Pregnancy outcome in patients following different types of bariatric surgeries

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.

Maternal Bariatric Surgery and Offspring Health: A Sibling Matched Analysis Comparing Offspring Born before and after the Surgery

(1) Background: Due to the global escalation in the prevalence of obesity, bariatric surgeries have become a popular solution in many western countries. The aim of the current study was to compare offspring health and the obesity of women before and after undergoing bariatric surgeries. (2) Methods: A retrospective population-based study was performed, including all singleton deliveries which occurred at a tertiary medical center between the years 1991-2021. Among women who had bariatric surgeries, the health of the offspring born before and after the surgery were compared. The offspring were followed up until the age of 18 years, and their hospitalization records were summarized. The incidence of hospitalization with either endocrine, cardiac, respiratory, neurologic, or infectious diagnoses were compared between the groups, as well as offspring obesity. Multivariable Cox proportional models were used to match between siblings and to address confounding variables, including maternal age, gestational age at delivery, fertility treatment, smoking and pregnancy hypertensive disorders. (3) Results: The study population included 3074 deliveries of women who underwent bariatric surgeries (1586 were before and 1488 after the surgery). Offspring born after maternal bariatric surgeries were at a comparable risk for most morbidities, besides endocrine-related morbidities (3.1% vs. 5.0%, OR = 1.61; 1.1-2.35) and obesity (2.5% vs. 4.1%, OR = 1.63; 1.08-2.48). The risk for these morbidities was higher among the offspring of mothers after, vs. before, the surgery, despite adjustment for maternal age and other confounding variables. (4) Conclusions: While bariatric surgeries are considered an effective treatment for obesity, it seems to have less of an effect on the offspring of women who underwent such surgeries. Other persistent factors are most likely associated with the offspring's risk for morbidities, especially endocrine morbidities and obesity, which remain even though the mother underwent bariatric surgeries.

Risk factors of lower birth weight, small-for-gestational-age infants, and preterm birth in pregnancies following bariatric surgery: a scoping review

PURPOSE

Bariatric surgery increases the risk of lower birth weight, small-for-gestational-age (SGA) infants, and preterm birth in a subsequent pregnancy. However, the factors that contribute to these adverse birth outcomes are unclear. This review aimed to collate available information about risk factors of lower birth weight, SGA, and preterm birth following bariatric surgery.

METHODS

A literature search was conducted using five databases (PubMed, PsycINFO, EMBASE, Web of Science, and Cochrane Library) to obtain relevant studies.

RESULTS

A total number of 85 studies were included. Studies generally excluded surgery-to-conception interval, pregnancy complications, cigarette use, and maternal age as influencing factors of birth weight, SGA, or preterm birth. In contrast, most studies found that malabsorptive procedures, lower gestational weight gain, lower glucose levels, abdominal pain, and insufficient prenatal care were associated with an elevated risk of adverse birth outcomes. Findings were mixed regarding the effects of surgery-to-conception weight loss, pre-pregnancy body mass index, micronutrient deficiency, and lipid levels on birth outcomes. The examination of maternal microbiome profiles, placental function, alcohol use, and exercise was limited to one study; therefore, no conclusions could be made.

CONCLUSION

This review identified factors that appear to be associated (e.g., surgery type) or not associated (e.g., surgery-to-conception interval) with birth outcomes following bariatric surgery. The mixed findings and the limited number of studies on several variables (e.g., micronutrients, exercise) highlight the need for further investigation. Additionally, future studies may benefit from exploring interactions among risk factors and expanding to assess additional exposures such as maternal mental health.

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.

Pregnancy After Sleeve Gastrectomy: Time Matters?

PURPOSE

Obesity has an especial implication for women of childbearing age because of a higher risk of adverse outcomes during pregnancy and labor. This report aimed to analyze complications of pregnancy after sleeve gastrectomy (SG) concerning the time after surgery.

METHODS

A retrospective descriptive-analytical study was conducted including women of childbearing age who underwent sleeve gastrectomy (SG) from 2006 to 2017. Patients were divided into two groups regarding the time elapsed from SG to pregnancy: less than and greater than one year (group A /group B, respectively).

RESULTS

During the studied time, 51 pregnancies with complete clinical records were found. The mean weight and gestational age (GA) of the newborn (NB) were normal. The mean time from surgery to pregnancy was 30.4 ± 21 months. Patients from Group A and B presented 28.6% and 16.7% respectively of preterm NB (p = 0.5). Group A registered no low birth weight (LBW) babies (3.0 ± 0.4 kg) with a GA of 37.2 ± 2.1 weeks, while in Group B, 8.6% of NB were at LBW 2.1 ± 0.1 kg and GA of 33.3 ± 3.8 weeks (p = NS).

CONCLUSION

After SG, no differences in terms of maternal and neonatal complications were found concerning the time between surgery and pregnancy.

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.

Pregnancy Complications in Women with Weight Loss Surgery Compared to a Non-Surgical Population of Women with Obesity

BACKGROUND

The objective of this study was to assess the effect of WLS on pregnancy and delivery complications in women who had WLS compared to women with obesity who did not undergo WLS.

METHODS

We used the National Inpatient Sample data from 2012 to 2017, with a study population of women between the ages of 20 and 44 who had a maternal admission code in the NIS data (n = 663,795). Weighted logistic regression models were fitted and the models were stratified by race. Covariates included age, race, primary payer, previous cesarean delivery, physical health comorbidities, and depression.

RESULTS

There were decreased odds of gestational diabetes in women of all races (aOR_all = 0.47, 95% CI_all = 0.44-0.49). There were decreased odds for gestational hypertension in women of all races (aOR_all = 0.55, 95% CI_all = 0.51-0.59). Compared to women who did not have WLS, there were lower odds of cesarean delivery among women with a history of WLS (aOR_all = 0.62, 95% CI_all = 0.60-0.65), which was true for White women, Black women, and Latinas with a history of WLS (aOR_White = 0.57, 95% CI_White = 0.53-0.60; aOR_Black = 0.67, 95% CI_Black = 0.61-0.74; aOR_Latina = 0.71, 95% CI_Latina = 0.64-0.78).

CONCLUSIONS

Overall, women with history of WLS had lower odds of most of the pregnancy outcomes (gestational diabetes, gestational hypertension, pre-eclampsia/eclampsia, and cesarean delivery) with results mediated by race.

Pregnancy after bariatric surgery - a narrative literature review

The purpose of this review was to analyze the literature about pregnancy after bariatric surgery. We searched for available articles on the subject from the last decade (2010 to 2020). The positive impact of bariatric surgery on the level of comorbidities and pregnancy and neonatal outcomes cannot be overrated. Weight loss after bariatric surgery reduces the incidence of obesity-related conditions in pregnancy. A pregnancy in a woman after bariatric surgery should be considered a high-risk pregnancy and taken care of by a multidisciplinary team with appropriate micronutrient and vitamin supplementation provided. Optimum time to conception should be chosen following the international recommendations. Every woman after bariatric surgery should be aware of symptoms of surgical complications and immediately contact their surgeon in case of abdominal pain.

A Matter of Timing-Pregnancy After Bariatric Surgery

PURPOSE

Current guidelines recommend to avoid pregnancy for 12-24 months after bariatric surgery because of active weight loss and an increased risk of nutritional deficiencies. However, high-quality evidence is lacking, and only a few studies included data on gestational weight gain. We therefore evaluated pregnancy and neonatal outcomes by both surgery-to-conception interval and gestational weight gain.

MATERIALS AND METHODS

A multicenter retrospective analysis of 196 singleton pregnancies following Roux-en-Y gastric bypass, sleeve gastrectomy, and one anastomosis gastric bypass was conducted. Pregnancies were divided into the early group (≤ 12 months), the middle group (12-24 months), and the late group (> 24 months) according to the surgery-to-conception interval. Gestational weight gain was classified as inadequate, adequate, or excessive according to the National Academy of Medicine recommendations.

RESULTS

Pregnancy in the early group (23.5%) was associated with lower gestational age at delivery (267.1 ± 19.9 days vs 272.7 ± 9.2 and 273.1 ± 13.5 days, P = 0.029), lower gestational weight gain (- 0.9 ± 11.0 kg vs + 10.2 ± 5.6 and + 10.0 ± 6.4 kg, P < 0.001), and lower neonatal birth weight (2979 ± 470 g vs 3161 ± 481 and 3211 ± 465 g, P = 0.008) than pregnancy in the middle and late group. Inadequate gestational weight gain (40.6%) was associated with lower gestational age at delivery (266.5 ± 20.2 days vs 273.8 ± 8.4 days, P = 0.002) and lower neonatal birth weight (3061 ± 511 g vs 3217 ± 479 g, P = 0.053) compared to adequate weight gain. Preterm births were also more frequently observed in this group (15.9% vs 6.0%, P = 0.037).

CONCLUSION

Our findings support the recommendation to avoid pregnancy for 12 months after bariatric surgery. Specific attention is needed on achieving adequate gestational weight gain.

Collateral Damage: Maternal Obesity During Pregnancy Continues to Rise

Importance

The pandemic of obesity during pregnancy now afflicts 1 out of every 2 pregnant women in the United States. Even though unintended pregnancy has decreased to 45% of all pregnancies, 50% of those unintended pregnancies occur in obese women.

Objective

This study aims to identify why current lifestyle interventions for obese pregnancy are not effective and what the newer complications are for obesity during pregnancy.

Evidence Acquisition

Available literatures on current treatments for maternal obesity were reviewed for effectiveness. Emerging maternal and infant complications from obesity during pregnancy were examined for significance.

Results

Limitations in successful interventions fell into 3 basic categories to include the following: (1) preconception weight loss; (2) bariatric surgery before pregnancy; and (3) prevention of excessive gestational weight gain during pregnancy. Emerging significant physiological changes from maternal obesity is composed of inflammation (placenta and human milk), metabolism (hormones, microbiome, fatty acids), and offspring outcomes (body composition, congenital malformations, chronic kidney disease, asthma, neurodevelopment, and behavior).

Conclusions and Relevance

Are current prepregnancy lifestyle and behavioral interventions feasible to prevent maternal obesity complications? Epigenetic and metabolomic research will be critical to determine what is needed to blunt the effects of maternal obesity and to discover successful treatment.

Obesity and Reproduction

OBJECTIVE

To provide a comprehensive review and evidence-based recommendations for the delivery of fertility care to women with obesity.

OUTCOMES

The impact of obesity on fertility, fertility treatments, and both short and long-term maternal fetal outcomes was carefully considered.

EVIDENCE

Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and key words. Results included systematic reviews, clinical trials, observational studies, clinical practice guidelines, and expert opinions.

VALUES

The Canadian Fertility & Andrology Society (CFAS) is a multidisciplinary, national non-profit society that serves as the voice of reproductive specialists, scientists, and allied health professionals working in the field of assisted reproduction in Canada. The evidence obtained for this guideline was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committee of the CFAS under the leadership of the principal authors.

BENEFITS, HARMS, AND COSTS

The implementation of these recommendations should assist clinicians and other health care providers in counselling and providing reproductive care to women with obesity.

VALIDATION

This guideline and its recommendations have been reviewed and approved by the membership, the CPG Committee and the Board of Directors of the CFAS.

SPONSORS

Canadian Fertility & Andrology Society.

RECOMMENDATIONS

Twenty-one evidence based recommendations are provided. These recommendations specifically evaluate the impact of obesity on natural fertility, fertility treatments, and maternal-fetal outcomes. Strategies to lose weight and BMI cut-offs are also addressed.

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

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper.

Offspring of women following bariatric surgery and those of patients with obesity are at an increased risk for long-term pediatric endocrine morbidity

OBJECTIVE

To assess whether offspring of women following bariatric surgery as well as offspring of obese women are at an increased risk for long-term pediatric endocrine morbidity.

SETTING

This study was conducted at the university hospital.

METHODS

A population-based cohort study compared the incidence of long-term (up to the age of 18 years) occurrence of endocrine morbidity between offspring of mothers following bariatric surgery and obese mothers, as compared with parturients without obesity and without prior bariatric surgery.

RESULTS

During the study period 220,563 newborns met the inclusion criteria; 1001 were delivered by patients following bariatric surgery, 2275 were delivered by obese women and 217,287 were delivered by normal weight women without prior bariatric surgery. Long-term endocrine morbidity was more common in the bariatric group (2.3%) and the obesity group (1.5%) as compared with the comparison group (0.5%; P < 0.001). Specifically, pediatric obesity was significantly more common in children of mothers following bariatric surgery (1.8%) and of mothers with obesity (1.2%) as compared with the comparison group (0.2%; P < 0.001). Children born to women following bariatric surgery as well as obese women had higher cumulative incidence of pediatric endocrine morbidity (Log rank, P < 0.001). The results remained significant when controlling for maternal factors, adjusted HR 6.25, 95% CI 4.10-9.50; P < 0.001 for women following bariatric surgery and aHR 2.40 95% CI 1.69-3.40; P < 0.001 for obese women.

CONCLUSION

Offspring of women following bariatric surgery as well as those of obese women are at an increased risk for long-term pediatric endocrine morbidity.

Preconception management of women with obesity: A systematic review

The prevalence of women of child-bearing age with obesity continues to rise at an alarming rate. This has significant implications for both the short-term and long-term health of mother and offspring. Given the paucity of evidence-based literature in this field, the preconception management of women with obesity is highly variable both between institutions and around the world. This systematic review aims to evaluate studies that inform us about the role of preconception weight loss in the fertility and pregnancy outcomes of women with obesity. Current therapeutic interventions are discussed, with a specific focus on the suitability of weight loss interventions for women with obesity planning pregnancy. There are significant knowledge gaps in the current literature; these are discussed and areas for future research are explored.

Gestational diabetes risk factors and long-term consequences for both mother and offspring: a literature review

INTRODUCTION

Established risk factors for gestational diabetes mellitus (GDM) include ethnicity, obesity, and family history of diabetes. Untreated GDM patients have higher rates of maternal and perinatal morbidity. GDM is an independent risk factor for future longer-term risk of type 2 diabetes mellitus (T2DM), metabolic syndrome, cardiovascular morbidity, malignancies, ophthalmic, psychiatric, and renal disease in the mother. Offspring risk long-term adverse health outcomes, including T2DM, subsequent obesity, impacted neurodevelopmental outcome, increased neuropsychiatric morbidity, and ophthalmic disease.

AREAS COVERED

We critically review data from retrospective, prospective, and meta-analysis studies pertaining to established GDM risk factors, complications during pregnancy and birth (both mother and offspring), and long-term consequences (both mother and offspring).

EXPERT COMMENTARY

Many of the adverse consequences of GDM might be avoided with proper management and treatment. Patients belonging to high-risk ethnic groups, and/or with body mass index ≥ 25 kg/m², and/or known history of diabetes in first-degree relatives may benefit from universal screening and diagnostic criteria proposed by the International Association of Diabetes and Pregnancy Study Group (IADPSG). The IADPSG one-step method has several advantages, including simplicity of execution, greater patient-friendliness, and higher diagnostic accuracy. Additionally, evidence suggests that the recent increased popularity of bariatric surgery will help to decrease GDM rates over next 5 years. Similarly, metformin may be useful for treating and preventing obstetrical complications in confirmed GDM patients.

Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome

Bariatric surgery (BS) is regarded to be the most effective treatment of obesity with long lasting beneficial effects including weight loss and improvement of metabolic disorders. A considerable number of women undergoing BS are at childbearing age.Although the surgery mediated weight loss has a positive effect on pregnancy outcome, the procedures might be associated with adverse outcomes as well, for example micronutrient deficiencies, iron or B12 deficiency anemia, dumping syndrome, surgical complications such as internal hernias, and small for gestational age (SGA) offspring, possibly due to maternal undernutrition. Also, there is no international consensus concerning the ideal time to conception after BS. Hence, the present narrative review intents to summarize the available literature concerning the most common challenges which arise before and during pregnancy after BS, such as fertility related considerations, vitamin and nutritional deficiencies and their adequate compensation through supplementation, altered glucose metabolism and its implications for gestational diabetes screening, the symptoms and treatment of dumping syndrome, surgical complications and the impact of BS on pregnancy outcome. The impact of different bariatric procedures on pregnancy and fetal outcome will also be discussed, as well as general considerations concerning the monitoring and management of pregnancies after BS.Whereas BS leads to the mitigation of many obesity-related pregnancy complications, such as gestational diabetes mellitus (GDM), pregnancy induced hypertension and fetal macrosomia; those procedures pose new risks which might lead to adverse outcomes for mothers and offspring, for example nutritional deficiencies, anemia, altered maternal glucose metabolism and small for gestational age children.

Screening and Management of Gestational Diabetes Mellitus after Bariatric Surgery

Gestational diabetes mellitus (GDM) is a frequent medical complication during pregnancy. This is partly due to the increasing prevalence of obesity in women of childbearing age. Since bariatric surgery is currently the most successful way to achieve maintained weight loss, increasing numbers of obese women of childbearing age receive bariatric surgery. Bariatric surgery performed before pregnancy significantly reduces the risk to develop GDM but the risk is generally still higher compared to normal weight pregnant women. Women after bariatric surgery therefore still require screening for GDM. However, screening for GDM is challenging in pregnant women after bariatric surgery. The standard screening tests such as an oral glucose tolerance test are often not well tolerated and wide variations in glucose excursions make the diagnosis difficult. Capillary blood glucose measurements may currently be the most acceptable alternative for screening in pregnancy after bariatric surgery. In addition, pregnant women after bariatric surgery have an increased risk for small neonates and need careful nutritional and foetal monitoring. In this review, we address the risk to develop GDM after bariatric surgery, the challenges to screen for GDM and the management of women with GDM after bariatric surgery.

Health consequences for mother and baby of substantial pre-conception weight loss in obese women: study protocol for a randomized controlled trial

BACKGROUND

Current guidelines for the management of obesity in women planning pregnancy suggest lifestyle modification before conception. However, there is little evidence that lifestyle modification alters pregnancy outcomes. Bariatric surgery results in significant weight loss. This appears to reduce the risk of adverse pregnancy outcomes for the mother but may increase the risk of adverse outcomes for the infant. In order to reduce the risks of obesity-related adverse pregnancy outcomes for both mother and offspring, alternative approaches to the management of obesity in women planning pregnancy are needed.

METHODS/DESIGN

This study, a two-arm, parallel group, randomized control trial, will be conducted at the Metabolic Disorders Centre, University of Melbourne. This trial will recruit 164 women aged 18-38 years with a body mass index of 30-55 kg/m² who plan to conceive in the next 6-12 months. Women will be randomized to one of two 12-week interventions (Group A and Group B). Group A will aim for modest weight loss (MWL; ≤ 3% body weight) using a hypocaloric diet. Group B will aim for substantial weight loss (SWL; 10-15% body weight) using a modified very low energy diet (VLED) program. All participants will be asked to comply with National Health and Medical Research Council (NHMRC) guidelines for exercise and will be provided with standard pre-pregnancy advice according to Royal Australian and New Zealand College of Obstetrics and Gynaecology guidelines. All participants will then be observed for the subsequent 12 months. If pregnancy occurs within the 12-month follow-up period, data on weight and metabolic status of the mother, and pregnancy outcomes of mother and offspring will be recorded. The primary outcome is maternal fasting plasma glucose at 26-28 weeks' gestation, given that this is known to correlate with pregnancy outcomes. Time to conception, live birth rate, gestational weight gain, and a composite of adverse pregnancy outcomes for mother and baby will comprise the secondary outcomes.

DISCUSSION

There is increasing emphasis on obese women losing weight before conception. To date, no randomized controlled trial has demonstrated an effective means of weight loss that results in improved pregnancy outcomes for both mother and baby. This study intends to determine if substantial pre-conception weight loss, achieved using a VLED, improves pregnancy outcomes for mother and baby when compared with standard care. This research will potentially change clinical care of an obese woman planning pregnancy.

TRIAL REGISTRATION

ANZCTR, 12,614,001,160,628 . Registered on 5 November 2014.

Pregnancy After Bariatric Surgery: National Survey of Obstetrician's Comfort, Knowledge, and Practice Patterns

OBJECTIVE

The objective of this study is to survey a nationally representative sample of obstetricians regarding comfort, knowledge, and practice patterns of caring for pregnant women after bariatric surgery.

MATERIALS AND METHODS

We conducted an online survey of US obstetricians and describe obstetrician's demographics, practice settings, and practice patterns. We assessed respondent's knowledge and recommended practices. We compared provider knowledge by years since completing residency, scope of practice (generalist or specialist), and practice setting (academic setting or other). Statistical significance was set at p < 0.05.

RESULTS

A total of 106 completed the survey (response rate of 54%). Respondents had a median age of 47 and median 17 years in practice. Sixty-two percent were generalists. Nearly all of the respondents (94%) had some experience with caring for pregnant women after bariatric surgery and 83% reported feeling "very comfortable" (48%) or "somewhat comfortable" (35%) providing care for this population. Most (74%) were aware of increased risk of small for gestational age after surgery. Only 13% were able to correctly identify all recommended nutritional labs and 20% reported that they "did not know" which labs are recommended. There were no differences in comfort, experience, knowledge, and practice patterns by physician characteristics and practice settings.

CONCLUSION

While most obstetricians are aware of perinatal risks after bariatric surgery, a substantial percentage of obstetricians are unaware of recommended practices regarding nutrition and nutritional monitoring. As bariatric surgery becomes increasingly prevalent among reproductive age women, educational interventions to increase obstetricians' knowledge of optimal care of pregnant women after bariatric surgery are urgently needed.

Pregnancy after bariatric surgery: improving outcomes for mother and child

The significant increase in the prevalence of obesity has led to an increase in the number of obese women who become pregnant. In this setting, in recent years, there has been an exponential rise in the number of bariatric procedures, with approximately half of them performed in women of childbearing age, and a remarkable surge in the number of women who become pregnant after having undergone bariatric surgery (BS). These procedures entail the risk of nutritional deficiencies, and nutrition is a crucial aspect during pregnancy. Therefore, knowledge and awareness of the consequences of these techniques on maternal and fetal outcomes is essential. Current evidence suggests a better overall obstetric outcome after BS, in comparison to morbid obese women managed conservatively, with a reduction in the prevalence of gestational diabetes mellitus, pregnancy-associated hypertensive disorders, macrosomia, and congenital defects. However, the risk of potential maternal nutritional deficiencies and newborns small for gestational age cannot be overlooked. Results concerning the incidence of preterm delivery and the number of C-sections are less consistent. In this paper, we review the updated evidence regarding the impact of BS on pregnancy.

Impact of bariatric surgery on fetal growth restriction: experience of a perinatal and bariatric surgery center

BACKGROUND

Bariatric surgery is known to improve some pregnancy outcomes, but there is concern that it may increase the risk of small for gestational age.

OBJECTIVE

To assess the impact of bariatric surgery on pregnancy outcomes and specifically of the type of bariatric surgery on the risk of fetal growth restriction.

STUDY DESIGN

A single-center retrospective case-control study. The study group comprised all deliveries in women who had undergone bariatric surgery. To investigate the effects of weight loss on pregnancy outcomes, we compared the study group with a control group matched for presurgery body mass index. Secondly, to assess the specific impact of the type of surgery on the incidence of fetal growth restriction in utero, we distinguished subgroups with restrictive and malabsorptive bariatric surgery, and compared outcomes for each of these subgroups with a second control group, matched for prepregnancy body mass index.

RESULTS

Among 139 patients operated, 58 had a malabsorptive procedure (gastric bypass) and 81 a purely restrictive procedure (72 a gastric banding and 9 a sleeve gastrectomy). Compared with controls matched for presurgery body mass index, the study group had a decreased rate of gestational diabetes (12% vs 23%, P = .02) and large for gestational age >90th percentile (11% vs 22%, P = .01) but an increased rate of small for gestational age <10th percentile. The incidence of small for gestational age was higher after gastric bypass (29%) than it was after restrictive surgery (9%) or in controls matched for prepregnancy body mass index (6%) (P < .01 between bypass and controls). In multivariable analysis, after adjustment for other risk factors, gastric bypass remained strongly associated with small for gestational age (adjusted odds ratio, 7.16; 95% confidence interval, 2.74-18.72).

CONCLUSION

Malabsorptive bariatric surgery was associated with an increased risk of fetal growth restriction.

Maternal and perinatal outcomes after bariatric surgery: a Spanish multicenter study

BACKGROUND

Bariatric surgery (BS) has become more frequent among women of child-bearing age. Data regarding the underlying maternal and perinatal risks are scarce. The objective of this nationwide study is to evaluate maternal and perinatal outcomes after BS.

METHODS

We performed a retrospective observational study of 168 pregnancies in 112 women who underwent BS in 10 tertiary hospitals in Spain over a 15-year period. Maternal and perinatal outcomes, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders (PAHD), pre-term birth cesarean deliveries, small and large for gestational age births (SGA, LGA), still births, and neonatal deaths, were evaluated. Results were further compared according to the type of BS performed: restrictive techniques (vertical-banded gastroplasty, sleeve gastrectomy, and gastric banding), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD).

RESULTS

GDM occurred in five (3 %) pregnancies and there were no cases of PAHD. Women whose pregnancies occurred before 1 year after BS had a higher pre-gestational body mass index (BMI) than those who got pregnant 1 year after BS (34.6 ± 7.7 vs 30.4 ± 5.3 kg/m(2), p = 0.007). In pregnancies occurring during the first year after BS, a higher rate of stillbirths was observed compared to pregnancies occurring after this period of time (35.5 vs 16.8 %, p = 0.03). Women who underwent BPD delivered a higher rate of SGA babies than women with RYGB or restrictive procedures (34.8, 12.7, and 8.3 %, respectively).

CONCLUSIONS

Pregnancy should be scheduled at least 1 year after BS. Malabsorptive procedures are associated to a higher rate of SGA births.

[Digestive surgical complications during pregnancy following bariatric surgery: Experience of a center for perinatology and obesity]

OBJECTIVE

To describe severe complications during pregnancy requiring surgery in patients with a history of obesity surgery.

MATERIEL AND METHODS

A retrospective study in a hospital with tertiary care perinatology and an obesity reference center, on all pregnancies following bariatric surgery over a 10-year period, analyzing all cases of surgical complications.

RESULTS

There were 8 major complications related to the procedure in 141 pregnancies with bariatric surgery. The 2 complications in women with gastric banding were band slippage resulting in severe dysphagia, one of which leading to intractable vomiting and serious hydrolectric disorders. Among the 6 complications after bypass surgery, 4 were occlusions: 3 on internal hernias of which 2 with volvulus and 1 associated with intestinal invagination, as well as one with intestinal invagination only. One patient had a laparotomy for a suspected invagination which was not confirmed. The other surgical complications after gastric bypass were a hernia and an exploratory laparotomy for suspected intussusception which was overturned. There was no case of maternal or perinatal death.

CONCLUSION

Pregnancies in patients with a history of bariatric surgery are at high risk, in particular for complications related to the surgery and thus require careful interdisciplinary surveillance, and determination of predictive factors.

Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients

OBJECTIVE

To analyze pregnancy outcomes after laparoscopic sleeve gastrectomy (LSG) according to body mass index (BMI) at conception and the interval between LSG and pregnancy.

METHODS

In a retrospective study, data were obtained for all women who became pregnant after LSG at a center in France between December 2001 and December 2011. Frequencies of perinatal events according to BMI at conception and the interval between LSG and pregnancy were compared.

RESULTS

A total of 63 pregnancies occurring in 54 patients were included, among which 52 (83%) occurred after the first postoperative year and 26 (41%) in women who remained obese. Compared with women who were no longer obese at conception, women who were still obese delivered neonates of significantly lower gestational age at birth (P=0.02) and birth weight (P=0.001). Odds of preterm delivery were also increased (odds ratio 4.37, 95% confidence interval 1.17-16.27; P=0.03). Maternal and neonatal outcomes according to the interval between LSG and pregnancy did not differ significantly.

CONCLUSION

Women who remain obese following LSG are at increased risk of adverse outcomes, including low gestational age at birth, low birth weight, and preterm delivery, and should be regarded as a risk group.

[Pregnancy and bariatric surgery: Critical points]

More than 200,000 people underwent obesity surgery in France. Most of them are women. Pregnancy after bariatric surgery is becoming a common situation. This surgery results in major nutritional and gastro-intestinal tract modifications that may influence or be influenced by pregnancy, and yields benefits as well as complications. A multidisciplinary management including a nutritionist, an obstetrician, an anesthesiologist, and a bariatric surgeon is required. The aim of this review is to analyze the impact of bariatric surgery on pregnancy and vice versa, and to identify the key points of this management.

Differences in gestational weight gain between pregnancies before and after maternal bariatric surgery correlate with differences in birth weight but not with scores on the body mass index in early childhood

BACKGROUND

Large maternal gestational weight gain (GWG) is associated with increased birth weight and increased risk of obesity in offspring, but these associations may be confounded by genetic and environmental factors. The aim was to investigate the effects of differences in GWG in all three trimesters on differences in birth weight and in body mass index (BMI) scores at 4 and 6 years of age, within siblings born before and after bariatric surgery.

METHOD

Women with at least one child born before and one after bariatric surgery were identified in national Swedish registers. Series of weight (and height) measurements were collected from antenatal medical records, with data on the nearest pregnancies before and after bariatric surgery.

RESULTS

The age-adjusted means of pre- and post-operative GWG of 124 women were 11.3 (standard deviation [SD] 7.2) and 8.3 (SD 6.4) kg, respectively (P = 0.01). Adjusted fixed effects regression models showed positive associations of differences in mean total GWG with differences in siblings' birth weight, 0.023 kg per 1-kg greater weight gain (95% confidence interval [CI]: 0.014-0.069) and for second trimester 0.53 kg for each 1-kg greater weight per week (95% CI: 0.32-1.61), whereas no associations were found with BMI in pre-school age.

CONCLUSION

This study showed positive associations between differences in total and second trimester maternal GWG and differences in children's birth weight, but no association with BMI scores in pre-school age. Maternal genetic, social and lifestyle factors fixed from one pregnancy to the next were taken into account in the analyses by the study design.

Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis

BACKGROUND

Obese women are at increased risk for many pregnancy complications, and bariatric surgery (BS) before pregnancy has shown to improve some of these.

OBJECTIVES

To review the current literature and quantitatively assess the obstetric and neonatal outcomes in pregnant women who have undergone BS.

SEARCH STRATEGY

MEDLINE, EMBASE and Cochrane databases were searched using relevant keywords to identify studies that reported on pregnancy outcomes after BS.

SELECTION CRITERIA

Pregnancy outcome in firstly, women after BS compared to obese or BMI-matched women with no BS and secondly, women after BS compared to the same or different women before BS. Only observational studies were included.

DATA COLLECTION AND ANALYSIS

Two investigators independently collected data on study characteristics and outcome measures of interest. These were analysed using the random effects model. Heterogeneity was assessed and sensitivity analysis was performed to account for publication bias.

MAIN RESULTS

The entry criteria were fulfilled by 17 non-randomised cohort or case-control studies, including seven with high methodological quality scores. In the BS group, compared to controls, there was a lower incidence of preeclampsia (OR 0.45, 95% CI 0.25-0.80; P=0.007), GDM (OR 0.47, 95% CI 0.40-0.56; P<0.001) and large neonates (OR 0.46, 95% CI 0.34-0.62; P<0.001) and a higher incidence of small neonates (OR 1.93, 95% CI 1.52-2.44; P<0.001), preterm birth (OR 1.31, 95% CI 1.08-1.58; P=0.006), admission for neonatal intensive care (OR 1.33, 95% CI 1.02-1.72; P=0.03) and maternal anaemia (OR 3.41, 95% CI 1.56-7.44, P=0.002).

CONCLUSIONS

BS as a whole improves some pregnancy outcomes. Laparoscopic adjustable gastric banding does not appear to increase the rate of small neonates that was seen with other BS procedures. Obese women of childbearing age undergoing BS need to be aware of these outcomes.

Obstetrical and neonatal outcomes in women following gastric bypass: a Danish national cohort study

OBJECTIVE

To assess obstetrical and neonatal outcomes in women following gastric bypass, compared with adipose women without surgery and with a normal weight control population.

DESIGN

Historical controlled cohort study.

SETTING

Denmark.

POPULATION

All women undergoing gastric bypass during the period 1996-2011, and subsequently giving birth.

METHODS AND MAIN OUTCOME MEASURES

Obstetrical and neonatal outcomes in women without gastric bypass matched on age, parity, plurality, year, and body mass index, and normal weight women.

RESULTS

In 415 women giving birth after gastric bypass we found significantly more women with hypertension in pregnancy; relative risk (RR) 2.5 (95% confidence interval 1.3-5.0), gestational diabetes; RR = 6.9 (3.5-13.5), and acute abdominal pain during pregnancy; RR = 4.7 (2.9-7.8) compared with normal weight controls. Compared with women with similar body mass index, they had a lower incidence of preeclampsia and emergency cesarean sections, and their children a lower incidence of asphyxia; RR = 0.4 (0.2-0.8). Their children were on average 212 g smaller than newborn of normal weight mothers, and 319 g smaller than newborn of adipose controls, and had significantly more admissions to neonatal intensive care unit compared with newborn of normal weight mothers; RR = 1.5 (1.1-2.0).

CONCLUSIONS

Gastric bypass may reduce the risk of preeclampsia, emergency cesarean section, and perinatal asphyxia, compared with adipose women without surgery. Compared with normal weight controls women who had had a gastric bypass had a higher risk of hypertension, gestational diabetes, and acute abdominal pain during pregnancy and their children a lower birthweight and higher incidence of admittance to neonatal intensive care.

Mineral malnutrition following bariatric surgery

Moderate/severe obesity is on the rise in the United States. Weight management includes bariatric surgery, which is effective and can alleviate morbidity and mortality from obesity-associated diseases. However, many individuals are dealing with nutritional complications. Risk factors include: 1) preoperative malnutrition (e.g., vitamin D, iron); 2) decreased food intake (due to reduced hunger and increased satiety, food intolerances, frequent vomiting); 3) inadequate nutrient supplementation (due to poor compliance with multivitamin/multimineral regimen, insufficient amounts of vitamins and/or minerals in supplements); 4) nutrient malabsorption; and 5) inadequate nutritional support (due to lack of follow-up, insufficient monitoring, difficulty in recognizing symptoms of deficiency). For some nutrients (e.g., protein, vitamin B-12, vitamin D), malnutrition issues are reasonably addressed through patient education, routine monitoring, and effective treatment strategies. However, there is little attention paid to other nutrients (e.g., zinc, copper), which if left untreated may have devastating consequences (e.g., hair loss, poor immunity, anemia, defects in neuro-muscular function). This review focuses on malnutrition in essential minerals, including calcium (and vitamin D), iron, zinc, and copper, which commonly occur following popular bariatric procedures. There will be emphasis on the complexities, including confounding factors, related to screening, recognition of symptoms, and, when available, current recommendations for treatment. There is an exceptionally high risk of malnutrition in adolescents and pregnant women and their fetuses, who may be vulnerable to problems in growth and development. More research is required to inform evidence-based recommendations for improving nutritional status following bariatric surgery and optimizing weight loss, metabolic, and nutritional outcomes.

Obesity and reproductive function

Obesity is associated with multiple adverse reproductive outcomes, but the mechanisms involved are largely unknown. Obesity has been referred to as a "complex system," defined as a system of heterogeneous parts interacting in nonlinear ways to influence the behavior of the parts as a whole. Human reproduction is also a complex system; hence the difficulty in identifying the mechanisms linking obesity and adverse reproductive function. This review discusses the adverse reproductive outcomes associated with obesity and the mechanisms involved and concludes with a discussion of public health policy with respect to the treatment of infertility in obese women.

Deflation of gastric band balloon in pregnancy for improving outcomes

BACKGROUND

In line with the rise in the prevalence of obesity, an increasing number of women of childbearing age are undergoing laparoscopic adjustable gastric banding (LAGB), resulting in an increasing number of pregnancies with a band in place. Currently, there is no consensus on optimal band management in pregnancy. Some clinicians advocate leaving the band balloon inflated to reduce gestational weight gain and associated adverse perinatal outcomes. However, there are concerns that maintaining balloon inflation during pregnancy might increase the risk of band complications and adversely affect fetal development and/or growth as a result of reduced nutritional intake.

OBJECTIVES

To compare maternal and perinatal outcomes for elective gastric band balloon deflation versus intention to maintain balloon inflation during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012) and the Web of Science database (1940 to September 2012).

SELECTION CRITERIA

Randomised-controlled trials comparing elective deflation of the gastric band balloon with intention to maintain balloon inflation in pregnant women who have undergone LAGB.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion.

MAIN RESULTS

No studies met the criteria for inclusion in the review.

AUTHORS' CONCLUSIONS

To date no randomised controlled trials exist that compare elective deflation of the gastric band balloon in pregnancy versus intention to maintain balloon inflation. Further research is needed to define the optimum management of the gastric band balloon in pregnancy.

Bariatric surgery: impact on pregnancy outcomes

The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.

Neonatal outcomes in pregnancies after bariatric surgery: a retrospective multi-centric cohort study in three French referral centers

OBJECTIVE

To analyze short-term neonatal outcomes in pregnancies after bariatric surgery according to procedure, to the body mass index (BMI) at the beginning of the pregnancy and to the interval from surgery to conception, using a retrospective multi-centric cohort study in three French tertiary perinatal care and bariatric centers.

METHODS

94 neonates in 79 women were included. Frequencies of adverse neonatal events by procedure, laparoscopic adjustable gastric banding (LAGB, n = 63) or Roux-en-Y gastric bypass (RYGB, n = 31), BMI class (72 women with BMI ≥ 30 kg/m(2)) and interval between surgery and conception (43 deliveries of patients who conceived during the first postoperative year) were compared with χ(2) tests. For parametric continuous data, t-tests or analysis of variance were used; non-parametric distributions were compared with the Wilcoxon or Kruskal-Wallis tests.

RESULTS

Significantly lower mean birth weight (2993 g vs. 3253 g; p = 0.02) was observed after RYGB and the mean Z-score for birth weight was significantly closer to 0 in neonates of the LAGB group than in those of the RYGB group. However, no significant differences were noticed regarding small-for-gestational age (32.3% vs. 17.1%; p = 0.06), umbilical arterial blood pH < 7.0 (9.7% vs. 0%; p = 0.11), low Apgar scores, perinatal mortality, and NICU admission. Neonatal outcomes according to the interval from surgery to conception or to the BMI at the beginning of the pregnancy were not significantly different.

CONCLUSIONS

The short-term neonatal outcomes are basically comparable in pregnancies after RYGB than after LAGB.

[Impact of bariatric surgery on obstetric prognosis]

OBJECTIVES

Assessment of pregnancy outcomes after bariatric surgery and analysis of follow-up particularities of such pregnancies.

PATIENTS AND METHODS

A retrospective study of 63 post-bariatric surgery pregnancies compared to 259 pregnancies of obese un-operated patients. Pregnancy outcomes, neonatal datas, delay influence between surgery and pregnancy beginning, bariatric surgery type and gastric banding (GB) loosening consequences were analysed.

RESULTS

In the surgical brand were developed less gestational diabetes (DG) (P=0,05), deliveries were more often normal (P=0,004) and births shown less macrosomias and small for gestational age newborns (P=0,04). Neonatal state was improved among operated patients: less Apgar scores less than 7 at 1 minute (P=0,05) and less cord blood pH less than 7,2 (P=0,03). They gained more weight during the pregnancy (P=0,0003) and only 53% had a nutritional management and assessment. Patients with GB loosening gained more weight (P=0,0003). Lastly, there were no difference due to the different bariatric surgery techniques or nutritional follow-up in the pregnancy course and neonatal state.

DISCUSSION AND CONCLUSION

Bariatric surgery improves obstetric and neonatal prognosis. Improvements have to be developed in the multidisciplinary follow-up in order to avoid nutritional deficiencies or important weight gain pregnancy in case of GB.

Pregnancy outcomes in women after bariatric surgery compared with obese and morbidly obese controls

OBJECTIVE

To estimate the rates of pregnancy outcomes of women after bariatric surgery relative to women in a control groups.

METHODS

The study was a chart review. Presurgery and prepregnancy body mass index (BMI) were calculated for 70 patients who had undergone bariatric surgery and who had a subsequent singleton pregnancy. Four control patients were then randomly selected for each case patient: two with a BMI within 6 points of the average presurgery BMI and two with a BMI within 6 points of the average prepregnancy BMI. The primary outcomes were the rates of gestational diabetes or hypertensive disorders of pregnancy.

RESULTS

There was a significant decrease in rate of gestational diabetes in bariatric surgery patients (0.0%) as compared with both control groups (morbidly obese 16.4%, obese 9.3%; corrected odds ratio (OR)morbidly obese 0.04, with a 95% confidence interval [CI] 0.00-0.62, P<.01; corrected OR obese 0.07, CI 0.00-1.20, P=.01). There was no significant difference in the rate of hypertensive disorders of pregnancy with bariatric surgery. Additionally, neonates were significantly more likely to be small for gestational age (SGA) in the bariatric surgery group (17.4%) than the morbidly obese group (5.0%) (OR 3.94, CI 1.47-10.53, P<.01).

CONCLUSION

Bariatric surgery is associated with reduction in gestational diabetes in a subsequent pregnancy, but possibly at the expense of an increase in SGA neonates.

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.