Dr Sumithra Giritharan1, Mrs Pushpa Sivakumar2, Dr Shin Lee3, Professor Jan Dickinson3, Dr Shivanthi Senaratne1
1Department of Obstetric Medicine, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 2Department of Dietetics, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 3Department of Maternal and Fetal Medicine, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia
Biography:
"Biographies to come"
Abstract:
We present a case of severe Vitamin A deficiency after bariatric surgery, manifesting in pregnancy with maternal visual symptoms and fetal abnormalities.
A 37-year-old hairdresser was referred after obstetric ultrasound at 16 weeks raised the possibility of small bowel atresia. Her medical history included gastric bypass surgery (2016), primary hypothyroidism and previous cholecystectomy. This was an unplanned pregnancy.
Ultrasound imaging performed at 21 weeks gestation revealed multiple fetal anomalies. During physician review at 26 weeks, the patient reported altered vision described as a sensation of darkness in daylight hours. After bariatric surgery, the patient had variable adherence to nutritional supplementation. She was taking levothyroxine, oral iron supplementation and oral B12 replacement. Clinical impression was that of Vitamin A deficiency causing the maternal visual impairment and potential fetal abnormalities. Subsequent blood results showed severe Vitamin A deficiency, with a serum level of <0.3µmol/L (1.0 – 4.0µmol/L). Patient was commenced on Vitamin A 5000 IU twice a day.
At the same time, MRI of the fetal head showed multiple cranial abnormalities including left anophthalmia and right sided dysplastic microphthalmia. After extensive discussion, the patient proceeded to a medical termination of pregnancy at 28 weeks gestation. At last review, she reported improvement in visual symptoms after 8 weeks of supplementation.
The increasing use of bariatric surgery in women of reproductive age can result in unplanned pregnancies when fertility is restored with weight loss. Vitamin A deficiency is widely reported after bariatric surgery(1) and can be further exacerbated by the increased demands of pregnancy(2). Adverse maternal and fetal morbidity secondary to vitamin A deficiency after bariatric surgery has been described(3). However, most women are unaware of these risks and do not receive appropriate preconception counselling alongside thorough nutritional assessment. This case highlights the importance to screen for this in pregnancy to prevent devastating sequalae.
Keywords
"Vitamin A Deficiency", "Bariatric Surgery"
References
1. Vanheule G, Ceulemans D, Vynckier AK, De Mulder P, Van Den Driessche M, Devlieger R. Micronutrient supplementation in pregnancies following bariatric surgery: a practical review for clinicians. Obes Surg. 2021;31(10):4542-54.
2. Bastos Maia S, Rolland Souza AS, Costa Caminha MF, Lins da Silva S, Callou Cruz R, Carvalho Dos Santos C, et al. Vitamin A and Pregnancy: A Narrative Review. Nutrients. 2019;11(3).
3. Chagas CB, Saunders C, Pereira S, Silva J, Saboya C, Ramalho A. Vitamin a deficiency in pregnancy: perspectives after bariatric surgery. Obes Surg. 2013;23(2):249-54.