Managing Dumping Syndrome During Pregnancy After Bariatric Surgery

Dumping syndrome following bariatric surgery is a common occurrence, yet its occurrence during pregnancy is rare, largely due to the advised avoidance of pregnancy shortly after the surgical procedure. This particular case underscores the critical importance of post-bariatric surgery pregnancy prevention. We present the case of a 35-year-old woman who, after struggling with subfertility for eight years, unexpectedly became pregnant just three months following gastric bypass surgery. This unexpected pregnancy arose due to the absence of contraceptive measures post-surgery. Throughout the pregnancy, she experienced complications marked by recurring episodes of hypoglycemia linked to dumping syndrome. Healthcare providers in primary care settings should maintain a heightened awareness and suspicion of dumping syndrome among pregnant women with a history of obesity who have undergone bariatric surgery.

Introduction on Dumping Syndrome

Dumping syndrome is not a singular ailment but a collection of symptoms categorized as early or late manifestations. Early dumping syndrome typically exhibits vasomotor and gastrointestinal symptoms occurring within an hour after meals, whereas late dumping syndrome presents with postprandial hypoglycemia occurring 1–3 hours post-meal ^[1]. This syndrome is recognized as one of the complications following bariatric surgery. Given the escalating prevalence of obesity worldwide, bariatric surgery has become increasingly common among women of reproductive age. Presently, no consensus exists regarding the optimal timing for conception following bariatric surgery, though a delay of at least one year is generally advised ^[2]. In cases of unplanned pregnancy, bariatric surgery correlates with dumping syndrome and nutrient deficiencies in mothers, as well as the potential for offspring to be born small for gestational age ^[3]. Additionally, it’s worth noting that the symptoms of dumping syndrome might be mistaken for early signs of pregnancy.

Case Presentation

Patient Profile

• Age: 35 years
• Obstetric History: Gravida 3, para 0+2
• Medical Background:

1. Polycystic Ovarian Syndrome
2. Hypertension
3. Type 2 Diabetes Mellitus
4. Obesity (BMI: 44.3 kg/m²)

• Primary Subfertility: Experienced for eight years

Medical Intervention

Bariatric Surgery

• Reason: Failure of intensive lifestyle modification
• Procedure: Laparoscopic Roux-en-Y gastric bypass
• Outcome: Successful with a weight reduction of 16 kg within three months
• Improvement: Remission of hypertension and type 2 diabetes mellitus

Pregnancy Complications

• Conception Shortly After Surgery
• Development of Hypoglycemic Symptoms During Pregnancy

Surgeon’s Advice and Pregnancy Timing

• Recommendation: Surgeon advised delaying pregnancy for at least one year post-surgery.
• Lack of Contraception: Unfortunately, no contraception was provided.
• Conception Timing: Despite the advice, she conceived three months after surgery.
• Clinic Booking: Attended health clinic at 8th week of gestation.
• Weight and BMI: We weighed 109 kg with a 38.6 kg/m² BMI.

Medical Testing and Symptoms

Oral Glucose Tolerance Test (OGTT):

1. Reason: High risk of type 2 diabetes mellitus.
2. Symptom Onset: Experienced giddiness, sweating, nausea, and palpitations about 2 hours post-OGTT ingestion.
3. Symptom Perception: Symptoms mistaken for early pregnancy signs.
4. Results: Fasting blood glucose level of 4.9 mmol/L and 2-hour postprandial blood glucose level of 3.2 mmol/L.

Diagnosis and Subsequent Episode

• Late Dumping Syndrome Diagnosis: Based on the history of bariatric surgery.
• 24th Week Episode: Experienced sweating, nausea, tremors, and palpitations 1 hour after drinking tea.
• Contributing Factor: Recent non-adherence to post-bariatric surgery diet.

Additional Medical Tests

Normal Findings:

• Electrocardiogram
• Full Blood Count Test
• Thyroid Function Test

Multidisciplinary Clinic Follow-up

• Team Composition: Family medicine specialists, obstetricians, fetomaternal physicians, bariatric surgeons, and dietitians.
• Regular Monitoring: Patient closely followed up in a joint clinic setting.

Hypoglycemic Episodes and Health Clinic Visit

• At-Home Attacks: Experienced hypoglycemic episodes at home, resolved with meals.
• Lack of Monitoring: Blood glucose level not measured during episodes.
• Clinic Readings: Blood pressure and capillary blood glucose levels were normal at the health clinic visit.

Pregnancy Complications and Delivery

• Fetal Growth Restriction:

1. Onset: Noted from the 30th week of gestation.
2. Indicators: Brain-sparing and high resistance on umbilical artery Doppler.

• Elective Caesarean Section:

1. Timing: Performed at the 34th week of gestation due to previous pregnancy and fetal complications.

• Neonatal Outcome:

1. Birth Weight: Baby girl born weighing 1.99 kg.

• Apgar Score: Good.
• Respiratory Distress: Required 18 hours of assisted ventilation due to respiratory distress syndrome.
• Subsequent Health: Baby remained well after the initial intervention.

Discussion

This case report details the experience of an overweight woman who struggled with infertility for eight years but became pregnant shortly after undergoing bariatric surgery. Bariatric surgery remains the most successful obesity treatment, typically recommended for adults with a BMI of ≥40.0 kg/m² or those with a BMI of 35.0–39.9 kg/m² who also have accompanying metabolic disorders, severe joint diseases, or psychological issues related to obesity. It’s crucial to meticulously plan pregnancies after bariatric surgery due to the potential for rapid weight loss within the first 12 months post-surgery, coupled with the time required for the body to stabilize its nutritional status ^[2,5]. Generally, it’s advised to postpone pregnancy for at least one year, not only to allow individuals to benefit from the surgical intervention fully but also to ensure optimal nutritional preparation before conception ^[3,6].

Current guidelines recommend prescribing contraception after surgery, but there is insufficient focus on counseling before the procedure. It may be prudent to consider initiating contraception before surgery if the patient agrees with continuation post-surgery. Presently, there is no consensus on the optimal contraception method, which should be tailored based on factors such as the mother’s age, comorbidities, and preferences. Notably, oral contraception’s effectiveness may diminish following bariatric surgery due to altered absorption ^[5].

In instances where a pregnancy arises within one year post-surgery, primary care providers should be vigilant regarding potential complications, including dumping syndrome. Patients may experience either early or late dumping syndrome. Early dumping syndrome arises from the swift transit of hyperosmolar chyme into the small intestine, prompting fluid shift from extracellular spaces to the intestinal lumen and triggering the release of gastrointestinal hormones. This cascade results in vasomotor and gastrointestinal symptoms within 1 hour after meals, such as palpitations, dizziness, cold sweats, abdominal pain, and diarrhea ^[1,7]. Late dumping syndrome is characterized by an exaggerated insulin response following rapid glucose transit into the small intestine, leading to reactive hypoglycemia occurring 1–3 hours post-meal ^[1].

Several tests have been proposed to confirm dumping syndrome diagnosis in non-pregnant adults, with OGTT using 50 or 75 g glucose solutions being the preferred method ^[8]. An increase in pulse rate exceeding ten beats/min or a rise in hematocrit count of over 3% at 30 minutes post-glucose ingestion indicates early dumping syndrome, while hypoglycemia occurring 60–180 minutes after glucose ingestion indicates late dumping syndrome ^[1,8]. Most studies define hypoglycemia as a plasma glucose level below 3.3 mmol/L (60 mg/dL) after OGTT, though some advocate for a stricter threshold of under 2.8 mmol/L (50 mg/dL) ^[8]. However, hypoglycemia post-OGTT, the primary indicator for diagnosing late dumping syndrome, is also a significant unwanted adverse effect ^[9].

In pregnancy, even a solitary episode of hypoglycemia with a plasma glucose level of 3.9 mmol/L (70 mg/dL) or less is linked to lower birth weight, reduced head circumference, and shorter body length in newborns ^[10]. Consequently, ordering OGTT to diagnose dumping syndrome in pregnant women is inappropriate ^[5]. However, there’s a lack of guidance on the diagnostic test for dumping syndrome in pregnant individuals.

In this case, OGTT was initially employed to assess for type 2 diabetes mellitus due to the patient’s advanced maternal age and high BMI, unaware of her history of type 2 diabetes mellitus in remission. This resulted in an unintended first episode of postprandial hypoglycemia, indirectly confirming the diagnosis of late dumping syndrome. OGTT has traditionally been considered the gold standard for screening gestational diabetes mellitus (GDM) and pre-existing type 2 diabetes mellitus ^[11]. However, women who have undergone gastric bypass surgery often struggle to tolerate OGTT.

As a result, guidelines have recommended alternative approaches, such as measuring glycated hemoglobin levels in the first trimester to screen for pre-existing type 2 diabetes mellitus. Additionally, capillary blood glucose monitoring before and after meals over one week or continuous glucose monitoring for 2–3 days around the 24th–28th week of gestation are suggested methods for GDM screening ^[2,5,12]. Daily self-monitoring of fasting and postprandial blood glucose levels throughout pregnancy, with additional checks when symptoms arise, is preferred for monitoring glycemic control in pregnant women with type 2 diabetes mellitus ^[13].

Following bariatric surgery in mothers, the risk of small for gestational age (SGA) among fetuses is heightened, particularly in patients who have undergone procedures inducing malabsorption like Roux-en-Y gastric bypass surgery ^[14]. Consensus suggests that initiating monthly ultrasound scans from the first trimester may be prudent for pregnant women who have undergone bariatric surgery, especially those with additional risk factors such as smoking or teenage pregnancy ^[15]. In this case, vigilant fetal growth monitoring was conducted every 4–6 weeks starting from the second trimester, considering the short interval between conception post-bariatric surgery and the potential onset of dumping syndrome. Despite being born preterm at the 34th week of gestation, no adverse fetal outcomes were observed.

Conclusion

It is important to assist women with plans of pregnancy after bariatric surgery with the use of contraception. However, if an unplanned pregnancy occurs, primary care providers must recognize and manage complications after bariatric surgery, including dumping syndrome. Thorough history-taking should be performed for all pregnant obese women at booking, and OGTT should be avoided in women who have undergone bariatric surgery. Random capillary blood glucose or continuous glucose monitoring is preferred for screening GDM. For monitoring of glycaemic control, daily fasting and postprandial self-blood glucose monitoring throughout pregnancy is recommended. Serial fetal growth assessment throughout pregnancy may be useful to detect fetal growth restriction earlier, especially in those at risk. A multidisciplinary approach is essential to achieve good pregnancy outcomes.

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References

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