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Huke CJ, Romsaas T, Vanky E, Huse K, Ødegård R, Nymo S, Hoff DAL, Sandvik J. The impact of obesity surgery on newborn anthropometrics in women with and without polycystic ovary syndrome. Arch Gynecol Obstet 2024:10.1007/s00404-024-07593-0. [PMID: 38951260 DOI: 10.1007/s00404-024-07593-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/06/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Obesity surgery and polycystic ovary syndrome (PCOS) are both associated with increased risk of intrauterine growth restriction. We investigated whether offspring of mothers with PCOS who underwent obesity surgery had an increased risk of deviating birth anthropometrics compared to offspring of mothers without PCOS. METHODS In this observational study, data from two study databases (BAROBS and PregMet2) were supplemented with data from patient's records from secondary and tertiary hospitals. In total, 162 offspring born to mothers with PCOS (n = 48) and without PCOS (n = 114) were included. Forty-nine offspring were born prior to, and 113 after obesity surgery. RESULTS Mean ± SD birthweight (BW), birth length (BL), and head circumference (HC) before and after surgery for offspring born to mothers with PCOS were 3987 ± 495 g vs 3396 ± 526 g (P = 0.001), 52.2 ± 1.6 cm vs 50.1 ± 2.2 cm (P = 0.010), and 36.3 ± 1.97 cm vs 35.3 ± 1.66 cm (P = 0.183), respectively. In the non-PCOS group BW, BL and HC before and after were 3859 ± 603 g vs 3490 ± 538 g (P = 0.001), 51.3 ± 2.0 cm vs 49.9 ± 2.5 cm (P = 0.013), and 36.4 ± 2.0 cm vs 35.3 ± 1.8 cm (P = 0.016), respectively. Post-surgery, we found no difference in z-score BW, (∆-0.08, P = 0.677), BL (∆0.21, P = 0.184), and HC (∆0.14, P = 0.476) between children of PCOS and non-PCOS mothers. COMCLUSION Babies born after obesity surgery were smaller and shorter in both the PCOS and non-PCOS group. Post-surgery anthropometrics were similar in babies born to mothers with and without PCOS.
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Affiliation(s)
- Camilla Johannesen Huke
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Therese Romsaas
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Obstetrics and Gynecology, St. Olav's University Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Karoline Huse
- Clinic of Obstetrics and Gynecology, Møre Og Romsdal Hospital Trust, Ålesund, Norway
| | - Rønnaug Ødegård
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - Siren Nymo
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway
- Clinic of Surgery, Nord-Trøndelag Hospital Trust, Namsos, Norway
| | - Dag Arne Lihaug Hoff
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Departments of Clinical Studies, Møre Og Romsdal Hospital Trust, Ålesund, Norway
| | - Jorunn Sandvik
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
- Centre for Obesity Research, Clinic of Surgery, St. Olav's University Hospital, Trondheim, Norway.
- Clinic of Surgery, Møre Og Romsdal Hospital Trust, Ålesund, Norway.
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Joly MA, Peyronnet V, Coupaye M, Ledoux S, Pourtier N, Pencole L, Mandelbrot L. Comparison of pregnancy outcomes after bariatric surgery by sleeve gastrectomy versus gastric bypass. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100309. [PMID: 38736525 PMCID: PMC11088267 DOI: 10.1016/j.eurox.2024.100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Bariatric surgery has an impact on subsequent pregnancies, in particular an association between gastric bypass and small for gestational age. Knowledge is lacking on whether sleeve gastrectomy is associated with more favorable pregnancy outcomes. This study aimed to compare the impact of sleeve gastrectomy and Roux-en-Y gastric bypass on the incidence of small for gestational age (SGA), and of adverse pregnancy outcomes. Study design We conducted a retrospective study in a single reference center, including all patients with a history of sleeve or bypass who delivered between 2004 and 2021 after their first pregnancy following bariatric surgery. We compared the incidence of SGA, intrauterine growth retardation, preterm delivery and adverse maternal outcomes between patients who had sleeve versus bypass. Results Of 244 patients, 145 had a sleeve and 99 had a bypass. The proportion of SGA < 10th percentile did not differ between the two groups (38/145 (26.2 %) vs 22/99 (22.22 %), respectively, p = 0.48). Preterm birth < 37 WG was lower in the sleeve group (5/145 (3.45%) vs 12/99 (12.12 %) in the bypass group (p = 0.01), as well as NICU hospitalizations (3 (2.07%) vs 12/99 (12.12%), p < 0.01). There was no difference regarding adverse maternal outcomes such as gestational diabetes and hypertensive complications. The proportion of SGA was not lower in patients with bypass when adjusting for other risk factors (BMI, smoking, geographic origin, diabetes and hypertension) (aOR 0.70; 95%CI 0.01 - 2.85). Conclusion sleeve was associated with an incidence of SGA which was as high as after bypass, however the incidence of preterm birth was lower.
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Affiliation(s)
- Marie-Anne Joly
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, FHU PREMA, Hôpital Louis-Mourier, Colombes, France
- Université Paris Cité, Paris, France
| | - Violaine Peyronnet
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, FHU PREMA, Hôpital Louis-Mourier, Colombes, France
| | - Muriel Coupaye
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de Prise en Charge de l′Obésité (CINFO), Hôpital Louis-Mourier, Colombes, France
- Inserm UMRS 1149, Paris 75018, France
| | - Séverine Ledoux
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service des Explorations Fonctionnelles, Centre Intégré Nord Francilien de Prise en Charge de l′Obésité (CINFO), Hôpital Louis-Mourier, Colombes, France
- Inserm UMRS 1149, Paris 75018, France
| | - Nicolas Pourtier
- Université Paris Cité, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service de Chirurgie Digestive, Centre Intégré Nord Francilien de Prise en Charge de l′Obésité (CINFO), Hôpital Louis-Mourier, Colombes, France
| | - Lucile Pencole
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, FHU PREMA, Hôpital Louis-Mourier, Colombes, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, FHU PREMA, Hôpital Louis-Mourier, Colombes, France
- Université Paris Cité, Paris, France
- Inserm IAME 1137, Paris, France
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3
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Alves FCR, Moreira A, Moutinho O. Maternal and long-term offspring outcomes of obesity during pregnancy. Arch Gynecol Obstet 2024; 309:2315-2321. [PMID: 38502190 DOI: 10.1007/s00404-023-07349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 03/21/2024]
Abstract
PURPOSE Obesity`s prevalence is rising in women of reproductive age worldwide and has become the most common medical condition at this age group. Besides, its occurrence is also rising during pregnancy. This condition not only increases the risk of noncommunicable diseases on the mother, such as cardiovascular disease and diabetes, but also transfers this risk to the offspring. METHODS This is a narrative review based on scientific and review articles on the matter. RESULTS Obesity is associated with an increased risk of gestational diabetes mellitus, gestational hypertension and preeclampsia, venous thromboembolism, infection, and mental health problems. Furthermore, it has an impact on the progress of labor and induction matters. Regarding offspring outcomes, it is related to higher incidence of congenital anomalies, perinatal mortality, and the occurrence of large for gestational age newborns. Still, it has implications on cardiometabolic risk and neurodevelopment in offspring. CONCLUSION It is, therefore, imperative to encourage the adoption of healthy lifestyles, especially in the peri-conception and interpregnancy periods. Likewise, there must be support in the multidisciplinary monitoring of these pregnant women to minimize associated complication rates.
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Affiliation(s)
- Fernanda Cristina Ribeiro Alves
- Obstetrics and Gynecology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, Vila Real, Portugal.
| | - Ana Moreira
- Obstetrics and Gynecology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, Vila Real, Portugal
| | - Osvaldo Moutinho
- Obstetrics and Gynecology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, Vila Real, Portugal
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Arvizu M, Wang S, Mitsunami M, Mínguez-Alarcón L, Gaskins AJ, Rosner B, Rich-Edwards JW, Chavarro JE. BMI status and weight trajectories across females' reproductive years and risk of adverse pregnancy outcomes: a prospective cohort study. Am J Clin Nutr 2024:S0002-9165(24)00460-X. [PMID: 38777663 DOI: 10.1016/j.ajcnut.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/08/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Prepregnancy body mass index (BMI) is a well-established risk factor of adverse pregnancy outcomes (APOs). The associations of long-term and short-term weight trajectories with APOs are less clear. OBJECTIVES This study aimed to determine the associations of weight trajectories during females' reproductive years, before and between pregnancies, with risk of APOs. METHODS We followed 16,241 females (25,386 singleton pregnancies) participating in a prospective cohort, the Nurses' Health Study II. Weight at age 18 y, current weight, and height were assessed at baseline (1989), and weight was updated biennially. Pregnancy history was self-reported in 2009. The primary outcome was a composite of hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm birth, and stillbirth. Secondary outcomes were individual APOs. The associations of weight change with APOs were estimated using log-binomial regression, adjusting for demographic, lifestyle, reproductive factors, and baseline BMI (in kg/m2). RESULTS The mean (standard deviation [SD]) age at first in-study pregnancy was 33.7 (4.1) y. The mean (SD) time from age 18 y to pregnancy, baseline to pregnancy, and between pregnancies was 16.3 (4.0), 6.1 (3.0), and 2.9 (1.6) y, with a corresponding weight change of 6.4 (9.1), 3.1 (5.8), and 2.3 (4.8) kg, respectively. Of the pregnancies, 4628 (18.2%) were complicated by ≥1 APOs. Absolute weight change since age 18 y was most strongly associated with APOs. Compared with females whose weight remained stable (0-2 kg) since age 18, females who gained >2 kg had higher risk of APO (2.1-9.9 kg, relative risk [RR]: 1.12; 95% confidence interval [CI]: 1.02, 1.23; 10.0-14.9 kg, RR: 1.43; 95% CI: 1.29, 1.60; ≥15 kg, RR: 1.87; 95% CI: 1.69, 2.08), primarily driven by HDP and GDM. The associations of per 1 kg weight gain before and between pregnancies with HDP were nearly identical. CONCLUSIONS Weight trajectories prior to and between pregnancies were associated with the risk of APOs, particularly HDP. Longer periods of weight gain, corresponding to greater absolute weight gain, were most strongly associated with higher risk of APOs.
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Affiliation(s)
- Mariel Arvizu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Siwen Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Makiko Mitsunami
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lidia Mínguez-Alarcón
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Audrey J Gaskins
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Bernard Rosner
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Janet W Rich-Edwards
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jorge E Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States.
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Drucker DJ. Prevention of cardiorenal complications in people with type 2 diabetes and obesity. Cell Metab 2024; 36:338-353. [PMID: 38198966 DOI: 10.1016/j.cmet.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 01/12/2024]
Abstract
Traditional approaches to prevention of the complications of type 2 diabetes (T2D) and obesity have focused on reduction of blood glucose and body weight. The development of new classes of medications, together with evidence from dietary weight loss and bariatric surgery trials, provides new options for prevention of heart failure, chronic kidney disease, myocardial infarction, stroke, metabolic liver disease, cancer, T2D, and neurodegenerative disorders. Here I review evidence for use of lifestyle modification, SGLT-2 inhibitors, GLP-1 receptor agonists, selective mineralocorticoid receptor antagonists, and bariatric surgery, for prevention of cardiorenal and metabolic complications in people with T2D or obesity, highlighting the contributions of weight loss, as well as weight loss-independent mechanisms of action. Collectively, the evidence supports a tailored approach to selection of therapeutic interventions for T2D and obesity based on the likelihood of developing specific complications, rather than a stepwise approach focused exclusively on glycemic or weight control.
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Affiliation(s)
- Daniel Joshua Drucker
- The Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, University of Toronto, Toronto, ON M5G1X5, Canada.
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Chen Z, Li Y. Association Between Bariatric Surgery and Breastfeeding Outcomes in Women: a Retrospective Case-Control Study. Obes Surg 2024; 34:442-448. [PMID: 38109012 DOI: 10.1007/s11695-023-06987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Bariatric surgery (BS) has shown promise in enhancing exclusive breastfeeding practices among women with obesity. Nevertheless, there remains a dearth of research exploring the intricate relationship between BS and breastfeeding outcomes. This study aims to investigate the potential association between bariatric surgery and exclusive breastfeeding outcomes. METHODS Employing a retrospective case-control design, this study undertook a comprehensive comparison of women who had undergone BS and subsequently gave birth during the study period. By meticulously matching the control group (No-BS group) based on key preoperative variables such as body mass index, age, parity, and delivery year, a robust comparative analysis was established. RESULTS Participants in the BS group exhibited a significantly extended duration of exclusive breastfeeding in comparison to the No-BS group (p < 0.001). However, there were no noteworthy disparities observed in terms of breast milk production between the two groups (p > 0.05). Notably, an independent risk factor associated with diminished exclusive breastfeeding duration was identified: gastroesophageal reflux symptoms (p = 0.003). CONCLUSION This study furnishes valuable insights into the efficacy of bariatric surgery in extending the duration of exclusive breastfeeding among pregnant women grappling with obesity. Furthermore, our findings underscore the discernible impact of postoperative gastroesophageal reflux symptoms on the duration of exclusive breastfeeding.
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Affiliation(s)
- Zhili Chen
- Nursing Department, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yanli Li
- Obstetrical Department, The First Affiliated Hospital of Jinan University, No. 613 Huangpu Avenue West, Guangzhou, China.
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Breslin TB, Dindinger RA, Andromalos L, Agunsday J. Perinatal Care for People With a History of Metabolic and Bariatric Surgery: AWHONN Practice Brief #19. Nurs Womens Health 2023; 27:e6-e8. [PMID: 37791944 DOI: 10.1016/j.nwh.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
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Perinatal Care for People With a History of Metabolic and Bariatric Surgery: AWHONN Practice Brief #19. J Obstet Gynecol Neonatal Nurs 2023; 52:e8-e10. [PMID: 37791934 DOI: 10.1016/j.jogn.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
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9
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Różańska-Walędziak A, Walędziak M, Mierzejewska A, Skopińska E, Jędrysik M, Chełstowska B. Nutritional Implications of Bariatric Surgery on Pregnancy Management-A Narrative Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1864. [PMID: 37893582 PMCID: PMC10608240 DOI: 10.3390/medicina59101864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/01/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
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.
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Affiliation(s)
- Anna Różańska-Walędziak
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland; (A.R.-W.); (A.M.); (E.S.)
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine—National Research Institute, Szaserów 128 St., 04-141 Warsaw, Poland
| | - Anna Mierzejewska
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland; (A.R.-W.); (A.M.); (E.S.)
| | - Ewa Skopińska
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland; (A.R.-W.); (A.M.); (E.S.)
| | - Malwina Jędrysik
- Department of Biochemistry and Laboratory Diagnostics, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland; (M.J.); (B.C.)
| | - Beata Chełstowska
- Department of Biochemistry and Laboratory Diagnostics, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warsaw, Poland; (M.J.); (B.C.)
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Boller MJ, Greenberg MB, Hedderson MM. In Reply. Obstet Gynecol 2023; 142:429-430. [PMID: 37473418 DOI: 10.1097/aog.0000000000005274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Affiliation(s)
- Marie J Boller
- Department of Obstetrics and Gynecology, The Permanente Medical Group, Oakland, California
| | - Mara B Greenberg
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Permanente Medical Group, Oakland, California
| | - Monique M Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, and the Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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Kahrs JC, Van Wickle K, Delahanty MT, Wood ME. Perinatal Outcomes After Bariatric Surgery Compared With a Matched Control Group. Obstet Gynecol 2023; 142:429. [PMID: 37473417 DOI: 10.1097/aog.0000000000005273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Affiliation(s)
- Jacob C Kahrs
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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