Pregnancy after Bariatric Surgery: An Interdisciplinary Approach

Pregnancy after bariatric surgery has become more commonly seen in the OB setting. There are several types of gastric by-pass surgeries available. These are either restrictive or malabsorptive, or both. Women who have experienced by-pass surgery are urged to wait at least 18 months prior to conception. For many women, having a gastric bypass has tremendously enhanced their ability to conceive. This may result in a highly desired pregnancy or result in an unplanned pregnancy. Pregnant women who have experienced bariatric surgery prior to pregnancy require high risk interdisciplinary care to minimize adverse effects to both the mother and fetus. An interdisciplinary protocol for the high risk team was developed to optimize healthy pregnancy outcomes.      The protocol was developed by the high risk nurse practitioner, beginning with the ACOG and nursing recommendations for screening. Each discipline provided information regarding their role and responsibilities. This included the maternal fetal medicine physicians, the high risk nurse practitioner, the RN’s, the patient educator, the social worker, and the dietician. The actions needed to integrate care for the mother and fetus can be demonstrated in an algorithm.       Initially the mother is assessed for type of surgery, length post-op. problems that occurred with the bypass, and other co-morbidities. Based on this assessment, the protocol is initiated. An early referral to the dietician is of paramount importance. The type of surgery also may indicate additional vitamin regimens. The plan of care for the patient is reviewed with the whole team. An excellent example is that the mother should not receive a one hour glucose or three hour glucose tolerance test, which may result in dumping syndrome or extreme nausea and vomiting. The protocol outlines how to obtain an accurate assessment.       Mothers who are experiencing natural weight gain due to the pregnancy may develop body/esteem issues. It is important to screen for possible eating disorders and to provide the support needed. A referral to the social worker may be indicated. A group prenatal care model may be very helpful and can be offered. This group would be headed by the high risk perinatal nurse practitioner.       Fetal surveillance is important especially if the patient has a malabsorptive surgery or combination. This includes targeted ultrasound and monthly growth scans. If the mother had a malabsorptive surgery, there is risk for the mother as the pregnancy progresses, to have intestinal displacement that may lead to herniation. After the birth, for mothers who are breastfeeding, health care providers must be alert for failure to thrive due to the decreased breast milk fat content.      Initial outcomes include consistency of health care across the continuum, patient satisfaction at being included in plan of care and knowing “big picture”, and most importantly, positive pregnancy outcomes. A interdisciplinary approach optimizes healthy pregnancy and birth outcomes.