Transcript of CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Bariatric Surgery and Pregnancy: Nutritional...
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- CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Bariatric
Surgery and Pregnancy: Nutritional Management Pre Post? Andrea
Langley RD MSc. CDE
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- CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Objectives
Overview of Obesity and Pregnancy Types of Bariatric Surgery
Nutrition and Bariatric Surgery Case Study Recommendations for
Pregnancy post Bariatric Surgery
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- Obesity in Pregnancy Prevalence ranges from 10-35% 1 29% of
U.S. women of childbearing age were obese 8% were morbidly obese
(BMI 40) 2 11-21% of Canadian women were obese 3 Weight gain
recommendations for women with BMI 30 is 11-20lbs 1 Kominiarek, MA.
Obstet Gynecol Clin N Am 2010; 37: 305-320 2 Artal R et al.
Obstetrics andGynecology 2010; 115(1): 152 3 Statistics Canada.
2005.
http://www.statcan.gc.ca/pub/82-620-m/2005001/article/adults-adultes/8060-eng.htm.
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- Obesity in Pregnancy Associated with increased risk of
stillbirth and intrauterine fetal death Greater risk for preterm
labour, miscarriage and fetal chromosomal anomolies Higher rates
of: GDM, gestational hypertension, pre-eclampsia and caesarian
section
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- Roux-en-Y Gastric Bypass Restrictive and malabsorptive
procedure Restricts stomach volume Requires lifelong vitamin and
mineral supplementation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19268.htm
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- Roux-en-Y Gastric Bypass Wt. loss of ~65% excess weight in 1
year Rapid onset of feeling full; satiety while eating Benefits:
Nutritional deficiencies (B12, zinc, calcium, fat-soluble vitamins,
thiamine, folate, iron) Dumping syndrome (w/ sugary foods)
Anastomotic leakage, stricture or ulcer Risks:
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- Biliopancreatic Diversion w/Duodenal Switch Half of the stomach
is permanently removed Stomach is then connected to distal part of
the SI Remainder of SI connected to the end of small bowel Requires
lifelong vitamin and mineral supplementation
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19500.htm
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- Biliopancreatic Diversion Duodenal Switch Pylorus is intact and
may prevent dumping syndrome Stomach pouch is larger than other
bariatric sx, so larger portions can be consumed Benefits: Frequent
soft BMs (up to 4-6/day) Frequent passing of foul-smelling gas Gas
pains and bloating Hair loss Intolerance of certain foods Side
effects: Fat soluble vitamins, iron, folate, B12 Greater risk of
nutritional deficiencies
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- Nutrient Absorption Duodenum Calcium, phosphorus, magnesium,
pantothenate, B6, C, zinc, chromium, molydenum, manganese, iron,
copper, selenium, thiamine, riboflavin, niacin, biotin, folate, A,
D, E, K lipids, monosaccharides, amino acids Jejunum C, folate, D,
B12, K, magnesium Bile acids and salts Ileum Sodium, chloride,
potassium, K, biotin, water Short chain fatty acids
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- Causes of Nutrient Deficiencies after Bariatric Surgery ie.
intolerances to red meat Decreased intake of certain foods May
result in B12 deficiency Decreased gastric acid secretion Duodenum
and jejunum Bypass of nutrient absorption sites
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- Recommended Supplements for Bariatric Surgery Patients Kusher
RF and Cummings S. Medical Management of patients after bariatric
surgery. UpToDate 2012: 1-38. SupplementDoseNote
Multivitamin/mineral with iron1-2/day Calcium1200-1500mg
(elemental)/day Preferably citrate form, divided dose Vitamin D800
IU/day Iron40-65mg (elemental) if premenopausal 18-27mg (elemental)
for other women B12500-1000mcg/d or 1000mcg IM/month
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- Recommended Diet Guidelines Post-Bariatric Surgery Avoid
grazing which may lead to higher calorie intake 3 meals and 1-2
planned snacks BPD-DS patients may need 1.5g/kg/d due to
malabsorption Aim for at least 60g protein May cause dumping
syndrome esp. after RYGB Limit simple carbohydratesSeparate fluids
and solids
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- Recommended Laboratory Tests CBC Lipid profile Electrolytes
Glucose Iron studies, ferritin Folate Albumin Vitamin B12 Bilirubin
Aminotransferases Alk Phos 25-hydroxyvitamin D PTH Thiamin
Recommended at 3 mo, 6 mo and annually after Kusher RF and Cummings
S. Medical Management of patients after bariatric surgery. UpToDate
2012: 1- 38.
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- Pregnancy Following Bariatric Surgery Recommended to wait
12-18months post-surgery Peak weight loss occurs between
12-18months Not associated with adverse perinatal outcomes Lower
risk of GDM, gestational HTN and macrosomia Assess for nutritional
deficiencies pre-pregnancy May need parenteral forms if labs do not
improve
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- Pregnancy Following Bariatric Surgery Discuss contraception as
fertility may improve If dumping syndrome, use an alternative to
the OGCT 24-28 weeks, test BG fasting and pc meals for 1 week 1
Counsel on risks of obesity in pregnancy One study demonstrated 41%
obese 2 after surgery 1 Kominiarek, MA. Semin Perinatol 2011. 35:
356-361. 2Lapolla et al. Obes Surg 2010. 20: 1251-1257.
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- Case Study 32 y.o. female, G 7 T 0 P 4 A 2 L 3, referred at 14
weeks G.A. re: pregnancy post BPD w/DS Followed from Oct. 2009-
Feb. 2010 Known from pregnancy in 2007 Lost 150 lbs with surgery;
prev. BMI 51 No regular follow-up with surgeon (in Michigan)
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- Case Study PMHx Bipolar (off meds), other mental health issues
PTSD Biliopancreatic diversion w/duodenal switch Meds OTC
X-strength Ranitidine (150mg 3-4/d) Vitamins: PNV calcium citrate
(2x 500mg) time-released vitamin C 1000mg liquid iron 20ml (?
elemental) water-soluble vitamin D
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- Case Study Anthropometrics: Ht 1.6m Pre-pregnancy wt. 58.1kg
BMI 22.7 Current wt. 64kg at 15 weeks Activity: No regular activity
Complaints: Bloating after meals Vomiting after every meal, but
subsiding now Heartburn Feels terrible, dizziness, SOB occ. blurred
vision with eating
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- Case Study Obstetrical Hx: Followed in 2007 pregnancy TPN for
~6 weeks (at her insistence) Dx: IFG and reports of hypoglycemia
Polyhydramnios Previous pregnancies: 1995 baby born at 26 wks -
died at 1 month 1998 female, 34 weeks 7lbs 2002 boy, 29 weeks 3
lbs; has CP (? GDM) 2007- boy, 33 weeks 4 lb 7oz,
IFG/polyhydramnios
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- Case Study contd Diet: Consumes 3 meals and 1-2 snacks/day.
Carbohydrates vary from 10-60g at meals Consuming protein powder
with soy milk most days Eating meat/chicken 1-2 x /day High GI
foods Financial: on CPP but recently lost benefits Applying for
ODSP Social: Relationship with partner of last child and current
Lives with her 3 children
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- Case Study Labs: DateTestValueReference Range Oct. 4/09Hgb Hct
108g/L 0.33 115-160g/L 0.34-0.48 Sept. 14/09Ferritin B12 11.1g/L
257pmol/L 35-291g/L (
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- Case Study Assessment : Significant weight gain at 15 weeks
Inadequate protein intake -needs ~90g/day Insufficient
dietary/supplementary iron No vitamin/mineral panel in the last
year Need PTH or albumin to assess calcium status ? Cause for
blurred vision food choices,BGs?
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- Case Study Plan at 14 weeks : Carbohydrate controlled diet 45g
CHO at meals and 30g CHO at snacks TID Controlled wt. gain of
0.5-1lb/week Aim for 90-100g protein/day
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- Case Study Plan at 14 weeks: Recommend vitamin/mineral status
PTH, vit D, B 1, B 12, folate, zinc, vit A, selenium, copper May
benefit from ferrous fumerate BID Provides 200mg elemental iron
Suggested testing BG when vision blurred May benefit from early
OGCT
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- Case Study Admitted to antenatal Dec. 27, 2009 for TPTL and
shortened cervix None of the recommendations from October for
vitamins or labs were done Dec. 15 th labs ferritin (10.3), B 12
(112) and Hgb (97) Recommended B 12 and triferex (150mg elemental)
B 12 ordered Dec. 30 th (2 nd admission)
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- Case Study Jan 4 th Vitamin C 500mg, Ca Carbonate 1250mg and
vitamin D 1000mg were ordered at RD request Jan 5 th OGTT results
3.2/8.3/2.9 reactive hypoglycemia Controlled carbohydrate diet
ordered in hospital Weekly BG fasting and 1hr pcb Ferrous gluconate
changed to Triferex Jan 11 th labs: Ca 1.85 (ref. 2.12-2.62),
vitamin D 25 (75-225) Fasting 3.7, 1hr pcB 4.5 not symptomatic
Spoke to bariatric surgeon re: labs and vitamin needs
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- Recommendations from Bariatric Surgeon : Pregnancy Aim for B12
>500 and ferritin at high end of N If protein low, order TP,
alb, pre-alb If iron low, 150mg TID elemental or IV iron 2-3
x/week, then 1x/week for 3-4 weeks Vitamin D need water soluble
2000 IU TID If low, drisdol (50 000 IU) x 6 months Repeat labs in 2
months; if still low at 6 mo - BID
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- Recommendations from Bariatric Surgeon : Pregnancy If vitamin A
low, need water soluble A and D TID (do not need separate vitamin
D) Ca citrate 3000mg/day May require rocaltrol or calcitrol
0.5mcg/d x 6 months Pancreatic enzymes 20mg TID Regular B vitamin
Complex carb, high protein for reactive hypo
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- Case Study Jan 18 th : Vitamin D 1000IU changed to Drisdol 50
000IU Ca carbonate 1250mg changed to Ca citrate 1500mg TID Received
1 dose IV iron, to be repeated in 1 week Pancreatic enzymes 20mg
TID to aid digestion
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- Case Study Jan 25 th : Ordered glucerna at HS snack
TestValueReference Range B12245pmol/L181-672pmol/L
Ferritin243g/L35-291g/L Prealbumin0.17g/L0.18-0.45g/L
Hgb86g/L115-160g/L Hct0.280.34-0.48 Vitamin A1.1mol/L1.2-2.8mol/L
Protein57g/L60-80g/L
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- Case Study Feb 2 nd : Beta carotene 25 000 IU ordered (3750g
RAE) Non-toxic as compared to preformed vitamin A Feb 24 th : Zinc
8.7umol/L (N 9.8umol/L) 175mg zinc gluconate ordered on
discharge
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- Case Study BG records: DateFasting1hr pcB1hr pcL1hr pcS Feb
1/103.14.2 Feb 2/103.44.85.23.1 Feb 3/103.54.8 Feb 17/107.9
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- Case Study Delivered Feb. 21 4lb 7oz at 34 weeks Baby in NICU,
trying to breastfeed Total wt. gain ~28lbs (had polyhydramnios)
Received a total of 3 treatments of IV iron Discharge meds:
seroquel 25mg pantoloc 40mg pancrealipase TID vitamin C 500mg B
carotene 25 000 IU Ca citrate 1500mg TID vit D 50 000 IU zinc
gluconate 175mg triferex 150mg
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- Case Study Postpartum received call from pt 1 hr pc BG 11 and 3
elevated BGs 2 hrs pc Reported she was low in Vitamin A, D,
ferritin, B 12, zinc Recommendations: Continue vitamin D and f/u BW
2-3 months Change beta carotene to water soluble A + D and reassess
in 2-3 months Continue zinc supplement and repeat 2-3 months Change
to ferrous fumerate 300mg BID Try testing ac meal or 2 hr pc or ? A
1C
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- Case Study April 14, 2010 patient seen by outpatient hematology
Changed from Triferex to ferrous gluconate 300mg OD Provides 36mg
elemental
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- Case Study October 2010 seen by Outpatient Nutrition
Counselling postpartum for nutritional deficiencies Current
supplements: Vitamin D 50 000IU - zinc gluconate 175mg Beta
carotene (same dose likely) - B complex Calcium 1200mg (? type) -
multivitamin/mineral Ferrous gluconate 300mg BID (72mg elemental)
Plans to d/c beta carotene and start preformed vitamin A (water
soluble)
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- Case Study Diet: consuming 3 meals and 1-2 snacks Aims for high
protein (actual intake 55-60g/d) Anthropometrics: ht 160cm wt. 64kg
BMI 25 Labs: DateTestValueRef Range April 10Ferritin Hgb Albumin
Creatinine B12 Protein 34g/L 119g/L 40g/L 42mol/L 477pmol/L 59g/L
35-291g/L 115-160g/L 35-50g/L 55-115mol/L 181-672pmol/L 60-80g/L
Sept 10Ferritin Hgb B12 Vitamin D Calcium 28g/L 111g/L 315pmol/L
44nmol/L 2.2mmol/L 35-291g/L 115-160g/L 181-672pmol/L 75-225nmol/L
2.12- 2.62mmol/L
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- Case Study Recommendations Increase protein by including high
pro smoothie Need vitamin A labs prior to starting preformed A
Outdoor activity to assist with increased vitamin D Need labs for
vitamin A, zinc, PTH Switch to ferrous fumerate to increase
elemental
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- Planning a Pregnancy - Recommendations Post Sx. Discuss
contraceptive use d/t increased fertility Review risks on obesity
in pregnancy (if obese) Aim for 3 meals and 1-2 planned snacks
Conduct a vitamin/mineral panel Adequate supplementation prior to
pregnancy Consider alternative to OGCT during pregnancy
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- References Karmon, A and Sheiner, E. Pregnancy after bariatric
surgery. Arch Gynecol Obstet. 2008; 277: 381-388. ACOG Practice
Bulletin. Bariatric Surgery and Pregnancy. 2009; 105: 1405- 1413.
Grazia Dalfa, M et al. Pregnancy and foetal outcome after bariatric
surgery. Journal of Maternal-Fetal and Neotatal Medicine. 2012;
Early online 1-7. Ziegler, O et al. Medical follow up after
bariatric surgery. Diabetes and Metabolism. 2009; 35: 544-557.
Hezelgrave, N.L. and Oteng-Ntim, E. Pregnancy after Bariatric
Surgery. J Obes. 2011. Online 2011 July 14. Ouyang, DW. UpToDate
2012. Counseling women about fertility and pregnancy after
bariatric surgery. Kominiarek, M.A. Preparing for and managing a
pregnancy after bariatric surgery. Semin Perinatol. 2011; 35:
356-361. Kominiarek, M.A. Pregnancy after bariatric surgery. Obstet
Gyneol Clin N Am. 2010; 37: 305-320. Kushner, RF and Cummings, S.
Medical Management of patients after bariatric surgery. UpToDate
2012.
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- Thank You