Sleeve gastrectomy as a bridge to maternity in a patient with obesity, infertility and tetraplegia. A case report

Abstract

Traumatic spinal cord injury (SCI) is a major cause of severe and permanent disability in young adults. Overweight and obesity are commonly observed among patients affected with SCI, with reports of a prevalence of over 60 and 30% respectively. Case report: A 34 year-old woman suffering from tetraplegia after sustaining a traumatic injury to C5-C6 at age 23 as a result of a motor vehicle accident was presented to our hospital’s multidisciplinary bariatric team due to class II obesity. At the time of presentation to the team, eleven years after the accident, her BMI was calculated to be 39 Kg/m² (weight 97 kg, height 1.57 meters). She was diagnosed with infertility while seeking pregnancy, and referred to our bariatric unit for weight loss. In addition, she had overcome the physical limitations of her injury, had a regular job and was engaged in regular physical activities such as swimming. In May 2017, she underwent laparoscopic sleeve gastrectomy (LSG) without complications and was discharged on postoperative day 2. 17 months following LSG, with a normal BMI, she became naturally pregnant. She had emergency cesarean at 35 weeks due to pneumonia but both patient and child recovered without sequelae. Currently, 4 years after surgery she maintains 37.11% total weight loss (weight 61 kg). She reports having a better quality of life with fewer medical intercurrencies. Conclusions: Patients with SCI and obesity, particularly women seeking to conceive, may be benefited by being referred to bariatric teams for assessment and treatment to improve results associated with sustained weight reduction.

Introduction

Obesity has become a major public health concern, with an increasing incidence worldwide [1]. According to the World Health Organization, 64% of Argentinians are overweight and 29.7% of them suffer from obesity [2].

Though the impact of obesity in the general population is well documented, less is reported about the impact it has on patients with spinal cord injury (SCI). Traumatic SCI is a major cause of severe and permanent disability mainly in young adults [3]. Obesity is frequent among people affected with SCI with reports of prevalence of overweight above 60 and 30% for obesity [4].

Patients with associated SCI and obesity are not only exposed to the documented health risks due to the SCI but to the additional deleterious effects of obesity [5]. A special issue for young patients suffering from SCI is parenthood, with many of them requiring assisted fertilization, which can also be challenging in patients with obesity [6–10]. Bariatric surgery is being offered worldwide for the treatment of obesity with good outcomes [11], but referral numbers for patients with concomitant SCI are unknown. We present the case of a young woman who suffered from traumatic tetraplegia, who later developed obesity and was referred from the fertility clinic after failed attempts to conceive.

Case report

A 34 year-old woman was referred to our bariatric team for evaluation. She became tetraplegic after sustaining a traumatic injury to C5-C6 at age 23 as a result of a motor vehicle accident. At the time of evaluation, her mJOA score is 3 and ASIA C [12, 13]. She has limited mobility of her left arm with total sensorimotor paralysis in both legs and right arm requiring 24 h assistance. She suffered from a neurogenic bladder requiring catheterization (with frequent urinary tract infections), impaired sleep due to snoring and severe chronic sacroiliac pain treated with opioids. At the time of the accident her body mass index (BMI) was 20 Kg/m² with an active and healthy life, but since then she started to gain weight. In addition, at the age of 29 (6 years after the accident) she consulted a Fertility Unit due to infertility. She was studied thoroughly (genetics anomalies, anatomical or functional impairments, medical interactions, etc) with no specific cause for her infertility. At that point, her BMI was > 34 Kg/m². Following two failed in vitro-fertilization (IVF) attempts, weight loss was strongly recommended, and after failing with conservative measures, she was referred to our Bariatric Unit. At the time of referral to the team, eleven years after the accident, her BMI was calculated to be 39 Kg/m² (her weight was 97 kg and height 1.57 meters). She had an unremarkable cardiac evaluation, a restrictive ventilatory defect (as was expected for her condition) and normal upper gastrointestinal endoscopy. Her case was treated in a multidisciplinary team meeting and a laparoscopic sleeve gastrectomy (LSG) was decided, confident that it would assist the patient’s weight loss without the risk of malabsorption associated with other procedures [11]. In May 2017, she underwent an uneventful LSG, and at 18 months postoperatively she had lost 39 kg, 40.2% total weight loss (TWL), achieving a normal BMI of 23.8 Kg/m². At 17 months after the LSG, she became naturally pregnant. A MDT closely monitored her case, and led to an uneventful pregnancy until 35 weeks when she delivered the baby due to maternal respiratory sepsis, with the baby and mother recovering without sequelae after two weeks in hospital. Currently, 4 years after surgery, she maintains 37.11% TWL (weight 61 kg). She reports having a better quality of life, and fewer medical intercurrencies.

Discussion

The association between disability and overweight is well documented and one is considered to be a consequence of the other, with obesity being more prevalent in disabled patients in comparison to non-disabled individuals [14]. Patients with SCI and overweight or obesity are at increased risk of premature death due to respiratory, urogenital or cardiovascular diseases [14]. Obesity in these patients is also thought to affect negatively in their rehabilitation, making exercise harder and increasing the risk for injury in the nursing staff [4]. Since SCI is mostly common in young adults, many of them manifest the need of fulfilling a sexual and reproductive life. Fertility of women with SCI is poorly addressed in the literature with only a few case reports or opinion articles published about it [15]. There’s a general opinion that fertility is unaffected in chronic SCI given that generally the hormonal status doesn’t change after the injury. Women may be able to have a normal pregnancy, with reports of at least 14% conception rate post injury [16]. However, obesity does play a significant role in reproductive disorders and is associated with anovulation, infertility and diminishing the success rate of assisted reproduction [6]. Furthermore, when needed, patients are advised to lose weight before a fertility treatment or before pregnancy in general, in order to reduce the poor obstetrical outcomes due to obesity. Sim and colleagues recently showed that losing just 6.9% of one’s baseline body weight is enough to improve pregnancy rates [10].

Several treatments are used to handle obesity in the general population such as diet therapy, physical exercise, medical and psychological follow-up and ultimately bariatric surgery, which shows the highest success rates for weight loss and resolution of comorbidities [17]. Despite these benefits, patients with SCI are very seldom referred to a bariatric center. Moreover, few cases of patients with obesity and SCI are reported in the literature [18] and to our knowledge, this is the first report on a patient with SCI, obesity and addressing fertility undergoing bariatric surgery.

Our patient is diagnosed with infertility years after her injury, with morbid obesity interpreted as the main cause. Following surgery our patient managed to lose all her excess weight, with a good nutritional status and remarkably improved her quality of life, even achieving her long-time desire of becoming pregnant and resulting in a healthy baby.

Conclusions

We hope our paper brings awareness that patients with SCI and obesity could and should be referred to bariatric teams for assessment and treatment not only to improve their quality of life in general but also to achieve their reproductive goals.

Author contributions

FAC, VMCB, and FGW drafted the manuscript. VMCB, AFB, SG, and FGW supervised the writing of the manuscript. FGW performed perioperative management and operation of the patient. All authors read and approved the final manuscript.

Competing interests

The authors declare no competing interests.