Malnutrition in pregnancy following bariatric surgery: three clinical cases of fetal neural defects

Abstract

ObjectiveBariatric surgery results in decreased food intake and a variable degree of malabsorption. Without adequate supplementation, the most common complications of this surgery are nutritional disorders. Pregnancy following surgery for obesity is a particular condition requiring strict monitoring of nutrient intake necessary for fetal development and a favourable neonatal prognosis.PatientsMalnutrition in pregnancy and congenital neural malformations are reported in three women who had previously undergone bariatric surgery (1, 5 and 18 years before pregnancy, respectively). Two patients underwent the Roux en Y bypass and one bilio-pancreatic diversion with gastroplasty. None of the three received pre-conceptional nutritional counselling. Patients 1 and 2 did not undergo postoperative nutritional surveillance; nutrient supplementation was started at 22 and 20 weeks gestation, respectively. In patient 3, supplementation was stopped at six weeks gestation.ResultsNewborns 1 and 2 presented with dorsal myelomeningocele and ventricular dilation. Both underwent surgery and a ventriculo-peritoneal shunt was inserted in the first month of life. Newborn 3 had microcephaly, bilateral microphthalmia and sensorineural deafness.ConclusionsDiet and nutritional status, before and during pregnancy, play an important role in the early processes of fetal development and neonatal outcome. Women of childbearing age who have had bariatric surgery, should be encouraged to follow a well-balanced diet as part of a weight management strategy. They should be advised to take recommended maternal supplements.

Maternal Micronutrient Deficiencies and Related Adverse Neonatal Outcomes after Bariatric Surgery: A Systematic Review

“…Data presented by Pelizzo et al (11,12) appear to derive from the same case in their 2 reports [2013 (case 2) and 2014 (case 1)]. The time interval between procedure and conception is not reported in 5 of 29 cases.…”

“…Maternal deficiency in vitamin B-12 may affect the amount of vitamin B-12 in breast milk, as reported in 2 exclusively breastfed children of mothers with a history of RYGB (30,31). Pelizzo et al (11,12) described 4 NTDs, of which 3 presented in a folate-deficient woman with RYGB and 1 in a folate-deficient woman with BPD. Another case of depleted maternal folate and vitamin B-12 concentrations accompanied with the presence of NTDs was described by Moliterno et al (34).…”

“…Vitamin B-12 deficiency in pregnancy after bariatric surgery did not always result in complications in the mother and child (29). Maternal vitamin B-12 deficiency can result in clinical neurological disease and developmental delay in the neonate (11,12,24,(30)(31)(32)(33)(34). Maternal deficiency in vitamin B-12 may affect the amount of vitamin B-12 in breast milk, as reported in 2 exclusively breastfed children of mothers with a history of RYGB (30,31).…”

Developmental programming by maternal obesity in 2015: Outcomes, mechanisms, and potential interventions

“…Bariatric surgery to induce weight loss lowers the risk of gestational diabetes mellitus (GDM), foetal macrosomia and the rate of obesity in the offspring as well as improving offspring insulin sensitivity, demonstrating that improving the maternal metabolic state prior to pregnancy is an effective intervention that improves the health of both mother and child (Kral et al, 2006;Shai et al, 2014;Smith et al, 2009). However, bariatric surgery is intrusive, high-risk, costly and can cause nutrient deficiency, the latter of which led to severe neural defects in some children conceived very soon after surgery (Pelizzo et al, 2014). A clearer understanding of the mechanisms mediating the increased risk of metabolic disease in offspring of obese women is required in order to develop less intrusive, better targeted interventions.…”

Protocols on prenatal care for pregnant women with Zika infection and children with microcephaly: nutritional approach

“…26 c) A more specific approach, many situations of nutritional deficiencies are capable of producing poor formation of SNC, including changes in the cerebral cortex, spinal bifida, microcephaly, and even instances of anencephaly and anophthalmia. 27 There would be cases extensively documented in experimental level and clinical, according to the severe energetic protein malnutrition, iodine, folate, B12, vitamin D, biotin, zinc, selenium deficiencies and other nutrients. These deficiency problems are found frequently in our pregnant women, with prevalence ranging from 5% to 40%.…”