Background:

Dumping syndrome is a recognized complication of bariatric surgeries, characterized by postprandial hyperinsulinemia followed by hypoglycemia. However, first presentation in the postpartum period with severe hypoglycemia is uncommon. Early recognition is important, particularly in women without diabetes.  Metabolic changes in the postpartum period, including increased glucose utilization during breastfeeding can exacerbate glycemic instability.

Case 1

A 40-y o woman, G1P1 with a history of sleeve gastrectomy in 2014 followed by gastric bypass in 2021 presented in the immediate postpartum period with recurrent symptomatic hypoglycemia, requiring intravenous dextrose infusions. She had no history of diabetes. She reported symptoms suggestive of hypoglycemia prior to pregnancy but never sought medical attention. Continues glucose monitoring and a mixed meal tolerance test confirmed postprandial hyperinsulinemic hypoglycemia consistent with late dumping syndrome. Management with dietary modifications and acarbose resulted in clinical improvement.

Case 2

A 32-y o woman, G2P2 with a history of sleeve gastrectomy in 2021 presented two months postpartum with severe hypoglycemia with loss of consciousness. She had no prior history of diabetes and was asymptomatic prior and during pregnancy. Continues glucose monitoring and biochemical, radiological evaluation supported a diagnosis of Dumping syndrome. She commenced on modified diet and semaglutide with ongoing follow up.

Discussion:

 Dumping syndrome is typically diagnosed within 2 years after bariatric surgery.  These cases highlight an under-recognized presentation of late dumping syndrome in the postpartum period in women with remote bariatric surgeries and no prior diagnosis. Risk factors for developing Dumping syndrome would include female sex, lower weight/BMI and lower HbA1c before surgery, which all existed in our patients. The metabolic changes of the postpartum period, together with increased glucose utilization during breastfeeding, may unmask or exacerbate underlying dumping syndrome, leading to clinically significant hypoglycemia.

Conclusion:

Postpartum hypoglycemia in women with previous bariatric surgery should be investigated for dumping syndrome as a cause of postpartum dysglycemia, regardless of time since procedure. With increasing rates of bariatric surgery among women of reproductive age, clinicians are likely to encounter more cases of hypoglycemia in postpartum period which can affect quality of life and safety for mothers and newborns.