Medical care and pregnancy outcome after gastric bypass surgery for obesity

Maternal overweight and obesity during pregnancy: strategies to improve outcomes for women, babies, and children

INTRODUCTION

Women with overweight and obesity, and their children, are at increased risk of adverse pregnancy, birth, and longer term health outcomes, believed to be compounded by excessive gestational weight gain (GWG). Research to date has focused on interventions to reduce excessive GWG through changes to maternal diet and/or lifestyle.

AREAS COVERED

Current clinical recommendations for GWG vary according to a woman's early pregnancy body mass index, based on assumptions that associations between GWG and adverse pregnancy outcomes are causal in nature, and modifiable. While there are small differences in GWG following pregnancy interventions, there is little evidence for clinically relevant effects on pregnancy, birth, and longer term childhood outcomes. This review considers interventional studies targeting women with overweight or obesity to reduce GWG in an effort to improve maternal and infant health, and the current evidence for interventions prior to conception.

EXPERT OPINION

GWG is not modifiable via diet and lifestyle change, and continued efforts to find the 'right' intervention for women with overweight and obesity during pregnancy are unjustified. Researchers should focus on gathering evidence for interventions prior to pregnancy to optimize maternal health and weight to improve pregnancy, birth, and longer term health outcomes associated with obesity.

Defining the role of bariatric surgery in polycystic ovarian syndrome patients

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women. To meet PCOS criteria, women must have a combination of hyperandrogenism, anovulation and ultrasound findings. Almost 10% of all reproductive age women worldwide show signs of PCOS. Although women often seek care for gynecological or body image concerns, many PCOS women are at risk for metabolic syndrome (MS). Many of the metabolic consequences are overlooked and undertreated by physicians because these patients tend to be young, reproductive age women. MS and obesity coexist commonly with PCOS. These young women are predisposed to glucose abnormalities and ultimately diabetes mellitus, dyslipidemia and eventually cardiovascular disease. Bariatric surgery can be an effective means of weight loss in PCOS women. Surgical techniques have become safer and less invasive over time and have been found to be effective in achieving significant weight loss. Surgical options have also increased, giving patients more choices. Bariatric surgery may prevent or reverse metabolic syndrome. Bariatric surgery may also have reproductive benefits in PCOS patients. Although bariatric surgery has historically been performed in older, reproductive aged women, it has recently gained favor in adolescents as well. This is of particular importance due to the prevalence of both PCOS and MS in adolescents. Treatment of PCOS and MS certainly requires a combination of medical therapy, psychological support and lifestyle modifications. These treatments are difficult and often frustrating for patients and physicians. Bariatric surgery can be effective in achieving significant weight loss, restoration of the hypothalamic pituitary axis, reduction of cardiovascular risk and even in improving pregnancy outcomes. Ultimately, bariatric surgery should be considered part of the treatment in PCOS women, especially in those with MS.

BARIATRIC SURGERY IN PREGNANCY: BENEFITS, RISKS AND OBSTETRIC MANAGEMENT

Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2% >50 kg/m2 with an association not only with social deprivation, but also with a higher prevalence of pre-existing medical disorders such as diabetes and hypertension and medical complications of pregnancy such as preeclampsia. Obesity was also associated with increased rates of macrosomia, operative delivery and postpartum haemorrhage. These data highlight the fact that obesity is an increasing health concern particularly in young women of childbearing age. Obesity will expose them to significant pregnancy complications ranging from miscarriage and fetal abnormality through to operative delivery and thromboembolism. There are also challenges for the delivery of maternity care to meet the needs of these women. As obesity is associated with significant pregnancy complications it is important that women enter pregnancy with an optimum body weight. Many complications, such as fetal abnormality occur in the first trimester and so pre-pregnancy weight reduction is preferred. Further, there is insufficient evidence to recommend specific dietary and/or physical activity interventions to reduce weight or moderate weight gain during pregnancy.

Obstetrical and neonatal outcomes of pregnancies following gastric bypass surgery: a retrospective cohort study in a French referral centre

BACKGROUND

The objective of this study was to analyze obstetrical and neonatal outcomes following Roux en Y Gastric Bypass procedures (RYGBP).

METHODS

A retrospective cohort study was conducted in a single French tertiary perinatal care and bariatric center. The study involved 24 pregnancies, following RYGBP (exposed group) and two different control groups (non-exposed groups). A body mass index (BMI)-matched control group included 120 pregnancies matched for age, parity, and pregnancy BMI. A normal BMI control group included 120 pregnancies with normal BMI (18.5-24.9 kg/m(2)), matched for age and parity. Hospital data were reviewed from all groups in the same 6-year period. Obstetrical and neonatal outcomes after RYGB were compared, separately, to the two different-matched control groups.

RESULTS

The median interval from RYGBP to conception was 26.6 (range: 3-74) months. Rates of perinatal complications did not differ significantly between the RYGBP group and normal BMI and BMI-matched controls groups. The rate of Cesarean section before labor was higher in the RYGBP patients than in the normal BMI control group (25% vs. 9.3% respectively, p = 0.04). Weight gain was lower in the RYGBP patients than normal BMI control group (5.8 kg vs. 13.2 kg respectively, p < 0.0001). Birthweight was also lower in the RYGBP group than those in normal BMI and BMI-matched controls groups (2,948.2 g vs. 3,368.2 g and 3,441.8 g, respectively, p < 0.0001).

CONCLUSIONS

RYGBP surgery was associated with reduced birthweight, suggesting a possible role of nutritional growth restriction in pregnancy.

Pregnancy after bariatric surgery: no problem?

Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence of severe obesity in the developed world, and the acknowledgement of the effectiveness of these procedures by National Institute for Clinical Excellence (in the UK) and the Food and Drug Administration (in the USA), women with severe obesity will increasingly seek such treatment. As the majority of these patients are women of reproductive age, obstetricians will encounter these patients frequently during pregnancy. It is therefore important for obstetricians to gain an insight into the types of surgery performed, the potential complications, including nutritional deficiency, and appropriate management of pregnancy following weight-loss surgery. In general, bariatric surgery is associated with a reduction in obesity related complication, with no apparent increased risk of adverse perinatal outcomes.

Reproductive outcome after bariatric surgery: a critical review

BACKGROUND

After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy.

METHODS

English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive.

CONCLUSIONS

Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

Pregnancy following gastric bypass surgery for morbid obesity: maternal and neonatal outcomes

BACKGROUND

The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery.

METHODS

Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI).

RESULTS

Despite gastric bypass, the 38 cases were heavier (BMI 33.4+/-7.3 vs. 28.1+/-6.7 kg/m2, p<0.001) and more often obese (BMI> or =30 kg/m2, 26/38 (68.4%) vs. 20/76 (26.3%), p<0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66-10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02-3.38), oligohydramnios (OR 2.39, 95% CI 0.66-8.61), and delivery > or =41 weeks (OR 0.57, 95% CI 0.11-2.97).

DISCUSSION

Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population.

Pregnancy following gastric bypass for morbid obesity: effect of surgery-to-conception interval on maternal and neonatal outcomes

BACKGROUND

Conception is discouraged during the period of maximal weight loss following Roux-en-Y gastric bypass (RYGB) because of speculative maternal and fetal concerns. We therefore performed a retrospective cohort study of obstetrical and neonatal outcomes by surgery-to-conception interval.

METHODS

Women with RYGB were stratified into two groups by surgery-to-conception interval of <or=18 or >18 months. Pregnancy and newborn outcomes excluding miscarriages were compared using the chi-square or unpaired t-test for dichotomous and continuous variables, respectively.

RESULTS

Twenty subjects conceived <or=18 months (11.4+/-5.0) and 32 conceived >18 months (47.5+/-41) after RYGB, p< .05. Maternal age, parity, body mass index, and weight gain were similar by group. There were no statistically significant differences in adverse obstetrical outcomes (preterm premature membrane rupture, gestational diabetes, oligohydramnios, intrauterine growth restriction, preterm or post-term delivery) or adverse newborn outcomes (5-min Apgar score <7, intensive care admission, or birth defect).

CONCLUSION

Obstetrical and neonatal outcomes are similar in women conceiving during or after the period of maximal weight loss following RYGB.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Improvement in infertility and pregnancy outcomes after weight loss surgery

The majority of bariatric surgical procedures are performed in young women. There is a concern about safety and outcomes of pregnancies after weight loss surgery. Pregnancy after weight loss surgery is not only safe, but is associated with more favorable outcomes in comparison to obese populations who do not undergo weight loss surgery. An interval of 2 years is recommended from surgery to pregnancy. This delay helps avoid most of the potential nutritional complications. Optimal patient care is achieved in an experienced, multidisciplinary center. Early involvement of the bariatric surgeon in evaluating abdominal pain is critical because the underlying pathology may relate to the previous weight loss surgery. Although infertility is improved after weight loss surgery, reliable modes of contraception may be limited in this population.

Pregnancy outcomes after gastric-bypass surgery

BACKGROUND

The purpose of this study is to compare outcomes of patients who become pregnant within the first year after surgery and those who delayed pregnancy until after 1 year after surgery.

METHODS

A retrospective review was performed to identify patients who became pregnant after their gastric-bypass surgery from 2001 to 2004. Endpoints included pregnancy complications, fetal birth weight and outcome, delivery method, weight change during pregnancy, and nutrition.

RESULTS

Of 2,423 patients who had undergone bariatric surgery from 2001 to 2004, 21 patients became pregnant within the first year after surgery and 13 became pregnant after 1 year. Similar outcomes were seen between the 2 groups regarding fetal weight, term pregnancy, and complications.

CONCLUSIONS

Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes, or pregnancy complications. Anxiety over poor outcomes of pregnancy during the first year after bariatric surgery can be allayed.

Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gestational weight gain

BACKGROUND

The prevalence of morbid obesity is increasing steadily among women of reproductive age. In addition to the well-known comorbidities of the disease, it has been shown that the pregnancy outcome for obese women is worse than for women with a normal body mass index. This study aimed to evaluate the pregnancy and perinatal outcomes for women who underwent laparoscopic adjustable gastric banding (LAGB) because of morbid obesity.

METHODS

This prospective, population-based study was conducted in a general surgery clinic of a tertiary hospital serving as a referral center for bariatric operations. All the patients underwent LAGB by the pars flaccida technique. A database containing information regarding age, pre- and postoperative weight and body mass index, weight gain, and LAGB-related or -unrelated complications during pregnancy was constructed for all women of childbearing age who underwent LAGB. A questionnaire was designed to provide perinatal data concerning both mother and neonate.

RESULTS

The 74 women enrolled in this study had 81 single tone pregnancies. Their body mass index decreased significantly after LAGB, from 43.3 +/- 5.8 to 30.3 +/- 3 kg/m2 at conception (p < 0.0001). The average time to the first live birth after surgery was 27 +/- 3 months. Band slippage was diagnosed and treated laparoscopically in two patients (2.4%). Weight gain during pregnancy was 10.6 +/- 2.1 kg. The rates of pregnancy-induced hypertension and gestational diabetes were 7.4% and 16% of all pregnancies, respectively. In 17 cases (20%), cesarean section was performed. Delivery occurred after 39.1 weeks of gestation. The mean birth weight was 3.09 +/- 0.5 kg. Major congenital anomalies, postnatal hypoglycemia, symptomatic polycythemia or neonatal death were not recorded.

CONCLUSIONS

The findings show that LAGB is safe for both mother and newborn during gestation and delivery.

The effect of obesity surgery on obesity comorbidity

Obesity is epidemic in the modern world. It is becoming increasingly clear that obesity is a major cause of cardiovascular disease, diabetes, and renal disease, as well as a host of other comorbidities. There are at present no generally effective long-term medical therapies for obesity. Surgical therapy for morbid obesity is not only effective in producing long-term weight loss but is also effective in ameliorating or resolving several of the most significant complications of obesity, including diabetes, hypertension, dyslipidemia, sleep apnea, gastroesophageal reflux disease, degenerative joint disease, venous stasis, pseudotumor cerebri, nonalcoholic steatohepatitis, urinary incontinence, fertility problems, and others. The degree of benefit and the rates of morbidity and mortality of the various surgical procedures vary according to the procedure.

Pregnancy after bariatric surgery is not associated with adverse perinatal outcome

OBJECTIVE

The purpose of this study was to investigate the pregnancy outcome of patients after bariatric surgery.

STUDY DESIGN

A population-based study was performed that compared all pregnancies of patients with and without previous obesity operations between the years 1988 and 2002. Stratified analyses with the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders.

RESULTS

Of the 159210 deliveries that were performed during the study period, 298 deliveries were to patients after bariatric operations. No significant differences regarding obstetric characteristics or pregnancy outcome were noted between the open (n=159) and laparoscopic procedures (n=139). With the use of a multivariable analysis, the following conditions were associated significantly with a previous bariatric operation: previous cesarean delivery (odds ratios, 1.4; 95% confidence interval, 1.1-2.0; P=.024), fertility treatments (odds ratios, 2.3; 95% confidence interval, 1.6-3.8; P<.001), premature rupture of membranes (odds ratios, 1.9; 95% confidence interval, 1.3-2.7; P=.001), labor induction (odds ratios, 2.1; 95% confidence interval, 1.6-2.7; P<.001), fetal macrosomia (birth weight, >4 kg; odds ratios, 2.1; 95% confidence interval, 1.4-3.0; P<.001), and obesity (odds ratios, 8.8; 95% confidence interval, 6.1-12.9; P<.001). No significant differences were noted between the groups regarding other pregnancy complications such as placental abruption, placenta previa, labor dystocia, or perinatal complications (such as meconium-stained amniotic fluid, perinatal mortality, congenital malformations and low Apgar scores at 1 and 5 minutes). However, there were higher rates of cesarean delivery among the bariatric operation group (25.2% vs 12.2%; odds ratios, 2.4; 95% confidence interval, 1.9-3.1; P <.001). When controlled for possible confounders (such as previous cesarean delivery, obesity, fertility treatments, premature rupture of membranes, labor induction, diabetes mellitus, hypertensive disorders and fetal macrosomia) by the Mantel-Haenszel technique, the correlation between previous bariatric surgery and cesarean delivery remained significant.

CONCLUSION

Previous bariatric surgery, although an independent risk factor for cesarean delivery, is not associated with adverse perinatal outcome.

Obesity and its surgical management

Obesity is increasing in epidemic proportions world-wide. Even mild degrees of obesity have adverse health effects and are associated with diminished longevity. For this reason aggressive dietary intervention is recommended. Patients with body mass indices exceeding 40 have medically significant obesity in which the risk of serious health consequences is substantial, with concomitant significant reductions in life expectancy. For these patients, sustained weight loss rarely occurs with dietary intervention. For the appropriately selected patients, surgery is beneficial. Various operations have been proposed for the treatment of obesity, many of which proved to have serious complications precluding their efficacy. A National Institutes of Health Consensus Panel reviewed the indications and types of operations, concluding that the banded gastroplasty and gastric bypass were acceptable operations for treating seriously obese patients. Surgical treatment is associated with sustained weight loss for seriously obese patients who uniformly fail nonsurgical treatment. Following weight loss there is a high cure rate for diabetes and sleep apnea, with significant improvement in other complications of obesity such as hypertension and osteoarthritis.

Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty

Pregnancy after gastric bypass for morbid obesity is well reported; however, the only maternal complications described have involved nutritional deficiencies. We report a case of gastrointestinal hemorrhage during pregnancy resulting from erosion of a synthetic graft from a vertical-banded gastroplasty performed 4 years previously.