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Internal Herniation in Pregnancy After Gastric Bypass: A Systematic Review

OBJECTIVE: To assess maternal and fetal outcomes of pregnancies complicated by internal herniation after Roux-en-Y gastric bypass. DATA SOURCES: Articles were identified through searches in online databases (ClinicalTrials.gov, MEDLINE, EMBASE, PubMed, and Google Scholar) from January 1980 to March 2015 for the following terms: [gastric bypass OR bariatric surgery] AND [pregnancy] AND [complication OR herniation OR obstruction]. Reference lists of relevant articles were hand-searched. Additionally, we searched our own hospital's obstetric database for cases of internal herniation after Roux-en-Y gastric bypass. METHODS OF STUDY SELECTION: Only articles in English and studies in humans were selected. Cases of internal herniation outside of pregnancy or internal herniation without a history of Roux-en-Y gastric bypass were excluded. Of 384 articles identified by the initial search, 22 were retained for further analysis. TABULATION, INTEGRATION, AND RESULTS: All retrieved articles were case reports or case series. There were no interventional studies. We retrieved 47 cases from the literature and five cases from our own database. The mean gestational age at diagnosis was 28.4±7.3 weeks. All women presented with abdominal pain. Nausea and vomiting were present in only 65%. Ultrasonography and laboratory results are usually noninformative, and computed tomography or magnetic resonance imaging confirmed the diagnosis in only 75% of cases. Nine of 52 women (17.3%) required bowel resections. There were two maternal deaths and three perinatal deaths, all in women treated later than 48 hours after onset of the symptoms. CONCLUSION: Internal herniation complicating pregnancy after Roux-en-Y gastric bypass typically presents with subtle signs in the third trimester of pregnancy. Timely recognition and early surgical intervention are associated with a reduced risk of bowel ischemia and maternal and fetal adverse outcomes.