1. Nutritional Deficiencies in Pregnant Patients who have undergone Bariatric Surgery Vaishali Doshi, MD Assistant Professor of Medicine Hematology/Oncology University of Arkansas for Medical Sciences

2. Gastric bypass and Pregnancy Gastric bypass surgery for morbid obesity is considered an appropriate intervention when other weight-loss measures have proven unsuccessful. Gastric bypass surgery for morbid obesity is considered an appropriate intervention when other weight-loss measures have proven unsuccessful. Weight loss often brings about improvement in overall health by lessening the effects of obesity-related comorbidities. Weight loss often brings about improvement in overall health by lessening the effects of obesity-related comorbidities. In fact, the ability to become pregnant is enhanced, as weight loss often allows for a normalization of sex hormones. In fact, the ability to become pregnant is enhanced, as weight loss often allows for a normalization of sex hormones. However, the nutrition challenges brought about by the surgery may have a profound impact on maternal health and pregnancy outcome. However, the nutrition challenges brought about by the surgery may have a profound impact on maternal health and pregnancy outcome.

3. Outline Different procedures Different procedures Effects of surgery and nutritional alterations Effects of surgery and nutritional alterations Implications for pregnancy Implications for pregnancy

4. Major Categories Surgical procedures for morbid obesity may be classified according to the digestive aftereffects brought about by the particular procedure. These categories include the These categories include the "restrictive" procedures "restrictive" procedures "restrictive-malabsorptive" procedures "restrictive-malabsorptive" procedures less common "malabsorptive" procedures. less common "malabsorptive" procedures.

5. Bariatric Surgery Nutritional needs Nutritional needs 1) vary depending on the degree of restriction and the degree of malabsorption caused by the surgery 1) vary depending on the degree of restriction and the degree of malabsorption caused by the surgery 2)specific area of the intestine is bypassed. 2)specific area of the intestine is bypassed. Individual nutrients generally have a specific site of absorption along the small intestine. Individual nutrients generally have a specific site of absorption along the small intestine.

6. Restrictive procedures vertical banded gastroplasty (VBG), vertical banded gastroplasty (VBG), silicon ring vertical banded gastroplasty (SRG) silicon ring vertical banded gastroplasty (SRG) adjustable silicone gastric banding (ASGB) adjustable silicone gastric banding (ASGB) weight loss simply by total volume of food intake. weight loss simply by total volume of food intake. Patients learn quickly that these surgeries require them to chew their food very well to slow down the pace of eating dramatically Patients learn quickly that these surgeries require them to chew their food very well to slow down the pace of eating dramatically

7. Vertical banded gastroplasty

8. Restrictive procedures Food leaves the newly constructed pouch and empties directly into the original stomach for normal digestion Food leaves the newly constructed pouch and empties directly into the original stomach for normal digestion It then moves through the entire duodenum and jejunum for normal absorption. It then moves through the entire duodenum and jejunum for normal absorption. Malnutrition may occur as a result of the necessity to limit food ingested,thus reducing caloric and nutrient intake. Malnutrition may occur as a result of the necessity to limit food ingested,thus reducing caloric and nutrient intake.

9. Restrictive Surgeries Generally, an adult multiple vitamin and mineral supplement is sufficient after restrictive surgeries since there is no malabsorption of specific nutrients. Generally, an adult multiple vitamin and mineral supplement is sufficient after restrictive surgeries since there is no malabsorption of specific nutrients. There is a significant decrease in the overall quantity of food intake and therefore a decrease in the quantity of all micronutrients; a supplement should bring intake up to the RDA levels. There is a significant decrease in the overall quantity of food intake and therefore a decrease in the quantity of all micronutrients; a supplement should bring intake up to the RDA levels.

10. Restrictive Restrictive- Malabsorbtion Malabsorbtive Vertical banded gastroplasty Roux-en Y gastric bypass Jejunoileal bypass Adjustable gastric banding Biliopancreatic diversion Duodenal switch Intragastric balloon Horizontal unreinforced gastroplasty

11. Roux-en-Y gastric bypass

12. RYGB A small pouch is formed by stapling the upper portion of the stomach across the fundus A small pouch is formed by stapling the upper portion of the stomach across the fundus The contents of the newly formed stomach empty directly into the distal jejunum via a constructed gastrojejunostomy. The contents of the newly formed stomach empty directly into the distal jejunum via a constructed gastrojejunostomy. The remainder of the stomach,duodenam, proximal jejunum are completely bypassed The remainder of the stomach,duodenam, proximal jejunum are completely bypassed

13. RYGB deficiencies of iron deficiencies of iron B12, folate, B12, folate, calcium. calcium. copper copper

14. Iron Deficiency after RYGB Iron deficiency is common after RYGB due to decreased intake of adequate quantities of meat and other iron rich foods Iron deficiency is common after RYGB due to decreased intake of adequate quantities of meat and other iron rich foods Anatomic changes resulting from the surgery prevent iron containing food from being exposed to the acid environment of the stomach, which is required for the release of iron from its protein source Anatomic changes resulting from the surgery prevent iron containing food from being exposed to the acid environment of the stomach, which is required for the release of iron from its protein source

15. Iron Deficiency after RYGB Gastric acidity is essential for the reduction of iron from the ferric state to the ferrous state which is necessary for absorption Gastric acidity is essential for the reduction of iron from the ferric state to the ferrous state which is necessary for absorption Iron is absorbed in the duodenum which is bypassed, some iron will be absorbed in the lower jejunum Iron is absorbed in the duodenum which is bypassed, some iron will be absorbed in the lower jejunum

16. Folate Deficiency after RYGB 1)decreased intake of folate-rich foods. 1)decreased intake of folate-rich foods. 2) dietary folate bypasses the duodenum which is the primary site of folate absorption. 2) dietary folate bypasses the duodenum which is the primary site of folate absorption. 3) Folate absorption, however, can take place along the entire length of the small bowel with adaptation after surgery. 3) Folate absorption, however, can take place along the entire length of the small bowel with adaptation after surgery.

17. B12 absorption and deficiency 1)Intake of foods that are good sources of B12 are consumed in very limited quantities; secondary, 1)Intake of foods that are good sources of B12 are consumed in very limited quantities; secondary, 2) with a less acidic environment in the pouch as compared to a normal stomach, it is difficult to release protein-bound B12 from foods ingested. 2) with a less acidic environment in the pouch as compared to a normal stomach, it is difficult to release protein-bound B12 from foods ingested. 3) the unbound b12 is then joined to R binders 3) the unbound b12 is then joined to R binders The R binders are normally degraded in the duodenum by pancreatic enzymes The R binders are normally degraded in the duodenum by pancreatic enzymes 4 )The absence of an acidic environment prevents the binding and subsequent release of b12 from food, 4 )The absence of an acidic environment prevents the binding and subsequent release of b12 from food,

18. B12 Absorption 1 It then must pair up with intrinsic factor (IF) to form IF/B12 complexes for absorption in the ileum. 2 A reduction in the availability of IF, (produced by parietal cells of stomach) combined with the decreased prescence of unbound Vit B12 prevents formation of IF/B12 complex resulting in malabsorbtion.

19. B12 Supplementation Hyperhomocysteinemia is associated with cardiac and neurological abnormalities Hyperhomocysteinemia is associated with cardiac and neurological abnormalities Long term supplementation of b12 following bariatric surgery Long term supplementation of b12 following bariatric surgery Daily oral supplementation 350 ucg of b12 sublingual Daily oral supplementation 350 ucg of b12 sublingual Occasionally oral supplementation is not adequate making monthly parenteral therapy a necessity Occasionally oral supplementation is not adequate making monthly parenteral therapy a necessity

22. Calcium deficiency Calcium deficiency is common and metabolic bone disease represents a long-term potential risk associated with RYGB surgery. Calcium deficiency is common and metabolic bone disease represents a long-term potential risk associated with RYGB surgery. Calcium with VIT D is absorbed in the duodenum Calcium with VIT D is absorbed in the duodenum Following RYGB,the duodenum is bypassed, preventing access to the primary absorption site for calcium. Following RYGB,the duodenum is bypassed, preventing access to the primary absorption site for calcium. Patients who have undergone gastric bypass surgery must rely on passive diffusion of dietary calcium along the length of the remaining intestine Patients who have undergone gastric bypass surgery must rely on passive diffusion of dietary calcium along the length of the remaining intestine

23. Typically, blood levels of calcium will be normal limits unless other causes create abnormal levels. Typically, blood levels of calcium will be normal limits unless other causes create abnormal levels. calcium deficiency is insidious in nature an individual is potentially releasing calcium from the bones constantly to maintain normal serum calcium. calcium deficiency is insidious in nature an individual is potentially releasing calcium from the bones constantly to maintain normal serum calcium.

24. METABOLIC BONE DISEASE Over time metabolic bone disease results. Oftentimes the individual is unaware of the problem until a bone or a tooth breaks. At this point the problem is significant.

25. Copper Deficiency Copper is an essential micronutrient that plays a vital role as a catalytic cofactor for a variety of metalloenzymes Copper absorption occurs in the stomach and duodenum Case reports of copper deficiency years after a gastric bypass

26. Copper Deficiency Copper deficiency is associated with iron deficiency Copper is a part of hephaestin,which converts iron to its ferric form which is necessary for its transport by transferrin Copper deficiency also causes a microcytic hypochromic anemia that is not responsive to iron supplementation

27. Micronutrient supplementation Micronutrient supplementation It is recommended that all patients following a gastric bypass be given iron supplementation with 40 to 65 mg of iron per day It is recommended that all patients following a gastric bypass be given iron supplementation with 40 to 65 mg of iron per day However women with an existing iron deficiency or those who are menstruating may require higher doses. However women with an existing iron deficiency or those who are menstruating may require higher doses. Women having a restrictive only procedure,where digestive continuity is not disrupted, generally do not experience iron deficiency Women having a restrictive only procedure,where digestive continuity is not disrupted, generally do not experience iron deficiency.

28. Some prescription prenatal vitamin supplements do contain this level of iron. Some prescription prenatal vitamin supplements do contain this level of iron. It is difficult to find an over-the-counter prenatal or a standard adult vitamin with this level of iron. It is difficult to find an over-the-counter prenatal or a standard adult vitamin with this level of iron. If an over-the-counter prenatal vitamin is selected, it is recommended that an iron supplement is added to total 40 to 60 mg of iron per day. This generally prevents deficiency in most individuals If an over-the-counter prenatal vitamin is selected, it is recommended that an iron supplement is added to total 40 to 60 mg of iron per day. This generally prevents deficiency in most individuals

29. Vitamin Supplementation post RYGB Generally, individuals who take the sublingual B12 very rarely develop sub optimal B12 levels Generally, individuals who take the sublingual B12 very rarely develop sub optimal B12 levels A very small percentage of individuals will still become B-12- deficient, despite oral therapy A very small percentage of individuals will still become B-12- deficient, despite oral therapy May require monthly injections on an ongoing basis. May require monthly injections on an ongoing basis. Supplementation with prenatal vitamins containing 1 mg of folicacid prior to and during pregnancy is sufficient to maintain adequate serunm levels and reduce the risk for neural tube defect Supplementation with prenatal vitamins containing 1 mg of folicacid prior to and during pregnancy is sufficient to maintain adequate serunm levels and reduce the risk for neural tube defect

30. Calcium deficiency is common and can generally be prevented by consuming the correct form and amount of calcium. Calcium citrate is the required form as it does not require acid to break it down to be absorbed. Calcium citrate is the required form as it does not require acid to break it down to be absorbed. Most supplements contain calcium carbonate, which is not effective after RYGB surgery. Most supplements contain calcium carbonate, which is not effective after RYGB surgery.

31. Micronutrient supplementation It is recommended to take 1200-1500 mg of calcium citrate per day. Tums ® and other calcium carbonate supplements are not effective with reduced stomach acid.

32. Periconceptual women Folic acid – 1 mg Folic acid – 1 mg Calcuim citrate -1200mg-1500mg Calcuim citrate -1200mg-1500mg Vit D Vit D B12 --- 350 ucg crystalline B12 --- 350 ucg crystalline Ferrous Iron 45-60 mg Ferrous Iron 45-60 mg

33. IMPLICATIONS FOR PREGNANCY PRECONCEPTION PRECONCEPTION ANTENATAL ANTENATAL POST PARTUM POST PARTUM

34. Preconception Preconception care is considered preventive care Preconception care is considered preventive care Most pregnancies are not planned and first prenatal visit occurs after the period of organogenesis is completed Most pregnancies are not planned and first prenatal visit occurs after the period of organogenesis is completed Women of childbearing age who have undergone a bypass,must continue taking vitamins so that a deficiency at pregnancy onset can be avoided Women of childbearing age who have undergone a bypass,must continue taking vitamins so that a deficiency at pregnancy onset can be avoided Because anemia is not as common following restrictive bariatric procedures iron supplementation is given only when necessary Because anemia is not as common following restrictive bariatric procedures iron supplementation is given only when necessary

35. Labs at outset Serum iron, total iron binding capacity, transferrin saturation, ferritin Serum iron, total iron binding capacity, transferrin saturation, ferritin Vit b12, red cell folate Vit b12, red cell folate Homocysteine and methyl malonic acid Homocysteine and methyl malonic acid S calcuim S calcuim Copper level Copper level

36. Antepartum If pregnancy was planned and preconception planning was obtained, the woman is advised to continue taking the prescribed supplements and a prenatal vitamin with iron is added If pregnancy was planned and preconception planning was obtained, the woman is advised to continue taking the prescribed supplements and a prenatal vitamin with iron is added If pregnancy was not planned early evaluation and correction of nutritional status should be carried out If pregnancy was not planned early evaluation and correction of nutritional status should be carried out

37. Anemia in Pregnancy Hyporegenerative,reticulocytopenic anemia Hyporegenerative,reticulocytopenic anemia To compensate for iron for fetal hemoglobin synthesis, to anticipate the losses due to bleeding To compensate for iron for fetal hemoglobin synthesis, to anticipate the losses due to bleeding Approximately 4 mg of iron needs to be absorbed daily Approximately 4 mg of iron needs to be absorbed daily Total of 1000 mg of additional iron is needed during the course of pregnancy Total of 1000 mg of additional iron is needed during the course of pregnancy This amount is greater than the normal -500 mg storage iron pool present in most women This amount is greater than the normal -500 mg storage iron pool present in most women Iron deficient state with low ferritin levels frequently occurs in the mother Iron deficient state with low ferritin levels frequently occurs in the mother Deficiencies of iron, folate Deficiencies of iron, folate

38. Physiological anemia of pregnancy

39. Iron deficiency anemia Oral iron (elemental of 200mg/day) Oral iron (elemental of 200mg/day) Ferrous sulphate tid ( 300 mg of ferrous sulphate =65 mg of elemental iron Ferrous sulphate tid ( 300 mg of ferrous sulphate =65 mg of elemental iron Iron is best absorbed if given without food Iron is best absorbed if given without food Side effects –constipation, diarrhoea,nauseau and abdominal pain Side effects –constipation, diarrhoea,nauseau and abdominal pain If these limit compliance the medication can be administered with food or the dose reduced by one half If these limit compliance the medication can be administered with food or the dose reduced by one half

41. Oral Iron therapy Oral iron therapy usually corrects the anemia within four to six weeks,oral iron to be continued for 3-6 mths for body stores Oral iron therapy usually corrects the anemia within four to six weeks,oral iron to be continued for 3-6 mths for body stores Addition of VIT C,to aid absorbtion have been tried with patients of gastric bypass Addition of VIT C,to aid absorbtion have been tried with patients of gastric bypass

42. Ferrous products are effective, but they are associated with more gastrointestinal side effects than ferric products. Ferrous products are effective, but they are associated with more gastrointestinal side effects than ferric products. Ferric products tend to have lower absorption Ferric products tend to have lower absorption

44. Parenteral Iron Therapy As patients with a gastric bypass have a true inability to absorb iron. As patients with a gastric bypass have a true inability to absorb iron. Two forms are available- Two forms are available- Iron –dextran Iron –dextran Infusion at a single visit Infusion at a single visit Iron dextran can cause severe allergic reactions including anaphylaxis Iron dextran can cause severe allergic reactions including anaphylaxis pregnancy criteria - C pregnancy criteria - C

45. Ferrlecet soduim ferric gluconate-ferrlecet soduim ferric gluconate-ferrlecet Pregnancy criteria –B Pregnancy criteria –B 125 MG/10 ML – Elemental iron 125 MG/10 ML – Elemental iron Slowly as 2.1 mg/min Slowly as 2.1 mg/min Weekly dosing Weekly dosing

46. Response to oral iron can be assesed within 2-3 weeks, if no adequate retic response Response to oral iron can be assesed within 2-3 weeks, if no adequate retic response May consider Parenteral iron especially patients with RYGB May consider Parenteral iron especially patients with RYGB Moniter with iron indices and ferritin every 2-3 mths Moniter with iron indices and ferritin every 2-3 mths

48. Vit B12 DEF Deficiency of VIT B12, B6,FOLIC ACID results in elevated levels of homocysteine Deficiency of VIT B12, B6,FOLIC ACID results in elevated levels of homocysteine The presence of hyperhomocysteinaemia may be used as a marker in pregnancy to indicate the increased risk for thrombotic events and early pregnancy loss The presence of hyperhomocysteinaemia may be used as a marker in pregnancy to indicate the increased risk for thrombotic events and early pregnancy loss Vascular disease of placenta increases. Vascular disease of placenta increases. Important to maintain normal b vitamins and folate levels Important to maintain normal b vitamins and folate levels Protect against recurrent early pregnancy loss Protect against recurrent early pregnancy loss

49. Complications maternal complications --- severe anemia maternal complications --- severe anemia fetal complications fetal complications neural tube defect neural tube defect intrauterine growth restriction intrauterine growth restriction failure to thrive failure to thrive Nutrient supplementation following Bariatric surgery and close supervision before, during, and after pregnancy can help prevent nutrition-related complications and improve maternal and fetal health. Nutrient supplementation following Bariatric surgery and close supervision before, during, and after pregnancy can help prevent nutrition-related complications and improve maternal and fetal health.