Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

Pregnancy After Bariatric Surgery-Experience from a Tertiary Center

INTRODUCTION

It is estimated that most people undergoing bariatric surgery are women of reproductive age; nonetheless, its effects on pregnancy outcomes are not yet fully understood.

METHODS

Retrospective observational study, conducted in a tertiary center in Portugal, included participants in two groups: (1) pregnant women with a history of bariatric surgery (n = 89) and (2) pregnant women with a BMI ≥ 35 kg/m2, without previous bariatric surgery (n = 176). Data was collected from the medical files. Multivariate analysis was conducted to adjust for confounders.

RESULTS

Pregnancy after bariatric surgery was associated with lower risk of gestational diabetes (15.7% vs. 30.1%, p = 0.002) and cesarean delivery (20.7% vs. 33.5%, p = 0.007), and a higher gestational weight gain (10.58 ± 9.95 vs. 7.33 ± 6.00 kg, p < 0.001). Participants in the bariatric surgery who experienced a gestational weight gain ≤ 10.0 kg had a higher risk of preterm delivery (16.7% vs. 2.5%, p = 0.031). No significant differences were found regarding hypertensive diseases of pregnancy between groups (4.5% vs 11.4%, p = 0.147). Pregnancy after bariatric surgery was associated with lower neonate weight percentile (34.24 ± 21.09 vs. 48.77 ± 27.94, p < 0.001), higher risk of fetal growth restriction (5.6% vs. 0.6%, p = 0.018), and lower risk of fetal macrosomia (0.0% vs. 7.5%, p = 0.005). There were no significant differences in the risk of SGA (12.5% vs. 7.0%, p = 0.127) or LGA neonates (2.3% vs. 6.4%, p = 0.069).

CONCLUSION

Pregnancy after bariatric surgery is associated with both risks and benefits, which should be considered by healthcare providers. Pregnancy after bariatric surgery requires individualized care, to ensure adequate gestational weight and avoid micronutrient deficiencies.

Beyond Weight Loss: A Comprehensive Review of Pregnancy Management following Bariatric Procedures

The increasing prevalence of bariatric surgery among women of childbearing age raises critical questions about the correct management of pregnancy following these procedures. This literature review delves into the multifaceted considerations surrounding pregnancy after bariatric surgery, with a particular focus on the importance of preconception counselling, appropriate nutrition assessment, and the necessity of correct folic acid supplementation. Key areas of investigation include nutrient absorption challenges, weight gain during pregnancy, and potential micronutrient deficiencies. Examining the relationship between bariatric surgery and birth defects, particularly heart and musculoskeletal issues, uncovers a twofold increase in risk for women who underwent surgery before pregnancy, with the risk emphasized before folic acid fortification. In contrast, a nationwide study suggests that infants born to mothers with bariatric surgery exhibit a reduced risk of major birth defects, potentially associated with improved glucose metabolism. In addition, this review outlines strategies for managing gestational diabetes and other pregnancy-related complications in individuals with a history of bariatric surgery. By synthesizing existing literature, this paper aims to provide healthcare providers with a comprehensive framework for the correct management of pregnancy in this unique patient population, promoting the health and well-being of both mother and child.

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

BACKGROUND

Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

METHODS

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

RESULTS

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030).

CONCLUSION

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Petersen's Hernia in a Pregnant Woman Following Roux-en-Y Gastric Bypass Surgery: The Importance of Emergency Surgical Treatment

Roux-en-Y gastric bypass (RYGB) patients are at risk of creating potential spaces for possible internal hernias during the procedure. During pregnancy, the pregnant uterus elevates the bowel, increasing intra-abdominal pressure. Cases reported to date have described mild abdominal pain and no evidence of peritoneal irritation, with inconclusive ultrasound and MRI findings for diagnosis of Petersen's hernia. We present the case of a 42-year-old female patient with a history of RYGB eight years earlier without complications, with a pregnancy of 34 weeks of gestation. Symptomatology began with colicky abdominal pain in the epigastric, with irradiation to the right upper quadrant. On physical examination, revealed a painful abdomen on the median and deep palpation in the epigastric and right upper quadrant, the rest of the studies were inconclusive. As there was no improvement of the symptoms in 12 hours, an emergency diagnostic laparoscopy was performed, finding a strangulated Petersen's hernia requiring resection, with the closure of the gastric pouch, intestinal anastomosis, and Stamm gastrostomy with closure of the mesenteric gap. Therefore, a pregnant patient presenting with upper quadrant abdominal pain with a history of RYGB, even one with normal labs and imaging, should be assumed to have an internal hernia until proven otherwise. The emergency surgical approach is associated with early resolution and prevents its progression with catastrophic results.

Association of bariatric surgery with indicated and unintended outcomes: An umbrella review and meta-analysis for risk-benefit assessment

Bariatric surgery can cause numerous functional changes to recipients, some of which are unintended. However, a systematic evaluation of wide-angled health benefits and risks following bariatric surgery has not been conducted. We systematically evaluated published systematic reviews of randomized controlled trials and observational studies reporting the association between bariatric surgery and health outcomes. We performed subgroup analyses by surgery type and sensitivity analysis, excluding gastric band. Thirty systematic reviews and 82 meta-analyzed health outcomes were included in this review. A total of 66 (80%) health outcomes were significantly associated with bariatric surgery, of which 10 were adverse outcomes, including suicide, fracture, gastroesophageal reflux after sleeve gastrectomy, and neonatal morbidities. The other 56 outcomes were health benefits including new-onset diabetes mellitus (DM) (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.19-0.79), hypertension (OR = 0.36; 95% CI = 0.33-0.40), dyslipidemia (OR = 0.33; 95% CI = 0.14-0.81), cancers (OR = 0.65; 95% CI = 0.53-0.80), cardiovascular diseases (CVDs), and women's health. Surgery is associated with reductions in all-cause mortality and death due to cancer, DM, and CVD. Bariatric surgery has both beneficial and harmful effects on a broader than expected array of patients' health outcomes. An expansion of the indication for bariatric surgery could be discussed to include a broader population with metabolic vulnerabilities.

Bariatric Surgery in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in premenopausal women and is a common cause of anovulatory subfertility. Although obesity does not form part of the diagnostic criteria, it affects a significant proportion of women with PCOS and is strongly implicated in the pathophysiology of the disease. Both PCOS and obesity are known to impact fertility in women; obesity also reduces the success of assisted reproductive technology (ART). With or without pharmacotherapy, lifestyle intervention remains the first-line treatment in women with PCOS and obesity. Bariatric surgery is still an experimental treatment in women with PCOS and subfertility. This review will present an overview of the pathophysiology of PCOS and obesity and the role of bariatric surgery. Although data are sparse regarding the impact of bariatric surgery on subfertility in women with PCOS and obesity, existing studies point to a beneficial role in treating metabolic and reproductive dysfunction.

Attitudes and Behaviors towards Food and Weight in Late Pregnancy: A Comparative Approach between Individuals with and without Previous Bariatric Surgery

The aims of this study were to compare, between pregnant individuals with and without bariatric surgery: (1) eating behaviors, (2) intuitive eating components and, (3) attitudes towards weight gain. This retrospective study included data collected in healthy pregnant individuals with and without previous bariatric surgery who were recruited at the Centre Hospitalier Universitaire (CHU) de Québec-Université Laval. Pregnant individuals who underwent bariatric surgery (biliopancreatic bypass with duodenal switch [n = 14] or sleeve gastrectomy [n = 5]) were individually matched, for age (±0.4 years) and body mass index (BMI) (±0.3 kg/m2), with pregnant individuals who have not received bariatric surgery. In the second trimester, participants completed the Three Factor Eating Questionnaire (TFEQ) and the Intuitive Eating Scale 2 (IES-2). In the third trimester, participants completed the French version of the Pregnancy Weight Gain Attitude Scale assessing attitudes towards weight gain. Pregnant individuals who have had bariatric surgery had a higher score for flexible restraint and a lower score for situational susceptibility to disinhibition compared to individuals who have not had undergone bariatric surgery (2.89 ± 1.15 vs. 1.95 ± 1.31; p = 0.04 and 1.11 ± 1.29 vs. 2.79 ± 1.44, respectively; p < 0.001). Regarding intuitive eating, pregnant individuals who experienced bariatric surgery had a higher score for reliance on internal hunger and satiety cues and a lower one for unconditional permission to eat compared with those who had not experienced bariatric surgery (3.99 ± 0.81 vs. 3.30 ± 1.03; p = 0.02 and 3.28 ± 0.54 vs. 3.61 ± 0.68, respectively; p = 0.03). No difference in attitudes towards weight gain was observed between groups. Overall, pregnant individuals who had undergone bariatric surgery had different eating behaviors and intuitive eating components compared to pregnant individuals without bariatric surgery. These results need to be confirmed in further studies with larger sample sizes.

Tackling the dual burden of malnutrition in pregnancy - pregnancy after weight loss surgery

The dual burden of malnutrition is characterised by the coexistence of undernutrition alongside overweight/obesity and diet-related noncommunicable diseases. It is a paradox which disproportionately affects women and is applicable to those who become pregnant after weight loss surgery. Obesity before and during pregnancy is associated with increased risk of adverse perinatal outcomes in both mother and child. Overall lifestyle interventions targeting weight loss in the preconception period have not proven effective, with people, and women in particular, increasingly seeking weight loss surgery. In women with severe obesity, surgery may normalise hormonal abnormalities and improve fertility. In those who become pregnant after surgery, evidence suggests a better overall obstetric outcome compared to those with severe obesity managed conservatively; however, there is heightened risk of maternal nutritional deficiencies and infants born small for gestational age. Specifically, pregnancy soon after surgery, in the catabolic phase when rapid weight loss is occurring, has the potential for poor outcomes. Lifelong micronutrient supplementation is required, and there is considerable risk of malnutrition if nutritional aftercare guidelines are not adhered to. It is therefore recommended that pregnancy is delayed until a stable weight is achieved and is supported by individualised advice from a multidisciplinary team. Further research is required to better understand how weight loss surgery affects the chances of having a healthy pregnancy and to ultimately improve nutritional management and patient care. In this review, we aim to summarise the evidence and guidance around nutrition during pregnancy after weight loss surgery.

Maternal and fetal/neonatal outcomes in pregnancy, delivery and postpartum following bariatric surgery and comparison with pregnant women with obesity: a study protocol for a prospective cohort

BACKGROUND

Being obese can lead to various complications during pregnancy, such as Gestational Diabetes Mellitus (GDM), pregnancy induced hypertension (PIH), Pre-Eclampsia (PE), and Large Gestational Age (LGA). Although bariatric surgery is an effective way to treat obesity, it can also result in complications and may be linked to having small for gestational age (SGA) babies. This cohort study protocol aims to compare the maternal and fetal/neonatal outcomes of two groups of Iranian pregnant women: those who have undergone bariatric surgery and those who are obese but have not had bariatric surgery.

METHODS

In this study Pregnant women (< 14 weeks' gestation) (n = 38 per group) are recruited either from one of the obesity clinic (exposure group = with a history of bariatric surgery) or primary healthcare clinics in Tehran city (comparison group = pregnant women with obesity and and no history of bariatric surgery). Dietary intake and nutrient status are assessed at < 14, 28, and 36 weeks. Maternal and fetal/neonatal outcomes are compared between the two groups, including gestational diabetes, preeclampsia, preterm labor, intrauterine growth restriction, severe nausea and vomiting, abortion, placenta previa and abruption, venous thrombosis, vaginal bleeding, cesarean delivery, meconium aspiration, and respiratory distress. Maternal serum levels of ferritin, albumin, zinc, calcium, magnesium, selenium, copper, vitamins A, B9, B12, and 25-hydroxy Vit D are checked during 24th to 28th weeks. Maternal and neonatal outcomes, including height, weight, head circumference, fetal abnormality, infection, small or large fetus, low birth weight, macrosomia, NICU admission, and total weight gain during pregnancy, are measured at birth. Maternal and offspring outcomes, including weight, height, head circumference, total weight gain during pregnancy, newborn diseases, postpartum bleeding, breastfeeding, and related problems, are assessed 6 weeks after delivery. Child's weight, height, and head circumference are followed at 2, 4, 6, 8, 10, and 12 months after birth. Maternal stress, anxiety, and depression are assessed with the DASS-21 questionnaire, and physical activity is evaluated using the PPAQ questionnaire in the first and third trimesters.

DISCUSSION

By assessing the levels of micronutrients in the blood of pregnant women along with the evaluation of pregnancy outcomes, it is feasible to gain a more accurate understanding of how bariatric surgery affects the health and potential complications for both the mother and the fetus/newborn. This information can help specialists and patients make more informed decisions about the surgery. Additionally, by examining issues such as stress, anxiety, and depression in women undergoing surgery, this study can contribute to recognizing these problems, which can also affect pregnancy outcomes.

Influence of preconception body mass index on perinatal outcomes after metabolic and bariatric surgery

INTRODUCTION

Metabolic and bariatric surgery (MBS) is a very effective weight loss intervention, although does not invariably reverses the obesity status. Our aim was to evaluate whether despite successful weight loss after MBS, persistence of obesity at time of conception still carries additional risks of adverse perinatal pregnancy outcomes.

METHODS

Retrospective study comparing pregnancy outcomes of women previously submitted to MBS with a preconception (PC) body mass index BMI < 30 kg/m2 or PC BMI ≥ 30 kg/m2.

RESULTS

Eighty pregnancies (n = 80) were included, 49 from women with a PC BMI < 30 kg/m2 and 31 with a PC BMI ≥ 30 kg/m2. Gestational weight gain was significantly lower (9.72 ± 7.10 vs. 13.81 ± 7.16 respectively; p = 0.01) and neonatal intensive care unit admissions were significantly higher (5% vs. 0% respectively; p = 0.02) in women with PC BMI ≥ 30 kg/m2 as compared to those with PC BMI < 30 kg/m2. There were no statistically significant differences in gestational diabetes, anemia, fetal growth restriction, prematurity rate, mode of delivery or birth weight between groups.

CONCLUSION

Perinatal outcomes of pregnancies after MBS may be significantly influenced by PC BMI. The benefits of MBS induced weight loss on obesity-associated adverse pregnancy outcomes can be maximized if the obesity status can be reverted before pregnancy.

Weight Management during Pregnancy and the Postpartum Period in Women with Gestational Diabetes Mellitus: A Systematic Review and Summary of Current Evidence and Recommendations

BACKGROUND

Weight management during pregnancy and the postpartum period is an important strategy that can be utilized to reduce the risk of short- and long-term complications in women with gestational diabetes mellitus (GDM). We conducted a systematic review to assess and synthesize evidence and recommendations on weight management during pregnancy and the postpartum period in women with GDM to provide evidence-based clinical guidance.

METHODS

Nine databases and eighteen websites were searched for clinical decisions, guidelines, recommended practices, evidence summaries, expert consensus, and systematic reviews.

RESULTS

A total of 12,196 records were retrieved and fifty-five articles were included in the analysis. Sixty-nine pieces of evidence were summarized, sixty-two of which focused on pregnancy, including benefits, target population, weight management goals, principles, weight monitoring, nutrition assessment and counseling, energy intake, carbohydrate intake, protein intake, fat intake, fiber intake, vitamin and mineral intake, water intake, dietary supplements, sugar-sweetened beverages, sweeteners, alcohol, coffee, food safety, meal arrangements, dietary patterns, exercise assessment and counseling, exercise preparation, type of exercise, intensity of exercise, frequency of exercise, duration of exercise, exercise risk prevention, and pregnancy precautions, and seven focused on the postpartum period, including target population, benefits, postpartum weight management goals, postpartum weight monitoring, dietary recommendations, exercise recommendations, and postpartum precautions.

CONCLUSIONS

Healthcare providers can develop comprehensive pregnancy and postpartum weight management programs for women with GDM based on the sixty-nine pieces of evidence. However, because of the paucity of evidence on postpartum weight management in women with GDM, future guidance documents should focus more on postpartum weight management in women with GDM.

Nutritional Implications of Bariatric Surgery on Pregnancy Management-A Narrative Review of the Literature

One in three women of reproductive age is obese. The mainstay treatment for obesity is bariatric surgery, and the following weight reduction results in a decrease in pregnancy adverse effects, including gestational diabetes mellitus, pregnancy-induced hypertension, and macrosomia. However, nutritional and vitamin deficiencies due to changes in the gastrointestinal tract after bariatric surgery are associated with an increase in the risk of fetal growth retardation and small for gestational-age neonates. The purpose of this review was to analyze the available recent literature on the subject of the management of pregnancy after bariatric surgery. We searched for available articles from 2007 to 2023 and chose articles of the greatest scientific and clinical value. Micronutrient, vitamin, and protein supplementation is recommended in the prenatal period and throughout the pregnancy. It is advised that pregnant women with a history of bariatric surgery should be provided with regular specialist dietary care. There is still a lack of recommendations about the optimum gestational weight gain after different types of bariatric surgery and for patients of different metabolic statuses. Women of reproductive age undergoing bariatric procedures should be provided with appropriate counseling about adequate contraception, the recommended time-to-conception interval, and the positive and negative influence of bariatric surgery on perinatal outcomes.

Preconception and Pregnancy Nutrition Support for Women with a History of Bariatric Surgery: A Mixed-Methods Survey of Healthcare Professionals in the UK

Preconception bariatric surgery improves obesity-related maternal pregnancy complications but may reduce the absorption of nutrients required for healthy fetal growth and development. Women who receive preconception nutritional support after bariatric surgery are less likely to have adverse pregnancy outcomes. This study aimed to investigate the provision of preconception and pregnancy-specific nutritional support for women having bariatric surgery in the UK. A mixed-methods survey was distributed to healthcare professionals working in obesity or maternity services between December 2018 and October 2019. We collected both quantitative and qualitative data which were analysed using a mixed-methods approach. We received 135 responses from online (n = 99) and postal (n = 36) questionnaires. Only 45% of participants reported being 'very familiar' with the preconception/pregnancy nutritional needs of this population. Barriers to providing nutritional support included: a lack of resources and time; poor communication both across services and with women; not having contact with women preconception; and a lack of information and guidance. Respondents felt that dietitians have the expertise in nutrition necessary to provide support; however, GPs and midwives have the most frequent patient access post-surgery, both before and during pregnancy. Optimal preconception and pregnancy-related nutritional support requires multidisciplinary care pre- and post-surgery, and healthcare professionals require training and guidance to inform practice.

Medical and Psychological Aspects of Pregnancy in Women with Obesity and after Bariatric Surgery

Chronic diseases are potential risk factors for pregnancy duration and neonatal outcomes. This narrative review aimed to summarize the research results on the specifics of pregnancy in women with obesity and after bariatric surgery. PubMed and Google Scholar databases were searched. Systematic reviews, meta-analyses, clinical trials, and references to identified articles from the last ten years (2013-2023) were included. Ultimately, 107 literature items were qualified. It has been shown that women with obesity planning pregnancy should reduce their body weight because obesity is a risk factor for adverse obstetric and neonatal outcomes. Bariatric surgery effectively reduces excessive body weight and the health risks in women with obesity during pregnancy and their offspring. However, at least a year interval between surgery and conception is recommended. An interdisciplinary medical team should provide patient care during pregnancy with knowledge and skills related to people after bariatric surgery. Due to the increased risk of mental disorders, especially depression, it is necessary to constantly monitor the mental state of women and provide psychological support and education on a healthy lifestyle during pregnancy and the postpartum period.

From Bariatric Surgery to Conception: The Ideal Timing to Optimize Fetal Weight

PURPOSE

Bariatric surgery (BS) increases the risk of small for gestational age (SGA) neonates. Guidelines recommend postponing pregnancy for 12-24 months, but optimal surgery-to-conception interval (BSCI) remains uncertain. We aimed to evaluate the impact of BSCI on birth weight and SGA.

MATERIALS AND METHODS

Retrospective cohort study of 42 pregnancies following BS, including Roux-en-Y gastric bypass, gastric sleeve, adjustable gastric banding and biliopancreatic diversion. Neonates were classified as SGA if birth weight < 10th percentile. Optimal BSCI was obtained from the analysis of ROC curves, and pregnancies were compared by that cut-off.

RESULTS

There was a linear association between BSCI and birth weight and an inverse association with SGA, with each additional month of BSCI translating into additional 4.5 g (95%CI: 2.0-7.0) on birth weight and -6% risk of SGA (95%CI: 0.90-0.99). We established a cut-off of 24.5 months of BSCI for lower risk of SGA. Pregnancies conceived in the first 24 months had a more than tenfold increased risk of SGA (OR 12.6, 95%CI: 2.4-66.0), even when adjusted for maternal age, gestational diabetes and inadequate gestational weight gain.

CONCLUSION

BSCI was associated with birth weight and SGA. Our results are in line with the recommendations of BSCI of at least 24 months to reduce the risk of SGA.

Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review

Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.

Bariatric surgery and reproduction-implications for gynecology and obstetrics

As the rates of obesity continue to rise across the world, there has been an increasing resort to bariatric surgery amongst the options for treatment. Through the reproductive lifespan, between menarche and menopause, women might benefit from this surgical intervention, which may have a bearing on other aspects of their health. The consequences of bariatric surgery have been reported and evaluated from various perspectives in obstetrics and gynecology. Fertility and sexuality are enhanced, but not all gynecological diseases are ameliorated. There are also psychological and behavioral sequelae to be cognizant of. With multi-disciplinary and responsive care, most post-bariatric pregnancies have satisfactory outcomes. The effects of bariatric surgery on the babies conceived thereafter remains a subject of interest, whereas the possible effect on the climacteric is speculative.

Gynecologic counseling for patients undergoing bariatric surgery: a scoping review

PURPOSE OF REVIEW

Obesity is associated with several gynecologic conditions. While bariatric surgery is regarded as the most effective treatment option for obesity, gynecologic counseling for patients planning bariatric surgery is limited and often focused on fertility. The goal of this scoping review is to investigate the current recommendations for gynecologic counseling prior to bariatric surgery.

RECENT FINDINGS

A comprehensive search was conducted to find peer reviewed studies written in English discussing a gynecologic issue of patients who were planning or previously had bariatric surgery. All the included studies identified a gap in preoperative gynecologic counseling. The majority of the articles made specific recommendations for a multidisciplinary approach to preoperative gynecologic counseling with a call to involve gynecologists or primary care providers.

SUMMARY

Patients deserve to receive appropriate counseling about how obesity and bariatric surgery impact their overall gynecologic health. We advocate that the scope of gynecologic counseling includes more than pregnancy and contraception counseling. We propose a gynecologic counseling checklist for female patients undergoing bariatric surgery. Offering patients a referral to a gynecologist from the patient's first entry to a bariatric clinic is imperative to facilitate appropriate counseling.

Survey of Australian clinicians' antenatal care and management practices in pregnant women with a history of bariatric surgery

Background

Pregnancy following bariatric surgery requires tailored care. The current Australian care provision and its alignment with consensus guidelines is unclear.

Methods

Antenatal care clinicians were invited to complete a web-based survey assessing multidisciplinary referral, gestational diabetes mellitus (GDM) and micronutrient management practices.

Results

Respondents (n = 100) cared for pregnant women with a history of bariatric surgery at least monthly (63%) with most (54%) not using a specific guideline to direct care. GDM screening methods included one-week of home blood glucose monitoring (43%) or the oral glucose tolerance test (42%). Pregnancy multivitamin supplementation changes (59%) with bariatric surgery type were common. Half (54%) screened for micronutrient deficiencies every trimester and conducted additional growth ultrasounds (50%).

Conclusion

The care clinicians report providing may not align with current international consensus guidelines. Further studies with increased obstetric clinician response may aid increased understanding of current practices. The development of workplace management guidelines for pregnancy in women with a history of bariatric surgery may assist with providing consistent evidence-based care.

A Systematic Review Investigating Maternal Nutrition During Pregnancy After Bariatric Surgery

The aim of this review was to report on maternal diet, micronutrient supplementation, and gestational weight gain (GWG) during pregnancy following bariatric surgery and explore the impact on maternal micronutrient deficiency, offspring growth, and perinatal outcomes. A search in PubMed, CINAHL, EMBASE, and ProQuest in July 2022 returned 23 eligible studies (n = 30-20, 213). Diet was reported in two studies, supplementation in six and GWG in 19 studies. Although many women did not achieve healthy GWG, no consistent link with adverse outcomes was reported. Studies were grades II and III on the National Health and Medical Research Council evidence hierarchy and received a neutral or negative score on the Academy of Nutrition and Dietetics Quality Criteria Checklist, suggesting that methodological limitations impact the reliability of reported findings.

Pregnancy after bariatric surgeries; best time, gestational, and neonatal outcomes

Background

Many studies and organizations described bases of pregnancy timing after bariatric surgeries, but there is still a need for uniform scientific evidence for accurate timing.

We aimed to assess pregnancy outcomes and neonatal findings by timing of surgery to pregnancy to compare adverse perinatal outcomes among women who underwent bariatric surgery prior to pregnancy with those who had not.

Patients and methods

We included 200 pregnant females who previously performed different bariatric surgeries. All pregnant females were divided into three groups: early group of patients who were conceived ≤ 12 months from bariatric surgery included 50 patients (25.0%), middle group of patients who were conceived from 12 to 24 months from bariatric surgery included 50 patients (25.0%) and late group of patients who were conceived > 24 months from bariatric surgery included 100 patients (50.0%).

Results

There is a more liability to preterm deliveries in the early group in comparison with the middle and late group (P = 0.064). Gestational weight gain in the early group was lower than the middle and the late group (P = 0.002). Females in the early group have a more liability to inadequate gestational weight gain in comparison with in the middle and late group P < 0.001).

Neonatal birth weight in the early group was significantly lower than the middle and late group P < 0.001).

Conclusion

We supported recommendations of postponing pregnancy for more than 12 months after performing bariatric surgery which allowed stabilization of maternal weight, allowing adequate gestational weight gain, better fetal and maternal health later on.

Benefits and Risks of Bariatric Surgery on Women's Reproductive Health: a Narrative Review

Bariatric surgery (BS) is escalating as the most efficient and endurable therapy for severe obesity. Women's reproductive health is essential to women's quality of life and is receiving increasing attention. However, despite the high prevalence of BS among women, the effect of BS on reproductive health remains underemphasis. The purpose of this narrative review is to provide an overview of BS on women's reproductive health, including their reproductive health before, during, and after pregnancy. Although limited attention has been given, current evidence highlights the substantial implications of bariatric surgery on reproductive health and reminds us of the importance of adopting decision-making conversations about reproductive health before bariatric surgery.

Pregnancy after Bariatric Surgery: Nutrition Recommendations and Glucose Homeostasis: A Point of View on Unresolved Questions

Obesity is increasing in all age groups and, consequently, its incidence has also risen in women of childbearing age. In Europe, the prevalence of maternal obesity varies from 7 to 25%. Maternal obesity is associated with short- and long-term adverse outcomes for both mother and child, and it is necessary to reduce weight before gestation to improve maternal and fetal outcomes. Bariatric surgery is an important treatment option for people with severe obesity. The number of surgeries performed is increasing worldwide, even in women of reproductive age, because improving fertility is a motivating factor. Nutritional intake after bariatric surgery is dependent on type of surgery, presence of symptoms, such as pain and nausea, and complications. There is also a risk of malnutrition after bariatric surgery. In particular, during pregnancy following bariatric surgery, there is a risk of protein and calorie malnutrition and micronutrient deficiencies due to increased maternal and fetal demand and possibly due to reduction of food intake (nausea, vomiting). As such, it is necessary to monitor and manage nutrition in pregnancy following bariatric surgery with a multidisciplinary team to avoid any deficiencies in each trimester and to ensure the well-being of the mother and fetus.

Roux-en-Y Gastric Bypass Increases Glycemic Excursions During Pregnancy and Postpartum: A Prospective Cohort Study

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) and pregnancy markedly alter glucose metabolism, but evidence on glucose metabolism in pregnancy after RYGB is limited. Thus, the aims of the Bariatric Surgery and Consequences for Mother and Baby in Pregnancy study were to investigate interstitial glucose (IG) profiles during pregnancy, risk factors associated with hypoglycemia, and the association between fetal growth and hypoglycemia in pregnant women previously treated with RYGB, compared with control participants.

RESEARCH DESIGN AND METHODS

Twenty-three pregnant women with RYGB and 23 BMI- and parity-matched pregnant women (control group) were prospectively studied with continuous glucose monitoring in their first, second, and third trimesters, and 4 weeks postpartum. Time in range (TIR) was defined as time with an IG level of 3.5-7.8 mmol/L.

RESULTS

Women with RYGB were 4 years (interquartile range [IQR] 0-7) older than control participants. Pregnancies occurred 30 months (IQR 15-98) after RYGB, which induced a reduction in BMI from 45 kg/m2 (IQR 42-54) presurgery to 32 kg/m2 (IQR 27-39) prepregnancy. Women with RYGB spent decreased TIR (87.3-89.5% vs. 93.3-96.1%; P < 0.01) owing to an approximately twofold increased time above range and increased time below range (TBR) throughout pregnancy and postpartum compared with control participants. Women with increased TBR had a longer surgery-to-conception interval, lower nadir weight, and greater weight loss after RYGB. Finally, women giving birth to small-for-gestational age neonates experienced slightly increased TBR.

CONCLUSIONS

Women with RYGB were more exposed to hypoglycemia and hyperglycemia during pregnancy compared with control participants. Further research should investigate whether hypoglycemia during pregnancy in women with RYGB is associated with decreased fetal growth.

Obesity management in women of reproductive age

With the increasing prevalence of obesity among women of reproductive age, the detrimental effects on maternal and neonatal health are increasing. The objective of this review is to summarise the evidence that comprehensive management of weight control in women of reproductive age has on maternal-fetal outcomes. First, the impact that obesity has on fertility and pregnancy is described and then the specific aspects of continued weight management in each of the stages (preconception, pregnancy and postpartum) during these years are outlined, not only to benefit women affected by obesity before pregnancy, but also to avoid and reverse weight gain during pregnancy that complicates future pregnancies. Finally, the special planning and follow-up needs of women with a history of bariatric surgery are discussed in order to avoid nutritional deficiencies and/or surgical complications that endanger the mother or affect fetal development.

A Case of Late Dumping Syndrome in a Post-bariatric Pregnant Lady Seen in a Primary Care Clinic

Dumping syndrome is a common complication of bariatric surgery. A high clinical suspicion of hypoglycaemic events is required as the symptoms mimic early pregnancy complaints. Diagnosis and treatment of dumping syndrome remain a challenge in pregnancy. Thus, diet modification remains a mainstay of management. This case report discusses dumping syndrome in a post-bariatric surgery mother who presented hypoglycaemia symptoms in the primary care clinic.

The outcome of pregnancies after bariatric surgery: an observational study of pregnancies during 2004-2016 in Finland

PURPOSE

Overweight and obesity are major risk factors for perinatal morbidity and mortality, and the need for bariatric surgery (BS) among fertile-aged women is increasing. This study evaluates the outcome of post-BS pregnancies and deliveries.

METHODS

All 20-45-year-old patients delivering between 2004 and 2016 in Finland were included. Patients with previous BS were identified from the hospital discharge register, and the medical birth register was queried for data on pregnancies, deliveries, and perinatal outcomes. The data were matched using personal identification codes, and the outcomes of women with previous BS were compared with those of other pregnancies.

RESULTS

Women with previous BS (n = 314) constituted the bariatric group. When compared with the non-bariatric group (n = 750,019), they were older (p < 0.001), heavier (p < 0.001) and had more previous pregnancies (p < 0.001). The overall incidence of pregnancy-induced hypertension (p = 0.002), gestational diabetes (GDM) (p = 0.018), pre-term contractions (p = 0.023), pre-term delivery (p = 0.003), labour induction (p < 0.001), planned (p = 0.001) and unplanned (p = 0.036) caesarean sections and low birthweight infants (p < 0.001) were significantly higher in the bariatric group. When compared with body mass index-specific categories, the main outcomes were increased incidence of GDM and small for gestational age (SGA) newborns in the bariatric group.

CONCLUSION

BS can be considered a safe and advisable treatment for obesity among fertile-aged women. The pregnancy outcome is associated with post-BS weight, but the risk for GDM and small for gestational-age newborns is increased.

Knowledge of Jordanian women of reproductive age who underwent bariatric surgery and its effect on birth outcomes: A cross-sectional study

Objectives

This study aims at exploring the knowledge of women of reproductive age who underwent bariatric surgery in Jordan regarding its effect on birth outcomes.

Methods

A cross-sectional study was conducted on 183 women (aged 15-49) who had undergone bariatric surgery at the Jordan University Hospital in Amman, Jordan, between 2016 and 2019, using telephone interviews with conveniently selected participants' samples. The survey tool obtained data on women's knowledge and other sociodemographic, obstetric health, and bariatric surgery information. Unfavorable birth outcomes include preterm delivery, small for gestational age, congenital abnormalities, low birth weight, and admission to the neonatal critical care unit.

Results

More than half of the participants did not know about the possible unfavorable birth outcomes after bariatric surgery and related practice guidelines. This is shown in their median score of 3 (interquartile range: 2-4) out of a maximum possible score of 8. Women who had a good score (>4) had received counseling about unfavorable bariatric surgery outcomes from their surgeon (p < 0.013); those who had educational qualifications higher than secondary school (p < 0.001) as well as those who were employed (p < 0.008) and believed that the surgery would affect the newborn (p < 0.001). The median score was also unfavorably associated with the parity of the participants (p < 0.003).

Conclusion

The extent of knowledge regarding the unfavorable birth outcome of bariatric surgery is low among women who underwent bariatric surgery at Jordan University Hospital in Jordan. Improving health literacy and information on bariatric surgery implications on pregnancy and birth outcomes amongst women of reproductive age is a recommendation from this study.

The Timing of Pregnancies After Bariatric Surgery has No Impact on Children's Health-a Nationwide Population-based Registry Analysis

PURPOSE

Bariatric surgery has a favorable effect on fertility in women. However, due to a lack of data regarding children's outcomes, the ideal time for conception following bariatric surgery is unknown. Current guidelines advise avoiding pregnancy during the initial weight loss phase (12-24 months after surgery) as there may be potential risks to offspring. Thus, we aimed to analyze health outcomes in children born to mothers who had undergone bariatric surgery. The surgery-to-delivery interval was studied.

MATERIALS AND METHODS

A nationwide registry belonging to the Austrian health insurance funds and containing health-related data claims was searched. Data for all women who had bariatric surgery in Austria between 01/2010 and 12/2018 were analyzed. A total of 1057 women gave birth to 1369 children. The offspring's data were analyzed for medical health claims based on International Classification of Diseases (ICD) codes and number of days hospitalized. Three different surgery-to-delivery intervals were assessed: 12, 18, and 24 months.

RESULTS

Overall, 421 deliveries (31%) were observed in the first 2 years after surgery. Of these, 70 births (5%) occurred within 12 months after surgery. The median time from surgery to delivery was 34 months. Overall, there were no differences noted in frequency of hospitalization and diagnoses leading to hospitalization in the first year of life, regardless of the surgery-to-delivery interval.

CONCLUSION

Pregnancies in the first 24 months after bariatric surgery were common. Importantly, the surgery-to-delivery interval had no significant impact on the health outcome of the children.

Dietary intakes in pregnant women with previous bariatric surgery

PURPOSE

To (1) assess dietary intakes of pregnant women with previous bariatric surgery in comparison with Dietary Reference Intakes (DRIs); (2) compare their dietary intakes as well as their diet quality with a control group of pregnant women with no history of bariatric surgery.

METHODS

Twenty-eight (28) pregnant women with previous surgery (sleeve gastrectomy, n = 7 and biliopancreatic diversion with duodenal switch, n = 21) were matched for pre-pregnancy body mass index with 28 pregnant women with no history of bariatric surgery. In at least one trimester, participants completed a minimum of 2 Web-based 24-h dietary recalls from which energy, macro- and micronutrient intakes as well as the Canadian Healthy Eating Index (C-HEI) were derived.

RESULTS

No differences were observed for energy intake between groups. All women had protein intakes within the recommended range, but most women with previous surgery had carbohydrate (67%) and dietary fiber intakes (98%) below recommendations. In both groups, mean total fat, saturated fatty acids, free sugars and sodium intakes were above recommendations, as opposed to mean vitamin D, folic acid and iron dietary intakes below recommendations for most women. Compared with the control group, pregnant women with previous bariatric surgery had lower overall C-HEI scores.

CONCLUSION

These results suggest that pregnant women with previous bariatric surgery would benefit from a nutritional follow-up throughout their pregnancy.

LEVEL OF EVIDENCE

III: Evidence obtained from well-designed cohort or case-control analytic studies.

Nutrition for pregnancy after metabolic and bariatric surgery: literature review and practical guide

When pregnancy follows metabolic and bariatric surgery (MBS), there are many important considerations related to nutritional status that may impact maternal and infant outcomes. Although evidence-based nutrition guidelines for pregnancy exist for the general population, there are limited practical recommendations that specifically address pregnancy after MBS. A literature search was conducted to investigate outcomes of women with a history of MBS and pregnancy. Search criteria focused on women 18 years of age and older who became pregnant after MBS. Search terms included "laparoscopic sleeve gastrectomy," "Roux-en-Y gastric bypass," "laparoscopic adjustable gastric banding," "biliopancreatic duodenal switch," and gestation terminology, and they were paired with the nutrition outcomes of interest. A total of 167 publications were identified; 46 articles were included in the final review. Data relating to gestation and fetal weight and nutrition and cardiometabolic data were extracted from the studies. Based on this review, women of childbearing age with a history of MBS should be evaluated and monitored for nutritional status before conception, during pregnancy, and postpartum.

Maternal Nutritional Status and Pregnancy Outcomes Post-bariatric Surgery

Obesity in childbearing women leads to pregnancy-related complications such as gestational diabetes mellitus, pregnancy-associated hypertensive disorders, and macrosomia. Weight loss helps reduce these complications. Studies show bariatric surgery reduces obesity-related complications during and after pregnancy. However, bariatric surgery might be associated with adverse outcomes, such as low birth weight and small-for-gestational-age infants. In addition, several studies suggest pregnancy occurring less than a year post-bariatric surgery adversely affects pregnancy outcomes and causes micronutrients deficiency since the dramatic weight loss occurs in the first year. These adverse outcomes may lead to nutritional malabsorption, such as anemia and low vitamin B12 and folic acid levels. The review aims to overview obesity-related complications during pregnancy and the benefits and risks of bariatric surgery on pregnancy outcomes and maternal nutrition status.

The Impact of Preconception Gastric Bypass Surgery on Maternal Micronutrient Status before and during Pregnancy: A Retrospective Cohort Study in the Netherlands between 2009 and 2019

Post-bariatric weight loss can cause iatrogenic malnutrition and micronutrient depletion. In this study, we evaluated the impact of gastric bypass surgery (GB) and multivitamin supplement use on maternal micronutrient status before and across pregnancy. A retrospective medical chart review of 197 singleton pregnancies after GB with a due date between 2009 and 2019 was performed at a bariatric expertise center in the Netherlands. Hemoglobin, calcium, iron status, folate, vitamin D, vitamin B12 and ferritin levels were determined before and after GB during standard follow-up and at all gestational trimesters and analyzed using linear mixed models. Patients were prescribed standard multivitamin supplements or multivitamins specifically developed for post-bariatric patients (FitForMe WLS Forte (FFM)). Overall, hemoglobin and calcium levels decreased after surgery and during pregnancy, whereas folate, vitamin D, and vitamin B12 levels increased, and iron levels remained stable. FFM use was associated with higher hemoglobin, folate, vitamin D, and ferritin levels. In conclusion, through adequate supplementation and follow-up, GB does not have to result in impaired micronutrient status. Supplements developed specifically for post-bariatric patients generally result in higher micronutrient values than regular multivitamins before and during pregnancy. These data emphasize the urgent need for nutritional counseling including dietary and multivitamin supplement advise for post-bariatric women contemplating and during pregnancy.

A Retrospective Evaluation of Pregnancy Outcomes Following Bariatric Surgery: A Single-Center Experience

BACKGROUND

Bariatric and metabolic surgery (BMS) is an effective treatment for obesity and its complications, but its effect on pregnancy outcomes is inconclusive. The present study aimed to investigate women's pregnancy status and outcomes as well as the impact of pregnancy intervals after BMS.

METHODS

The menstrual cycle and fertility status of women who underwent BMS in our centre between July 2010 and January 2021 were retrospectively analyzed and followed up until one-year post-delivery. The pregnancy outcomes after BMS were observed, including changes in weight, pregnancy interval, pregnancy complications, weight and health status of the newborn (premature birth, admission to neonatology, or deformity).

RESULTS

We identified 31 women who were successfully conceived after BMS. There were statistical differences in weight and menstrual status before and post-operation (P < 0.05), and 77.97% of them had remission or recovery of obesity-related comorbidities. Eighteen patients delivered successfully after BMS, but there were still 12 cases of spontaneous abortion and 1 case of induced abortion. The abortion rate in pregnancy intervals less than 2 years was higher than those ≥2 years (P = 0.045). Of the women who delivered successfully, 5 had pregnancy-specific complications, including gestational diabetes mellitus and hypertensive disorder of pregnancy. However, the growth and development of the newborn are normal since the birth follow-up.

CONCLUSION

The present results suggest that the abortion rate in pregnancy intervals less than 2 years was higher than those ≥2 years. It is recommended that postoperative patients avoid pregnancy until their weight is stable to reduce the risk of adverse pregnancy outcomes.

Metabolic Surgery on Patients With Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis

Polycystic ovary syndrome (PCOS) is a complicated reproductive endocrine disease that is closely related to obesity. Metabolic surgery ameliorates a series of clinical manifestations and related comorbidities of PCOS. However, the overall efficacy of metabolic surgery on PCOS remains uncertain. This systematic review and meta-analysis aimed to evaluate the therapeutic effects of metabolic surgery on obese patients with PCOS. A systematic literature search for relevant studies was conducted on PubMed, Embase, Web of Science, and the Cochrane Library from inception to June 2021. Data extraction and quality evaluation were performed by three researchers, and RevMan 5.4 software was used to conduct the meta-analysis. A total of 14 studies involving 501 obese patients with PCOS were included. Incidence of PCOS in obese women ranged from 5.5% to 63.5% among the included studies. The results showed the incidence of abnormal menstruation decreased from 81% to 15% (OR=0.03, 95% confidence interval (CI): 0.01-0.08), while the incidence of hirsutism dropped from 71% to 38% (OR=0.21, 95% CI: 0.06-0.74). Serum total testosterone and free testosterone levels decreased by 25.92 ng/dL (MD = -25.92, 95% CI: -28.90- -22.93) and 2.28 ng/dL (SMD = -2.28, 95% CI: -3.67- -0.89), respectively. Sex hormone-binding globulin (SHBG) levels increased by 26.46 nmol/L (MD = 26.46, 95% CI: 12.97-39.95). Serum anti-Mullerian hormone (AMH) levels decreased by 1.29 ng/mL (MD = -1.29, 95% CI: -1.92- -0.66). Small sample size studies revealed that pregnancy rates ranged from 95.2% to 100% postoperatively. Metabolic surgery contributed to marked improvement of abnormal menstruation, hirsutism, and levels of free testosterone, total testosterone, SHBG, and AMH in patients with PCOS. Our findings indicate that patients with PCOS are expected to benefit from metabolic surgery, and could help potentially improve their reproductive outcomes. Metabolic surgery could thus be a new viable option for the clinical treatment of PCOS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021251524.

Reproductive outcomes after bariatric surgery in women

The presence of obesity may significantly influence female fertility through various mechanisms. Impairment of the hypothalamic-pituitary-ovarian axis in obese women may induce anovulation and infertility. Obesity may have an effect on women’s spontaneous and assisted conception rates, increased miscarriage rates, premature labor, stillbirth and perinatal risks, and menstrual irregularity. It has been suggested that weight loss improves reproductive outcomes due to fertility amelioration and an improvement in menstrual irregularity and ovulation. It is still not known which weight reduction procedures (changes in lifestyle, pharmacological management or bariatric intervention) result in optimal outcome on infertility. Currently, bariatric surgery is defined as the best available method for the management of obesity and its associated diseases.

We have analyzed literature facts about effects of bariatric surgery on the function of the hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (PCOS), anti-Mullerian hormone (AMH) and sexual dysfunction in obesity and pregnancy in obesity. Immediate positive effects of bariatric surgery are evident at the moment, while for long-term outcomes more prolonged follow-up investigations should be done.

The Effect of Gastric Sleeve Resection on Menstrual Pattern and Ovulation in Premenopausal Women with Classes III-IV Obesity

PURPOSE

Bariatric surgery is very efficacious in treating severe obesity. However, its effect on menstruation and ovulation is currently unknown. The purpose of this study was to assess the effect of gastric sleeve resection (GSR) on menstrual pattern in women with stages III-IV obesity and ovulatory dysfunction compared with conventional management.

METHODS

This was a prospective, multicentre, non-randomized trial, in premenopausal women, who fulfilled the criteria for gastric sleeve resection (GSR). Both women with and without polycystic ovary syndrome (PCOS) were evaluated at 3, 6, 9, 12 and 15 months post-surgery.

RESULTS

Menstrual cycle irregularities were identified in 122 severely obese women (60 with PCOS; 62 without PCOS). The % total weight loss was greater with GSR than with conventional management (33.4% vs. 3.6% in PCOS; 24.8% vs. 3.6% in non-PCOS, respectively). Intermenstrual interval was shortened towards normal length (≤ 35 days) both in PCOS and non-PCOS GSR groups, by the 6th and 12th post-surgical month, respectively. Furthermore, ovulation at 6 months was achieved in 63.6% of PCOS and 45% of non-PCOS subjects post-GSR, which was higher than in controls (11.1% and 13.6%, respectively; p < 0.05). This percentage rose to 75.7% and 81.8% at 12 and 15 months in PCOS, respectively, but not in the non-PCOS group (55% and 52.5%, respectively; p < 0.05).

CONCLUSIONS

Weight reduction after GSR improved menstrual irregularity towards normality in women with severe obesity. Ovulation dysfunction was also resumed in more than half of these patients at 6-15 months. These effects were more evident in women with PCOS.

The influence of gestational weight gain after bariatric procedures on selected pregnancy outcomes: a single center study

Pregnancy after bariatric surgery is known to be associated with a higher risk of small for gestational age infants (SGA) and maternal anemia. 71 patients with a history of bariatric surgery, who had at least one pregnancy ended with a delivery of a single live-born neonate after the bariatric surgery were included in the study. The main endpoints were gestational weight gain (GWG), GWG as % of the maternal weight at the beginning of pregnancy (GWG%), maternal anemia, SGA and large for gestational age infants (LGA), neonatal intensive care unit admission (NICU). GWG% was 23.8% ± 14.1 in the LGA group vs 13.9% ± 11.0 in the normal weight neonates group; p < 0.03. Patients diagnosed with anemia before pregnancy had higher GWG% than patients without pre-pregnancy anemia (20.1% ± 11.1 vs 13.4% ± 11.6); p < 0.05. GWG% was higher in patients, whose infants were admitted to NICU (25.3% ± 17.6 vs 14.1% ± 11.0; p < 0.04). GWG% can be considered a risk predictor of the LGA and NICU admissions in bariatric patients. Anemia diagnosed before pregnancy is associated with higher GWG%.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus

BACKGROUND

Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS.

METHODS

A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus.

RESULTS

The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively.

CONCLUSION

Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Pregnancy and Bariatric Surgery: Significant Variation in Bariatric Surgeons' Practices and Preferences: A National Survey

Background:

Bariatric complications may occur during pregnancy, potentially causing serious maternal and fetal problems. The aim of this study was to determine the current practice and preferences of bariatric surgeons regarding the pregnancy care of fertile women before and after bariatric surgery.

Methods:

A 26-question anonymous online survey was designed and sent to all bariatric surgeons of the Dutch Society of Metabolic and Bariatric Surgery.

Results:

At least one bariatric surgeon from each bariatric center (n = 18) completed the survey. In case of a future child, wish sleeve gastrectomy became more popular than Roux-en-Y gastric bypass. All surgeons provided preoperative education regarding bariatric complications during pregnancy. Nine centers without neonatal intensive care would not refer pregnant women with acute complications. Half of the centers had a standard operating procedure. Seven per 18 bariatric centers had seen at least one postbariatric pregnant patient with severe maternal morbidity. One case of perinatal mortality was reported.

Conclusion:

There is an inconsistent and often below guideline standard daily practice regarding pregnancy before and after bariatric surgery. There is limited experience with pregnant women with acute bariatric complications. Referral to tertiary centers is inadequate. Better information provision for both professionals and patients regarding possible complications is needed.