Tubal Reversal and Obesity Risks

I have a high bmi can the tubal reversal still be done?

Dr. Pabon after surgery 2013

This is a question that we received in an email this weekend.

The answer is yes. Unfortunately, just because I can do something, it does not mean that it should be done.

The question should not be not only about whether a tubal reversal is a difficult or risky procedure for a patient with a high BMI, but should address the subsequent high risk pregnancy that may result.

Please “Google”   “Obesity and Pregnancy Risk”    “Obesity and Surgical Risk”

I spend a significant amount of my time counseling patients about the importance of good health before elective procedures, IVF, and pregnancy. This is only because there is a large amount of scientific data supporting this. It is difficult to tell a lady that her BMI is too high. I try to be sensitive and bring up my own struggles with weight. Nonetheless, some patients don’t listen and some are sometimes offended.

Regarding elective surgery like a microsurgical tubal reversal, it is in the best interest of the patient to help to make the procedure as safe as possible. Obese patients have a higher risk of many surgical complications. It makes sense to try to become more fit for the surgery and the subsequent pregnancy.

Regarding IVF, many studies have shown a lower chance of pregnancy in obese patients and a higher risk of many subsequent complications in the pregnancies that are achieved.

As many of you know, I am a fan of a low carbohydrate lifestyle. I often recommend it. I also inform patients about Weight Watchers programs. I am not a fan of “bariatric surgery.” In may opinion, the main problem leading to the obesity epidemic is our over-indugence in a high energy diet full of sugar, flour, and all forms of Carbs.

Sincerely,

Julio E. Pabon, M.D.

Sarasota and Bonita Springs Florida

www.geneticsandfertility.com

Please read the attached documents for detailed information about this subject:

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Number 549, January 2013

(Replaces Committee Opinion Number 315, September 2005)

Committee on Obstetric Practice

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Obesity in Pregnancy

ABSTRACT: In the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese, putting them at a greater risk of pregnancy complications. Therefore, preconception assessment and counseling are strongly encouraged for obese women and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy, as well as encouragement to undertake a weight-reduction program. At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of body mass index (calculated as weight in kilograms divided by height in meters squared), and recommendations for appropriate weight gain should be reviewed at the initial visit and periodically throughout pregnancy. Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated. Obese patients undergoing cesarean delivery may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight heparin. For all obese patients, anesthesiology consultation early in labor should be considered, and consultation with weight-reduction specialists before attempting another pregnancy should be encouraged.

The prevalence of obesity in the United States has increased dramatically over the past 25 years. The recent National Health and Nutrition Examination Survey found that in the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese (1). The obesity problem is greatest among non-Hispanic black women (50%) compared with Mexican American women (45%) and non-Hispanic white women (33%) (1).

In 2009, the Institute of Medicine (IOM) published revised pregnancy weight gain guidelines that are based on prepregnancy body mass index (BMI) ranges recommended by the World Health Organization. These ranges are independent of age, parity, smoking history, race, and ethnic background (2, 3). The revised IOM recommendations define normal weight as a BMI of 18.5–24.9, overweight as a BMI of 25–29.9, and obesity as a BMI of 30 or greater. The IOM guidelines do not differentiate between Class I obesity (BMI=30–34.9), Class II obesity (BMI=35–39.9), and Class III obesity (BMI≥40) (2).

Pregnancy Complications

Overweight and obese women are at increased risk of several pregnancy complications, including gestational diabetes mellitus, hypertension, preeclampsia, cesarean delivery, and postpartum weight retention (4–8). Similarly, fetuses of pregnant women who are overweight or obese are at increased risk of prematurity, stillbirth, congenital anomalies, macrosomia with possible birth injury, and childhood obesity (9, 10). Additional concerns include potential intrapartum, operative, and postoperative complications and difficulties related to anesthesia management. Obese women are also less likely to initiate and sustain breastfeeding (11).

Maternal Complications

In a prospective multicenter study of more than 16,000 patients, a BMI of 30–39.9 was associated with an increased risk of gestational diabetes mellitus (odds ratio [OR], 2.6 and 4.0), gestational hypertension (OR, 2.5 and 3.2), preeclampsia (OR, 1.6 and 3.3), and fetal macrosomia (OR, 1.7 and 1.9), when compared with a BMI of less than 30 (7). In this same study, the cesarean delivery rate was 20.7% for women with a BMI of 29.9 or less, 33.8% for women with a BMI of 30–34.9, and 47.4% for women with a BMI of 35–39.9. Other studies have consistently reported higher rates of preeclampsia, gestational diabetes mellitus, and cesarean delivery (particularly for arrest of labor) in obese women than in nonobese women (4–6).

At least three cohort studies suggest that obesity is an independent risk factor for spontaneous abortion among women who undergo infertility treatment (12–14). In recognition of this association, it is recommended that health care providers encourage obese women to lose weight before beginning infertility therapy. Data also link obesity with spontaneous abortion among women who conceive naturally (15).

Fetal Complications

When counseling obese women about potential pregnancy complications, it is important to inform them of the associated fetal risks, including prematurity, stillbirth, congenital abnormalities (eg, neural tube defects), macrosomia, and childhood and adolescent obesity. Some studies have reported a higher rate of premature delivery for obese women than for women of normal weight (4, 16). However, in a study of more than 2,900 obese women, prepregnancy obesity was associated with a lower rate of spontaneous preterm birth (17). A large Swedish cohort study reported a greater risk of antepartum stillbirth among obese patients than among women who had a BMI of less than 20 (16).

Obese pregnant women are more likely to give birth to an infant with congenital anomalies (9), and obesity also lowers detection rates of fetal anomalies during prenatal ultrasonography (18). Data establish that the risk of neural tube defects among obese pregnant women is double that of pregnant women of normal weight after correcting for diabetes as a potential confounding factor (19–21). The benefit of the administration of folic acid doses higher than 400 micrograms per day has not been studied in obese pregnant women without diabetes.

Multiple studies have shown that maternal obesity and excessive weight gain during pregnancy are associated with large-for-gestational-age infants (5, 22–24). Furthermore, these large-for-gestational-age infants are at increased risk of childhood and adolescent obesity (6, 25, 26). Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 g in women without diabetes and greater than 4,500 g in women with diabetes (27).

Intrapartum Complications

It is important to discuss potential intrapartum complications with obese women, such as the challenges associated with anesthesia management and the increased risk of complicated and emergent cesarean delivery. Other potential problems include difficulty estimating fetal weight (even with ultrasonography) and the inability to obtain interpretable external fetal heart rate and uterine contraction patterns.

Anesthesia Management

If an anesthesiology consultation was not obtained antepartum, it should be conducted early in labor to allow adequate time for the development of an anesthetic plan. The use of epidural or spinal anesthesia is recommended in the obese pregnant patient when anesthesia is needed or elected; however it may be technically difficult or impossible to administer this type of anesthesia because of obscured landmarks, difficult positioning, and excessive layers of adipose tissue. Alternatively, the use of general anesthesia in obese pregnant women also poses several challenges, including difficult endotracheal intubation due to excessive tissue and edema (28) and intraoperative respiratory events from failed or difficult intubation (29).

Cesarean Delivery

Operative and postoperative complications among obese pregnant women include increased rates of excessive blood loss, operative time greater than 2 hours, wound infection, and endometritis (30–32). Sleep apnea occurring in this group of women may further complicate anesthetic management and postoperative care (33).

Obese women who require cesarean delivery have an increased incidence of wound breakdown and infections (31, 34). Antimicrobial prophylaxis is recommended for all cesarean deliveries unless the patient is already receiving appropriate antibiotics (eg, for chorioamnionitis) (35). For obese women who require cesarean delivery, consideration should be given to using a higher dose of preoperative antibiotics for surgical prophylaxis (36). Attempts to decrease the incidence of wound breakdowns and infections that have been studied include closure of the subcutaneous layers and the placement of subcutaneous drains. Investigators have demonstrated that suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption (37, 38). However, postoperative placement of subcutaneous draining systems has not consistently been shown to be of value in reducing postcesarean delivery morbidity (39, 40).

Because of an increased risk of venous thromboembolism, placement of pneumatic compression devices before cesarean delivery is recommended for all women not already receiving thromboprophylaxis (41). Obese patients, especially those who are hospitalized and immobile, may be at increased risk of thromboembolism. Individual risk assessment will lead some health care providers to plan thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight (LMW) heparin in such patients (42). However, cesarean delivery in the emergency setting should not be delayed because of the timing necessary to implement thromboprophylaxis (41). Postpartum unfractionated heparin or LMW heparin prophylaxis has been recommended for patients thought to be at high risk of venous thromboembolism (43, 44); however, data are insufficient to determine whether the benefits of unfractionated heparin or LMW heparin prophylaxis in this group of patients outweigh the risks (45, 46).

Because of the increased likelihood of complicated and emergent cesarean delivery, extremely obese women may require specific resources, such as additional blood products, a large operating table, and extra personnel in the delivery room. Particular attention to the type and placement of the surgical incision is needed (ie, placing the incision above the panniculus adiposus) (34, 47). There are additional logistical challenges to monitoring labor and performing an emergent cesarean delivery in the extremely obese patient. Therefore, these patients should be counseled about these possible complications of an emergent cesarean delivery.

Bariatric Surgery Considerations

The number of obese reproductive-aged women undergoing bariatric surgery is increasing (48). Although maternal gastrointestinal complications, including obstruction and hemorrhage, can occur as a result of this procedure, the incidence is infrequent (49, 50). Furthermore, pregnancies after bariatric surgery are less likely to be complicated by gestational diabetes mellitus, hypertension, preeclampsia, and macrosomia than are pregnancies of obese women who have not undergone such surgery (51, 52).

Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium. Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary (53). Bariatric surgery is not an independent indication for cesarean delivery (54).

Counseling

Obese women are at increased risk of several pregnancy complications; therefore, preconception assessment and counseling are strongly encouraged. Obstetricians should provide education about the possible complications and should encourage obese patients to undertake a weight-reduction program, including diet, exercise, and behavior modification, before attempting pregnancy. Specific medical clearance may be indicated for some patients.

At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain should be reviewed both at the initial visit and periodically throughout pregnancy (3). The 2009 IOM guidelines recommend a total weight gain of 15–25 lb (6.8–11.3 kg) for overweight women (BMI=25–29.9) and 11–20 lb (5.0–9.1 kg) for all obese women (BMI ≥ 30). (For an online BMI calculator, see http://www.nhlbisupport.com/bmi). Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy. Because these patients are at increased risk of emergent cesarean delivery and anesthetic complications, anesthesiology consultation early in labor should be considered (22).

Recommendations

Recommendations for obese women who are pregnant or planning a pregnancy include the following:

  • Preconception assessment and counseling are strongly encouraged and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy and encouragement to undertake a weight-reduction program.
  • At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain, guided by IOM recommendations, should be reviewed both at the initial visit and periodically throughout pregnancy.
  • Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy.
  • Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation, when indicated, because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium.
  • For patients undergoing cesarean delivery who have additional risk factors for thromboembolism such as obesity, individual risk assessment may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or LMW heparin.
  • Consideration should be given to using a higher dose of preoperative antibiotics for cesarean delivery prophylaxis.
  • The use of suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption.
  • Anesthesiology consultation early in labor should be considered.
  • Consultation with a weight-reduction specialist before attempting another pregnancy should be encouraged.

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Copyright January 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Obesity in pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:121;213–7

As seen on HealthDay News in 2011:

Obesity May Increase Risk of Surgical Complications

Inflammation, infection much more likely following elective procedures, study shows

FRIDAY, July 8 (HealthDay News) — Obese people who have elective surgery are nearly 12 times more likely to suffer from complications than those of normal weight, new research indicates.

Since data on surgical outcomes are often used by insurance companies, the Johns Hopkins researchers argued that the findings should change how doctors and hospitals are reimbursed for more complex procedures or penalized for higher complication rates.

Operations on obese patients are more demanding because they take longer and the operating fields are deeper, study leader Dr. Marty Makary, an associate professor of surgery, explained in a Hopkins news release. Obese patients who undergo surgery are also at greater risk for surgical site infection and slower healing because of reduced blood flow in fat tissue, Makary noted. Despite these added risks, Makary noted, “payments are based on the complexity of the procedure and are not adjusted for the complexity of the patient.”

The study is published online in the journal Plastic and Reconstructive Surgery.

In conducting the study, researchers examined insurance claims, identifying 2,403 obese patients and 5,597 normal weight patients who underwent elective breast procedures, such as breast lifts, reductions and augmentations, between 2002 and 2006.

Within 30 days of surgery, 18.3 percent of the obese group experienced at least one complication, compared to 2.2 percent of non-obese patients. More specifically, obese patients were 22 times more likely to have inflammation, 13 times more likely to develop infection and 11 times more likely to experience pain.

The findings are significant, given that 34 percent of adults in the United States are estimated to be obese — up from just 15 percent a decade ago. Meanwhile, the number of people having elective plastic surgery is also on the rise. Annual plastic surgery volume increased 725 percent between 1992 and 2005. Despite the trend, the study’s authors concluded the increased risk of complications could deter some surgeons from taking on these higher-risk obese patients.

“It’s more work, and it’s a more complex surgery, as opposed to operating on a thin patient. And the payment is the same,” Makary pointed out. “There are definitely incentives there for surgeons and institutions to select healthier patients. They’re getting reimbursed less per unit of work for obese patients.”

The researchers concluded that more research is needed to determine the role obesity plays in a wider range of surgeries so that new standards can be established to account for any differences, particularly increased risks.

More information

The American Heart Association details some of the cardiac risks associated with surgery in obese patients.

 

FDA and EPA advice about fish consumption and pregnancy

FDA News Release

FDA and EPA issue draft updated advice for fish consumption for persons trying to conceive, pregnant, or breastfeeding.

For Immediate Release

June 10, 2014

The U.S. Food and Drug Administration and the U.S. Environmental Protection Agency today issued draft updated advice on fish consumption. The two agencies have concluded pregnant and breastfeeding women, those who might become pregnant, and young children should eat more fish that is lower in mercury in order to gain important developmental and health benefits. The draft updated advice is consistent with recommendations in the 2010 Dietary Guidelines for Americans.

Previously, the FDA and the EPA recommended maximum amounts of fish that these population groups should consume, but did not promote a minimum amount. Over the past decade, however, emerging science has underscored the importance of appropriate amounts of fish in the diets of pregnant and breastfeeding women, and young children.

“For years many women have limited or avoided eating fish during pregnancy or feeding fish to their young children,” said Stephen Ostroff, M.D., the FDA’s acting chief scientist. “But emerging science now tells us that limiting or avoiding fish during pregnancy and early childhood can mean missing out on important nutrients that can have a positive impact on growth and development as well as on general health.”

An FDA analysis of seafood consumption data from over 1,000 pregnant women in the United States found that 21 percent of them ate no fish in the previous month, and those who ate fish ate far less than the Dietary Guidelines for Americans recommends—with 50 percent eating fewer than 2 ounces a week, and 75 percent eating fewer than 4 ounces a week. The draft updated advice recommends pregnant women eat at least 8 ounces and up to 12 ounces (2-3 servings) per week of a variety of fish that are lower in mercury to support fetal growth and development.

“Eating fish with lower levels of mercury provides numerous health and dietary benefits,” said Nancy Stoner, the EPA’s acting assistant administrator for the Office of Water. “This updated advice will help pregnant women and mothers make informed decisions about the right amount and right kinds of fish to eat during important times in their lives and their children’s lives.”

The draft updated advice cautions pregnant or breastfeeding women to avoid four types of fish that are associated with high mercury levels: tilefish from the Gulf of Mexico; shark; swordfish; and king mackerel. In addition, the draft updated advice recommends limiting consumption of white (albacore) tuna to 6 ounces a week.

Choices lower in mercury include some of the most commonly eaten fish, such as shrimp, pollock, salmon, canned light tuna, tilapia, catfish and cod.

When eating fish caught from local streams, rivers and lakes, follow fish advisories from local authorities. If advice isn’t available, limit your total intake of such fish to 6 ounces a week and 1-3 ounces for children.

Before issuing final advice, the agencies will consider public comments, and also intend to seek the advice of the FDA’s Risk Communication Advisory Committee and conduct a series of focus groups.

From Dr. Pabon: Please keep up to date by following the final recommendations from the FDA.  My most practical advice is to try to limit the consumption of fish products from fish “higher in the sea food chain” as mercury levels seem to concentrate in the top predators like shark, grouper, and swordfish.

J. Pabon, M.D.

Sarasota and Bonita Springs, Florida

Julio E. Pabon, M.D. 2014
Julio E. Pabon, M.D. 2014

Dr. Pabon’s Best Wishes For Father’s Day

Twins Happen
Twins Happen

 

My little guy, James (11), has been asking me many questions about my likes and preferences.  I did not catch on that father’s day was close.  My wife finally told me friday morning that he has been planning to make a gift for me.  I told her that all I wanted was time and memories.  Later, my eyes teared as I drove to the office when I thought about my boys and the fact that both of them prefer time and memories over material things.

Holidays have become very materialistic.  Many of us are concerned about the next gift to give or receive.  Instead, it is important to use the dates to center ourselves about our religions, our veterans, our presidents, our heroes, our mothers and fathers.

Remember fathers:

The time we share is the greatest gift.

Father and Son being silly
Father and Son being silly

Best wishes to all.

Most Sincerely,

Julio E. Pabon, M.D.

Sarasota and Bonita Springs, Florida

U.S.A.

Julio E. Pabon, M.D. 2014
Julio E. Pabon, M.D. 2014