Caution on Pregnancy on Heels of Obesity Surgery

Doctors find it can have deadly complications for mom, baby

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HealthDay Reporter

WEDNESDAY, Aug. 11, 2004 (HealthDayNews) -- Pregnancy after obesity surgery is by-and-large safe, but doctors warn that occasionally there could be deadly complications.

A letter in the Aug. 12 issue of the New England Journal of Medicine details the case of a pregnant woman who died 18 months after she had undergone gastric bypass surgery.

The woman, and her baby, died as a result of an internal hernia that occurred as a complication of the gastric surgery. The hernia, which wasn't diagnosed in time, caused a large section of the woman's bowel to become infected and die.

"This complication is something that can happen after [gastric bypass surgery]," said one of the letter's authors, Dr. Edward Whang, an attending surgeon at Brigham and Women's Hospital in Boston. "It's probably more difficult to diagnose in a patient who is pregnant because some of the symptoms, such as nausea and vomiting, are symptoms that also happen in pregnancy."

The 41-year old woman was 31 weeks pregnant at the time she started feeling ill.

She was admitted to a community hospital complaining of abdominal pain, nausea and vomiting. The problem, Whang said, is that along with symptoms similar to those of pregnancy, all of the standard tests can come back normal even as the problem is occurring.

"There is no perfect way to diagnose this condition without an operation. Of all of the tests that are available, CT is the best one, but the results could be normal and you could still have this condition," he added.

She was transferred to Brigham and Women's after spending 48 hours at the community hospital.

"When she came to our hospital, she was already nearly dead," Whang said.

Surgeons at Brigham and Women's removed a large section of the woman's diseased bowel, and they also performed a Caesarean section to deliver the baby, who was already dead.

Three hours after the surgery, the woman, who weighed 440 pounds, died of cardiac complications.

Whang noted that the gastric bypass surgery, prenatal care and initial evaluation of the woman's symptoms did not occur at his hospital.

Dr. Daniel Herron, chief of bariatric surgery at Mt. Sinai Medical Center in New York City, agreed that surgery is the only way to definitively diagnose such a complication.

But, he added, "If a patient who has had weight loss surgery has abdominal pain, they should be quickly identified and evaluated by a bariatric surgeon." That's because bariatric surgeons are familiar with such a complication and can probably diagnose it faster. And, he added, time is of the essence in diagnosing this problem.

Herron also noted that this complication should become less common because of new methods of bariatric surgery.

There are two or three spaces in the abdomen where hernias can occur after many types of abdominal surgery, he said. After gastric bypass surgery, fat starts to disappear, allowing the intestines to become more mobile. If the hernia spaces exist, hernias are more likely to occur.

That's why bariatric surgeons now suture those spaces closed, which should substantially decrease the likelihood of an internal hernia, he said.

Herron said that, based on other studies, he doesn't believe that pregnancy after gastric bypass is generally associated with bad outcomes. He does, however, advise all of his female patients to wait at least one to two years before becoming pregnant to give their body time to heal and adjust to its new nutritional needs after surgery.

Pregnancy during this time, he said, generally isn't good for a fetus because the mother's body is in a near-starvation mode, and can't supply proper nutrition to a developing baby.

In this case, the woman became pregnant about 10 months after her surgery.

The authors of the letter wrote that their concern is that more and more women are having this procedure. In 2003, 103,000 gastric bypass operations were performed in the United States, according to the letter; 84 percent of those patients are women and most are of childbearing age. As these women lose weight, they may increase their sexual activity. And, weight loss often triggers a rise in fertility, the letter authors said.

The dramatic rise in the number of gastric bypass surgery hasn't caught the attention of only the letter's authors. On Aug. 4, the Massachusetts Department of Public Health issued new guidelines for weight loss surgery programs.

Along with detailed guidelines for health practitioners, the expert panel recommended that anyone who is having gastric bypass surgery should select a hospital that does more than 100 such surgeries a year, as well as a physician who does 50 to 100 cases annually, because they'll be less likely to have complications from the surgery.

More information

Visit the Massachusetts Office of Health and Human Services to learn more about weight loss surgery.

SOURCES: Edward Whang, M.D., attending surgeon, Brigham and Women's Hospital, and assistant professor of surgery, Harvard Medical School, Boston; Daniel Herron, M.D., chief of bariatric surgery, Mount Sinai Medical Center, New York City; Aug. 12, 2004, New England Journal of Medicine

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