UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Fertility and pregnancy after bariatric surgery

Author
David W Ouyang, MD
Section Editors
Charles J Lockwood, MD, MHCM
Daniel Jones, MD
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

Bariatric surgery has become an increasingly utilized and effective approach for achieving sustainable weight loss, as well as reducing morbidities associated with severe obesity. More than 80 percent of bariatric procedures are performed in women, and approximately half of these are performed in reproductive aged women [1]. Thus, it has become increasingly common for women who have undergone bariatric surgery to present for preconceptional counseling or prenatal care.

The data presented in this topic review have been derived from retrospective studies, case reports, and personal experience. There are no available data from randomized trials or prospective cohort studies. Other issues related to bariatric surgery are discussed separately (refer to appropriate topic reviews).

TYPE OF BARIATRIC PROCEDURE

Bariatric surgical procedures can be divided into two varieties, malabsorptive and restrictive. This difference is based upon the anatomic configuration of the procedure, which in turn contributes to the mechanisms by which they induce weight loss (table 1). Some procedures have both a restrictive and malabsorptive component (eg, Roux-en-Y gastric bypass). (See "Bariatric procedures for the management of severe obesity: Descriptions".)

Clinical implications — It is important for the clinician to know which procedure a woman has undergone in order to counsel her about potential complications and reproductive issues, as well as possible interventions. Multiple anatomic and physiologic changes that occur after bariatric surgery can affect absorption of medications [2]. As examples:

If the patient has undergone placement of a laparoscopic adjustable gastric band procedure, the volume of fluid within the band can be adjusted during pregnancy to help manage pregnancy-related nausea and vomiting and prevent excessive or inadequate gestational weight gain [3,4]. The band is tightened by adding more fluid to a reservoir attached to the band, which creates increased pressure and tightens the band. The band is loosened by removing fluid from the reservoir, which reduces pressure in the band and loosens it. The best management of the gastric band during pregnancy has not been determined and there is variation in care [5].

                            

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Nov 07 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005; 294:1909.
  2. Magee SR, Shih G, Hume A. Malabsorption of oral antibiotics in pregnancy after gastric bypass surgery. J Am Board Fam Med 2007; 20:310.
  3. Dixon JB, Dixon ME, O'Brien PE. Pregnancy after Lap-Band surgery: management of the band to achieve healthy weight outcomes. Obes Surg 2001; 11:59.
  4. Weiss HG, Nehoda H, Labeck B, et al. Pregnancies after adjustable gastric banding. Obes Surg 2001; 11:303.
  5. Jefferys AE, Siassakos D, Draycott T, et al. Deflation of gastric band balloon in pregnancy for improving outcomes. Cochrane Database Syst Rev 2013; :CD010048.
  6. Miller AD, Smith KM. Medication and nutrient administration considerations after bariatric surgery. Am J Health Syst Pharm 2006; 63:1852.
  7. Sheiner E, Menes TS, Silverberg D, et al. Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery. Am J Obstet Gynecol 2006; 194:431.
  8. Clark AM, Thornley B, Tomlinson L, et al. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998; 13:1502.
  9. Nelson SM, Fleming R. Obesity and reproduction: impact and interventions. Curr Opin Obstet Gynecol 2007; 19:384.
  10. Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004; 14:318.
  11. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000; 95:927.
  12. Weiner R, Blanco-Engert R, Weiner S, et al. Outcome after laparoscopic adjustable gastric banding - 8 years experience. Obes Surg 2003; 13:427.
  13. Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:77.
  14. Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual patterns. Obes Surg 2006; 16:1457.
  15. Bastounis EA, Karayiannakis AJ, Syrigos K, et al. Sex hormone changes in morbidly obese patients after vertical banded gastroplasty. Eur Surg Res 1998; 30:43.
  16. Kopp HP, Krzyzanowska K, Schernthaner GH, et al. Relationship of androgens to insulin resistance and chronic inflammation in morbidly obese premenopausal women: studies before and after vertical banded gastroplasty. Obes Surg 2006; 16:1214.
  17. Sarwer DB, Spitzer JC, Wadden TA, et al. Changes in sexual functioning and sex hormone levels in women following bariatric surgery. JAMA Surg 2014; 149:26.
  18. Karmon A, Sheiner E. Pregnancy after bariatric surgery: a comprehensive review. Arch Gynecol Obstet 2008; 277:381.
  19. Merhi ZO. Weight loss by bariatric surgery and subsequent fertility. Fertil Steril 2007; 87:430.
  20. Doblado MA, Lewkowksi BM, Odem RR, Jungheim ES. In vitro fertilization after bariatric surgery. Fertil Steril 2010; 94:2812.
  21. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113:1405.
  22. Beard JH, Bell RL, Duffy AJ. Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations. Obes Surg 2008; 18:1023.
  23. Parent B, Martopullo I, Weiss NS, et al. Bariatric surgery in women of childbearing age, timing between an operation and birth, and associated perinatal complications. JAMA Surg 2016.
  24. Wax JR, Cartin A, Wolff R, et al. Pregnancy following gastric bypass for morbid obesity: effect of surgery-to-conception interval on maternal and neonatal outcomes. Obes Surg 2008; 18:1517.
  25. Dao T, Kuhn J, Ehmer D, et al. Pregnancy outcomes after gastric-bypass surgery. Am J Surg 2006; 192:762.
  26. Patel JA, Patel NA, Thomas RL, et al. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:39.
  27. Sheiner E, Edri A, Balaban E, et al. Pregnancy outcome of patients who conceive during or after the first year following bariatric surgery. Am J Obstet Gynecol 2011; 204:50.e1.
  28. Alatishe A, Ammori BJ, New JP, Syed AA. Bariatric surgery in women of childbearing age. QJM 2013; 106:717.
  29. Roehrig HR, Xanthakos SA, Sweeney J, et al. Pregnancy after gastric bypass surgery in adolescents. Obes Surg 2007; 17:873.
  30. Paulen ME, Zapata LB, Cansino C, et al. Contraceptive use among women with a history of bariatric surgery: a systematic review. Contraception 2010; 82:86.
  31. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  32. Kjaer MM, Nilas L. Pregnancy after bariatric surgery--a review of benefits and risks. Acta Obstet Gynecol Scand 2013; 92:264.
  33. Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300:2286.
  34. Vrebosch L, Bel S, Vansant G, et al. Maternal and neonatal outcome after laparoscopic adjustable gastric banding: a systematic review. Obes Surg 2012; 22:1568.
  35. Bilenka B, Ben-Shlomo I, Cozacov C, et al. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand 1995; 74:42.
  36. Sheiner E, Levy A, Silverberg D, et al. Pregnancy after bariatric surgery is not associated with adverse perinatal outcome. Am J Obstet Gynecol 2004; 190:1335.
  37. Ducarme G, Revaux A, Rodrigues A, et al. Obstetric outcome following laparoscopic adjustable gastric banding. Int J Gynaecol Obstet 2007; 98:244.
  38. Wittgrove AC, Jester L, Wittgrove P, Clark GW. Pregnancy following gastric bypass for morbid obesity. Obes Surg 1998; 8:461.
  39. Weintraub AY, Levy A, Levi I, et al. Effect of bariatric surgery on pregnancy outcome. Int J Gynaecol Obstet 2008; 103:246.
  40. Lesko J, Peaceman A. Pregnancy outcomes in women after bariatric surgery compared with obese and morbidly obese controls. Obstet Gynecol 2012; 119:547.
  41. Johansson K, Cnattingius S, Näslund I, et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015; 372:814.
  42. Dirksen C, Jørgensen NB, Bojsen-Møller KN, et al. Mechanisms of improved glycaemic control after Roux-en-Y gastric bypass. Diabetologia 2012; 55:1890.
  43. Adami GF, Murelli F, Briatore L, Scopinaro N. Pregnancy in formerly type 2 diabetes obese women following biliopancreatic diversion for obesity. Obes Surg 2008; 18:1109.
  44. Roos N, Neovius M, Cnattingius S, et al. Perinatal outcomes after bariatric surgery: nationwide population based matched cohort study. BMJ 2013; 347:f6460.
  45. Stephansson O, Johansson K, Näslund I, Neovius M. Bariatric Surgery and Preterm Birth. N Engl J Med 2016; 375:805.
  46. Kjær MM, Lauenborg J, Breum BM, Nilas L. The risk of adverse pregnancy outcome after bariatric surgery: a nationwide register-based matched cohort study. Am J Obstet Gynecol 2013; 208:464.e1.
  47. Richards DS, Miller DK, Goodman GN. Pregnancy after gastric bypass for morbid obesity. J Reprod Med 1987; 32:172.
  48. Ehrenberg HM, Mercer BM, Catalano PM. The influence of obesity and diabetes on the prevalence of macrosomia. Am J Obstet Gynecol 2004; 191:964.
  49. Josefsson A, Blomberg M, Bladh M, et al. Bariatric surgery in a national cohort of women: sociodemographics and obstetric outcomes. Am J Obstet Gynecol 2011; 205:206.e1.
  50. Granström L, Granström L, Backman L. Fetal growth retardation after gastric banding. Acta Obstet Gynecol Scand 1990; 69:533.
  51. Chevrot A, Kayem G, Coupaye M, et al. Impact of bariatric surgery on fetal growth restriction: experience of a perinatal and bariatric surgery center. Am J Obstet Gynecol 2016; 214:655.e1.
  52. Wax JR, Cartin A, Wolff R, et al. Pregnancy following gastric bypass surgery for morbid obesity: maternal and neonatal outcomes. Obes Surg 2008; 18:540.
  53. Josefsson A, Bladh M, Wiréhn AB, Sydsjö G. Risk for congenital malformations in offspring of women who have undergone bariatric surgery. A national cohort. BJOG 2013; 120:1477.
  54. Moliterno JA, DiLuna ML, Sood S, et al. Gastric bypass: a risk factor for neural tube defects? Case report. J Neurosurg Pediatr 2008; 1:406.
  55. Pelizzo G, Nakib G, Alfei A, et al. Fetal neural tube defects in pregnant women previously submitted to bariatric surgery: more attention to a new emerging entity. Prenat Diagn 2013; 33:196.
  56. Haddow JE, Hill LE, Kloza EM, Thanhauser D. Neural tube defects after gastric bypass. Lancet 1986; 1:1330.
  57. Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 2009; 301:636.
  58. Ledoux S, Msika S, Moussa F, et al. Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass. Obes Surg 2006; 16:1041.
  59. Weissman A, Hagay Z, Schachter M, Dreazen E. Severe maternal and fetal electrolyte imbalance in pregnancy after gastric surgery for morbid obesity. A case report. J Reprod Med 1995; 40:813.
  60. Smets KJ, Barlow T, Vanhaesebrouck P. Maternal vitamin A deficiency and neonatal microphthalmia: complications of biliopancreatic diversion? Eur J Pediatr 2006; 165:502.
  61. Van Mieghem T, Van Schoubroeck D, Depiere M, et al. Fetal cerebral hemorrhage caused by vitamin K deficiency after complicated bariatric surgery. Obstet Gynecol 2008; 112:434.
  62. Eerdekens A, Debeer A, Van Hoey G, et al. Maternal bariatric surgery: adverse outcomes in neonates. Eur J Pediatr 2010; 169:191.
  63. Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 2009; 15:189.
  64. Recker RR. Calcium absorption and achlorhydria. N Engl J Med 1985; 313:70.
  65. Rhode BM, Shustik C, Christou NV, MacLean LD. Iron absorption and therapy after gastric bypass. Obes Surg 1999; 9:17.
  66. Faintuch J, Dias MC, de Souza Fazio E, et al. Pregnancy nutritional indices and birth weight after Roux-en-Y gastric bypass. Obes Surg 2009; 19:583.
  67. Poitou Bernert C, Ciangura C, Coupaye M, et al. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab 2007; 33:13.
  68. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005; 142:547.
  69. Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive issues following bariatric surgery. Obstet Gynecol Surv 2007; 62:595.
  70. Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for morbid obesity. N Engl J Med 2004; 351:721.
  71. Loar PV 3rd, Sanchez-Ramos L, Kaunitz AM, et al. Maternal death caused by midgut volvulus after bariatric surgery. Am J Obstet Gynecol 2005; 193:1748.
  72. Vannevel V, Jans G, Bialecka M, et al. Internal Herniation in Pregnancy After Gastric Bypass: A Systematic Review. Obstet Gynecol 2016; 127:1013.
  73. Charles A, Domingo S, Goldfadden A, et al. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report. Am Surg 2005; 71:231.
  74. Baker MT, Kothari SN. Successful surgical treatment of a pregnancy-induced Petersen's hernia after laparoscopic gastric bypass. Surg Obes Relat Dis 2005; 1:506.
  75. Kakarla N, Dailey C, Marino T, et al. Pregnancy after gastric bypass surgery and internal hernia formation. Obstet Gynecol 2005; 105:1195.
  76. Ahmed AR, O'Malley W. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery. Obes Surg 2006; 16:1246.
  77. Bellanger DE, Ruiz JF, Solar K. Small bowel obstruction complicating pregnancy after laparoscopic gastric bypass. Surg Obes Relat Dis 2006; 2:490.
  78. Efthimiou E, Stein L, Court O, Christou N. Internal hernia after gastric bypass surgery during middle trimester pregnancy resulting in fetal loss: risk of internal hernia never ends. Surg Obes Relat Dis 2009; 5:378.
  79. Wax JR, Wolff R, Cobean R, et al. Intussusception complicating pregnancy following laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007; 17:977.
  80. Tohamy AE, Eid GM. Laparoscopic reduction of small bowel intussusception in a 33-week pregnant gastric bypass patient: surgical technique and review of literature. Surg Obes Relat Dis 2009; 5:111.
  81. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Obes Surg 2000; 10:509.
  82. Wax JR, Pinette MG, Cartin A. Roux-en-Y gastric bypass-associated bowel obstruction complicating pregnancy-an obstetrician's map to the clinical minefield. Am J Obstet Gynecol 2013; 208:265.
  83. Kummer N, Cackovic M, Paidas M, Funai E. Hypoxic hepatitis in a pregnant patient: a complication of gastric bypass surgery. Am J Perinatol 2008; 25:469.
  84. Ramirez MM, Turrentine MA. Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty. Am J Obstet Gynecol 1995; 173:1630.
  85. Erez O, Maymon E, Mazor M. Acute gastric ulcer perforation in a 35 weeks' nulliparous patient with gastric banding. Am J Obstet Gynecol 2004; 191:1721.
  86. Villegas L, Schneider B, Provost D, et al. Is routine cholecystectomy required during laparoscopic gastric bypass? Obes Surg 2004; 14:60.
  87. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292:1724.
  88. Skull AJ, Slater GH, Duncombe JE, Fielding GA. Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes. Obes Surg 2004; 14:230.
  89. Assas A, Bryson EO, Frost EA. Deceptive level after intrathecal block for cesarean section in a patient with prior abdominoplasty--a case report. Middle East J Anaesthesiol 2011; 21:305.
  90. Joshi P, Thomas DI. The influence of abdominoplasty surgery on assessment of level of subarachnoid block. Anaesthesia 2002; 57:515.
  91. Celiker MY, Chawla A. Congenital B12 deficiency following maternal gastric bypass. J Perinatol 2009; 29:640.
  92. Grange DK, Finlay JL. Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass. Pediatr Hematol Oncol 1994; 11:311.