Zwangerschap na gastric bypass, een moeilijk evenwicht

Roland Devlieger MD, PhDDepartment of Obstetrics and GynaecologyUniversity Hospitals Leuven, Belgium

Zwangerschap na bariatrie is:A. Af te radenB. Aan te bevelenC. Ik weet het niet

Overzicht• Bariatrische heelkunde

o Effect op gezondheido Effect op fertiliteito Effect op zwangerschap

• Aurora studie• Aanbevelingen voor klinische opvolging

“Venus in front of the mirror” PP Rubens, 1613

Overweight and Obesity figures have doubled since 1980

Chooi et al, Metabolism 2019

Women are affected more than men

Obesity in women of reproductive age

* WHO, 2016

Trend in number of procedures (IFSO)Angrisani et al. 2015

Obesity surgery

Up to 80% of the procedures are performed in women of reproductive age

Laparoscopic Gastric Bypass

Sjöström et al. NEJM 2007

Weight loss following bariatric surgery SOS study

BARIATRIC SURGERY

WEIGHT LOSS

IMPROVED FERTILITY

IMPROVED OVARIAN FUNCTION

↓MIS

IMPROVED SELF IMAGE

IMPROVED SEXUAL ACTIVITY

↓ADIPOSE TISSUE

↓ESTRADIOL ↓INSULIN

↑GnRH↑LH, FSH

↑SHBG

↓TESTOSTERONE

DECREASED CONTRACEPTIVE

EFFICACY

Abbreviations: FSH Follicular Stimulating Hormone, GnRH Gonadotropin Releasing Hormone, LH Lutenising Hormone, MIS Müllerian Inhibiting Substance, SHBG Sex Hormone Binding Globuline.

Effect on pregnancy?

Pregnancy outcomes following bariatric surgery

Same pre-operative BMI Same pre-pregnancy BMI

OR 0.21 (NNB 5)

Kwong et al, AJOG 2018

OR 2.3 (NNH 21)

20 cohort studiesN=8364

33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls.

• Pre/early-pregnancy BMI–matched controls (N=9)• Obese controls (N=14)

• ≥30 kg/m2, 35 kg/m2, or 40 kg/m2

• Matched for pre-surgery BMI• Pregnancies before and after bariatric surgery

(N=11)• General population (N=9) • Healthy BMI (N=5)

Perinatal mortality and congenital anomalies after bariatric surgery meta-analysis

Akhter Z, Rankin J, Ceulemans D, Ngongalah L, Ackroyd R, et al. (2019) Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLOS Medicine 16(8): e1002866. https://doi.org/10.1371/journal.pmed.1002866https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002866

NICU admission after bariatric surgery meta-analysis.

Akhter Z, Rankin J, Ceulemans D, Ngongalah L, Ackroyd R, et al. (2019) Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLOS Medicine 16(8): e1002866. https://doi.org/10.1371/journal.pmed.1002866https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002866

Pregnancy outcomes summary

Pregnancy outcomes Compared to pre-operative BMI Compared to pre-pregnancy BMI

Gestational diabetes mellitus ↘↘ =

Caeseaean section ? ↗

Pregnancy induced hypertension ↘ =

Pre-eclampsia / eclampsia ↘ =

Preterm delivery ↗ ↗

SGA/IUGR ↗↗ ↗

LGA/ macrosomia ↘↘ ↘

Perinatal mortality ↗ ↗↗

Obesity surgery

Nutritional deficienciesSurgical complications

Micronutrient deficiencies

Devlieger et al PLOS ONE 2014

• Small bowel obstruction due to internal herniation, volvulus, leak, …• Not unfrequent (2-11%)

High mortalityGuelinckx et al, Hum Reprod Update 2009 ; Wax JR et al, AJOG 2013

Delay in diagnosis and treatment• Symptomatology (abdominal pain, vomiting) frequent in

pregnancy• Diagnostic procedures delayed in pregnancy• Changed anatomy

Chirurgische complicaties

Fetal growth after bariatric surgery

Intrauterine growth restriction

• Growth index significantly lower in pregnant women with bariatric surgery compared to a control group of non-surgical pregnant women

• No influence interval surgery - pregnancy

Obesity surgery

Trajectories of Fetal Adipose Tissue Thickness in Pregnancies After Gastric Bypass Surgery Yerlikaya-Schatten et al, Obes Surg 2019

RYGB N=41 BMIm N=41 Obese N=61

• Decreased body weight• Decreased body fat• Decreased placental weight

Bariatric surgery mimics in-utero starvation

Long term health effects??

Bariatric Surgery

ObeseControl

Normal WeightControl

2009-2014Weight-loss

procedure

2006 -2008

2007-2008

2017-2019

6.5 ± 1.3 years

10.8 ± 0.3 years

10.6 ± 0.2 years

Prospective cross-sectional data collection: single home visit (trained paediatrician) Data on: Body composition, adiposity and metabolic profile

Vascular functionPsychomotor functioning and eating habits

N =36

N =71

N =36

Offspring after Bariatric Surgery present with least favorable body adiposity profile

Unpublished data 2019 – Van De Maele K, Bogaerts A, De Schepper J, Provyn S, Ceulemans D, Guelinckx I, Gies I* & Devlieger R*

Obese Control

Bariatric Surgery

Normal Weight Control

P < 0.001

Highest Waist/Height ratio

0.47 ± 0.06 0.43 ± 0.05 0.41 ± 0.04Obese

ControlBariatric Surgery

Normal Weight Control

P < 0.001

Highest body fat percentage excess by BIA

5.7 % ± 5.1 1.4 % ± 5.4 -0.1% ± 4.1

Obese ControlBariatric Surgery

Normal Weight Control

P = 0.04

0.61 ± 1.54 0.16 ± 1.09 -0.15 ± 1.12

Highest Waist SD score

The Aurora Study: a prospective cohort study

Surgery

Pregnancy and 6m postpartum

incl

usio

n

Online questionnaires

Blood sampling

incl

usio

n

The Aurora Study: current status on general characteristics

422 patients, 144 completed pregnancies

Age at inclusion: 29.8y ± 5.6

Gastric banding9%

RYGB83%

Biliopancreatic diversion

1%Sleeve

gastrectomie7%

BMI before surgery: 42.4kg/m2 ± 5.8 BMI at start of pregnancy: 28.4kg/m2 ± 5.6

Weight loss after surgery: 45.3kg ± 16.5 Weight gain during pregnancy: 12.5kg ± 6.4

The Aurora Study: current status on weight loss/gain

32% BMI>30

AURORA study:Birth Weight

Low birth weight (<2500g) present in 16.2%

Mean birth weight: 3080g ± 67

AURORA-study outputSubject Reference

Reviews Guelinckx et al, Hum Rep Update 2009Devlieger et al, AJOG 2011Akther et al, PLoS Med 2019

Protocols Jans et al, BMC Pregnancy Childbirth 2016Van de Maele et al, BMJ Ped Open 2019

Lifestyle Guelinckx et al, Obes Surg 2012

Neonatal complications Eerdekens et al, Eur J Ped 2010Van Mieghem et al, Obstet Gynecol 2010

Depression and anxiety Jans et al, Obes Surg 2018

Nutritional deficiencies Jans et al, SORD 2013Devlieger et al, PLoS-one 2015Jans et al, Adv Nutr 2015

Contraception and sexuality Luyssen et al, Obes Surg 2018

Surgical complications Devlieger et al, NEJM 2015Vannevel et al, Obstet Gynecol 2016

Screening for gestational diabetes Benhalima et al, Nutrients 2018

Breast feeding Jans et al, Obes Surg 2015Jans et al, J Nutr 2018

G id li Sh t l Ob R i 2019

Recommendations for periconception, antenatal and

postnatal care

Jill ShawUnited Kingdom

Dries CeulemansBelgium

Zainab AkhterUnited Kingdom

Karl NeffUnited Kingdom

Kathryn HartUnited Kingdom

Nicola HeslehurstUnited Kingdom

IztokŠtotlSlovenia

SanjayAgrawalUnited Kingdom

RegineSteegers-TheunissenThe Netherlands

ShahradTaheriQatar

BethGreensladeUnited Kingdom

Judith RankinUnited Kingdom

BobbyHudaUnited Kingdom

Isy DouekUnited Kingdom

SanderGaljaardThe Netherlands

OritBlumenfeldIsrael

Ann RobinsonUnited Kingdom

MartinWhyteUnited Kingdom

Elaine MathewsUnited Kingdom

Roland DevliegerBelgium

20 – 21 April 2017, University of Surrey, UK

Zwangerschap na bariatrie is:A. Af te radenB. Aan te bevelenC. Ik weet het niet

Bedankt!

Glucose metabolism during pregnancy after bariatric surgery

Van Beek et al. 2017

The risk of GDM after bariatric surgery

• BS diminishes the risk for GDM when compared to pre-surgery BMI matched controls

• But no effect is seen when compared to pre-pregnancy BMI matched controls

• As more than half of women after BS are still overweight or obese, the risk of GDM remains higher than in the normal population and screening for GDM is advised. (Alatishe et al. 2013.)

OGTT in pregnant women after bariatric surgery

Adverse events due to dumping in 65% of patients undergoing OGTT after BS (Andrade et al. 2016)

Pregnant women after RYGB had lower fasting glucose levels, but had more often a high glucose excursion at 1 h and 55% had a reactive hypoglycaemia at 2 h. (Feichtinger et al. 2016)

Reactive hypoglycaemia is associated to SGA (11.9 vs. 1.7%)(Rottenstreich et al, 2018)

Bariatric Normal weight

ObeseBMI matched

Benhalima et al, Nutrients 2018

Screening for DM/GDM after RYGB