Obesity is defined as BMI > 30 and further subdivided into Class 1, BMI 30 to < 35; Class 2, BMI 35 to < 40; and Class 3, BMI ≥ 40 [6]. A diagnosis of obesity during pregnancy is based on the pre-pregnancy BMI. Given the growing prevalence of obesity in females ages 20–39 years, BMI has become an increasingly important aspect of preconception counseling [7]. Excess adipose tissue evolves into an active endocrine organ with harmful systemic effects, including insulin resistance and defective placental development [8]. Complications associated with maternal obesity during pregnancy include gestational hypertension, preeclampsia, gestational diabetes, preterm birth, and infants who are large for their gestational age [9]. The Barker hypothesis postulates that maternal obesity increases the propensity for adult cardiovascular disease among infants due to changes in metabolic programming in utero [10]. Thus, BS may be a suitable treatment for pre-pregnancy obesity in women that meet the established criteria.
To date, there is no consensus regarding the time interval between BS and time of conception [11]. Rapid weight loss can lead to higher fertility rates by improving menstrual regularity and relieving the symptoms of polycystic ovarian syndrome [12]. However, the dramatic weight loss following BS can hinder follicle development [13]. Studies revealed that pregnancy < 12 months following RYGB was associated with a higher incidence of urinary tract infection, inadequate birth weight, and dumping syndrome compared to pregnancies initiated 12–24 months after the procedure [14]. More research will be required to understand the full impact of the length of this interval on pregnancy outcomes.
This case is unique because of our patient’s advanced maternal age and history of two BS procedures. Fecundity begins to decline at age 32 and accelerates after age 37 due to a decrease in egg quality and levels of circulating hormones [15]. While we did not have access to her obstetrical records, our patient reported no difficulties with conception. Studies report that neonates born to mothers who had undergone RYGB surgery were more likely to have lower fetal growth rates [11]. Although our patient had undergone two BS procedures, she did not experience this complication. More research will be needed to understand the potential detrimental physiological and nutritional changes and their impact on pregnancies among women who have undergone BS.
The patient was treated with phentermine three months after the RYGB revision. The use of phentermine and topiramate as weight loss adjuncts was approved by the United States Food and Drug Administration in 2012 [16]. Studies show increased efficacy of these weight loss medications when used in conjunction with laparoscopic sleeve gastrectomy versus RYGB, in which these drugs resulted in a 2.8% versus a 0.3% loss of total body weight, respectively [17]. More data will be needed to understand the appropriate use of the adjuncts, particularly in reproductive-aged women[18].
Patients who have undergone BS should be followed up every three months for two years to screen for nutritional deficiencies [13]. Deficiencies in vitamins A, B12, K, iron, folate, and calcium can harm the health of the mother and growing fetus. After the onset of the COVID-19 pandemic in March 2020, our patient was followed by telemedicine appointments for one year. The electronic health records documenting these encounters do not indicate any desire to conceive, although our patient’s obstetrician was aware. While there are currently no specific guidelines, our patient presented at advanced maternal age and thus may have benefitted from counseling regarding pregnancy after BS.