Contraceptive Use in Women Having Bariatric Surgery: A Q&A

May 1, 2015

Pregnant_womanMore and more reproductive-age women are undergoing bariatric surgery, but the American Congress of Obstetricians and Gynecologists recommends delaying pregnancy following the surgery to get past the period of highest weight loss.

Lead researcher Iris Tong, MD, director of Women’s Primary Care at the Women’s Medicine Collaborative, and colleagues at the Women’s Medicine Collaborative and The Miriam Hospital, set out to study if women of reproductive age undergoing bariatric surgery are using contraception and being counseled about contraceptive options.

What is the importance of contraceptive counseling for women undergoing bariatric surgery?  

Iris Tong, MD: There has been concern about fetal growth restriction in women who become pregnant immediately after bariatric surgery. That’s why The American Congress of Obstetricians and Gynecologists recommends women delay pregnancy for 12 to 24 months following bariatric surgery, as this is the period of greatest weight loss. In addition, weight loss leads to more regular ovulation and improved fertility, and women who may have had difficulties becoming pregnant before bariatric surgery may experience regular menstrual cycles and increased fertility after the surgery. Contraceptive use immediately after bariatric surgery is important not only to decrease unplanned pregnancies, but to help women plan for a pregnancy at a time in their lives that is safer and healthier for the fetus.

What do women learn during contraceptive counseling?  

Iris Tong, MD: There are many different available contraception options today. Each method has advantages and potential side effects, and choosing the right method for an individual patient can optimize adherence. Contraceptive counseling involves a discussion between patients and providers to review a patient’s personal preferences, as well as a method that is best for that individual. Successful contraceptive counseling will ultimately result in choosing the best contraceptive option for each individual patient.

What did this study determine and what makes it unique?  

Ghada Bourjeily, MD, attending physician in pulmonary services and obstetric medicine, and director of research at the Women’s Medicine Collaborative:

The goal of the study was to examine contraception methods in women of reproductive age being evaluated for bariatric surgery or who have already had bariatric surgery and educate patients and providers about the importance of contraceptive counseling in women undergoing bariatric surgery. The study is unique in how it highlights an important issue in the care of obese reproductive-age women considering contraceptive options. Adverse pregnancy outcomes are associated with both obesity and pregnancy soon after bariatric surgery, and that is why contraceptive counseling is key while these women work with their providers to better plan for a pregnancy and optimize their health for more successful outcomes for mother and baby.

What changes occur in a woman’s body following bariatric surgery?

Siva Vithiananthan, MD, chief of minimally invasive and bariatric surgery at The Miriam Hospital:

For the first 18 to 24 months after bariatric surgery, a patient is actively losing weight. During this time, there could be significant fluctuations in maternal protein and vitamin levels (especially vitamin B12, folate). This is usually monitored closely by the surgeon and the other providers such as the obstetrician and the obstetric medicine provider so that adequate supplementation is provided to maintain a steady level of maternal nutrient levels. During this time, getting pregnant can significantly alter these maternal levels, possibly impacting the health of the pregnancy and the developing fetus. What is especially dangerous is the inadequate development of the neural tube, which is essential for a normal nervous system. This is due to abnormal folate levels even before a patient recognizes that she is pregnant, and might result in serious neurological damage to the developing fetus. Additionally, there is a concern about low birth weight and prematurity.

The current recommendation is to wait close to 24 months after bariatric surgery and ensure steady nutrition levels before planning a pregnancy under the guidance of an obstetric team that specializes in high-risk and medically complicated pregnancies. Close observation of the nutritional status and nutrient levels prior to pregnancy is crucial, as is maintenance of these levels throughout the pregnancy. A healthy pregnancy and a healthy, normal weight baby usually follow a planned pregnancy that occurs after bariatric surgery.

In some instances, losing significant weight from successful bariatric surgery aids in a successful pregnancy for patients who previously could not get pregnant or carry a pregnancy. The weight loss allows for hormonal and physical conditions to improve for pregnancy. This is another important reason to ensure adequate contraception use – since the chance of accidental pregnancy is higher after surgery – and patients should be aware of this.

How does this study help health care providers help their patients?  

Siva Vithiananthan, MD:Even though we discuss delaying pregnancy after surgery with patients in at least three or four different settings and in different forums prior to surgery, it is obvious that understanding of this risk is not universal. Patients who have understood the importance do practice some form of contraception, while those who are unaware are less likely to do so. There could be many reasons for this, including lack of knowledge, an infertility experience before surgery, and not having an obstetrician. The contraception conversation should occur preoperatively among the surgeon, patient and obstetrician. We need to go beyond the discussion of delaying pregnancy. Contraception education and various contraception options should be a discussion between a patient and her obstetrician or input should be sought from a primary care provider before surgery.

For more information, please contact Women’s Primary Care at the Women’s Medicine Collaborative by calling 401-793-5700 or by clicking here or The Miriam Hospital Bariatric Surgery hotline at 401-793-3922 or by clicking here.

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