Baby on Board: A Guide to Pregnancy after Bariatric Surgery
Article By: Rachel Ignomirello, MS, RDN, CSOWM, LDN
Rachel Ignomirello is a Bariatric Dietitian and Board-Certified Specialist in Obesity and Weight Management.
Obesity in women is associated with an increased risk of infertility and an increased rate of complications during every stage of pregnancy. Weight loss rapidly improves ovulation and therefore fertility. Given that most bariatric patients are female and of reproductive age, it is important to understand considerations for a safe and healthy pregnancy. Research suggests that bariatric surgery might lower the risk of obesity-related problems during pregnancy, including gestational diabetes, high blood pressure, pre-term delivery, large-for-gestational-age (LGA) infants, and cesarean delivery. There is an increased risk of small-for-gestational-age (SGA) infants, but the risk does not warrant avoiding bariatric surgery. Although pregnancy outcomes are positive after bariatric surgery, nutritional complications can occur. This article will review changes and guidelines for a healthy pregnancy after bariatric surgery.
1) Timing. According to the American Society of Metabolic and Bariatric Surgery (ASMBS), pregnancy should be postponed until weight stabilizes — typically at least 12 to 18 months after surgery. However, many groups encourage closer to 2 years after surgery. Infants born less than two years from surgery typically have a higher rate of prematurity, NICU admissions, and SGA.
To help postpone pregnancy, patients should be counseled on contraceptive choices following bariatric surgery. Birth control pills do not work as well in patients who have overweight or obesity, and they are not reliable during rapid weight loss. For this reason, most programs will encourage non-oral contraceptives such as IUDs or implants together with condoms and spermicide. Menstrual periods may be irregular, and pregnancy can happen when you least expect it. It is important to rely on successful pregnancy prevention methods.
2) Weight gain guidelines. It can be a scary thing seeing the scale start to increase again, but this is normal during pregnancy. Since there are no clear pregnancy weight gain recommendations after bariatric surgery, patients should follow the IOM guidelines.
3) Nutrition guidelines. There are no clear calorie recommendations for bariatric pregnancy, but patients should follow IOM guidelines for weight gain based on pre-pregnancy BMI. There is no “eating for two” during pregnancy. Calories should start to increase in the 2nd trimester (+340 calories per day) and even more in the 3rd trimester (+ 450 calories per day). Supplements can be used if calorie intake is difficult to achieve. For protein, most patients will do well with 60-80 grams per day. For food safety purposes, pregnant women should avoid high mercury fish, raw fish (sushi), undercooked/raw meat, undercooked/raw eggs, unpasteurized milk, and unpasteurized/soft cheeses. For carbohydrates, patients should consume a minimum of 150-175 grams per day with a focus on complex carbohydrate choices. Examples include oats, beans, and starchy vegetables. To help achieve these nutrition goals, small, frequent meals and snacks are encouraged.
4) Glucose tolerance test. When it comes time to screen for diabetes, patients normally complete a glucose tolerate test (OGTT) to measure the body’s response to glucose (sugar). However, this test may not be tolerated in bariatric patients and should be avoided. It risks dumping syndrome. Instead of an OGTT, patients often will get measurements of glycated hemoglobin (A1c) and fasting blood glucose. If diagnosed with gestational diabetes, OB/GYN offices can provide education.
5) Vitamins & lab work. It is recommended that post-bariatric surgery patients use a prenatal multivitamin instead of a bariatric formulated one. The vitamin should have DHA and folic acid, and it should not exceed 5000IU vitamin A. With the help of their bariatric team, the patient may also consider adding calcium citrate, iron, vitamin D, and/or vitamin B12. If a patient has hyperemesis (severe nausea and vomiting), the team may also consider adding vitamin B1 (thiamine).
Every trimester, lab screening should be completed for: folate, vitamin B12, thiamine, parathyroid hormone (PTH), calcium, vitamin A, vitamin D, vitamin K, serum iron, ferritin, and zinc.
Pregnancy is an exciting thing for many postoperative patients, especially those who previously struggled with infertility. With the help of a multi-disciplinary team and these guidelines, patients can have optimized nutrition and a healthy pregnancy.
BariMelts provides general recommendations, not to be construed as medical advice. Please consult your doctor.
Leave a comment