The possibility of having a healthy pregnancy and maintaining one’s own health is an issue that comes up again and again for young women who are affected by Hereditary Diffuse Gastric Cancer (HDGC) and are contemplating prophylactic total gastrectomy. Pardeep Kaurah provides the following report titled “Pregnancy after prophylactic total gastrectomy” which was published in January, 2010.
As more and more young people discover their genetic predisposition for stomach cancer and choose total gastrectomy (TG), young women who undergo this procedure face a new challenge: family planning. TG patients are at lifelong risk for several problems associated with malabsorption and nutritional deficiencies so one might think that it would be impossible to carry a healthy baby to full term.
“It’s not the case,“ says Melissa Delaney, D.O. an OB/GYN practicing in Pennsylvania. Dr. Delaney’s longtime patient Rachel Wick became pregnant in the fall of 2008 about one year after having undergone TG. It is definitely considered a high risk pregnancy but quite manageable.
“The biggest thing with the high risk is the nutrition for both mommy and for baby. Her main problems are simple calorie intake, nutrition intake, let alone the vitamins,” says Delaney. “On top of that you worry about iron; it’s a normal process of pregnancy to become anemic.”
In January 2010, Pardeep Kaurah and Dr. David Huntsman of the University of British Columbia and two colleagues in the U.K., Rebecca Fitzgerald and Sarah Dwerryhouse, published the paper "Pregnancy after prophylactic total gastrectomy."
According to this paper, “Deficiencies in iron, vitamin B12, folate and calcium can result in maternal complications such as severe anemia, and in fetal complications, such as neural tube defects, intrauterine growth restriction, and failure to thrive.”
But with proper medical supervision and guidance there’s no reason why an otherwise healthy young gastrectomy patient can’t deliver a healthy child. The paper goes on to say,
“It would appear that the anxiety over poor pregnancy outcomes may be allayed as long as the appropriate supplementation for likely nutritional deﬁciencies is implemented.”
Special attention to maternal nutrition during pregnancy is becoming more commonplace as many women are having gastric bypass surgery, which while less extreme than TG, carries many of the same post-surgical complications, albeit to a lesser degree. Delaney notes such similarities between patients who have had gastric bypass and TG patients.
“It’s not just even just for her [Wick]. I’ve also had problems with patients that have had gastric bypass and trying to nutrify – is a word that we use – the children as well,” Delaney says, adding that she is seeing more and more bypass patients and their difficulty with nutrient absorption ranges from mild to severe. “We have a lot of them and it varies in degree. Now, Rachel was the most severe degree, as there’s no stomach.”
Indeed, Lisa Gill chose her obstetrician specifically because she has had several gastric bypass patients. Gill lives in Minnesota and has two children born in 2008 and 2009. She had her TG in December 2010 and is currently in her first post-TG pregnancy.
“During my preconception appointment, she did a blood workup to check for nutritional deficiencies and to check for proper liver and kidney functioning,” says Gill, who believes that seeing specialists who deal with gastric bypass patients is helpful for all TG patients.
Gill offers a unique perspective because she can compare this pregnancy to her earlier ones.
“I am just as nauseous with this pregnancy as I was with my first two kids. However, I’m vomiting much, much less with my current, post-TG pregnancy. I’m also, in general, feeling sick much more often than I did with previous pregnancies: nauseous, run down, headache, etc. My basic pregnancy symptoms but on overdrive.”
Gill says it’s in step with what her endocrinologist told her as he “described pregnancy symptoms post-gastric surgery as exaggerated, and I think that is a pretty good explanation of what is occurring.” Gill stresses, “Everything that happened with my previous pregnancies but amplified a bit.”
Wick’s post-TG pregnancy was her first and she actually reports a reduction in nausea as compared to her immediate recovery from the TG.
“I almost felt better,” says Wick. “I could eat better.”
You’ll want to make sure you’ve sufficiently recovered from your TG before you think about trying to conceive. Wick’s surgeon told her that the general consensus is to wait at least a year post-TG because that’s how long it takes to get back to what your “new normal’ will be. Also, if your TG was not prophylactic, you’ll obviously want to make sure your body is completely cancer-free prior to conception.
“Yes. Their surgeon will have to clear them before they get pregnant,” says Delaney.
In addition, the OB should consult with the mother’s other doctors to get the big picture and be able to move forward with her care throughout the pregnancy.
“Each patient is going to be an individual case. I work between myself, the high risk doctors, the gastric people and who ever did the surgery,” says Delaney.
As far as how an OB approaches this kind of pregnancy, there are obvious things to look out for.
“I think its pretty much common sense when you’re looking at someone with nutrition risks, premature labor risks; you’re just going to watch them more closely,” says Delaney. “You’re going to guide them with their weight and have nutritionists come in if you have to.”
During Wick’s pregnancy Delaney monitored fetal growth via ultrasound more often than usual.
“I was watching the growth of the baby because I was worried that she wasn’t going to have nutrients for herself, let alone for the child, the placenta was going to be poorly developed, or she’s going to have poor fluid.” But Delaney found no problems, “She did great!”
Sometimes tests need to be modified to accommodate the peculiarities of not having a stomach. Gestational diabetes is a common problem during pregnancy that can lead to complications for both mother and baby. To screen for it, it is standard for pregnant women to have a sugar load test in which they have to drink a large amount of a sugary liquid in a very short time. Because TG patients can neither tolerate too much sugar nor drink large amounts of fluid in a short time, Delaney used a different method.
“I couldn’t do a sugar load on her, the one hour sugar – you just can’t handle the sugar – so I just did a fasting blood sugar.”
When a woman’s post-TG condition creates a problem for normal testing procedures Delaney says, “There are little nuances that you can work around.”
Another possibility with post-TG mothers that can cause problems is adhesions, a common effect of abdominal surgery. These fibrous bands of scar tissue can cause mild to acute pain both during pregnancy and postpartum.
“The normal process of what happens in pregnancy, as the uterus grows, everything [other internal organs] gets pushed up,” says Delaney, adding that the movement of the adhesions can cause pain to the mother. “So in patients who’ve had any type of gastric surgery or bowel surgery, in pregnancy you hope that you can manage the pain. And then afterwards when the organs come back down they may have more acute pain.”
Delaney stresses that this won’t happen to everyone, but it can be a concern. “It’s all theoretical but it’s something that exists that you have to worry about that’s unique in pregnancy if you’ve had gastric or bowel surgery.”
After the baby is born, it may take longer for a TG woman to bounce back after delivery. It’s simply a matter of adding the issues of post-TG life to the already standard post-delivery difficulties.
“What happens postpartum … a woman feels pretty horrible for a few months from everything changing. They’re exhausted; they’re up with the kid all the time. And then you have these girls with no stomachs who have poor nutrition to begin with,” says Delaney, adding that, “You need to not do too much, you need to relax, you need to eat right … no junk food.”
For women considering pregnancy after TG, a general piece of advice from Wick is to make sure you are seeing one doctor throughout your pregnancy. Because of the added scrutiny a post-TG pregnancy needs to be under, she feels it’s important to have just one doctor who knows all the specific aspects of your pregnancy.
“If you go to an OB practice and there’s more than one doctor, you end up having to see all of them throughout your pregnancy because any one of them can deliver. I would recommend just having one doctor. It’s a pain to have to go through everything over and over with each new doctor.”
Gill hopes women who want to have children are not discouraged from starting or adding to their families.
“Don’t be deterred,” she says. “It’s true that there aren’t many women out there who have walked our same path, and that can seem scary. But when you think of all the gastric bypass patients out there and how many of them have gone on to have healthy pregnancies, and you think of all the similarities between our surgeries, it’s a lot less daunting to realize we’re not all that unique.”
If you have or will be facing TG, know that it doesn’t mean you can’t have children. All it takes is detailed discussion with all the professionals on your medical team and a commitment to do what it takes for yourself and your baby all throughout your pregnancy.
Written by Teresa Feeney