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

Impact of bariatric surgery on maternal gestational weight gain and pregnancy outcomes in women with obesity: A population-based cohort study from Qatar

BACKGROUND

Bariatric surgery is performed in obese women of reproductive age to help achieve a healthy prepregnancy weight to reduce the complications associated with obesity in pregnancy. However, these procedures can impact maternal nutrition and gestational weight gain (GWG). This study evaluates the maternal and neonatal outcomes in women with prepregnancy bariatric surgery and determines the impact on GWG.

METHODS

This study included 24 weeks gestation or more pregnancies, with a maternal BMI at delivery of 30 kg/m2 or more. It was categorized into two groups based on whether they had prepregnancy bariatric surgery (exposed) or not (unexposed). The outcomes included gestational diabetes (GDM), gestational hypertension (GHT), mode of delivery, preterm birth (PTB), GWG, birthweight (BW) and customized BW centiles, low birthweight (LBW), congenital anomalies, and admission to the neonatal intensive unit (NICU). Categorization was also done based on the adequacy of GWG (low, adequate, and excess).

RESULTS

A total of 8,323 women were included in the study, 194 of whom had prepregnancy bariatric surgery. After adjusting for confounders, the exposed group had a mean GWG 1.33 kg higher than the unexposed group (95% CI 0.55-2.13, p = 0.001). The exposed group had higher odds of PTB (aOR 1.78, 95% CI 1.16-2.74, p = 0.008), CD (aOR 6.52, 95% CI 4.28-9.93, p < 0.001), LBW in term babies (aOR 2.60, 95% CI 1.34-5.03, p = 0.005), congenital anomalies (aOR 2.64, 95% CI 1.21-5.77, p = 0.015), low APGAR score (aOR 3.75, 95% CI 1.12-12.5, p = 0.032) and 80.4g lesser birthweight (95% CI -153.0, -5.8; p = 0.034). More women in the low GWG category had LBW babies (28.6% versus 6.7% in the high GWG group, p = 0.033), lowest mean BW and median BW centiles (2775 grams versus 3289 grams in the high GWG group, p = 0.004 and 57.5% versus 74.5% in the high GWG group, p = 0.040, respectively).

CONCLUSION

The findings of this study highlight differences in perinatal outcomes such as preterm birth, low birth weight, congenital anomalies, cesarean deliveries, and gestational weight gain between post-bariatric women and controls. These insights can help inform the planning and provision of appropriate maternity care to enhance patient safety and outcomes. The results of this study can also guide the counseling of reproductive age-group women who are planning to undergo bariatric surgery.

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.

Bariatric surgery and reproduction-implications for gynecology and obstetrics

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

The Effect of Sleeve Gastrectomy on Pregnancy Complications: A Cross-Sectional Study in Saudi Arabia

BACKGROUND

Obesity is defined as abnormal or excessive fat accumulation that may impair health. Until recently, the only effective method for treating morbid obesity over the long term was bariatric surgery (BS). During pregnancy, obesity is correlated with higher risks for numerous complications, including gestational diabetes mellitus, pre-eclampsia, mortality, and large-for-gestational-age neonates. The most commonly reported complications among women who underwent sleeve gastrectomy and experienced pregnancy were placental bleeding, oligohydramnios, urinary tract infection, appendicitis, and recurrent abortions.

OBJECTIVES

We aim to estimate the consequence of sleeve gastrectomy and its relation with pregnancy outcomes among women in Saudi Arabia.

METHODOLOGY

This study adopted a quantitative, descriptive, cross-sectional design. It was conducted in Saudi Arabia between February and May 2023 among women who became pregnant after undergoing sleeve gastrectomy.  Result: Anemia was experienced by 78.8% of the patients during pregnancy. In our study, 18% of the individuals experienced complications during or right after delivery, with postpartum hemorrhage being the most frequent (43.1%). We discovered that pre-eclampsia and delivering a baby small for gestational age were considerably more common in pregnant women who smoked (p ≤ 0.05). On the other hand, no significant association was discovered between any comorbidity and mode of delivery, birth weight, child complications, or difficulties that occurred during or right after labor.

CONCLUSION

We concluded that weight gain after sleeve gastrectomy negatively impacted pregnancy and increased the probability of several complications for the mother and fetus. Healthcare providers must inform every woman undergoing BS about the possible complication of an unhealthy lifestyle after the procedure.

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.

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.

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.

Pregnancy after Bariatric Surgery: A Nested Case-Control Study of Risk Factors for Small for Gestational Age Babies in AURORA

Bariatric surgery prior to pregnancy is a significant risk factor for small for gestational age (SGA) babies. This case-control study investigated differences between mothers delivering an SGA baby following bariatric surgery, compared to those delivering an appropriate for gestational age (AGA) baby. Out of 129 babies born to mothers in the AURORA cohort study, 25 were SGA (<10th percentile) and 97 were AGA (10th-90th percentile). Higher gestational weight gain (GWG) was significantly associated with decreased odds of SGA (aOR per kg 0.92, 95% CI 0.85-0.99). According to the Institute of Medicine GWG guidelines, 44% of SGA mothers had 'inadequate' GWG compared to 17% of AGA mothers. Nearly half of the mothers had 'excessive' GWG yet still gave birth to an SGA or AGA baby. Mothers of SGA babies lost more weight following bariatric surgery (45.6 ± 14.4 kg vs. 39.0 ± 17.9 kg). Women who reported receiving nutritional advice following bariatric surgery were significantly less likely to have an SGA baby (aOR 0.15, 95% CI 0.0.4-0.55). Women with a history of bariatric surgery should be provided with specialized support before and during pregnancy to encourage adequate nutritional intake and weight gain to support healthy fetal growth.