Ideally weight reduction, diet, exercise and behavior modification should be attempted before pregnancy. Women that have undergone bariatric surgery require special attention, depending upon the type of surgery performed. At least 3 studies suggest that obesity is an independent risk factor for spontaneous abortion among women who undergo infertility treatment, as well as natural conception. A Class I BMI is associated at least with a 2.5 increase in risk for gestational hypertension (high blood pressure that occurs during pregnancy). Fetal macrosomia (larger than average), chance of cesarean was 1 out 3 for BMI class I and almost 50% in class II, gestational diabetes are all potential risks. Operative and post-operative complications include increased rates of excessive blood loss, operative time greater than 2 hours, wound infection, and endometritis (infection of the lining of the uterus), difficult epidural/spinal anesthesia induction, difficult intubations and pre-existing sleep apnea occurring in this group of women may further complicate anesthetic management and postoperative care.
Height and weight should be recorded for all women at the initial prenatal visit to allow calculation of the BMI. Nutritional consultation should be offered to all obese women. And they should be encouraged to follow an exercise program. Consideration should be given to screening for gestational diabetes upon presentation or during the first trimester and repeating it later in pregnancy if the initial screening result is negative. At New Life Ob/Gyn Group, LLP, we use 135 mg/dl as our cut-off for normal.
Antibiotic prophylaxis should be given if cesarean delivery is required, even if elective due to the increased incidence of wound breakdowns and infections. Investigators have demonstrated that suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption. Graduated compression stockings, hydration and early mobilization should be used to reduce complications of deep vein thrombosis.
Bariatric surgery is relatively new, and the complications are still evolving in respect to pregnancy. Gastrointestinal bleeding, anemia, intrauterine growth restriction and neural tube defects are early case reports. These pregnancies are less likely to have gestational diabetes, hypertension, and macrosomia than obese women without the surgery. There are two main categories of surgery: malabsorptive procedures (jejuno-ileal bypass and biliopancreatic diversion) and restrictive procedures (gastric banding and vertical banded gastroplasty). Both result in deficiencies in iron, vitamin B12, folate and calcium. All patients are advised to delay pregnancy for 12-18 months after surgery to avoid pregnancy during the rapid weight loss phase. Gastric bands may require adjustment during the pregnancy. Evaluation for nutritional deficiencies and vitamin supplementation where indicated.
Fetal risks are prematurity, stillbirth, neural tube defect (double the risk) and macrosomia. Large for gestational age infants are at increased risk for childhood obesity.
