Pregnancy and contraception
It is recommended that women wait 18-24 months after bariatric surgery before considering pregnancy. This is due to the increased risk of miscarriage, malnutrition, high blood pressure in pregnancy and need for caesarean delivery. Oral contraceptive pill is not absorbed the same way after bariatric surgery, so it is recommended that non-oral forms of contraception are used, or two methods of contraception concurrently.
There are currently no specific guidelines for the management of bariatric patients through their pregnancy; however, the following is a list of recommendations. The RCGP's “Ten top tips for the management of patients post-bariatric surgery in primary care” contains some information regarding pregnancy after bariatric surgery. This can be found on their website.
- Regular nutritional blood screens at a minimum of every trimester increasing to every month if the patient is early post-bariatric surgery (within the first year post-op), has current nutritional deficiencies, is at risk of nutritional issues or has concerning GI symptoms. Continue with regular bariatric post-op blood screens on a 3-4 monthly basis.
- At least two additional growth scans suggested at 26 and 34 weeks gestation alongside the regular 12 and 20-week scans.
- Continued 20,000IU Colecalciferol (vitamin D3) supplementation once weekly alongside a pregnancy-formulated complete multivitamin and mineral supplement twice daily (vitamin A should be in the beta-carotene form, such as Forceval or Pregnacare) and vitamin B12 IM 3 monthly injections (if applicable).
- Additional folic acid supplement. Ladies with a BMI of more than 30 are advised to take a higher dose of 5 mg daily for the first trimester.
- No more than 300mg of caffeine daily.
- It is important for patients to remain off NSAID’s for the prevention of gastric ulcers. If there is no alternative a PPI will need to be taken also.
- It is not appropriate to carry out an oral glucose tolerance test on bariatric patients due to the risk of dumping syndrome. Testing two hours post prandial blood glucose for a week at between 26-28 weeks’ gestation is an option. There are no guidelines in terms of blood results, only suggestions of consistently high readings, looking at HbA1C for long-term exposure of raised blood sugars. A guide would be pre-prandial bloods of > 7mmol/l or post-prandial> 11mmol/l, which would then be discussed with the diabetes team.
- It is important that common symptoms experienced during pregnancy are not overlooked such as excessive vomiting and abdominal pain. Rapid weight loss is expected within the first few months after surgery for up to 6 months approximately, however, any sudden or rapid decrease in weight, that is significantly different from the patient’s bariatric weight loss history will need further investigation.
A referral to an obstetrician with a specialist interest in bariatric surgery should be considered. A referral back to the specialist bariatric surgery service as soon as pregnancy is confirmed must be considered for specialist dietetic and medical advice.