Pregnancy after sleeve gastrectomy

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I am 2.5 years out of surgery and I am doing pretty well. I am at 165 from 246. My husband and I are finally ready to start a family in about a year. Is there anything I need to consider? Taking extra vitamins early or seeing a high risk Doctor?

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Dear KN,
There has been quite a bit written about the effect of gastric bypass on pregnancy. Sleeve is much newer, and medical reports are just starting to come in. As a general rule, pregnancy after weight loss surgery is safe both for mom and baby. Maternal complications decrease as the mother loses weight. There has been a higher risk of need for cesarean section in some studies of women who've had gastric bypass. There are very few fetal complications reported. There are some reports that suggest that there may be an increased incidence in babies who have a low birthweight. There are also reports of vitamin deficiencies. Most surgeons recommend that patients weight a year or 18 months before pregnancy, but some research suggests that this may not be necessary. 
Get good prenatal care from a reputable obstetrician. Ask her or him if you need to visit a "high risk" clinic. Your OB will make that decision based on his or her comfort level and experience with managing pregnancies after weight loss surgery. Managing the pregnancy during the acute weight loss phase, the first year, is trickier than later when mom's weight is stable. Be sure to take adequate protein and prenatal vitamins. Folate is especially important to avoid neural tube defects. Your vitamin levels should be checked before and during the pregnancy. 
Best of luck with very wonderful part of life.
Dr. Callery
2015 Jul 15;6(4):420-9. doi: 10.3945/an.114.008086. Print 2015 Jul.

Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review.

Pregnant and postpartum women with a history of bariatric surgery are at risk of micronutrient deficiencies as a result of the combination of physiologic changes related to pregnancy and iatrogenic postoperative alterations in the absorption and metabolism of crucial nutrients. This systematic review investigates micronutrient deficiencies and related adverse clinical outcomes in pregnant and postpartum women after bariatric surgery. A systematic approach involving critical appraisal was conducted independently by 2 researchers to examine deficiencies of phylloquinone, folate, iron, calcium, zinc, magnesium, iodide, copper, and vitamins A, D, and B-12 in pregnant and postpartum women after bariatric surgery, together with subsequent outcomes in the neonates. The search identified 29 relevant cases and 8 cohort studies. The quality of reporting among the case reports was weak according to the criteria based on the CARE (CAse REporting) guidelines as was that for the cohort studies based on the criteria from the Cohort Study Quality Assessment list of the Dutch Cochrane Center. The most common adverse neonatal outcomes related to maternal micronutrient deficiencies include visual complications (vitamin A), intracranial hemorrhage (phylloquinone), neurological and developmental impairment (vitamin B-12), and neural tube defects (folate). On the basis of the systematically collected information, we conclude that the evidence on micronutrient deficiencies in pregnant and postpartum women after bariatric surgery and subsequent adverse neonatal outcomes remains weak and inconclusive. 

2013 Jun;23(6):756-9. doi: 10.1007/s11695-012-0858-y.

Pregnancy outcomes after laparoscopic sleeve gastrectomy in morbidly obese Korean patients.

Laparoscopic sleeve gastrectomy (LSG) is an effective procedure for treating morbid obesity, and the majority of female patients who received LSG were at childbearing age. Female patients, who successfully lost weight following LSG and became pregnant, need to be evaluated carefully. Information was gathered, through prospectively maintained database and phone interview, on women who underwent LSG from May 2003 to July 2011. A total of 136 women underwent LSG in this period. There were 13 (9.6 %) pregnancies in 12 patients after LSG. The age before surgery was 28.3 ± 4.0. The mean weight and body mass index (BMI) before LSG were 95.3 ± 9.4 kg and 35.1 ± 3.5 kg/m(2), respectively. The average time from LSG to the first live birth was 32.0 ± 19.1 months. Mean BMI decreased significantly after LSG, from 35.1 ± 3.5 to 24.9 ± 2.3 kg/m(2) at conception. The mean percentage of excess body mass index loss was 85.8 ± 16.7 % at conception and 42.7 ± 25.1 % at delivery. Gained weight during pregnancy was 15.1 ± 5.2 kg. The mean gestational age and birth weight were 39.0 ± 1.6 weeks and 3,229.0 ± 505.9 g. In two cases (15.4 %), cesarean section was performed. No cases of pregnancy-induced hypertension and diabetes developed. Major congenital anomalies and neonatal deaths were not recorded. Larger study with longer follow-up is needed to evaluate the effect of LSG in pregnancies. However, these findings show that LSG seems to be a safe option for morbidly obese women in their reproductive period.



2015 Aug;130(2):127-31. doi: 10.1016/j.ijgo.2015.03.022. Epub 2015 Apr 24.

Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients.

OBJECTIVE:To analyze pregnancy outcomes after laparoscopic sleeve gastrectomy (LSG) according to body mass index (BMI) at conception and the interval between LSG and pregnancy.

METHODS:In a retrospective study, data were obtained for all women who became pregnant after LSG at a center in France between December 2001 and December 2011. Frequencies of perinatal events according to BMI at conception and the interval between LSG and pregnancy were compared.

RESULTS:A total of 63 pregnancies occurring in 54 patients were included, among which 52 (83%) occurred after the first postoperative year and 26 (41%) in women who remained obese. Compared with women who were no longer obese at conception, women who were still obese delivered neonates of significantly lower gestational age at birth (P=0.02) and birth weight (P=0.001). Odds of preterm delivery were also increased (odds ratio 4.37, 95% confidence interval 1.17-16.27; P=0.03). Maternal and neonatal outcomes according to the interval between LSG and pregnancy did not differ significantly.

CONCLUSION:Women who remain obese following LSG are at increased risk of adverse outcomes, including low gestational age at birth, low birth weight, and preterm delivery, and should be regarded as a risk group.



 2014 Nov-Dec;10(6):1166-73. doi: 10.1016/j.soard.2014.02.011. Epub 2014 Feb 24.

Pregnancy outcomes and nutritional indices after 3 types of bariatric surgery performed at a single institution.

BACKGROUND:  Nutritional status during pregnancy and the effects of nutritional deficiencies on pregnancy outcomes after bariatric surgery is an important issue that warrants further study. The objective of this study was to investigate pregnancy outcomes and nutritional indices after restrictive and malabsorptive procedures.

METHODS:  We investigated pregnancy outcomes of 113 women who gave birth to 150 children after biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between June 1994 and December 2011. Biochemical indices and pregnancy outcomes were compared among the different types of surgery and to overall 20-year hospital data, as well as to 56 presurgery pregnancies in 36 women of the same group.

RESULTS:  Anemia was observed in 24.2% and 15.6% of pregnancies after BPD and RYGB, respectively. Vitamin B12 levels decreased postoperatively in all groups, with no further decrease during pregnancy; however, low levels were observed not only after BPD (11.7%) and RYGB (15.6%), but also after SG (13.3%). Folic acid levels increased. Serum albumin levels decreased in all groups during pregnancy, but hypoproteinemia was seen only after BPD. Neonates after BPD had significantly lower average birth weight without a higher frequency of low birth weight defined as<2500 g. A comparison of neonatal data between babies born before surgery and siblings born after surgery (AS) showed that AS newborns had lower average birth weight with no significant differences in body length or head circumference and no cases of macrosomia.

CONCLUSION: Our study showed reasonably good pregnancy outcomes in this sample population after all types of bariatric surgery provided nutritional supplement guidelines are followed. Closer monitoring is required in pregnancies after malabsorptive procedures especially regarding protein nutrition.



2015 Mar;25(3):436-42. doi: 10.1007/s11695-014-1387-7.

Maternal and perinatal outcomes after bariatric surgery: a Spanish multicenter study.

BACKGROUND:  Bariatric surgery (BS) has become more frequent among women of child-bearing age. Data regarding the underlying maternal and perinatal risks are scarce. The objective of this nationwide study is to evaluate maternal and perinatal outcomes after BS.

METHODS:  We performed a retrospective observational study of 168 pregnancies in 112 women who underwent BS in 10 tertiary hospitals in Spain over a 15-year period. Maternal and perinatal outcomes, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders (PAHD), pre-term birth cesarean deliveries, small and large for gestational age births (SGA, LGA), still births, and neonatal deaths, were evaluated. Results were further compared according to the type of BS performed: restrictive techniques (vertical-banded gastroplasty, sleeve gastrectomy, and gastric banding), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD).

RESULTS:  GDM occurred in five (3 %) pregnancies and there were no cases of PAHD. Women whose pregnancies occurred before 1 year after BS had a higher pre-gestational body mass index (BMI) than those who got pregnant 1 year after BS (34.6 ± 7.7 vs 30.4 ± 5.3 kg/m(2), p = 0.007). In pregnancies occurring during the first year after BS, a higher rate of stillbirths was observed compared to pregnancies occurring after this period of time (35.5 vs 16.8 %, p = 0.03). Women who underwent BPD delivered a higher rate of SGA babies than women with RYGB or restrictive procedures (34.8, 12.7, and 8.3 %, respectively).

CONCLUSIONS: Pregnancy should be scheduled at least 1 year after BS. Malabsorptive procedures are associated to a higher rate of SGA births.


2013 Aug;23(8):1281-5. doi: 10.1007/s11695-013-0903-5.

Timing of pregnancy after gastric bypass-a national register-based cohort study.

Current recommendations suggest postponing pregnancy by at least 1 year after gastric bypass. During the first postoperative year, women are in a catabolic phase with a rapid weight loss which may increase the risk of adverse pregnancy and neonatal outcomes. This study tested the hypothesis that the risk of adverse pregnancy and neonatal outcomes is increased in women who conceive during the first year after gastric bypass surgery.

METHODS: This is a national register-based cohort study covering all Danish deliveries during 2004-2010 in women with prior Roux-en-Y gastric bypass surgery. Only the first postoperative birth was included. The risk of adverse pregnancy and neonatal outcomes was compared between women who conceived within the first postoperative year and women who conceived later. Data were extracted from the Danish National Patient Registry and The Danish Medical Birth Register.

RESULTS: Of 286 women who had a singleton delivery after Roux-en-Y gastric bypass surgery, 158 women conceived within the first year and 128 later. There was no statistically significant difference (p > 0.05) between the two groups regarding neonatal birth weight, gestational age, risk of preeclampsia, gestational diabetes mellitus, labor induction, cesarean section, postpartum hemorrhage (>500 ml), preterm birth (before 37 weeks), small for gestational age, large for gestational age, or Apgar score (5 min ) below 7, or in the need of neonatal intensive care.

CONCLUSIONS: This study showed no evidence to support a recommendation to delay pregnancy until after the first postoperative year. At present, the optimal time for pregnancy after gastric bypass is unknown.

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