prematurity and hypoplastic lungs as a result of the diaphragmatic hernia. Autopsy confirmed the prenatal findings of large diaphragmatic hernia, fused eyelids, skin tag at the tip of the left nostril, high arched palate, right supernumerary thumb, fused single right lung lobe, and cardiac anomalies. Microarray analysis was normal, demonstrating a 46 XX female. The patient presented to us at 10 weeks’ gestation in her next pregnancy on standard supplemental dosing for patients with a history of duodenal switch. Despite these supplements, she was found to be deficient in vitamins A, D, E, and K, iron, and zinc, as detailed in the Table. By 24
ABBREVIATIONS BPD
biliopancreatic diversion
ACOG
American Congress of Obstetricians and Gynecologists
IUGR
intrauterine growth restriction
RCOG
Royal College of Obstetricians and Gynaecologists
LGA
large for gestational age
SGA
small for gestational age
2 • ■■ JOGC ■■ 2017
weeks and after, we were able to increase most levels to normal or near normal, except for vitamin D and zinc, using the dosages as detailed in the last column of the Table. At 32 weeks, IUGR was diagnosed. She was instructed to continue Ensure (Abbott Laboratories) daily. By 34 weeks, the estimated fetal weight had decreased to the sixth percentile, and she was admitted to initiate total parenteral nutrition until delivery based on literature noting success in the outpatient setting.5 She was also started on Ursodiol to increase bile flow, pancreatic enzyme supplementation, a water soluble form of fat-soluble vitamins (AquADEK, Yasoo Health), thiamine 100 mg, and selenium 100 µg/day. At 37 weeks, she was induced and delivered an SGA neonate weighing 2135 g (fifth percentile) with normal-appearing features. At postpartum follow-up, the patient and baby girl were doing well. DISCUSSION
The biliopancreatic diversion with duodenal switch procedure, as performed in our patient, is efficacious, but it is a more severe type of bariatric surgery.6 It involves a decrease in stomach volume and transection and reattachment of the duodenum, such that a large portion of the small bowel, where many nutrients are absorbed, is removed from the primary tract and the pancreatic and biliary salts, which help absorb fats, are dumped into the small bowel far distally immediately before entry into the large bowel. Alternate bariatric methods include (1) gastric banding, in which a band is placed over the stomach to restrict intake and can be
Managing Malnourishment in Pregnancy after Bariatric Surgery
inflated or deflated; (2) gastric sleeve, a resection of the greater curvature of the stomach, leading mostly to restriction with milder degrees of malabsorption; and (3) Rouxen-Y gastric bypass, which creates a small gastric pouch with a gastrojejunostomy that bypasses the duodenum and early jejunum, leading to restrictive and malabsorptive weightloss benefits. Deficiencies after these procedures result from multifactorial causes: resection of the stomach and the cells that secrete intrinsic factor necessary for vitamin B12 absorption; changes in gastric secretions essential for absorption of iron, calcium, selenium, copper, and zinc; and bypass of the duodenum and jejunum, where absorption typically occurs. Vitamins K, A, D, and E are poorly absorbed due to inadequate mixing of bile and pancreatic enzymes and decreased small bowel absorption. Additionally, the malabsorptive effects of surgery are often worsened by the physiology of pregnancy, including an increase in renal perfusion and subsequent excretion of water-soluble vitamins, a decrease in nutrient-binding proteins, effects on fat storage, and the effects of hemodilution due to increased maternal blood volume. Vitamin deficiencies manifest in different ways for the mother and the fetus. Severe neurologic complications in patients and dysmorphic features in fetuses7,8 have been reported and were evident in our case. Hypovitaminosis A led to our patient’s night blindness and fetal ocular abnormalities.8,9 Although we cannot confirm our hypothesis, we believe the diaphragmatic hernia in her first pregnancy may also have been related to hypovitaminosis A based on findings in animal models10 and human case studies.11,12 In a study by Khalessi et al., maternal hypovitaminosis D correlated to low birth weight and small head circumference, as seen in our case.13 Furthermore, Wagner et al. demonstrated that women with lower vitamin D levels experience more comorbidities in pregnancy,14 and deficiency can lead to hypocalcemia, hypomagnesemia, and secondary hyperparathyroidism. Vitamin K is important for normal blood clotting due to its role in the production of clotting factors, with deficiencies putting the fetus at risk for intracranial hemorrhage, although this complication is potentially preventable with vitamin K supplementation.15,16 In a review of society recommendations for nutritional monitoring and supplementation, the American Congress of Obstetricians and Gynecologists17 and the Royal College of Obstetricians and Gynaecologists18 list recommendations for bariatric surgery patients in pregnancy. According to ACOG, nutritional monitoring should include complete blood count (CBC), iron, ferritin, calcium, and vitamin D levels every trimester and a “broad evaluation for micronutrient deficiencies at the beginning of pregnancy … should be considered.”
Supplementation suggestions are also given, including use of parenteral infusions if improvement is not seen with oral supplements, protein intake of 60 g daily, and a prenatal vitamin plus a multivitamin daily. According to RCOG, nutritional monitoring should include ferritin; vitamins A, D, B1, B12, and K1; and folate “regardless of surgery type,” and supplementation should be given as required. Both ACOG and RCOG recommend dietician consult. After our review of the literature, for all patients with a history of bariatric surgery beyond a simple banding procedure, we recommend a broader evaluation of nutritional status at the initial visit and every trimester, to include CBC, comprehensive metabolic panel (CMP), magnesium, phosphorus, zinc, copper, total iron, Total Iron Binding Capacity (TIBC), transferrin, ferritin, vitamin B12, folate, vitamin D, thiamine, and prothrombin time (PT)/partial thromboplastin time (PTT) as a measure of vitamin K. If significant nutritional deficiencies are detected or suspected, and in patient with Roux-en-Y and BPD, additional tests include vitamin A, vitamin E, selenium, vitamin C, TSH, free T4, and parathyroid hormone levels. Oral supplementation should be initiated as soon as possible and levels monitored every 2 to 4 weeks. If no improvement is seen, escalating doses and formulations should be taken in consultation with a gastroenterologist. This may include parenteral administration of various vitamins, and in extreme cases, total parenteral nutrition supplemented with extra vitamins, micronutrients, and thiamine. In retrospect, our patient had such severe protein, calorie, and nutrient malabsorption that earlier administration of total parenteral nutrition may have mitigated the IUGR. Of note, if total parenteral nutrition is initiated in a severely malnourished individual, care must be taken to avoid refeeding syndrome, and additional thiamine should be supplemented to avoid precipitation of WernickeKorsakoff’s encephalopathy. CONCLUSION
Bariatric surgery in women of child-bearing age should be considered as a viable treatment for morbid obesity and results in improved pregnancy outcomes, but the type of surgery performed should be taken into consideration. Women of child-bearing age should avoid the BPD procedures and elect for the gastric sleeve because it is effective for weight loss with fewer risks.19–21 Malnourished mothers may require extreme treatments, including parenteral nutrition and very high doses of nutrient replacements. The treatment for these women should be accomplished with the help of a wide variety of specialists with a focus on
■■ JOGC ■■ 2017 • 3
CASE REPORTS
pre-conception planning. Some may even consider revision prior to their conception. REFERENCES 1. Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008;300:2286–96. 2. Caughey AB. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015;372:2267–8. 3. Billeter AT, Fischer L, Wekerle AL, Senft J, Müller-Stich B. Malabsorption as a therapeutic approach in bariatric surgery. Viszeralmedizin 2014;30:198–204. 4. Roos N, Neovius M, Cnattingius S, Trolle Lagerros Y, Sääf M, Granath F, et al. Perinatal outcomes after bariatric surgery: nationwide population based matched cohort study. BMJ 2013;347:f6460. 5. Mundi MS, Vallumsetlas N, Davidson JB, McMahon MT, Bonnes SL, Hurt RT. Use of home parenteral nutrition in post-bariatric surgeryrelated malnutrition. JPEN J Parenter Enteral Nutr 2016;pii: 0148607116649222. 6. Anthone GJ, Lord RVN, DeMeester TR, Crookes PF. The duodenal switch operation for the treatment of morbid obesity. Ann Surg 2003;238:618–27, discussion 627–8. 7. Grabosch S, Pennycook J, Pakravan A, et al. Vitamin deficiency in pregnancy. Obstet Gynecol 2013;434–6. 8. Pelizzo G, Calcaterra V, Fusillo M, Nakib G, Ierullo AM, Alfei A, et al. Malnutrition in pregnancy following bariatric surgery: three clinical cases of fetal neural defects. Nutr J 2014;13:59. 9. Varela RM, Teixeira SG, Batista M. Hypovitaminosis A in the sugarcane zone of southern Pernambuco State, Northeast Brazil. Am J Clin Nutr 1972;25:800–4. 10. Greer JJ, Babiuk RP, Thebaud B. Etiology of congenital diaphragmatic hernia: the retinoid hypothesis. Pediatr Res 2003;53:726–30.
4 • ■■ JOGC ■■ 2017
11. Beurskens LW, Tibboel D, Lindemans J, Duvekot JJ, Cohen-Overbeek TE, Veenma DC, et al. Retinol status of newborn infants is associated with congenital diaphragmatic hernia. Pediatrics 2010;126:712–20. 12. Beurskens LW, Schrijver LH, Tibboel D, Wildhagen MF, Knapen MF, Lindemans J, et al. Dietary vitamin A intake below the recommended daily intake during pregnancy and the risk of congenital diaphragmatic hernia in the offspring. Birth Defects Res A Clin Mol Teratol 2013;97:60–6. 13. Khalessi N, Kalani M, Araghi M, Farahani Z. The relationship between maternal vitamin D deficiency and low birth weight neonates. J Family Reprod Health 2015;9:113–7. 14. Wagner CL, McNeil RB, Johnson DD, Hulsey TC, Ebeling M, Robinson C, et al. Health characteristics and outcomes of two randomized vitamin D supplementation trials during pregnancy: a combined analysis. J Steroid Biochem Mol Biol 2013;136:313–20. 15. Van Mieghem T, Van Schoubroeck D, Depiere M, Debeer A, Hanssens M. Fetal cerebral hemorrhage caused by vitamin K deficiency after complicated bariatric surgery. Obstet Gynecol 2008;112:434–6. 16. Jans G, Guelinckx I, Voets W, Galjaard S, Van Haard PM, Vansant GM, et al. Vitamin K1 monitoring in pregnancies after bariatric surgery: a prospective cohort study. Surg Obes Relat Dis 2014;10:885–90. 17. American College of Obstetricians and Gynecologists. ACOG. Practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009;113:1405–13. 18. Royal College of Obstetricians and Gynaecologists. Scientific impact paper No 17: the role of bariatric surgery in improving reproductive health. 2015. Available at: https://www.rcog.org.uk/globalassets/ documents/guidelines/scientific-impact-papers/sip_17.pdf. Accessed December 6, 2016. 19. Devlieger R, Guelinckx I, Jans G, Voets W, Vanholsbeke C, Vansant G. Micronutrient levels and supplement intake in pregnancy after bariatric surgery: a prospective cohort study. PLoS ONE 2014;9:e114192. 20. Li J, Lai D, Wu D. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy to treat morbid obesity-related comorbidities: a systematic review and meta-analysis. Obes Surg 2015;26:429–42. 21. Gletsu-Miller N, Wright BN. Mineral malnutrition following bariatric surgery. Adv Nutr 2013;4:506–17.
Managing Malnourishment in Pregnancy after Bariatric Surgery Rachel K. Harrison, MD;1 Charles Berkelhammer, MD;2 Victor Suarez, MD;3 Helen H. Kay, MD3 1
Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL
2
Department of Gastroenterology, Advocate Christ Medical Center, Oak Lawn, IL
3
Department of Maternal Fetal Medicine, Advocate Christ Medical Center, Oak Lawn, IL
Abstract Background: Little information exists to guide monitoring and treatment of malnourishment during pregnancy after bariatric surgery. Here we present a case with severe deficiencies and recommendations for testing and treatment. Case: Our patient underwent a duodenal switch procedure resulting in significant weight loss and numerous deficiencies. She then experienced a neonatal demise with multiple congenital abnormalities, including diaphragmatic hernia, possibly related to severe vitamin A deficiency. After high doses of oral and parenteral replacement, pancreatic enzymes, and total parenteral nutrition, she delivered an anatomically normal but growthrestricted neonate in a subsequent pregnancy. Conclusion: Bariatric procedures may result in nutritional deficiencies that affect pregnancy outcome. Women with severe deficiencies require pre-pregnancy counselling, monitoring, aggressive treatment, and a multidisciplinary approach to care.
Résumé Contexte : Il n’existe que peu de données pour guider le suivi et le traitement de la malnutrition pendant la grossesse à la suite d’une chirurgie bariatrique. Nous présentons ici un cas caractérisé par de graves carences nutritionnelles ainsi que des recommandations aux fins de dépistage et de traitement. Cas : Notre patiente a subi une permutation duodénale qui a entraîné une importante perte de poids et de nombreuses carences nutritionnelles. Sa grossesse s’est soldée par le décès du fœtus, qui présentait plusieurs anomalies congénitales, dont une hernie diaphragmatique, possiblement attribuables à une grave carence en vitamine A. La patiente a par la suite reçu de grandes doses de produits de remplacement par voies orale et parentérale et d’enzymes pancréatiques, et a été alimentée par nutrition parentérale totale avant de donner naissance à un bébé ne présentant aucune anomalie anatomique, à l’exception d’un retard de croissance.
de la grossesse. Avant de tomber enceintes, les femmes présentant de graves carences ont besoin d’être conseillées, suivies et traitées de façon intensive au moyen d’une approche de soins multidisciplinaire. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.06.019
INTRODUCTION
O
bese women generally experience an improvement in overall health after bariatric surgery, with benefits extending to pregnancy.1,2 These benefits include weight loss, decreased rates of diabetes and hypertension, and improvement in cardiovascular health.3 In pregnancy, rates of preeclampsia, gestational diabetes, and LGA infants decline,1,2 but the risks of SGA infants and shorter gestation increase for these women compared to BMI-matched control groups.2,4 Additionally, some investigators have demonstrated a trend toward stillbirth or neonatal death.2
Key Words: Bariatric surgery, pregnancy, malnourishment, vitamin deficiency
From 2003 to 2005, 49% of all bariatric procedures were performed on women of child-bearing potential.1 Despite the benefits, malnutrition due to malabsorption of essential vitamins and nutrients is a common complication. The type of bariatric procedure performed further determines which nutrients will be most affected and how severe the effect will be. Therefore, in those patients who have not completed child-bearing, it is important to keep in mind the type of bariatric surgery and the impact of bariatric surgery on the health of the patient and on her future pregnancies.
Corresponding Author: Dr. Rachel K. Harrison, University of Illinois at Chicago, Department of Obstetrics and Gynecology, Chicago, IL. [email protected]
CASE
Conclusion : Les chirurgies bariatriques peuvent être à l’origine de carences nutritionnelles ayant des effets défavorables sur l’issue
Competing interests: None declared. Received on March 11, 2017 Accepted on June 9, 2017
Our patient had undergone a duodenal switch procedure at age 21, after which she lost 215 pounds to reach her current weight of 155 pounds. She had two early spontaneous abortions and ■■ JOGC ■■ 2017 • 1
CASE REPORTS
Table. Serum nutrient levels in second pregnancy Nutrient
10 weeks
Calcium ionized Copper
24 weeks
33 weeks
1.20 81
35 weeks
1.16 79
Folate
17.3
Irona
Vitamin E-α
80–155 µg/dL
2 mg daily
>5.4 ng/mL
1 mg daily
50–170 µg/dL
100 mg IV weekly PRN
86 1.9
2.4
1.6–2.4 mg/dL
70 mg daily
0.13
0.16
0.25
0.32
0.3–1.2 mg/L
18,000 IU daily PO (PNV), 100,000 IU weekly IM PRN
300
326
211–911 pg/mL
12 µg daily
10.0
18.7
10.2
9.5
30–100 ng/mL
50,000 IU daily
4
5.3
5.9
6.0–23.0 mg/L
1200 IU daily
2.6
Vitamin B12 Vitamin D 250-H
Supplement, highest dose given 2400 mg daily
27
Magnesium Vitamin A
Normal range 1.17–1.31 mmol/L
Vitamin E-γ
0.2
0.3
0.3–3.2 mg/L
1200 IU daily
Vitamin K
0.21
0.43
0.2
0.22–4.88 nmol/L
700 µg daily (PNV) + 5 mg IM per month, 10 mg SQ weekly PRN
34
33
43
70–120 µg/dL
150 mg daily
Zinc
PRN: as needed; PO: by mouth; PNV: prenatal vitamin; SQ; subcutaneous injection. a
Blank cells indicate the nutrient was not measured at GA.
in her third pregnancy was transferred to us at 22 weeks due to fetal diaphragmatic hernia. She was profoundly deficient in many vitamins and micronutrients, including vitamin A deficiency resulting in night blindness. Intrauterine growth restriction was also identified. At 31 weeks, she experienced preterm premature rupture of membranes with chorioamnionitis and delivered. The neonate weighed 1630 g with Apgar scores of 2/4/7 but shortly after passed away due to prematurity and hypoplastic lungs as a result of the diaphragmatic hernia. Autopsy confirmed the prenatal findings of large diaphragmatic hernia, fused eyelids, skin tag at the tip of the left nostril, high arched palate, right supernumerary thumb, fused single right lung lobe, and cardiac anomalies. Microarray analysis was normal, demonstrating a 46 XX female. The patient presented to us at 10 weeks’ gestation in her next pregnancy on standard supplemental dosing for patients with a history of duodenal switch. Despite these supplements, she was found to be deficient in vitamins A, D, E, and K, iron, and zinc, as detailed in the Table. By 24
ABBREVIATIONS BPD
biliopancreatic diversion
ACOG
American Congress of Obstetricians and Gynecologists
IUGR
intrauterine growth restriction
RCOG
Royal College of Obstetricians and Gynaecologists
LGA
large for gestational age
SGA
small for gestational age
2 • ■■ JOGC ■■ 2017
weeks and after, we were able to increase most levels to normal or near normal, except for vitamin D and zinc, using the dosages as detailed in the last column of the Table. At 32 weeks, IUGR was diagnosed. She was instructed to continue Ensure (Abbott Laboratories) daily. By 34 weeks, the estimated fetal weight had decreased to the sixth percentile, and she was admitted to initiate total parenteral nutrition until delivery based on literature noting success in the outpatient setting.5 She was also started on Ursodiol to increase bile flow, pancreatic enzyme supplementation, a water soluble form of fat-soluble vitamins (AquADEK, Yasoo Health), thiamine 100 mg, and selenium 100 µg/day. At 37 weeks, she was induced and delivered an SGA neonate weighing 2135 g (fifth percentile) with normal-appearing features. At postpartum follow-up, the patient and baby girl were doing well. DISCUSSION
The biliopancreatic diversion with duodenal switch procedure, as performed in our patient, is efficacious, but it is a more severe type of bariatric surgery.6 It involves a decrease in stomach volume and transection and reattachment of the duodenum, such that a large portion of the small bowel, where many nutrients are absorbed, is removed from the primary tract and the pancreatic and biliary salts, which help absorb fats, are dumped into the small bowel far distally immediately before entry into the large bowel. Alternate bariatric methods include (1) gastric banding, in which a band is placed over the stomach to restrict intake and can be
Managing Malnourishment in Pregnancy after Bariatric Surgery
inflated or deflated; (2) gastric sleeve, a resection of the greater curvature of the stomach, leading mostly to restriction with milder degrees of malabsorption; and (3) Rouxen-Y gastric bypass, which creates a small gastric pouch with a gastrojejunostomy that bypasses the duodenum and early jejunum, leading to restrictive and malabsorptive weightloss benefits. Deficiencies after these procedures result from multifactorial causes: resection of the stomach and the cells that secrete intrinsic factor necessary for vitamin B12 absorption; changes in gastric secretions essential for absorption of iron, calcium, selenium, copper, and zinc; and bypass of the duodenum and jejunum, where absorption typically occurs. Vitamins K, A, D, and E are poorly absorbed due to inadequate mixing of bile and pancreatic enzymes and decreased small bowel absorption. Additionally, the malabsorptive effects of surgery are often worsened by the physiology of pregnancy, including an increase in renal perfusion and subsequent excretion of water-soluble vitamins, a decrease in nutrient-binding proteins, effects on fat storage, and the effects of hemodilution due to increased maternal blood volume. Vitamin deficiencies manifest in different ways for the mother and the fetus. Severe neurologic complications in patients and dysmorphic features in fetuses7,8 have been reported and were evident in our case. Hypovitaminosis A led to our patient’s night blindness and fetal ocular abnormalities.8,9 Although we cannot confirm our hypothesis, we believe the diaphragmatic hernia in her first pregnancy may also have been related to hypovitaminosis A based on findings in animal models10 and human case studies.11,12 In a study by Khalessi et al., maternal hypovitaminosis D correlated to low birth weight and small head circumference, as seen in our case.13 Furthermore, Wagner et al. demonstrated that women with lower vitamin D levels experience more comorbidities in pregnancy,14 and deficiency can lead to hypocalcemia, hypomagnesemia, and secondary hyperparathyroidism. Vitamin K is important for normal blood clotting due to its role in the production of clotting factors, with deficiencies putting the fetus at risk for intracranial hemorrhage, although this complication is potentially preventable with vitamin K supplementation.15,16 In a review of society recommendations for nutritional monitoring and supplementation, the American Congress of Obstetricians and Gynecologists17 and the Royal College of Obstetricians and Gynaecologists18 list recommendations for bariatric surgery patients in pregnancy. According to ACOG, nutritional monitoring should include complete blood count (CBC), iron, ferritin, calcium, and vitamin D levels every trimester and a “broad evaluation for micronutrient deficiencies at the beginning of pregnancy … should be considered.”
Supplementation suggestions are also given, including use of parenteral infusions if improvement is not seen with oral supplements, protein intake of 60 g daily, and a prenatal vitamin plus a multivitamin daily. According to RCOG, nutritional monitoring should include ferritin; vitamins A, D, B1, B12, and K1; and folate “regardless of surgery type,” and supplementation should be given as required. Both ACOG and RCOG recommend dietician consult. After our review of the literature, for all patients with a history of bariatric surgery beyond a simple banding procedure, we recommend a broader evaluation of nutritional status at the initial visit and every trimester, to include CBC, comprehensive metabolic panel (CMP), magnesium, phosphorus, zinc, copper, total iron, Total Iron Binding Capacity (TIBC), transferrin, ferritin, vitamin B12, folate, vitamin D, thiamine, and prothrombin time (PT)/partial thromboplastin time (PTT) as a measure of vitamin K. If significant nutritional deficiencies are detected or suspected, and in patient with Roux-en-Y and BPD, additional tests include vitamin A, vitamin E, selenium, vitamin C, TSH, free T4, and parathyroid hormone levels. Oral supplementation should be initiated as soon as possible and levels monitored every 2 to 4 weeks. If no improvement is seen, escalating doses and formulations should be taken in consultation with a gastroenterologist. This may include parenteral administration of various vitamins, and in extreme cases, total parenteral nutrition supplemented with extra vitamins, micronutrients, and thiamine. In retrospect, our patient had such severe protein, calorie, and nutrient malabsorption that earlier administration of total parenteral nutrition may have mitigated the IUGR. Of note, if total parenteral nutrition is initiated in a severely malnourished individual, care must be taken to avoid refeeding syndrome, and additional thiamine should be supplemented to avoid precipitation of WernickeKorsakoff’s encephalopathy. CONCLUSION
Bariatric surgery in women of child-bearing age should be considered as a viable treatment for morbid obesity and results in improved pregnancy outcomes, but the type of surgery performed should be taken into consideration. Women of child-bearing age should avoid the BPD procedures and elect for the gastric sleeve because it is effective for weight loss with fewer risks.19–21 Malnourished mothers may require extreme treatments, including parenteral nutrition and very high doses of nutrient replacements. The treatment for these women should be accomplished with the help of a wide variety of specialists with a focus on
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CASE REPORTS
pre-conception planning. Some may even consider revision prior to their conception. REFERENCES 1. Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008;300:2286–96. 2. Caughey AB. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015;372:2267–8. 3. Billeter AT, Fischer L, Wekerle AL, Senft J, Müller-Stich B. Malabsorption as a therapeutic approach in bariatric surgery. Viszeralmedizin 2014;30:198–204. 4. Roos N, Neovius M, Cnattingius S, Trolle Lagerros Y, Sääf M, Granath F, et al. Perinatal outcomes after bariatric surgery: nationwide population based matched cohort study. BMJ 2013;347:f6460. 5. Mundi MS, Vallumsetlas N, Davidson JB, McMahon MT, Bonnes SL, Hurt RT. Use of home parenteral nutrition in post-bariatric surgeryrelated malnutrition. JPEN J Parenter Enteral Nutr 2016;pii: 0148607116649222. 6. Anthone GJ, Lord RVN, DeMeester TR, Crookes PF. The duodenal switch operation for the treatment of morbid obesity. Ann Surg 2003;238:618–27, discussion 627–8. 7. Grabosch S, Pennycook J, Pakravan A, et al. Vitamin deficiency in pregnancy. Obstet Gynecol 2013;434–6. 8. Pelizzo G, Calcaterra V, Fusillo M, Nakib G, Ierullo AM, Alfei A, et al. Malnutrition in pregnancy following bariatric surgery: three clinical cases of fetal neural defects. Nutr J 2014;13:59. 9. Varela RM, Teixeira SG, Batista M. Hypovitaminosis A in the sugarcane zone of southern Pernambuco State, Northeast Brazil. Am J Clin Nutr 1972;25:800–4. 10. Greer JJ, Babiuk RP, Thebaud B. Etiology of congenital diaphragmatic hernia: the retinoid hypothesis. Pediatr Res 2003;53:726–30.
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11. Beurskens LW, Tibboel D, Lindemans J, Duvekot JJ, Cohen-Overbeek TE, Veenma DC, et al. Retinol status of newborn infants is associated with congenital diaphragmatic hernia. Pediatrics 2010;126:712–20. 12. Beurskens LW, Schrijver LH, Tibboel D, Wildhagen MF, Knapen MF, Lindemans J, et al. Dietary vitamin A intake below the recommended daily intake during pregnancy and the risk of congenital diaphragmatic hernia in the offspring. Birth Defects Res A Clin Mol Teratol 2013;97:60–6. 13. Khalessi N, Kalani M, Araghi M, Farahani Z. The relationship between maternal vitamin D deficiency and low birth weight neonates. J Family Reprod Health 2015;9:113–7. 14. Wagner CL, McNeil RB, Johnson DD, Hulsey TC, Ebeling M, Robinson C, et al. Health characteristics and outcomes of two randomized vitamin D supplementation trials during pregnancy: a combined analysis. J Steroid Biochem Mol Biol 2013;136:313–20. 15. Van Mieghem T, Van Schoubroeck D, Depiere M, Debeer A, Hanssens M. Fetal cerebral hemorrhage caused by vitamin K deficiency after complicated bariatric surgery. Obstet Gynecol 2008;112:434–6. 16. Jans G, Guelinckx I, Voets W, Galjaard S, Van Haard PM, Vansant GM, et al. Vitamin K1 monitoring in pregnancies after bariatric surgery: a prospective cohort study. Surg Obes Relat Dis 2014;10:885–90. 17. American College of Obstetricians and Gynecologists. ACOG. Practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009;113:1405–13. 18. Royal College of Obstetricians and Gynaecologists. Scientific impact paper No 17: the role of bariatric surgery in improving reproductive health. 2015. Available at: https://www.rcog.org.uk/globalassets/ documents/guidelines/scientific-impact-papers/sip_17.pdf. Accessed December 6, 2016. 19. Devlieger R, Guelinckx I, Jans G, Voets W, Vanholsbeke C, Vansant G. Micronutrient levels and supplement intake in pregnancy after bariatric surgery: a prospective cohort study. PLoS ONE 2014;9:e114192. 20. Li J, Lai D, Wu D. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy to treat morbid obesity-related comorbidities: a systematic review and meta-analysis. Obes Surg 2015;26:429–42. 21. Gletsu-Miller N, Wright BN. Mineral malnutrition following bariatric surgery. Adv Nutr 2013;4:506–17.