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Pregnancy after Lap-Band Surgery: Management of the Band to Achieve Healthy Weight Outcomes

Authors:
  • Iverson Health Innovation Research Institute

Abstract and Figures

Severely obese women have higher obstetric risks and poorer neonatal outcomes. Weight loss reduces obstetric risk. The introduction of a laparoscopically-placed adjustable gastric band, a safe and effective method of weight loss, has given us the ability and responsibility to adjust the band in relation to pregnancy. Our aim was to devise a safe management plan to achieve healthy maternal weight gain (Institute of Medicine 1990) during pregnancy. In a cohort group of 650 patients to have a Lap-Band placement for severe obesity, we have reviewed the management of the band and pregnancy outcomes of all women (n=20) to complete a pregnancy (n=22) with a band in-situ. All 22 pregnancies were singleton, with no primary caesarean sections (3 for recurring indications). The mean maternal weight gain was 8.3 kg compared with 15.2 kg for the 15 previous pregnancies of women in this group (p<0.05). There was no difference in birth weights. Obstetric complications were minimal, and there were no premature or low birth weight infants. 11 of 15 subjects with active management of the band achieved a maternal weight gain within the advised range compared with only 2 of 7 prior to this. The ability to adjust gastric restriction allows optimal control of maternal weight change in pregnancy and should help avoid the risks of excessive weight change.
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, 59-65
© FD-Communications Inc. Obesity Surgery, 11, 2001 59
Background: Severely obese women have higher
obstetric risks and poorer neonatal outcomes.
Weight loss reduces obstetric risk. The introduction
of a laparoscopically-placed adjustable gastric band,
a safe and effective method of weight loss, has given
us the ability and responsibility to adjust the band in
relation to pregnancy.
Objective: Our aim was to devise a safe manage-
ment plan to achieve healthy maternal weight gain
(Institute of Medicine 1990) during pregnancy.
Methods: In a cohort group of 650 patients to have
a Lap-Band
®
placement for severe obesity, we have
reviewed the management of the band and preg-
nancy outcomes of all women (n=20) to complete a
pregnancy (n=22) with a band in-situ.
Results: All 22 pregnancies were singleton, with
no primary caesarean sections (3 for recurring indi-
cations). The mean maternal weight gain was 8.3 kg
compared with 15.2 kg for the 15 previous pregnan-
cies of women in this group (p<0.05). There was no
difference in birth weights. Obstetric complications
were minimal, and there were no premature or low
birth weight infants. 11 of 15 subjects with active
management of the band achieved a maternal weight
gain within the advised range compared with only 2
of 7 prior to this.
Conclusion: The ability to adjust gastric restriction
allows optimal control of maternal weight change in
pregnancy and should help avoid the risks of exces-
sive weight change.
Key words: Morbid obesity, gastric banding, laparoscopy,
pregnancy, obstetric management
Introduction
Pregnancy in severely obese women is associated
with increased risks and costs. These women suffer
an increased incidence of complications during
pregnancy including hypertension, preeclampsia,
late fetal death and gestational diabetes.
1-5
There is
a higher risk of induction of labor, primary caesar-
ian section and perioperative morbidity.
6-8
Their
infants are more likely to have fetal growth abnor-
malities, macrosomia and intrauterine growth
retardation, and are more likely to require admis-
sion to a neonatal intensive care unit.
2
They may
also be at greater risk of developmental abnormal-
ities including neural tube defects.
9-11
Duration of
hospital stay and overall cost is strongly related to
maternal weight.
8
Weight loss has been shown to lead to improved
fertility and lower obstetric complications.
5,12
Effective and durable weight loss is rarely achieved
by medical programs alone, and in the reports
cited, the weight loss was achieved by gastric sta-
pling or bypass surgery. These forms of bariatric
surgery generate a fixed restriction to food and/or
malabsorption, which continues through the preg-
nancy and thus must be seen to carry risks as well
as benefits. Specific nutritional deficiencies may
cause fetal abnormalities,
13
and weight-loss or
inadequate weight gain during pregnancy may lead
to low birth weight with its associated risks.
14-17
The introduction of a laparoscopically-placed
adjustable gastric band for the surgical manage-
ment of morbid obesity provides an opportunity for
achieving weight loss prior to the pregnancy and
Pregnancy after Lap-Band
®
Surgery: Management
of the Band to Achieve Healthy Weight Outcomes
John B. Dixon, MBBS, Dip RACOG, FRACGP; Maureen E. Dixon, BSc,
Dip Ed; Paul E. O’Brien, MD, FRACS
Monash University Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
Reprint requests to: Dr. John Dixon, Monash University
Department of Surgery, Alfred Hospital, Melbourne 3181,
Australia. Tel: 61 3 9903 0608; fax: 61 3 9510 3365; e-mail:
john.dixon@med.monash.edu.au
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60 Obesity Surgery, 11, 2001
Dixon et al
then modifying the degree of restriction of food
intake during the pregnancy to ensure optimal out-
come for the mother and the baby. The gastric band
is placed 2 cm below the gastroesophageal junction
and functions by producing gastric restriction and a
sense of early satiety. There is no malabsorption.
The band has an internal balloon into which saline
can be instilled or removed to adjust the degree of
gastric restriction. The balloon is connected via
tubing to a Portacath reservoir attached to the ante-
rior rectus sheath and adjusted percutaneously.
Further description and outcomes have been pub-
lished elsewhere.
18
Optimal weight gain for pregnancy requires a
balance between allowing sufficient weight gain to
allow for normal fetal growth and development,
and yet avoiding excess weight gain with its obstet-
ric risks, macrosomia and post-pregnancy weight
retention. The Institute of Medicine (IOM) in 1990,
issued total gestational weight gain recommenda-
tions based on pre-pregnancy BMI.
19
These guide-
lines may not apply to severely obese women
where recommendations for a minimum weight
gain may be unnecessary.
20,21
We have found no
reference recommending a net weight loss during
pregnancy.
From a group of 650 patients who have had
placement of the Lap-Band system
®
(BioEnterics
Corporation, Carpinteria, CA), a laparoscopically-
placed silicone adjustable gastric band, we have
followed all women having a pregnancy. We pre-
sent the results of these pregnancies and our cur-
rent approach to the management of the Lap-
Band
®
system during pregnancy. In addition,
obstetric histories have been taken from severely
obese women presenting for Lap-Band
®
surgery,
and their incidence of obstetric complications is
compared with the group who have completed
pregnancy after Lap-Band
®
placement.
Methods
Patients with a body mass index (BMI) greater than
35 kg/m
2
, suffering significant medical, physical or
psychosocial disabilities and who have attempted
weight reduction by other means for at least 5 years
were considered for entry into the Lap-Band
®
pro-
gram. Preoperative assessment included as part of
the medical assessment a questionnaire that
enquired about infertility, parity and obstetric his-
tory. Details of this history were then obtained at
preoperative interview or at post-operative review
visits. The history was dependent on the mother’s
recall of obstetric events. A history of gestational
hypertension was difficult in many cases to further
classify; consequently this category contains all
women diagnosed with hypertension in pregnancy
who had no pre-gestational hypertension.
All patients were followed regularly at a central
multidisciplinary bariatric clinic and urged to
inform us of any intention to become pregnant or
of pregnancy, as soon as possible. Patients are
advised to delay pregnancy for at least 1 year after
Lap-Band
®
placement, but this recommendation is
not always followed, as obesity-related infertility
often resolves with early weight loss.
During the period of study an active approach for
the management of the Lap-Band
®
during preg-
nancy evolved. The key elements of this were:
1) Close co-operation was established with the
obstetrician.
2) As early as possible during pregnancy, all fluid
was removed from the band to minimize band
restriction, thereby allowing optimal nutrition dur-
ing embryogenesis and minimizing the effect of the
band on hyperemesis during the first trimester.
3) Optimal weight gain for the pregnancy was dis-
cussed with all women, and fluid was added after
14 weeks gestation or later if weight gain is exces-
sive. The adjustment was aimed to limit excessive
weight gain rather than to assist with weight loss.
4) All fluid was again removed from the band at 36
weeks gestation to minimize its impact on delivery
and the establishment of lactation. Once lactation
was established, the band was adjusted to near pre-
pregnancy level, to allow for continued weight-loss
or weight maintenance as appropriate. Feeling the
band reservoir through the skin allows us to make
band adjustments, and we have not required ultra-
sound to locate the site in any pregnant women to
date.
5) Optimal weight gain for pregnancy was based
on the IOM recommendations for weight gain at
varying BMI levels. In addition, we did not set a
minimum weight gain for those with a BMI >35
kg/m
2
at the commencement of pregnancy.
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Obesity and Pregnancy: Outcomes after Lap-Band® Surgery
Data Analysis
Descriptive statistics include mean and standard
deviation for continuous variables. The chi-squared
test was used for binary variables to assess the sig-
nificance of proportions. Unpaired t-test was used
to assess pregnancy weight outcomes before and
after weight loss. A p-value of 0.05 or less was con-
sidered statistically significant.
Results
We obtained obstetric histories from 264 parous
women prior to Lap-Band
®
surgery; 88 (30%) of
the 264 parous women had had at least one cae-
sarean section, with 168 (31%) of 621 babies born
by caesarean section. This is significantly above
the Australian caesarean section rate of 20%
(p<0.01).
22
Gestational hypertension complicated
pregnancies in 98 women (37%). It was a factor in
35% of 264 primigravids, 34% of 217 second, 39%
of 101 third and 38% of 39 fourth or subsequent
pregnancies, all significantly higher than the
expected community incidence of 10-13%
(p<0.001).
23
Gestational diabetes had been diag-
nosed in 9.4% of women compared with a commu-
nity incidence of 5.5% (p<0.05)
24
with universal
screening.
Twenty women have completed 22 pregnancies
with a Lap-Band
®
in-situ. One woman (not
included in this study) had a spontaneous first
trimester abortion. The details of the mothers’
demographics, weight gain and pregnancy out-
comes are shown in Table 1. All were singleton
pregnancies. Nineteen of 22 had vaginal deliveries,
with two primigravids requiring low forceps assis-
tance. Three had elective caesarean section for
recurring indications: two for previous obstructed
labors and one for previous pelvic fracture. There
were no primary caesarean sections.
Eight of these 20 women suffered infertility prior
to weight loss. Four had primary and four had sec-
ondary infertility. In seven, infertility appeared to
be related to anovulation associated with severe
obesity and resolved spontaneously with weight
loss. The remaining woman achieved a pregnancy
following in vitro-fertilization.
Ten women had a past history of 15 previous
deliveries, with average maternal weight gain for
pregnancy of 15.3 (SD 8) kg and a mean infant
birth weight of 3,415 (SD 520) gm. The mean
maternal weight gain in the patients with a band in-
situ was significantly less 8.3 (SD 7) kg (p<0.05),
but this was not at a cost of lower birth-weight
(mean 3,495 SD 485 gm).
There were few pregnancy complications. One
primigravid woman developed mild uncomplicated
gestational hypertension in late pregnancy. A dia-
betic woman developed mild hyperglycemia late in
her second pregnancy. She had previously devel-
oped gestational diabetes in her first pregnancy,
and 2 years later type 2 diabetes was diagnosed and
controlled with diet. Before Lap-Band
®
placement,
fasting blood glucose was 9.6 mmol/l and HbA1c
7.8%. With weight loss after surgery and prior to
pregnancy she was normoglycemic with fasting
glucose 4.5 mmol/l and HbA1c 5.4%. Fluid was
added to the band during pregnancy to limit weight
gain. She re-developed mild diabetes late in preg-
nancy. Her macrosomic infant (4,540 gm) was
delivered normally and required management of
hypoglycemia in the early neonatal period. There
were no long-term effects.
In this small group of 22 pregnancies, there was
a lower incidence of gestational hypertension
(p<0.05) and primary caesarean (p<0.05) than the
severely obese comparison group.
There were only two other maternal complica-
tions, both possibly indirectly related to weight
Table 1. Pregnancy (N=22) details for 20 women with Lap-
Band in situ during pregnancy
Mean (SD) Range
Maternal age (years) 28.8 (4.4) 22-40
Parity 1.85 (0.8) 1-4
Pre Lap-Band‚ weight (kg) 129 (18) 105-172
Pre Lap-Band‚ BMI (kg/m
2
) 46.4 (6.0) 37-60
Time from L/B placement to
conception (months) 16.6 (11) 1-43
% EWL at start of pregnancy (%) 45 (17) 17-80
Pre-pregnancy BMI (kg/m
2
) 35 (7) 26-49
Pre-pregnancy weight (kg) 99 (19) 72-145
Pre-delivery weight (kg) 107.3 (17) 82-139
Pregnancy weight gain (kg) 8.3 (7) -8-26
Gestation (weeks) 39.3 (1.3) 37-42
Birth weight (gm) 3495 (485) 2735-4540
Infants Male : Female 14:8
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62 Obesity Surgery, 11, 2001
Dixon et al
loss surgery. One woman managed at a distant cen-
ter without liaison developed hyperemesis in late
pregnancy, having a net weight loss of 2 kg for the
pregnancy. The band had not been adjusted for the
pregnancy and she had not attended for follow-up.
She was induced for hyperemesis but continued to
vomit post-natally and required urgent post-natal
removal of all fluid to control vomiting. Another
woman developed symptomatic gallstones with
frequent attacks of biliary colic and an episode of
pancreatitis during the last trimester. Fluid was
removed from the band on diagnosis of the biliary
colic but despite this she had a net weight loss of 7
kg for the pregnancy. She had an uncomplicated
delivery of a 3,560 gm healthy male after induction
at 38 weeks gestation. An uneventful laparoscopic
cholecystectomy was performed 6 weeks post-par-
tum.
There were no premature deliveries, low birth
weight infants (< 2,500 gm), congenital abnormal-
ities or major neonatal problems. There were 5
infants with weight less than 3,000 gm and 4 over
4,000 gm with one macrosomic infant (> 4,500
gm).
Maternal weight gains for pregnancy with pre-
pregnancy BMI levels are plotted in Figure 1, with
IOM recommended gains indicated and a possible
adjustment for maternal BMI>35 kg/m
2
also indi-
cated (Table 2). Two of three who had all fluid
removed for the pregnancy and were not reviewed
until after the pregnancy had excessive weight
gain. Three of four who had fluid in the band and
had no adjustments at all during pregnancy had a
net weight loss. Of 15 with planned active man-
agement, all had the fluid removed from the band
early in pregnancy and were given advice regard-
ing nutrition and optimal weight gain. Only 6
required the addition of fluid during pregnancy.
Eleven of 15 patients with active band management
had weight gain within the advised range. Only
two of seven treated prior to establishing the active
management plan achieved weight gain within this
range.
Discussion
The obstetric histories of severely obese women
presenting for Lap-Band
®
gastric restrictive
surgery are consistent with known increased risks
of hypertension during pregnancy, gestational dia-
Figure 1. Weight gain for pregnancy vs pre-pregnancy BMI (N=22).
Institute of Medicine recommendations for gestational weight gain.
Possible adjustment for no recommended minimum gain during pregnancy
for women with a BMI >35 kg/m
2
.
1,36,37
Fluid removed to relieve Lap-Band restriction.
Lap-Band restriction not altered for pregnancy.
Active management of band.
30
25
20
15
10
5
0
-5
-10
15 20 25 30 35 40 45 50 55
Maternal weight gain (kg)
Start pregnancy BMI (kg/m
2
)
n
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Obesity and Pregnancy: Outcomes after Lap-Band® Surgery
betes and high caesarean section rate in these
women. In our series of 22 pregnancies, these
obstetric complications were lower than the com-
parison group and consistent with reports from
other groups reporting pregnancy outcomes after
bariatric surgery and for a non-obese popula-
tion.
5,12,23,24
Neonatal outcomes were also excel-
lent, with a mean birth weight of 3,495 gm consis-
tent with community birth weight, and not different
from the mean birth weight of infants born to these
women prior to weight loss surgery.
25
A low mean
birth weight has been reported following other
non-adjustable forms of weight loss surgery.
14,15,26
Obese women are extremely concerned at the
possibility of gaining excessive weight during
pregnancy and there is some justification for this
concern. Obese women tend to gain less weight
during pregnancy than women of normal weight
do.
27
However, they have greater weight retention
after pregnancy and tend to gain more weight
between pregnancies.
28
For this reason, women are
reluctant to have their gastric restriction relieved
for pregnancy. A policy of removing the fluid may
lead to excessive weight gain. Because of this fear,
women may delay informing us of the pregnancy
in an attempt to continue weight loss. However, not
relieving the gastric restriction may put the fetus at
risk of nutritional deficit and low birth weight, both
preventable risks, which may have long-term con-
sequences. Fetal malnutrition in infants born into
an affluent society may have increased risk of the
metabolic syndrome as proposed by Barker.
17,29
These children have, of course, a family history of
severe obesity. Active management of the
adjustable band permitted women to choose a
healthy weight gain for their child with the knowl-
edge that, if necessary, restriction could be added
during the pregnancy to prevent excessive weight
gain. Only six of our patients required some added
restriction during pregnancy. With the presence of
adjustability, they are also reassured that increase
of the level of gastric restriction when lactation is
established will minimize weight retention and
allow continued weight loss.
Nutritional considerations are also important
during pregnancy. It is vital that women of child-
bearing age have adequate folic acid prior to preg-
nancy to minimize the risk of neural tube defects.
An oral supplement of 400 mcg /day is recom-
mended for all women who could become preg-
nant.
30
We have recently found that patients losing
weight after Lap-Band
®
surgery require higher
plasma levels of folate and vitamin B12 to main-
tain normal homocysteine levels.
31
Multivitamin
supplements containing folate, vitamin B6 and vit-
amin B12 help minimize this effect. Recent weight
loss by the mother may put the child at increased
risk of neural tube defects. Robert et al
32
found an
association between weight loss in the month after
conception and neural tube defect. While selective
multivitamin supplements during pregnancy may
be appropriate, care should be taken to avoid risk.
Supplement of vitamin A more than 5000 IU/day
should be avoided.
33
Iron deficiency is not associated with gastric
restrictive Lap-Band
®
surgery, and routine supple-
mentation during pregnancy is of no proven value
and unnecessary.
34
Iron tablets can be locally ero-
sive
35
in association with delayed gastric emptying,
a necessary feature of gastric restrictive surgery.
Monitoring hemoglobin and iron status prior to and
during pregnancy would be more appropriate, with
liquid oral or parenteral iron therapy given if nec-
essary. A calcium intake of 1200-1500 mg is rec-
ommended throughout pregnancy and lactation,
and dietary advice to achieve this intake is neces-
sary.
36
Severely obese women are at high risk for obstet-
ric complications. The introduction of a laparo-
scopically-placed, adjustable and effective method
of weight loss gives us the opportunity to use this
system in severely obese women planning future
pregnancies, to reduce obstetric risks in addition to
the other advantages of losing weight. While it is
Table 2. Recommended weight gain in pregnancy
BMI Range Lower Upper
wt gain kg (lbs) wt gain kg (lbs)
BMI < 20* 11.5 (25) 18 (39)
BMI 19-26* 11.5 (25) 15.5 (34)
BMI 26-29* 7 (15) 13 (24)
BMI 29+* 7 (15) 13 (24)
BMI 35+** 0 13 (24)
*Institute of Medicine 1990 recommendations for weight gain in preg-
nancy.
** Minimum weight gain in pregnancy for severely obese women in preg-
nancy may be inappropriate.
1,37,38
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64 Obesity Surgery, 11, 2001
Dixon et al
ideal for women to lose most of their excess weight
prior to pregnancy, it is reassuring that the system
can be used with the knowledge that band restric-
tion can be decreased during pregnancy.
Conclusion
In our experience, an active management which
utilizes the adjustability of the Lap-Band
®
and
planned and careful monitoring of pregnant women
with a Lap-Band
®
in situ, has achieved optimal
weight control and appears to be associated with
reduction of the risks and complications of preg-
nancy for the mother and infant.
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38. Ratner RE, Hamner LHd, Isada NB. Effects of ges-
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(Received September 26, 2000; accepted October 25, 2000)
... Overall, women with a history of BS gain less weight during pregnancy compared with women without prior BS, especially during the third trimester (level 2++). 27,[109][110][111][112][113] Women who conceive within 18 months after surgery also appear to have less GWG in comparison with those who conceive after this period (level 2+). 27 In women with AGB, evidence regarding band management and weight gain during pregnancy is also limited. ...
... Active band management appears to facilitate adherence to the IOM guidelines and was not associated with low birth weight (level 2++). 26,99,109,117 In contrast, band deflation was associated with macrosomia (level 3). 117 We recommend health professionals caring for women after BS to measure BMI and monitor GWG in order to advise regarding adequate GWG relating to their prepregnancy BMI in accordance to the IOM guidelines (level 2+). ...
Article
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The objective of the study is to provide evidence‐based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow‐up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print‐friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high‐quality evidence and warrant further research. These areas are highlighted in the paper.
... avant une perte de poids notable [31]. L' incidence des fausses couchesetcelledes complications de la grossesse telles que diabète, hypertension et pré- éclampsie semblent diminuer en comparaison à une groupe de femmes nettement obèses non opérées [32][33][34][35][36][37][38][39][40][41][42][43][44]. La prise pondérale normale pendant la grossesse semble également moins importante [39]. ...
... Les données cabinet de la littérature ne sont pas tout à fait claires quant à la fréquence des césariennes. Certaines études l'ont trouvée inférieure [32][33][34][35]48] et d'autres supérieure [36-38, 49, 50] après opérations bariatriques. Dans l'interprétation de ces données de la littérature, il ne faut pasoublier qu'elles ont été enregistrées presque exclusivement dans des études d'observation. ...
... Ils ont ainsi montré que ce contrôle du desserrage de l'anneau permettait un bon contrôle de la prise de poids maternelle pendant la grossesse par rapport à un desserrage systématique (8,3 kg versus 15,2 kg, p<0,05) [31]. ...
Thesis
Face à l'augmentation croissante de l'obésité au cours de ces dernières années, les procédures chirurgicales ayant pour but une perte pondérale n'ont cessé d'augmenter en France. L'objectif principal de l'étude était d'évaluer le pronostic maternel, obstétrical et néonatal des patientes ayant bénéficié d'une chirurgie bariatrique. Une étude rétrospective comparative a été menée sur 37 grossesses issues de patientes opérées et 74 grossesses issues de patientes obèses non opérées, après appariement sur l'âge. Les patientes opérées ont présenté moins de diabète gestationnel (p=0,014), se sont mises en travail plus spontanément (p=0,0007). Elles ont donné naissance à moins d'enfants macrosomes (p=0,0012). L'état néonatal était amélioré chez les patientes opérées avec un pH à la naissance supérieur (p=0,015). Les patientes opérées ont pris plus de poids au cours de la grossesse (p=0,0099). La chirurgie bariatrique améliore ainsi le pronostic obstétrical et néonatal. Néanmoins, il est important de mettre en place un suivi pluridisciplinaire afin d'éviter les carences nutritionnelles.
Book
Full-text available
Nutrition Management is vitally important to the management of health & prevention of disease especially in this century. In earlier centuries we suffered from several diseases of “Want & Poverty”. In this millennium, in most parts of the world, especially in our cities, we are falling victim to the disease of “Plenty & Overabundance”. As a consequence of our modern day diets, high fat, high calorie, highly chemical, we see a new spectrum of disease, such as high blood pressure, diabetes, arteriosclerosis, heart attack, stroke, obesity, cancer etc. occurring & while modern medicine has several curative medicines and surgeries, we are more and more coming to realize that these miraculous procedures even while lifesaving; not prevent these ailments from recurring, unless the basic cause (diet) is not managed. Part 1 of this book deals with the principles of normal & therapeutic nutrition, covering lifecycle diets, Hospital diets, diets in relation to various diseases, weight loss diets etc. As a consequence it is often quite technical. However it also deals with Nutrition in a more social way by covering topics of recent interest. Accordingly, the naturopathic diet, health foods and also megavitamin therapy, find a mention for the more selective student. This book is a work in progress since 2000, & has been written in bits & pieces over the years. Part 2, which deals with the Medical Management of Obesity was added as late as in 2010. As a consequence the reader may find that the chapters are sometimes, not sequenced according to topic.
Article
Résumé L’issue des grossesses après chirurgie bariatrique semble favorable associant réduction de l’incidence du diabète gestationnel, des troubles hypertensifs et de la macrosomie. Néanmoins une augmentation de l’incidence des nouveaux nés de petit poids pour l’âge gestationnel et de la prématurité est constatée dans plusieurs études. Des carences nutritionnelles de sévérité variable pour la mère et le nouveau-né set des complications chirurgicales avec un pronostic conditionné par les difficultés diagnostiques sont également observées. Notre groupe de travail multidisciplinaire propose une série de recommandations élaborées selon la méthodologie de la HAS et concernent les questions suivantes: quel délai entre la chirurgie et la grossesse ? Quelle contraception ? Quel type de chirurgie pour les femmes en âge de procréer ? Quel support nutritionnel et quelle gestion des carences nutritionnelles ? Quel dépistage et quelle gestion du diabète gestationnel ? Quelle prise de poids optimale ? Comment gérer l’anneau gastrique au cours de la grossesse ? Comment prendre en charge les urgences chirurgicales, la prise en charge obstétricale et les soins spécifiques pendant la période post-partum et pour les nouveau-nés ?
Article
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Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.
Article
Full-text available
Obesity has negative impact on female reproductive health. Various medical conservative and surgical interventions have been used to improve the reproductive function in obese women. In this literature review, we featurethe main modern methods of treating obesity in order to restore reproductive function in women.
Chapter
Obesity is a worldwide epidemic. It affects both developed and developing countries with rates that more than doubled since 1980. The prevalence of overweight and obesity increased by 28% in adults and 47% in children between 1980 and 2013. It affects people of all ages, including women of reproductive age. In the United States, more than 55% of reproductive age women are overweight or obese, over 30% are obese, and 7% are considered morbidly obese. It is estimated that about a third of women are now obese at the beginning of their pregnancy. Obesity is a known risk factor for diabetes mellitus (DM), and in pregnancy has been associated with an increased risk for the development of gestational diabetes mellitus (GDM). Other obesity-related complications of pregnancy include preeclampsia, fetal macrosomia, stillbirth, post-term pregnancy, and cesarean delivery (CD). Long-term maternal complications include higher risks for cardiovascular disease, ophthalmic disease, and even gynecological malignancies such as ovarian and breast cancer. Maternal obesity is related to neonatal complications, including higher rates of early neonatal death and even long-term sequelae leading to future metabolic syndrome in the offspring. Bariatric surgery (BS) for obese patients with DM results in the largest degree of sustained weight loss along with the largest improvement in blood glucose control. It is indicated for morbidly obese patients or obese patients with obesity-related comorbidities. From an obstetrical point of view, reaching normal pre-pregnancy weight and BMI may reduce the risk of complications in pregnancy and adverse perinatal outcomes. BS is becoming an increasingly utilized approach to achieve weight loss. It has been shown to be the most effective and durable treatment for obesity and to reduce obesity-related complications during pregnancy. This chapter addresses the impact of BS on GDM and the resulting perinatal outcomes.
Chapter
IntroductionThe evolution of surgical techniqueThe initial phase (1950-70) - small bowel bypassThe middle phase (1970-90) - stomach staplingThe current phase (1990-present)-minimally invasive and adjustable proceduresOverview of outcomes from bariatric proceduresWeight loss outcomes from bariatric surgeryChanges in health after bariatric surgeryCharacteristics of the ideal surgical procedureRoux-en-Y gastric bypassBiliopancreatic diversionLaparoscopic adjustable gastric bandingConclusions
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Blood pressure measurements obtained in a physician's office may not represent a patient's blood pressure during an entire day. Ambulatory blood pressure monitoring (ABPM) provides multiple readings over time. This review of the literature on ABPM addresses the current state of ABPM methods, normal blood pressure profiles, the clinical and research uses of ABPM, cost considerations, and recommendations for use of ABPM in selected circumstances. Current ABPM devices use either auscultatory or oscillometric methods to determine blood pressure. A rigorous comparison of these methods is needed to determine whether one method is more reliable. A nonbiased assessment of all available equipment is necessary. Normative data provided by ABPM research are needed for populations by age, race, gender, body habitus, and conditions, such as pregnancy. While ABPM is not cost-effective for all hypertensive patients, it can assist in the evaluation of such problems as target organ complicaions, syncopal episodes, episodic hypertension, and autonomic dysfunction.
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We present data from a case series in France of pregnant women who lost 2 to 14 kg during the first month after conception and whose fetuses developed neural tube defects (NTDs). Preliminary epidemiologic evidence from other data sets suggest that relative lack of weight gain during pregnancy may be associated with NTDs. The role of starvation, diabetes, and valproic acid in the etiology of NTDs is established. This etiologic information coupled with our data suggest an hypothesis that ketoacidosis induced by weight loss in early pregnancy is a risk factor for NTDs.
Article
Objective. —To examine the relation between prepregnant weight and the risk of neural tube defects (NTDs). Design. —Data were collected from 1988 to 1994 in a case-control surveillance program of birth defects. Setting. —Study subjects were ascertained at tertiary care centers and birth hospitals in the greater metropolitan areas of Boston, Mass, and Philadelphia, Pa, and in southeastern Ontario. Participants. —Cases were 604 fetuses or infants with an NTD identified within 6 months of delivery. Controls were 1658 fetuses or infants with other major malformations identified within 6 months of delivery. For 1992 to 1994, there were 93 control infants without major malformations. Main Outcome Measure. —Relative risk of NTDs in infants or fetuses for different maternal weights. Results. —Relative to women who weighed 50 to 59 kg, risk of NTDs increased from 1.9 (95% confidence interval [CI], 1.2 to 2.9) for women weighing 80 to 89 kg to 4.0 (95% CI, 1.6 to 9.9) for women weighing 110 kg or more. When women were classified according to daily intake above or below the recommended level of 400 μg of folate, approximate threefold increases in risk were estimated for the heaviest weights in both groups. Intakes of 400 μg of folate or more reduced risk of NTDs by 40% among women weighing less than 70 kg, but no risk reduction was observed among heavier women. Conclusion. —The risk of NTDs increased with increasing prepregnant weight, independent of the effects of folate intake.(JAMA. 1996;275:1089-1092)
Article
Background: 239 pregnancies occurred in 1136 women who had undergone biliopancreatic diversion (BPD). Methods: There were 73 abortions, and 14 pregnancies are presently in their course. The 152 term pregnancies (six twins) occurred in 129 women 2-173 months (mean 42.7) after BPD. Mean age and current excess weight were 31.4 years (20-42) and 29.1% (-6.9-78.2), and mean excess weight loss was 72.9% (30.4-110.5). Results: Mean weight gain during pregnancy was 6.2 kg (-21-25). In 32 patients (21%), parenteral nutritional support was needed. In all the other patients (79%), the usual supplementations were given. Of the newborns, 122 were delivered at term (84.7%) with a mean weight of 2842.4 g (1760-4600 g) and a mean length of 48.5 cm (43-59 cm), while the 22 preterm babies (15.3%) weighed 2151.1 g (1400-3850 g) and had a length of 44.6 cm (33-56 cm). Forty infants (27.8%) were small for gestational age but 17 of them weighed more than 2500 g. Eleven twins (one abortion at 26th week) were also delivered, with a mean weight of 2088.6 g (1200-3100 g) and a mean length of 45.6 cm (35-50 cm). Delivery was spontaneous in 85 instances (56%), while vacuum extractor was used in one, and 66 cesarean sections were performed. There were two birth malformations, one infant died after surgery for meconium obstruction and two died from unknown causes. Of the 129 women, 35 had been infertile before BPD. Conclusions: Disappearance of infertility and decrease of pregnancy risk are to be considered among the beneficial effects of weight reduction following BPD.
Article
Objective: To evaluate the relationship between the time elapsed from the administration of ampicillin prophylaxis to delivery and its efficacy in interrupting intrapartum transmission of group B streptococcus. Methods: During the 12-month study period, all women who came to the Virgen de las Nieves Hospital (Granada, Spain) for delivery were screened for group B streptococcus vaginal carriage by a pigment-detection culture-based procedure. Colonized women were treated with ampicillin (2 g intravenously), and the interval between ampicillin administration and delivery was recorded. Newborns from colonized mothers also were screened to detect group B streptococcus colonization. Results: During the study period, 4525 women were admitted to the hospital for delivery and screened for group B streptococcus vaginal colonization. Group B streptococcus was detected in 543 women (12%), of whom 454 gave birth vaginally to 454 liveborn infants. Intrapartum ampicillin was given to 201 of these 454 women (44%), and 10% of the newborns from mothers who received intrapartum ampicillin prophylaxis were colonized by group B streptococcus. The relationship between timing of ampicillin administration and rate of neonatal group B streptococcal transmission was as follows: less than 1 hour before delivery, 46%; 1-2 hours, 29%; 2-4 hours, 2.9%; and more than 4 hours, 1.2%. Among the 253 mothers who received no intrapartum prophylaxis, colonization was found in 120 of their newborns (47%). Conclusion: When the time between the start of ampicillin prophylaxis and delivery is at least 2 hours, vertical transmission of group B streptococcus is minimized. (C) 1998 The American College of Obstetricians and Gynecologists
Article
Our objective was to determine the impact of massive obesity during pregnancy, defined as maternal weight > 300 pounds, on perinatal outcome. A case-controlled study was conducted. Between Jan. 1, 1986, and Dec. 31, 1990, 111 pregnant women weighing > 300 pounds who were delivered at Long Beach Memorial Women's Hospital were identified with a perinatal data base search. A control group matched for maternal age and parity was selected, and perinatal variables were compared between groups. To control for potential confounding medical complications, massively obese patients with diabetes and/or chronic hypertension antedating the index pregnancy were excluded from the obese group, and the data were reanalyzed. The Student t test chi 2, and Fisher's exact statistical analysis were used where appropriate. Massively obese pregnant women are significantly more likely to have a multitude of adverse perinatal outcomes, including primary cesarean section (32.4% vs 14.3%, p = 0.002), macrosomia (30.2% vs 11.6%, p = 0.0001), intrauterine growth retardation (8.1% vs 0.9%, p = 0.03), and neonatal admission to the intensive care unit (15.6% vs 4.5%, p = 0.01). They also are significantly more likely to have chronic hypertension (27.0% vs 0.9%, p < 0.0001) and insulin-dependent diabetes mellitus (19.8% vs 2.7%, p = 0.0001). However, when those massively obese pregnant women with diabetes and/or hypertension antedating pregnancy are excluded from analysis, no statistically significant differences in perinatal outcome persisted. Massively obese pregnant women are at high risk for adverse perinatal outcome; however, this risk appears to be related to medical complications of obesity.
Article
Gestational diabetes mellitus (GDM) was diagnosed in 1928 of 35,253 (5.5%) tested pregnancies at the Mercy Maternity Hospital in Melbourne between 1979 and the end of 1988. Compared with women born in Australia and New Zealand, the incidence of GDM was significantly greater in women born on the Indian subcontinent (15%); in women born in Africa (9.4%), Vietnam (7.3%), Mediterranean countries (7.3%), and Egypt and Arabic countries (7.2%); and in Chinese (13.9%) and other Asian (10.9%) women. There was no significant difference for women born in the United Kingdom and northern Europe (5.2%), Oceania (5.7%), North America (4.0%), or South America (2.2%). With the World Health Organization criteria as a guide to the severity of hyperglycemia, compared with mothers born in Australia and New Zealand, there were significant increases in the incidences of the more severe grades of GDM in parturients born in the Mediterranean region, Asia, the Indian subcontinent, Egypt, and Arabic countries. The incidence of GDM increased significantly in all racial groups, rising from 3.3% during 1979-1983 to 7.5% during 1984-1988.
Article
Current recommendations for appropriate weight gain in pregnancy suggest an optimum of 120% of ideal body weight (IBW) at delivery. This represents an increase of approximately 24 pounds in the normal weight woman and even the obese patient (more than 135% IBW) is told to gain 16 pounds. Information concerning gestational weight gain in the morbidly obese woman (more than 160% IBW) has not been reported. We evaluated 40 morbidly obese pregnant women for maternal morbidity relative to gestational weight gain. No correlation was found between maternal weight gain and the development of gestational diabetes, pregnancy-induced hypertension, preeclampsia, preterm labor, premature rupture of membranes, incompetent cervix, or intrauterine growth retardation. The incidence of primary cesarean delivery was statistically greater in those women gaining more than 24 pounds (p less than 0.05). It appears that current recommendations for gestational weight gain in the morbidly obese are excessive and may result in increased maternal risk.