R. Magdaleno

Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges.

With the increase in the number of bariatric surgeries being performed in women of childbearing age, physicians must have concerns regarding the safety of pregnancy after bariatric surgery. The aim of this review is to summarize the literature reporting on maternal, obstetrical and perinatal implications of pregnancy following BS.MethodsEnglish, Spanish and Portuguese-language articles were identified in a PUBMED search from 2005 to February 2011 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.ResultsThe studies show improved fertility and a reduced risk of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia, macrosomia in pregnant women after bariatric surgery. The incidence of intrauterine growth restriction and small for gestational age are increased. No conclusions can be drawn concerning the risk for cesarean delivery and the best surgery-to-conception interval. Deficiencies in iron, vitamin A, vitamin B12, vitamin K, folate and calcium can result in maternal and fetal complications.ConclusionsPregnancy outcome of women who delivered after BS, as compared to obese populations, is better and safer and comparable to the general population. Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient’s individual requirements can prevent nutrition-related complications and improve maternal and fetal health.

Características psicológicas de pacientes submetidos a cirurgia bariátrica

INTRODUCTION: The great number of patients submitted bariatric surgery who have psychological and psychiatric complications during the postoperative period require a thorough preoperative investigation and a categorization with the purpose of predicting possible complications and personalizing psychological care that might favor patient compliance. Psychodynamic assessment may provide data for such categorization and, thus, suggest effective pre- and postoperative approach strategies. Therefore, the objective of this study was to identify personality structures that may be useful in the postoperative follow-up, as well as additional inclusion and exclusion criteria for the surgical procedure. METHOD: Report of empirical survey conducted during psychotherapy sessions with an open group of patients who underwent bariatric surgery. DISCUSSION: After surgery, patients may experience phases of emotional restructuring, such as an initial phase of feeling triumphant, followed by a phase when there is risk of melancholic behavior and new addictions. We identified three categories of psychological structures: melancholic structure (patients seem to be more likely to develop other postoperative addictive behaviors, mainly eating disorders, since they cannot tolerate the frustration of the loss); dementalized structure (due to the lack of elaborative capacity, patients are unable to reorganize themselves in face of the challenge of keeping their weight under control); and perverse structure (patients comply with the scheduled weight loss; however, their behavior makes the health team experience uncomfortable situations). Establishing psychological categories may be crucial in order to suggest postoperative management strategies, including referral to a psychotherapist with the purpose of providing personalized care, thus increasing specific therapeutic success.

Weight regain among women after metabolic and bariatric surgery: a qualitative study in Brazil

INTRODUCTION Due to the increased number of bariatric surgeries over the years, aspects contributing or hindering the achievement of outcomes, among them weight regain, have acquired increased significance. Psychological factors directly influence on this unwanted situation, but there are few studies and controversies about the degree of participation of these factors. We propose a qualitative investigation to analyze the meanings of weight regain after surgery among women and how these factors influence this outcome. METHOD This study uses the clinical-qualitative method, by means of a semi-structured interview with open questions in an intentional sample, closed by saturation, with eight women who underwent surgery at the Bariatric Surgery Outpatient Clinic of Hospital das Clínicas, Universidade Estadual de Campinas (UNICAMP), in the state of São Paulo, Brazil. RESULTS A feeling of defeat and failure emerges with weight regain, which contributes to social isolation; there is no regret, but gratitude for the surgery; among patients, there is a sense of feeling rejected greater than a rejection that actually exists. CONCLUSION We found out the need for further qualitative studies that help the health team to better understand the dynamic psychological factors involved in the meaning of weight regain after bariatric surgery among women, in order to adopt appropriate conducts to deal with this problem.

P02-139 - Psychological characteristics of anorexic patients’ mothers in the Southeast Brazil: Implications for treatment and prognosis of anorexia nervosa in a public service

Introduction Considering both the complexity of factors that composes the anorexia nervosa (AN) and the recommendation of important organizations related to health, it becomes fundamental the reflection on psychotherapeutic interventions proposed to patients relatives. Objectives Expand the knowledge about the mother-daughter relationship in AN in order to develop a conceptual framework that improves the way to handle with this disorder, to reduce the factors that maintain it and to improve the prognosis. Method Clinical method, through clinical observation regarding a group of patients’ relatives with eating disorders at an outpatient service at a university hospital in the Southeast Brazil. Results We have identified common characteristics in the mother-daughter relationship in AN, that maintain the structure of anorexic patients, influencing directly on the severity of each case and therapeutic possibilities. The mutual control: anorexics mothers showed the need of controlling their daughters, denying the daughters individuality, trying to become tutors of their actions and thus also become controlled by them; The dialectic between omnipotence and impotence: sense of powerlessness in face of numerous failed attempts to help their daughters, with feelings of guilt, as if they were fully responsible for the daughters disorder; The relationship of devotion, passion and hostility between mother and daughter: with a fused attitude with her daughter, the mother is even more limited to understand their real needs, invading their personal space. Conclusions The findings allowed to identify important aspects of mother-daughter relationship in AN, that can improve clinical interventions for the treatment.

P02-138 - Body contouring following bariatric surgery: emotional meanings for patients of a public outpatient service in the Southeast Brazil

Introduction Morbid obesity is accompanied by impairment of the body image. Bariatric surgery is seen like a solution for the problems concerning body image. An element that contributes to disillusions with the results is when patients realize that their bodies, even though thinner, still maintain the sequel of obesity, flaccidity and excess skin. Once weight loss has been achieved, the body image is not infrequently cosmetically unacceptable. To complete treatment, body contouring procedures are performed. Aim of this study To understand the emotional meaning of body contouring after bariatric surgery. Method Clinical-qualitative method, semi-directed interviews with open-ended questions. Results Shame that had previously been attributed to obesity is attributed to the sequel of obesity that contributes to the frustrated expectations of having a beautiful and healthy body. The risk of isolation and lose interest to fulfil the objectives of surgery is great. Plastic surgery takes the place occupied by bariatric surgery, that is, the hope of achieving acceptance. Conclusion Body contouring following significant weight loss can re-establish a good psychosocial functioning because of the perception of improved body image. The plastic surgery is accompanied by a substantial normalization of the self esteem. It could gradually lead to the cessation of distressing and pathological body-related behaviour. The psychosocial benefits of plastic surgery are: increase self-esteem, improved self-confidence, more intense social activities, better interpersonal relationships, relief from depression and anxiety, improvement in emotional stability, better relationship with colleagues and partner, less stigmatization, better sexual performance and fewer physical limitations during sexual intercourse.

P-1001 - Pregnancy following bariatric surgery: psychological aspects reported by patients in a public service in Southeast Brazil

Introduction The prevalence of obesity has become a health problem worldwide. Amidst this epidemic, obesity among pregnant women has risen dramatically. Bariatric surgery (BS) has become an important alternative for obese women planning pregnancy and should be considered in the pre-conception management of morbidly obese women. Psychological aspects related to this field are still unknown. Objective To understand psychological meanings of pregnancy following BS. Methods Qualitative study conducted with an intentional sample of women seen in an outpatient service. Results Pregnancy following BS has specific emotional characteristics. There is a greater concern derived from fantasies of causing harm to the baby. There is an evident conflict between desire of eating to feed the fetus and desire of staying thin by eating little. The surprise these women experience when they learn they are pregnant relates to the ambivalence between desire of getting pregnant and fear of losing what was gained after the surgery, as well as to the perception of deviation of the eating compulsion and the inability to postpone pregnancy for the recommended period. Weight loss following BS reduces the worry with obesity during pregnancy, opening affective space for maternity. Conclusions Pregnancy following BS imposes on women intense experiences related to fears about the babys integrity, especially about its weight; risk of losing what was gained after surgery; and ambivalent emotions towards the fetus. Surgeons and obstetricians should be prepared to deal with the complex web of affects related to this specific clinical condition marked by intense emotional reactions.

P-562 - Life experiences reported by brazilian women with weight regain after metabolic and bariatric surgery seen in a public service: a qualitative study

Introduction The high prevalence of obesity and the failure of conventional treatments have raised the number of weight loss surgeries worldwide. The problem of weight regain following metabolic and bariatric surgery (MBS) became an important clinical issue that concerns surgeons and other health professionals. Psychological and psychiatric factors are among the causes of weight regain. Objective To understand the emotional meanings of weight regain in women submitted to MBS and propose strategies to manage patients clinically. Method Qualitative study conducted with a purposive sample submitted to semi-directed interviews in-depth in a university general hospital, Sao Paulo, Brazil. Results With weight regain comes the loss of social insertion and self-esteem achieved after weight loss. Even losing some of the benefits derived from surgery, the memory of the positive experience stays with the patient, and they may even desire to repeat the surgical treatment. There is no regret for having been submitted to surgery, but a feeling of gratitude. The choice for the MBS is experienced as good. However, patients feel abandoned by the health team after weight regain, and tend to feel mistreated and not understood when they are criticized or considered as weak by others. Conclusions This clinical situation has a complex psychological constitution: there is gratitude, but a tendency to avoid the environment where the caregivers who have helped are. We suggest action programs to seek for patients with weight regain, aiming at psychosocial work. This search can provide incentive to treat this severe long-term complication of MBS.

P-564 - Waiting for bariatric surgery: Emotional experiences reported by brazilian morbidly obese women in preoperative period in public service

Introduction Obesity is a severe global public health problem that increases from year to year. Consequently, the number of bariatric surgeries has grown significantly. Obese seeking surgical treatment have a characteristic psychological profile and a greater incidence of psychiatric disorders. Emotional meaning of bariatric surgery for such patients is not sufficiently known. Objective To understand the emotional experiences and the expectations of morbidly obese women candidates for bariatric surgery. Method Qualitative study. Semi-structured interviews were conducted. Purposeful sampling was closed by the criterion of saturation of information. The corpus was addressed by content analysis. Results are discussed with a psychodynamic theoretical framework. Results Women candidates for bariatric surgery have particular emotional experiences. They have magic expectations, believing that weight loss is certain after surgery and that their health, affective, and self-esteem problems will be resolved. They believe in social reinsertion and acceptance without prejudice, and also in improved affective relationships and sexual life. Rational understanding of postoperative difficulties conceals a veiled belief in a magic solution for personal problems. Inability to control amount of food ingested is transferred to an urgency to have surgery, perceived as a pressing need by these women. Conclusion Team in charge of preparing patients should be attentive to a strong denial about the difficulties to be faced after surgery. Previous relationship with surgery is marked by an urgency that has the same cause of the yen for food typical of morbid obesity, and the team should be prepared to suggest appropriate moment for surgery.

P-561 - Brazilian mothers of anorexic patients: a qualitative study about their influence to the development and prognosis of the anorexia nervosa of their daughters

Introduction Considering studies that have confirmed that family environment and some characteristics of parents, especially mothers, affect the development and maintenance of anorexia nervosa (AN) in their daughters, research on how to improve knowledge of therapeutic intervention for family members of patients became crucial. Objectives To understand the emotional experiences of mothers that affect the development and prognosis of AN. Method Qualitative study interviewing in depth mothers of female outpatients seen at the General Hospital of the State University of Campinas, Brazil. Results Mothers propose a fusional relationship with their daughters, in which aspects of individuality are ill-defined. The daughters’ attempts to become individuals are felt as an attack, and experienced by mothers as injustice and aggression. In this context, the daughters’ food symptoms can be understood as a desperate attempt at individuation. The mothers do not understand their daughters’ logic and try to remedy a qualitative deficiency with quantity, especially of food. The feelings of devotion/hostility that characterize these mothers express their violent attempt to annihilate the other as an individual, who can only exist as an opponent. These are mothers who cannot bear that their daughters are not extensions of themselves, and who have serious difficulties to understand their own real emotional needs. The attempt to meet these needs with food can only aggravate the alimentary symptoms of their daughters. Conclusion The findings made it possible to identify important aspects in mothers of anorexic patients, which can improve knowledge of AN and clinical interventions to treat it.

P02-140 - Group therapy during the post-surgery period for bariatric patients from a public service in the Southeast Brazil: Main aspects

Introduction With the worldwide increase of severe obesity, the demand for and performance of bariatric surgery has increased. Objective To show the importance of the group therapy approach in the research and treatment of the surgerys psychological consequences. Method Clinical method of research, through weekly open therapeutic groups with patients that have undergone bariatric surgery. Results After the surgery the patients: feel empty, which leads them to search for alternative routes to give their lives meaning, some healthy, such as exercising intensely, others unhealthy, such as addictions, especially the consumption of alcohol; they are divided between the control of impulses sensation that the surgery provides and the food temptation that generates anguish, conflicts and fears of failing and gaining weight again; they experience the presence of new identity elements that arise with the weight loss and that lead to feelings of strangeness in relation to themselves and their personality; they are not stigmatized anymore and assume new social roles, with an important improvement of their self-esteem and social functioning; they may experience conflicts that are hard to handle in parental and marital relationships, especially due to jealousy and competitiveness. Conclusions Despite the undeniable benefits that the bariatric surgery provides to the patients, psychological conflicts arise. The bariatric surgery is a procedure that causes, in addition to massive weight loss, deep changes in the patients’ psychic structure that, if well conducted in what concerns psychotherapy, lead to a significant improvement of the patients life quality.