Table 8.

Summary of the recommendations for post-bariatric surgery pregnancy

	Preconception	During pregnancy	Postpartum and breastfeeding
Contraception	• Reproductive health counseling pre-bariatric surgery • To avoid oral contraceptives, due to decrease the drug bioavailability post-bariatric surgery • To use long-acting reversible contraception (etonogestrel implants and intrauterine devices)
Surgery-to-conception interval	• Postponing pregnancy from 12 to 18 months post-surgery • The dramatic weight loss occurs in the first year
Nutritional intake	• Monitor the weight prior to pregnancy • In case of underweight to refer patient to clinical dietitian to correct the weight • If the pregnant is obese, it is preferable to lose weight before pregnancy to avoid obesity-related complications in pregnancy	• Monitor nutrition intake during pregnancy and assess for GWG if it is inadequate or excessive • To avoid excessive or inadequate gestational weight gain; appropriate gestational weight gain 11.5–16 kg for normal BMI as the IOM guidelines stated • Protein intake should be at least 60 g per day • Oral supplementation might be considered in case of inadequate nutrient intake or in the presence of hyperemesis gravidarum	• Ensure adequate calorie and protein during breastfeeding • Avoid excessive calories to avoid weight retention after pregnancy
Maternal and fetal screening		• Guidelines for pregnant women post-bariatric surgery should be considered as they are high-risk pregnancies as diabetic and hypertensive pregnancies • Check fasting glucose level and hgb A1C if there is a history of diabetes • Check fetal growth every 4–6 weeks of pregnancy starting from the 24th week for LGA and SGA • Oral glucose tolerance test at 24–28 weeks as possible. Noted that it was associated with dumping syndrome in some cases of post-bariatric surgery pregnancy
Laboratory assessment	• Serum indices to be checked every 3 months: full blood count, vitamins A, B12, iron, ferritin, transferrin, and folic acid • Serum indices to be checked every 6 months: serum vitamin K1, vitamin D, protein, albumin, calcium, phosphate, magnesium, and PTH. In addition to renal and liver function Other extra serum indices to be checked especially during the 1st trimester: serum zinc, copper, selenium, and vitamin E	• Serum indices to be checked every 3 months: full blood count, vitamins A, B12, iron, ferritin, transferrin, and folic acid. In addition to transcobalamin • Serum indices to be checked every 6 months: INR, prothrombin time, serum vitamin K1, vitamin D, protein, albumin, calcium, phosphate, magnesium, and PTH. In addition to renal and liver function • Other extra serum indices to be checked especially during the 1st trimester: serum zinc, copper, selenium, and vitamin E
Micronutrient’s supplementations	• Folic acid 0.4 mg should be taken daily since preconception and in the 1st trimester, 4–5 mg if obese or diabetic • Vitamin B12 taken as 1 mg IM for 3 months • Vitamin A taken as beta-carotene form. 5000 IU • If vitamin K deficiency noted to be taken orally in weekly doses • To keep vitamin D level above 50 nmol/L (1000 IU) • Add calcium as needed. 1200–1500 mg including dietary intake • Iron 45–60 mg (elemental iron) • Thiamine > 12 mg	• Thiamine supplementation 300 mg with vitamin B complex 3 times daily if pregnant women with vomiting. In case of prolonged vomiting, intravenous route should be considered • To continue with the suplmentation as periconception period • Additional supplements to be given in case of deficiencies