Wonder Iron?

Iron-deficiency anemia is the number one complication after all forms of weight loss surgery, but more so with RNY gastric bypass – the most popular form of WLS to date.  With more and more women turning to WLS to conceive, it can be a scary statistic, given that women are prone to anemia to begin with.

JAMA recently published a study regarding prenatal micronutrient supplementation in Nepal, a country rife with iron-deficient anemia.  This study looked at the impact of various supplements and their affects on motor and intellectual affects a few years after birth.  It reveals that prenatal iron and folate are absolutely critical.

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Suggested Pregnancy Labs

On June 8, 2010, in Pregnancy after WLS, Tests, by Andrea

So you’ve peed on a stick and you’re pregnant post WLS.

Now what?

Well.  That’s quite the question, isn’t it?  And the answer is multi-faceted depending on which surgery you’ve had, how far out you are, etc.

But for now let’s tackle blood tests.

I’ve had two kids post RNY Gastric Bypass.  And I’ve learned a few universal truths from those two pregnancies:

  1. most doctors have no clue what to do with pregnant WLSers (including the surgeons that DID this to us!)
  2. ask three medical professionals what to do and you’ll get three completely contradictory answers
  3. not enough attention was paid to my nutrition, despite seeing a nutritionist associated with my OB as evidenced by extremely low ferritin, serum iron, b12, and vitamin D levels

With this in mind, knowing what I know now, I’ve put together a list of suggested labs for the post-WLS patient.  These are not to be construed as medical advice, but simply if I were to end up pregnant tomorrow (and that had better not happen or Mirena and I will be having a long discussion requiring lawyers and a check with many $0′s…), this is what I would tell my doc that I wanted drawn and why.  (And yes, I really do walk into a doc’s office with lists of labs to draw.  If they don’t like it, I go somewhere else.)

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I believe in stronger testing and vitamin supplementation than this article, but this is pretty comprehensive none-the-less.

A few takeaways -

  • generally recommended that women avoid pregnancy until 12-18 months, or until weight stabilizes
  • oral contraceptives poorly absorbed after RNY and transdermal patch has decreased efficacy in patients over 198.4lbs (90kg); recommended use of IUC’s or injections with regular use of condoms for full efficacy
  • iron, B12, folate, and calcium deficiencies most notable problems in post-RNY pregnancies; no data to exist demonstrate higher protein requirements during pregnancy unless weight loss or fetal growth is slow
  • folate deficiency great concern due to neural tube defects – however deficiency is rare
  • post-RNY patients should be supplemented with 40-65mg iron, 1200-1500mg calcium citrate, B12
  • post-RNY patients may not tolerate traditional 50-gram or 100-gram glucose tolerance test due to dumping; rather do 2-hour post paradinal test
  • follow hemoglobin, hematocrit, serum iron, ferritin, erythrocyte folate, methylmalonic acid, albumin, prealbumin, serum calcium, phosphate, and 25-hydroxy vitamin D levels; erythrocyte folate is better indicator of true deficiency and MMA is more sensitive in detecting vitamin B12 deficiency
  • RNY may lead to serious GI complications during pregnancy, most notably internal hernia resulting in small bowel obstruction
  • most common complications following gastric banding were band leakage and band migration – both requiring surgical intervention

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As if some of us needed yet MORE reasons..

From Medscape:

Higher Pre-Pregnancy BMI Linked to Major Heart Defects

NEW YORK (Reuters Health) Feb 01 – A higher pre-pregnancy body mass index (BMI) correlates with an increased risk of congenital heart defects, particularly conotruncal and right ventricular outflow tract (RVOT) defects, according to a recent study.

Common types of conotruncal defects include tetralogy of Fallot, truncus arteriosus, transposition of the great vessels, and double outlet of the right ventricle. RVOT defects include pulmonary atresia and pulmonary valve stenosis.

“Given the increased prevalence of pre-pregnancy obesity, the increased risk of alterations in glucose metabolism among women who are overweight or obese, and the association of maternal pregestational diabetes mellitus with congenital heart defects, it is valuable to clarify the association between pre-pregnancy BMI and congenital heart defects,” lead author Dr. Suzanne M. Gilboa, of the Centers for Disease Control and Prevention, Atlanta, and colleagues write.

As reported in the American Journal of Obstetrics and Gynecology for January, the researchers used data from the National Birth Defects Prevention Study (1997-2004) to study links between pre-pregnancy weight and congenital heart defect phenotypes. The data came from 6440 infants with defects and 5673 control infants.

Mothers were categorized as underweight, normal weight, overweight, moderately obese, or severely obese according to standard BMI criteria.

Overweight, moderate obesity, and severe obesity increased the odds of a congenital heart defect by 16%, 15%, and 31%, respectively, relative to normal weight.

Overall, above-normal BMI (>25 kg/meters-squared) was associated with a number of phenotypes, including conotruncal defects in general (OR 1.16) and tetralogy of Fallot in particular (OR 1.24), total anomalous pulmonary venous return (OR 1.53), hypoplastic left heart syndrome (OR 1.32), RVOT defects in general (OR 1.34) and pulmonary atresia (OR 1.55) and valve stenosis (OR 1.36) in particular, septal defects in general (OR 1.15) and secundum atrial septal defects (OR 1.29) in particular.

“Given the increased prevalence of obesity and the public health importance of congenital heart defects, further work is warranted to determine the extent to which…type of obesity, patterns of dieting and weight change before and during pregnancy, physical inactivity, and inadequate levels of essential vitamins and nutrients, play a role in the associations with congenital heart defects,” the researchers conclude.

Am J Obstet Gynecol 2010;51:e1-e10.

The WLS world is buzzing today.  And being the conformist that I am, you know that I’m going to add to it — right?  Cause I’m so meek and un-opnionated and all.  (you really should have put that drink down before reading that, eh?)

So one of our stars — Carnie Wilson — had her new show on last night.  I didn’t watch it.  No other reason than I was desperate for the silence.  To be honest, I’m not certain I get that channel anyway.  But after a day of two sick kids whining, a sick husband that I will not discuss too much in the blog because he may actually read this, and children’s programming droning on and on all day long, I longed for silence.  The TV was off as soon as the kids went to bed.  Not that I could have concentrated on a show because the kids did not actually go to sleep, just to bed.  Which is a misnomer as well since the toddler can get out of his bed and does not appreciate “bed time” as much as I do.

In any case, without having watched the show, I can still gather what happened on the show from all of the buzz.   Carnie has regained weight from her low weight after gastric bypass.  Considering her two pregnancies post RNY and her cross-addictions, her life in the spotlight, and all of the stress therein — not shocking.  Hell, I’ve been in her shoes for part of this, and so I get where she is.

Twice, actually.

And until you’ve been pregnant post RNY, don’t you dare condemn her.

Let me tell you something about post RNY pregnancy:  RNY rules go completely out the window.

RNYers are told to go protein first.  But when pregnant, you have to stay out of ketosis to avoid fetal brain damage.  So that sandwich?  Yeah, eat it.

RNYers are supposed to lose weight.  But when pregnant, you’re supposed to gain it.  So the scale is supposed to go up?  Wha?

And vitamins.  Really?  Who do you listen to?  The OB who has never had an RNY patient in their entire career?  The skinny nutritionist that is only going off book learning?  The surgeon who hasn’t had a nutrition class in ten years and is male (and thus has never had the hormones swimming through his veins that are making you want that doughnut from Krispy Kreme?).  Cause, well, each tells you something completely different and are completely contradicting each other.

How about that special level of hell called a glucose tolerance test that determines gestational diabetes?  50g of glucose in a slightly carbonated, traffic-cone orange syrupy-sweet liquid form that can reduce a hormonal RNYer into a fetal ball of hypoglycemic dumpage in ten minutes flat.  It’s great when our doctors guilt us into this test — “if you don’t do this, you’re putting your baby at risk” — and I wish I were kidding on that but yes I was told that very line.  This is the guilt trip I got by telling the doctor that I would NOT put myself through this I would be putting my baby at risk despite the fact that dumping and the severe reactive hypoglycemic reaction that I WOULD HAVE would maybe stress the baby and put the baby at risk.  Because telling a mother-to-be this is just what we should do, yes?

Each prenatal appointment had a scale — banishing my own did no good.  I cannot tell you how hard it is to see the scale go up.  And up.  And up more.  Knowing that it HAD to go up for the safety of the baby.  Knowing that I had to eat despite not really wanting to.  How many times I stared at my reflection in the mirror in horror — where normal mothers would stare in awe at their bellies I would be in disgust at the fat — because I didn’t get a cute baby belly — my skin just filled back out with fat.  It was ironic that when I was fat people thought I was pregnant and when I was pregnant people just thought I was fat.  Jeans I swore I’d never wear again, but had kept “just in case” were pulled back out and worn again.  Stores I swore I’d never walk back in?  Yeah, you guessed it.

I had horrible hypoglycemia with my first pregnancy.  To the tune of passing out every five minutes.  We couldn’t figure it out — until I added in a SERIOUS amount of simple carbs back into my life.  Guess what — they ARE addictive.  Do you know how hard it is to get those back out of your life after you’re told to rely on them to keep you upright for 9 months?  While trying to deal with all the hormones that come with pregnancy?  OMG my house was not a happy place to be after the baby came — detox off carbs AND post-partum hormones?  It’s a wonder I didn’t end up divorced.

The family

But all of this was mixed with happiness of having a child.  Knowing that I had this surgery that gave me the opportunity to have a baby.  If I had not had the surgery, there was a chance of not having a child.  I’ll never know since I never tried to get pregnant prior to surgery.

And then there’s the “after.”

Some women are lucky to lose all their pregnancy weight — and some even lost more than their pregnancy weight.  I wasn’t that lucky.  Sure, I lost some of it, but not all of it.  I wasn’t one of the lucky ones.  I had to work at it.  Even now, I’ve recently just lost all of my pregnancy weight from my first post op pregnancy.

The point is this — it’s easy to sit back and criticize and judge someone — especially someone who is out there in the spotlight.  But unless you’ve been in those shoes you have no idea what it’s like.  A post-op pregnancy is not like a standard pregnancy at all.  It bends, if not breaks WLS rules — and sometimes it’s really really hard to go back to those rules after almost a year off them.  It takes seven days to make a habit — so what happens in 40 weeks?

Carnie is one of us.  She has the same struggles as we all do, but we have one luxury that she doesn’t have — privacy.  Maybe she could choose to make her life a bit less public, but to some degree, her life will never be private given her past.  So let’s give her what we would all want for ourselves — support and compassion.  Cause who knows — maybe YOU would end up in the same position as she is in, despite saying “That will never be me.”

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