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Recognition and Treatment of Roux-en-Y Gastric Bypass Complications in Pregnancy

Feb 21, 2014

The August 12, 2004 New England Journal of Medicine reports a complication of gastric bypass surgery that resulted in the death of a pregnant woman and her fetus (Moore, Ouyang, & Whang, 2004).

 "At 31 weeks' gestation, a 41 year-old woman (gravida 1) presented at her community hospital with midepigastric pain, nausea, and vomiting that had begun 30 minutes after she had ingested a fatty meal. She had undergone Roux-en-Y gastric bypass surgery 18 months previously but still weighed 199.6 kg (440 lb). Initial evaluation revealed a tender epigastrum without rebound. The white-cell count was 14,500 per cubic millimeter; the amylase level was 54 units per liter. The fetal heart rate was 160 beats per minute. An ultrasonographic study of the right upper quadrant was negative for gallstones. After 48 hours, the patient transferred to our obstetrical service with a presumed diagnosis of worsening pancreatitis in the setting of clinical deterioration and a rising amylase level (500 U per liter at the time of the transfer). Her temperature was 39 C (102.2 F), her heart rate was 170 beats per minute and her systolic blood pressure was 78 mm Hg. Measurements of arterial blood bas revealed a pH of 7.13 and a base deficit of 12 mmol per liter. Ultrasonography showed fetal death. The patient was intubated, and fluids and vasopressors were administered. She underwent an emergency laparotomy, which revealed that most of her small bowel was herniated through a mesenteric defect resulting from the gastric bypass surgery. Gangrenous bowel 61 cm (2 ft) length was resected. A cesarean section was performed to evacuate the non-viable fetus. Three hours postoperatively, the patient had a ventricular fibrillatory arrest and died."

A known complication after Roux-en-Y gastric bypass surgery (RYGB) in pregnant women is small bowel obstruction due to internal herniation, intussusception, or volvulus (Renault, Gyrtrup, Damgaard, Hedegaard, & Sorensen, 2012). The symptoms are often subtle and include abdominal pain, nausea, and vomiting which are common symptoms in pregnancy and can cause a delay in the recognition and treatment of RYGB complications. Identification of prior bariatric surgery in the patient's history is a critical element of the pre-natal chart and exam. Measures to improve early recognition include the following (Wax, Pinette, & Cartin, 2013):

  1. Improved education for patients, obstetricians, and surgeons of post RYGB associated complications, clinical presentation, and early evaluation if symptoms develop.
  2. Post RYGB pregnant patients presenting with abdominal complaints should be considered to have a small bowel obstruction until proven otherwise. Bariatric surgical consult should be a routine consideration upon presentation.
  3. Small bowel obstruction post RYGB is usually a surgical condition. If a pregnant patient with prior RYGB undergoes surgery in the presence of abdominal complaints, the entire small bowel should be evaluated.
  4. A CT with contrast is currently the imaging study of choice for suspected RYGB associated complications. A negative study should not preclude surgery if appropriate clinical symptoms are present.

The April 2013 edition of the American Journal of Obstetrics and Gynecology reports the following concerning women and bariatric surgery (Wax, Pinette, & Cartin, 2013):

"Over 80% of patients undergoing bariatric surgery are women, approximately half of whom are of reproductive age. The most common procedure in the United States is the Roux-en-Y gastric bypass. Small bowel obstruction is one of many recognized postoperative complications. For such a serious condition, this entity presents with remarkable subtlety and is easily misdiagnosed, particularly in pregnant women. The consequences of late recognition can be life threatening to both mother and fetus. We aim to decrease preventable maternal and perinatal morbidity and mortality by revealing diagnostic and therapeutic missteps related to Roux-en-Y gastric bypass small bowel obstruction."

REFERENCES:
Moore, K., Ouyang, D., Whang, E. (2004). "Maternal and Fetal Deaths after Gastric Bypass Surgery for Gastric Bypass Surgery for Morbid Obesity." New England Journal of Medicine, 351(7), 721-722.

Renault, K., Gyrtrup, H., Damgaard, K., Hedegarrd, M., & Sorensen, J. (2012). "Pregnant woman with fatal complication after laparoscopic Roux-en-Y gastric bypass." ACTA Obstetricia et Gynecologica  Scandinavica, 91, 873-875. Retrieved January 1, 2014 from http://web.ebscohost.com

Wax, J., Pinette, M., & Cartin, 2013). "Roux-en-Y gastric bypass-associated bowel obstruction complicating pregnancy - an obstetrician's map to the clinical minefield." American Journal of Obstetrics & Gynecology, April 2013, 265-271. Retrieved January 1, 2014 from  http://web.ebscohost.com