Impact of gestational weight gain on perinatal outcomes after a bariatric surgery

Pregnancy Outcomes After Bariatric Surgery: Importance of Maternal Ferritin on Birth Weight

PURPOSE

The risks carried by pregnancy after bariatric surgery (BS) include small-for-gestational age (SGA) newborn and prematurity. However, the underlying mechanisms are not yet fully understood in pregnant women after BS.

MATERIAL AND METHODS

This single-center retrospective observational cohort study includes all women with a first and single pregnancy after BS who completed at least one clinical and biological nutritional assessment during pregnancy between 2010 and 2016. The quarterly biological assessment comprised blood count, ferritin, calcium, 25OH vitamin D, parathyroid hormone, fasting glucose, albumin, prealbumin, vitamin A, vitamin B12, folic acid, and zinc.

RESULTS

Among 120 pregnancies analysed, two-thirds underwent gastric bypass (Roux-en-Y and one-anastomosis) and one-third a restrictive procedure (adjustable gastric band or sleeve gastrectomy). The median [Q1-Q3] preoperative BMI was 43.8 [41.1-47.7] kg/m2 and the mean age at pregnancy was 32.6 ± 5.3 years. Weight loss and time from surgery to pregnancy were 35.1 ± 15.4 kg and 2.9 [1.3-4.5] years, respectively. Ten women (8%) gave birth prematurely, and 22 newborns (19%) were SGA. Univariate analysis shows that ferritin was significantly higher in mothers with SGA than in those without SGA (35.5 [22.3-69.5] vs. 15 [10-32] ng/ml) at third trimester of pregnancy. Women who received pre-pregnancy nutritional assessment seemed less likely to give birth to a SGA newborn (32% vs. 54%, p = 0.07).

CONCLUSION

Iron supplementation should be carefully prescribed and closely monitored during pregnancy in women who have undergone BS.

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.

John T, Corcelles R, Rodriguez J, Kroh M, Uy-Kroh MJ. The Effects of Post-Surgical Pregnancy on Weight Loss Trajectories after Bariatric Surgery: Are Initial Weight and Age Prognostic Factors?

Introduction: A substantial percentage of patients undergoing bariatric surgery are of childbearing age. Pregnancy outcomes after bariatric surgery are known. However, there are limited data on the impact of pregnancy on weight loss after surgery. Objectives: This study aims to evaluate the effects of pregnancy on post-bariatric surgery weight loss trajectories (WLTs) and to determine the association with age and initial weight. Methods: All who had primary bariatric surgeries (Roux-en-Y gastric bypass or sleeve) between September 2015 and July 2020 were classified into two groups: post-surgery gravid (GG) and post-surgery non-gravid (NG). WLTs were examined using a random intercept mixed-effects model with repeated measures nested within patients. The post-surgery/pre-gravid time phase (PoPG) was modelled using a third-degree polynomial. For GG, two third-degree spline functions modelled the post-surgery while gravid (PoWG) and post-partum (PoPP) time phases. Age and initial weight were used to control for pre-existing differences during PoPG. Weight differences at 6 months PoPP were examined by applying general linear hypothesis testing to the mixed-model results. Results: A total of 508 patients were included, 20 in GG and 488 in NG. The mean age at surgery was 33 years in GG and 37 years in NG. The mean initial BMI was 47 kg/m2 and 43 kg/m2, respectively. During PoPG, adjusted average weight in both groups follows the path across time. For GG, weight decreases and then increases during PoWG. For GG during PoPP, weight immediately decreases after delivery and then increases over time to levels similar to NG. Weight differences at 6 months PoPP for GG and NG were not statistically different. Older age was associated with reduced weight loss during PoPG by Baseline Age, while higher initial weight was associated with increased weight loss during PoPG by Baseline Weight. In both instances, these effects attenuate over time. Conclusions: This model indicates that pregnancy following bariatric surgery affects WLT during PoWG and PoPP, and no difference in weight is expected after 6 months post-gravid. Age and initial weight could be considered prognostic factors during PoPG. Patients wishing to conceive should undergo preconception counselling and be advised to avoid pregnancy during the period of rapid weight loss. They also should be informed that WLT may vary during pregnancy and early post-partum.

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.

Pregnancy Weight Gain After Gastric Bypass or Sleeve Gastrectomy

Importance

Pregnancy weight gain may affect the association of bariatric surgery with postsurgery pregnancy outcomes. However, the association of pregnancy weight gain with bariatric surgery is unclear.

Objective

To compare pregnancy weight gain among women with a history of bariatric surgery vs those without and to investigate whether pregnancy weight gain differs by surgical procedure, surgery-to-conception interval, and/or surgery-to-conception weight loss.

Design, Setting, and Participants

This nationwide, population-based matched cohort study was conducted in Sweden from 2014 to 2021. Singleton pregnancies with a history of bariatric surgery were propensity score matched (1:1) to pregnancies without such a history according to early-pregnancy body mass index (BMI), prepregnancy diabetes, prepregnancy hypertension, maternal age, smoking status, education level, height, country of birth, and delivery year. In addition, post-gastric bypass pregnancies were matched to post-sleeve gastrectomy pregnancies using the same matching strategy. Data analysis was performed from November 2022 to May 2023.

Exposure

History of bariatric surgery.

Main Outcomes and Measures

Pregnancy weight gain was standardized by gestational age into early-pregnancy BMI-specific z scores.

Results

This study included 12 776 pregnancies, of which 6388 had a history of bariatric surgery and 6388 were matched controls. The mean (SD) age was 31.6 (4.9) years for the surgery group and 31.4 (5.2) for the matched controls, with an early-pregnancy mean (SD) BMI of 29.4 (5.2) in both groups. Across all early-pregnancy BMI strata, women with a history of bariatric surgery had lower pregnancy weight gain than matched controls. The differences in pregnancy weight gain z score values between the 2 groups were -0.33 (95% CI, -0.43 to -0.23) for normal weight, -0.33 (95% CI, -0.40 to -0.27) for overweight, -0.21 (95% CI, -0.29 to -0.13) for obese class I, -0.16 (95% CI, -0.29 to -0.03) for obese class II, and -0.08 (95% CI, -0.28 to 0.13) for obese class III. Pregnancy weight gain did not differ by surgical procedure. A shorter surgery-to-conception interval (particularly within 1 year) or lower surgery-to-conception weight loss was associated with lower pregnancy weight gain.

Conclusions and Relevance

In this nationwide matched cohort study, women with a history of bariatric surgery had lower pregnancy weight gain than matched controls with similar early-pregnancy characteristics. Pregnancy weight gain was lower in those with a shorter surgery-to-conception interval or lower surgery-to-conception weight loss, but did not differ by surgical procedure.

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.

Maternal and perinatal outcomes in women conceiving after bariatric surgery: A cohort study

Obesity in women, a global issue, is being widely managed with bariatric surgery worldwide. According to recommended guidelines, pregnancy should be avoided for 12 to 24 months following surgery due to various risks. We assessed if surgery-to-conception time has a relation with pregnancy outcomes taking into account gestational weight gain. A cohort study between 2015 and 2019 followed-up pregnancies after various types of bariatric surgeries performed (e.g. Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, gastric bypass with Roux-en-Y gastroenterostomy) in Tawam Hospital, Al Ain, United Arab Emirates. There were 5 surgery-to-conception groups: <6 months, 6 to 12 months, 13 to 18 months, 19 to 24 months, and >24 months. There were 3 gestational weight gain groups: inadequate, adequate, or excessive (based on the National Academy of Medicine classification). Maternal and neonatal outcomes were compared using analysis of variance and chi-square tests. There were 158 pregnancies. Booking maternal body mass index and weight were higher among mothers who conceived <6 months following surgery (P < .001). Gestational weight gain was not related to the type of bariatric surgery (P = .24), but it was far more often inadequate in mothers who conceived <12 months following surgery (P = .002). Maternal (including pregnancy-induced hypertension and gestational diabetes mellitus) and neonatal outcomes were not statistically significantly associated with surgery-to-conception duration. However, birth weight was lower when gestational weight gain was inadequate (P = .03). There is a negative relationship between shorter bariatric surgery-to-conception interval and gestational weight gain, a feature related to neonatal birth weight. Conception should be delayed to improve pregnancy outcomes following bariatric surgery.

Maternal and Neonatal Outcomes of Pregnancy within 7 years after Roux-Y Gastric Bypass or Sleeve Gastrectomy Surgery

PURPOSE

Few studies examine whether maternal and neonatal outcomes differ by time from metabolic and bariatric surgery (MBS) to conception. We describe maternal and neonatal outcomes among women with pregnancy after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) overall and by whether conception occurred during the period when pregnancy is not recommended (< 18 months postoperative) versus later.

MATERIALS AND METHODS

A prospective cohort study enrolled 135 US adult women (median age, 30 years, body mass index [BMI], 47.2 kg/m2) who underwent RYGB or SG (2006-2009) and subsequently reported ≥ 1 pregnancy within 7 years. Participants self-reported pregnancy-related information annually. Differences in prevalence of maternal and neonatal outcomes by postoperative conception timeframe (< 18 versus ≥ 18 months) were assessed.

RESULTS

Thirty-one women reported ≥ 2 postoperative pregnancies. At time of postoperative conception (median 26 [IQR:22-52] months postoperative) median BMI was 31 (IQR:27-36) kg/m2. Excessive gestational weight gain (55%), cesarean section (42%) and preterm labor or rupture of membranes (40%) were the most common maternal outcomes. Forty percent of neonates had a composite outcome of still birth (1%), preterm birth (26%), small for gestational age (11%), or neonatal intensive care unit admission (8%). Prevalence of outcomes did not statistically significantly differ by timeframe.

CONCLUSION

In US women who conceived ≤ 7 years following RYGB or SG, 40% of neonates had the composite neonatal outcome. The prevalence of maternal and neonatal outcomes post-MBS were not statistically significant by conception timeframe.

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.

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.

Gestational Weight Gain in Pregnancies Following Bariatric Surgery

INTRODUCTION

To compare the gestational weight gain (GWG) between women with previous bariatric surgery and those without and investigate whether GWG correlates with birthweight (BW) or delivery of a small-for-gestational-age (SGA) neonate.

MATERIALS AND METHODS

Prospective, longitudinal study, include 100 pregnant women with previous bariatric surgery and 100 without weight loss surgery, but with similar early-pregnancy body mass index (BMI). In a sub-study, 50 of the post-bariatric women were also matched to 50 women without surgery, but early-pregnancy BMI similar to the pre-surgery BMI of the post-bariatric ones. All women had their weight/BMI measured at 11-14 and 35-37 weeks of gestation, and the difference in maternal weight/BMI between the two time points was expressed as GWG/BMI gain. Associations between maternal GWG/BMI gain and birthweight (BW) were examined.

RESULTS

Compared to no bariatric women with similar early-pregnancy BMI, post-bariatric women had similar GWG (p = 0.46), and the number of women with appropriate, insufficient, and excessive weight gain was comparable between groups (p = 0.76). However, post-bariatric women delivered smaller babies (p < 0.001), and GWG was not a significant predictor of BW or of delivering a SGA neonate. Compared to no bariatric women with similar pre-surgery BMI, post-bariatric ones had higher GWG (p < 0.01) but still delivered smaller neonates (p = 0.001).

CONCLUSIONS

Post-bariatric women seem to have similar or greater GWG compared to women without surgery matched for early-pregnancy or pre-surgery BMI, respectively. Maternal GWG was not associated with BW or higher prevalence of SGA neonates seen in women with previous bariatric surgery.

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 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.

Risk factors for preterm birth in pregnancies following bariatric surgery: an analysis of the Longitudinal Assessment of Bariatric Surgery-2

BACKGROUND

Bariatric surgery has been shown to increase the risk for preterm birth in a subsequent pregnancy. Determining factors that contribute to this heightened risk will inform the development of targeted interventions to improve birth outcomes postbariatric surgery.

OBJECTIVES

This study aimed to identify risk factors of preterm birth in pregnancies following bariatric surgery. Factors being considered were preoperative medical conditions and behaviors (e.g., obesity-associated co-morbidities, gastrointestinal symptoms, substance use), antenatal factors (e.g., prepregnancy body mass index, gestational weight gain), and surgery-specific factors (e.g., surgery type, surgery-to-conception interval).

SETTING

Bariatric surgery centers in the United States.

METHODS

This is a retrospective analysis of the Longitudinal Assessment of Bariatric Surgery-2. Participants were women who reported at least 1 singleton live birth during the 7-year postoperative period. Logistic regressions were used to identify risk factors of preterm birth, adjusting for covariates such as maternal age, race, and ethnicity.

RESULTS

Participants (n = 97) were mostly White (84.5%) and non-Hispanic (88.7%). At the time of surgery, the mean age was 29.4 ± 4.6 years, and the mean body mass index was 47.6 ± 6.3 kg/m2. The prevalence of preterm birth was 13.4%. Preoperative gastrointestinal symptoms significantly increased (odds ratio: 1.12; 95% confidence interval: 1.00-1.26), while unexpectedly, excessive versus adequate gestational weight gain (odds ratio: .12; 95% confidence interval: .02-1.00) decreased the odds of preterm birth following bariatric surgery.

CONCLUSIONS

This analysis identified potential risk and protective factors of preterm birth among pregnancies postbariatric surgery. However, given the small sample size, findings should be regarded as hypothesis-generating and merit further study.

Impact of Gestational Weight Gain on Maternal and Perinatal Outcomes After Laparoscopic Sleeve Gastrectomy

PURPOSE

This study aimed to evaluate the impact of gestational weight gain (GWG) after laparoscopic sleeve gastrectomy (LSG) on maternal and perinatal outcomes according to the Institute of Medicine (IOM) recommendations.

MATERIALS AND METHODS

A retrospective, multicenter, observational study of pregnant women who had undergone LSG between 2012 and 2021 was conducted. According to the IOM criteria, GWG was grouped as insufficient, appropriate, and excessive.

RESULTS

A total of 119 pregnancies were included in this study. GWG was appropriate in 28 (23.5%), insufficient in 32 (26.9%), and excessive in 59 (49.6%) of the cases. The time from operation to conception was significantly longer in the excessive group than in the insufficient (P = 0.000) and appropriate groups (P = 0.01). The mean GWG was significantly higher in the excessive group than in the appropriate (P = 0.000) and insufficient groups (P = 0.000). When the groups were evaluated according to the IOM recommendations, no statistically significant difference were found between the groups regarding birthweight, gestational age (GA), preterm birth, and whether their child was small or large for their gestational age. Furthermore, there were no differences in terms of anemia and ferritin deficiency level at early pregnancy and predelivery between the groups.

CONCLUSION

The GWG after LSG did not impact maternal and perinatal outcomes.

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.

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.

Trimester-specific gestational weight gain in women with and without previous bariatric surgeries

OBJECTIVES

The study aimed 1) to compare trimester-specific and total gestational weight gain (GWG) between mothers who had undergone biliopancreatic diversion with duodenal switch (BPD) and two control groups of unoperated women and 2) to examine the associations between GWG, intrauterine fetal growth and neonatal birthweight.

METHODS

This retrospective study included data collected in medical records of newborns and mothers from 3 groups: the first control group (PP) included mothers (n = 158) with a pre-pregnancy BMI similar to that of the surgical group (n = 63) and the second one (PS) included mothers (n = 85) with a pre-pregnancy BMI corresponding to that of the surgical group prior to BPD or a BMI > 40 kg/m². Trimester-specific GWG was obtained using linear interpolation and compared to the recommendations.

RESULTS

Women exposed to BPD have an increased prevalence of insufficient weight gain in the second and third trimesters as well as for the whole pregnancy in comparison with women in the PP group. The weekly GWG rate in the third trimester was significantly lower in women exposed to BPD, compared to both control groups. Although the newborns of women with previous BPD were significantly smaller during pregnancy and at birth, no association was found with GWG.

CONCLUSION

Women exposed to BPD are at substantial risk of insufficient GWG, however, mechanisms and long-term impacts require further investigation.

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%.

Bariatric surgery in the treatment of adolescent obesity: current perspectives in the United States

Introduction: Rates of severe obesity in adolescents have increased at an alarming rate. Unfortunately, there are limited successful treatments for severe obesity in adolescents. Metabolic and bariatric surgery (MBS) is the most effective treatment available for adolescents with Class 2 and above severe obesity and has demonstrated variable degrees of sustained long-term weight loss which leads to resolution of multiple associated conditions and an improved quality of life.Areas covered: We discuss the current landscape of MBS in adolescents and evidence to support its long-term safety and efficacy. A literature search through PubMed, ResearchGate and HOLLIS Harvard Library Online Catalog was performed from the date of inception until 3/15/2021. A combination of the following keywords was used: Pediatric metabolic/bariatric surgery; long term outcomes of Pediatric metabolic/bariatric surgery, perioperative assessment, pediatric metabolic/bariatric surgery barriers; attitudes toward metabolic/bariatric surgery.Expert opinion: MBS is emerging as a safe and effective treatment strategy for adolescents with severe obesity, with recent studies demonstrating durable and sustainable weight loss. There remains an urgent need for longitudinal studies to assess durability of weight loss. Obesity stigma and bias, limited access to tertiary care centers, and skepticism around the treatment of obesity poses a major challenge.

Adverse Neonatal and Obstetric Outcomes in a 20-year Brazilian Retrospective Cohort of Pregnancies after Bariatric Surgery

PURPOSE

Evaluation of obstetric and neonatal outcomes in a Brazilian retrospective cohort of pregnancies after Roux-en-Y gastric bypass (RYGB), regarding the 2009 Institute of Medicine (IOM) recommendations about gestational weight gain (GWG) and RYGB-conception interval. Additionally, search for intrapopulation risk factors for small gestational age (SGA) offspring and mental health assessments.

MATERIAL AND METHODS

Retrospective analysis of 132 singleton pregnancies after RYGB. Obstetric and neonatal outcomes were analyzed with stratification in above, below, or meeting the target regarding GWG guidance, and 0-12, 12-47, and ≥48 months for RYGB-conception interval. SGA risk factors were identified through Poisson regression analysis.

RESULTS

GWG below the recommendations was associated with prematurity (p 0.003). Late conceptions (≥48 months) were associated with iron deficiency (p 0.025). Parenteral iron prescription was a protective factor for SGA, with a relative risk of 0.41 (95% CI, 0.20-0.85; p 0.017), and GWG below target was a SGA risk factor, with a relative risk of 4.68 (95% CI, 1.48-14.8; p 0.008). In all, 15.2% of patients had psychopharmacological treatment during pregnancy, and 7.6% received a diagnosis of postpartum depression. Any alcohol and tobacco consumption were reported in 3.8 and 6.8% of patients, respectively.

CONCLUSION

The recommendations regarding GWG apply to the RYGB population, and surgery-conception intervals should be individualized. The parenteral iron prescription was a protective factor for SGA, and GWG below the recommendations of the IOM was a risk factor for SGA. Psychological and psychiatric care should be offered to every possible pregnancy after RYGB.

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.

Gestational weight gain and postpartum weight retention after bariatric surgery: data from a prospective cohort study

BACKGROUND

It is unknown whether international guidelines on gestational weight gain can be used in pregnancies after bariatric surgery.

OBJECTIVES

To investigate gestational weight gain, intrauterine growth, and postpartum weight retention in postbariatric women.

SETTING

8 Belgian hospitals.

METHODS

Prospective data from 127 postbariatric pregnancies from September 2014 through October 2018. Patients were grouped according to achievement of 2009 Institute of Medicine (IOM) guidelines.

RESULTS

In 127 patients with a mean age of 30.2 years (standard deviation [SD], 4.7), the mean gestational weight gain was 12.5 kg (SD, 6.7). Of these patients, 24% (30 of 127) showed insufficient weight gain, 20% (26 of 127) showed adequate weight gain, and 56% (71 of 127) showed excessive weight gain. Of 127 patients, 27 (21%) had small-for-gestational-age infants. This peaked in the group with insufficient weight gain (47%; 95% confidence interval [CI], 29%-65%; P < .001). The prevalence of large-for-gestational-age infants was comparable between groups, although highest in the group with excessive weight gain (0% in those with insufficient weight gain, 4% in those with adequate weight gain, and 8% in those with excessive weight gain). Preterm births were recorded more in patients with insufficient weight gain (23%; 95% CI, 8%-38%; P = .048). The mean amounts of postpartum weight retained were 4.0 kg (SD, 7.4) at 6 weeks and 3.0 kg (SD, 9.1) at 6 months. Weight retention at 6 weeks (7.1 kg; 95% CI, 5.5-8.7; P < .001) and 6 months (8.3 kg; 95% CI, 4.5-12.2; P < .001) was highest in women gaining excessive weight.

CONCLUSION

Achievement of IOM guidelines is low in postbariatric pregnancies. Insufficient weight gain increases the risk for small-for-gestational-age babies. Excessive weight gain increases weight retention after delivery and could precipitate weight regain. After bariatric surgery, women should be encouraged to achieve IOM recommendations.

Glucose Homeostasis, Fetal Growth and Gestational Diabetes Mellitus in Pregnancy after Bariatric Surgery: A Scoping Review

Background: Pregnancies in women with a history of bariatric surgery are becoming increasingly prevalent. Surgically induced metabolic changes benefit mother and child, but can also lead to some adverse pregnancy outcomes. Knowledge about glucose homeostasis in these pregnancies could elucidate some of the mechanisms behind these outcomes. This review focusses on glucose homeostasis and birth weight. Methods: We considered papers dealing with glucose homeostasis, gestational diabetes mellitus (GDM) and/or small-for-gestational age infants (SGA) in pregnancies with a history of sleeve gastrectomy (SG) or Roux-en-y gastric bypass (RYGB). Results: Since an OGTT is unreliable to diagnose GDM in a pregnancy after bariatric surgery, the true incidence of GDM is unknown. Alternative screening strategies are needed. Furthermore, these pregnancies are marked by frequent hypoglycemic events as well as wide and rapid glycemic excursions, an issue that is very likely underreported. There is a lack of uniformity in reporting key outcomes and a large variation in study design and control population. Conclusion: Alteration of glucose homeostasis in a pregnancy after bariatric surgery should be further studied using unequivocal definition of key concepts. Glycemic control may prove to be a modifiable risk factor for adverse pregnancy outcomes such as the delivery of an SGA baby.

Clinical Practice Guidelines for Childbearing Female Candidates for Bariatric Surgery, Pregnancy, and Post-partum Management After Bariatric Surgery

Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.

[Which management of pregnancy after bariatric surgery?]

Obesity represents a major public health issue and a potential threat for people health. Moreover, the incidence of obesity has been increasing and therefore, the incidence of women with an history of bariatric surgery with a pregnancy desire has been also increased. Although the weight loss after bariatric surgery has positive effects on pregnancy outcomes, these surgical procedures may be associated with adverse outcomes as well, for example micronutrient deficiencies, dumping syndrome, surgical complications such as internal hernias, and obstetrical complications such as small for gestational age as instance. Nevertheless, physician knowledge about pregnancy management after bariatric surgery is currently insufficient and a multidisciplinary approach is therefore mandatory. The aim of this article is to provide to readers general and recent data regarding the management of pregnancy after bariatric surgery.

Weight Status of Brazilian's Mother-Son Dyad after Maternal Bariatric Surgery

PURPOSE

Pregnant women who have undergone bariatric surgery must be followed to ensure healthy mother-child nutritional status. This study aimed to compare weight status of mother-child dyad after maternal bariatric surgery in public and private Brazilian healthcare system units.

MATERIALS AND METHODS

This retrospective matched case-control included 19 women who underwent Roux-en-Y gastric bypass surgery performed by the same private clinical surgical team and 19 age- and preoperative body mass index (BMI) matched patients from a public hospital. All 38 female patients reported a postoperative spontaneous pregnancy. The T test of independent samples and Pearson chi-square test were used to investigate inter-group differences.

RESULTS

Patients in the private system were more frequently married (94.7% versus 68.4%, p = 0.036) and had a higher educational level (94.7% versus 36.8%, p = 0.01 for tertiary education) but lower BMI, compared with those in the public system (pre-gestational = 25.7 ± 3.2 versus 28.5 ± 5.0 kg/m², p = 0.049; post-gestational = 24.6 ± 1.6 versus 29.0 ± 6.0 kg/m², p = 0.040). The interval from bariatric surgery to conception was shorter among public system patients (21.1 ± 13.9 versus 43.4 ± 31.2 months, p = 0.009). In both groups, almost 90% of children were born at full term and with adequate weights.

CONCLUSION

Despite differences in the characteristics of public and private systems, the mother-child dyads in both groups achieved satisfactory post-bariatric surgery gestation outcomes. The type of medical system does not appear to influence pregnancy outcomes or neonatal weight status conditions.

Nutritional and perinatal outcomes of pregnant women with a history of bariatric surgery: a case series from a UK centre

BACKGROUND

Women with obesity who become pregnant after bariatric surgery have a reduced risk of several obstetric complications; however, limited data exist from the UK population. The present study aimed to characterise a case series of women who attended a medical antenatal clinic for pregnancy following bariatric surgery.

METHODS

Routine clinical information was collected retrospectively from the medical notes of women who had bariatric surgery and subsequently delivered between January 2012 and November 2018. All were seen in the medical antenatal clinic at Musgrove Park Hospital, Taunton.

RESULTS

Data were available for 46 pregnancies. Of these, 27.9% conceived in the first year after surgery. At 9 weeks of gestation, 13.3%, 28.9%, 33.3% and 24.4% were in the healthy, overweight, obese or severely obese category, respectively. Mean (SD) gestational weight gain was 11.9 (6.9) kg, with 54.1% gaining excess weight. Less than half (39.1%) of women were taking the recommended dose of 5 mg of folic acid when first seen. Some 56.1% and 64.6% had suboptimal iron or vitamin D statuses, respectively. Following advice from the clinic, a greater proportion of women took suitable micronutrient supplements. Subsequently, 93% of babies were born at full term, of whom 88% were of healthy weight.

CONCLUSIONS

Despite the nutritional risks associated with bariatric surgery and the high prevalence of obesity during pregnancy, perinatal outcomes were generally positive, with low rates of infants born preterm or low birth weight. Nutritional supplementation practices and iron status improved with input from a specialist team, underlying the importance of individualised input in this population.