Screening and Management of Gestational Diabetes Mellitus after Bariatric Surgery

[Pregnancy after bariatric surgery: blowing hot and cold]

Introduction

The 2024 Flemish consensus on screening for gestational diabetes mellitus early and later in pregnancy

BACKGROUND

Screening for gestational diabetes mellitus (GDM) is important to improve pregnancy outcomes and to prevent type 2 diabetes after pregnancy. Due to a lack of evidence, the 2019 Flemish consensus did not recommend screening for GDM in early pregnancy. Recently, a large randomized controlled trial (TOBOGM) demonstrated that screening for GDM before 20 weeks reduces the risk of neonatal complications in women with risk factors when using higher cut-offs to define GDM compared to the criteria used later in pregnancy.

METHODS

Based on this new evidence, members of the Diabetes Liga, the Flemish associations of general physicians (Domus Medica), obstetricians (VVOG), midwives (VBOV), diabetes nurse educators (BVVDV), dieticians (VBVD) and clinical chemists (RBSLM) have adapted the Flemish consensus on screening for GDM.

BACKGROUND

Recommendations: As in 2019, this new consensus recommends universal screening for overt diabetes in early pregnancy preferably by measuring fasting plasma glucose by using the same diagnostic criteria as in the non-pregnant state. Based on the new evidence, women with fasting plasma glucose 95-125 mg/dL (5.3-6.9 mmol/L) before 20 weeks gestation should be diagnosed as early GDM. In addition, in women with obesity and/or a history of GDM, it is advised to perform already a 75 g oral glucose tolerance test (OGTT) between 6 and 20 weeks gestation using higher cut-offs to diagnose early GDM [fasting ≥95 mg/dL (5.3 mmol/L), 1 hour ≥ 19 mg/dL (10.6 mmol/L) and/or 2 hour ≥ 162 mg/dL (9.0 mmol/L))]. The recommendation concerning screening for GDM between 24 and 28 weeks remains unchanged with a diagnosis of GDM based on the 75 g OGTT and IADPSG criteria [fasting ≥ 92 mg/dL (5.1 mmol/L), 1 hour ≥ 180 mg/dL (10.0 mmol/L) and/or 2 hour ≥ 153 mg/dL (8.5 mmol/L)].

Gestational Diabetes Risk and Low Birth Weight After Metabolic Bariatric Surgery: a Complex Interplay to be Balanced

INTRODUCTION

Metabolic bariatric surgery (MBS) is known to improve the obstetric outcomes of women with obesity and to prevent gestational diabetes (GD). To what extent does MBS decreases GD, without incurring at additional risks is a matter of concern.

METHODS

A retrospective case-control study to compare the pregnancy outcomes of women previously submitted to MBS to those of age and preconception body mass index (PC BMI) matched non-operated controls.

RESULTS

Pregnancies of women after MBS (n = 79) and matched controls (n = 79) were included. GD was significantly less frequent after MBS (7.6% vs. 19%; p = 0.03). Fasting blood glucose (76.90 ± 0.77 vs 80.37 ± 1.15 mg/dl, p < 0.05; 70.08 ± 1.34 vs. 76.35 ± 0.95 mg/dl; p < 0.05, first and second trimesters respectively) and birth weight (2953.67 ± 489.51 g vs. 3229.11 ± 476.21 g; p < 0.01) were significantly lower after MBS when compared to controls. The occurrence of small-for-gestational-age (SGA) was more frequent after MBS (22.8% vs. 6.3%; p < 0.01), but no longer significant after controlling for smoking habits (15.5% vs. 6%, p = 0.14). There were no significant differences in gestational weight gain, prematurity rate nor mode of delivery between groups.

CONCLUSION

MBS was associated with a lower prevalence of GD than observed in non-operated women with the same age and BMI. After controlling for smoking, this occurred at the expense of a lower birth weight. Our data reinforces the hypothesis that MBS has body weight independent effects on glucose kinetics during pregnancy with distinctive impacts for mother and offspring, which need to be balanced.

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

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

Continuous glucose monitoring in individuals undergoing gestational diabetes screening

BACKGROUND

Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.

OBJECTIVE

This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening.

STUDY DESIGN

This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes.

RESULTS

Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups.

CONCLUSION

In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Management of type 2 diabetes in pregnancy: a narrative review

The prevalence of type 2 diabetes (T2DM) at reproductive age is rising. Women with T2DM have a similarly high risk for pregnancy complications as pregnant women with type 1 diabetes. To reduce adverse pregnancy and neonatal outcomes, such as preeclampsia and preterm delivery, a multi-target approach is necessary. Tight glycemic control together with appropriate gestational weight gain, lifestyle measures, and if necessary, antihypertensive treatment and low-dose aspirin is advised. This narrative review discusses the latest evidence on preconception care, management of diabetes-related complications, lifestyle counselling, recommendations on gestational weight gain, pharmacologic treatment and early postpartum management of T2DM.

Pregnancy post-bariatric surgery: Improved outcomes with telephonic nutritional management program

BACKGROUND

Pregnancies post-bariatric surgery are increasingly common. It is important to understand how to manage prenatal care in this high-risk population to optimize perinatal outcomes.

OBJECTIVE

To determine among pregnancies post-bariatric surgery whether participation in a telephonic nutritional management program was associated with improved perinatal outcomes and nutritional adequacy.

STUDY DESIGN

Retrospective cohort study of pregnancies post-bariatric surgery from 2012 to 2018. Participation in a telephonic management program with nutritional counseling, monitoring and nutritional supplement adjustment. Modified Poisson Regression estimated the relative risk using propensity score methods to account for baseline differences between the patients who participated in the program and patients who did not.

RESULTS

1575 pregnancies occurred post-bariatric surgery, of which 1142 (72.5 % of pregnancies) participated in the telephonic nutritional management program. Participants in the program were less likely than non-participants to have a preterm birth (aRR 0.48, 95 % CI 0.35-0.67), preeclampsia (aRR 0.43, 95 % CI (0.27-0.69)), gestational hypertension (aRR 0.62, 95 % CI 0.41-0.93), and to have neonates admitted to a Level 2 or 3 (aRR 0.61, 95 % CI0.39-0.94; aRR 0.66, 95 % CI 0.45-0.97, respectively), after adjusting for the propensity score to account for baseline differences. Risk of cesarean delivery, gestational weight gain, glucose intolerance and birthweight did not differ by participation. Among 593 pregnancies with nutritional labs available, participants in the telephonic program were less likely to have nutritional inadequacy in late pregnancy (aRR 0.91, 95 % CI 0.88-0.94).

CONCLUSION

Participation in a telephonic nutritional management program post-bariatric surgery was associated with improved perinatal outcomes and nutritional adequacy.

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

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

Hypoglycemia in Pregnancies Following Gastric Bypass-a Systematic Review and Meta-analysis

The aims of this systematic review were to identify the prevalence of hypoglycemia among pregnant women treated with gastric bypass, and risk factors of hypoglycemic events in pregnancy. We searched MEDLINE, EMBASE, Cochrane, and Scopus databases from inception to April 6, 2021. Six studies investigating glucose metabolism in pregnancy following gastric bypass were included (n = 330). As assessed by the oral glucose tolerance test and continuous glucose monitoring, 57.6% (95% CI [40.1, 75.1]) of women with gastric bypass were exposed to hypoglycemia during pregnancy. No studies performed the mixed meal test, and no studies reported on risk factors associated with hypoglycemia. Further studies are required to determine the magnitude of hypoglycemia in these women's everyday-life using continuous glucose monitoring and mixed meal test.

The prevalence of gestational diabetes mellitus before and after the implementation of the universal two-child policy in China

BACKGROUND

After the universal two-child policy has been fully implemented, challenges regarding pregnancy complications seemed to be more severe in China. This study aimed to evaluate the prevalence of gestational diabetes mellitus (GDM) and the main risk factors for GDM before and after the implementation of the universal two-child policy in China.

METHODS

A retrospective study was performed with 128,270 pregnant women who delivered at Ningbo Women & Children's Hospital from January 2010 to December 2020. Univariate and multivariate logistic regression analysis was applied to estimate the risk factors associated with GDM prevalence. Segmented regression analyses of interrupted time series (ITS) were conducted to assess the effect of the universal two-child policy on the trends of GDM.

RESULTS

The prevalence of GDM increased remarkably from 4% in 2010 to 21% in 2020. ITS analysis presented that the prevalence of GDM increased by 0.190% (β1) per month from 2010 to 2016 (P<0.05), and by 0.044% (β1+β3) per month after the implementation of the universal two-child policy; the rate of elevation of GDM slowed down significantly (β3=-0.146, P=0.004). Advanced maternal age (>30 years), multigravidity, multiparity, multiple gestation and gestational hypertension were significantly associated with GDM. Advanced age remained an independent risk factor for GDM even after cross stratification with gravidity and parity. The proportion of women with advanced maternal age (>30 years) increased by 0.161% per month before the implementation of the universal two-child policy and increased by 5.25% during the policy took effect month, and gradually increased by 0.124% (β1+β3) per month after then.

CONCLUSIONS

The prevalence of GDM has sharply increased in the past decade. The growth rate of GDM slowed down after the implementation of the universal two-child policy in China, but the rate would maintain at a high plateau. The rise in the proportion of older pregnant women could increase the GDM rate. We recommend having children at a relatively optimal reproductive age when encouraging childbearing.

Gestational Diabetes, Colorectal Cancer, Bariatric Surgery, and Weight Loss among Diabetes Mellitus Patients: A Mini Review of the Interplay of Multispecies Probiotics

Diabetes mellitus has been steadily increasing over the past decades and is one of the most significant global public health concerns. Diabetes mellitus patients have an increased risk of both surgical and post-surgical complications. The post-surgical risks are associated with the primary condition that led to surgery and the hyperglycaemia per se. Gut microbiota seems to contribute to glucose homeostasis and insulin resistance. It affects the metabolism through body weight and energy homeostasis, integrating the peripheral and central food intake regulatory signals. Homeostasis of gut microbiota seems to be enhanced by probiotics pre and postoperatively. The term probiotics is used to describe some species of live microorganisms that, when administered in adequate amounts, confer health benefits on the host. The role of probiotics in intestinal or microbial skin balance after abdominal or soft tissue elective surgeries on DM patients seems beneficial, as it promotes anti-inflammatory cytokine production while increasing the wound-healing process. This review article aims to present the interrelation of probiotic supplements with DM patients undergoing elective surgeries.

Reproductive outcomes after bariatric surgery in women

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

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

Care of Pregnant Women With a History of Bariatric Surgery

In recent years, the incidence of bariatric surgery has increased among women of reproductive age. Health care providers should be knowledgeable about the impact bariatric surgery has on women and developing fetuses to effectively provide care from preconception through postpartum. Although pregnancy in women with normal weight or with excess weight after bariatric surgery has better outcomes when compared to pregnancy complicated by obesity, it is associated with complications such as nutritional deficiencies, low birth weight, and fetal growth restriction. Consequently, a multidisciplinary approach is recommended to ensure adequate nutrition, counseling, and screening before and during pregnancy. This article summarizes evidence regarding pregnancy complications that may occur in women with a history of bariatric surgery and presents a nursing, advanced practice nursing, and midwifery plan of care for these women before, during, and after pregnancy.

The Relationship between Social Capital and Self-Efficacy in Women with Gestational Diabetes Mellitus: A Cross Sectional Study

Background

Self-efficacy is one of the most likely determinants of glucose self-management and self-monitoring by diabetic patients. Also, social capital is one of the effective social factors that may affect health behaviors. The aim of this study was to evaluate the relationship between social capital and self-efficacy in women with gestational diabetes mellitus (GDM).

Methods

This descriptive-analytical cross-sectional study was conducted on 212 women with GDM in two diabetes center in Mazandaran, north of Iran, from April to July 2019. Patients' social capital and self-efficacy levels were measured using the Social Capital Questionnaire (SCQ) and Confidence in Diabetes Self-Care Scale questionnaire, respectively.

Results

Among eight dimensions of social capital, the highest and the lowest mean scores were related to proactivity (21.3) and tolerance of diversity (5) dimensions. The mean (standard deviation=SD) of self-efficacy total score was 40.7(18.2), indicating moderate self-efficacy. Pearson correlation coefficient indicated that there was significant positive relationship between all dimensions of social capital and self-efficacy (p˂0.05). In addition, the results of multiple regression analysis indicated that community participation, neighborhood connections, family and friends' connections, tolerance of diversity and work connections, explained 55% of the variance in self-efficacy in women with GDM (p˂0.05).

Conclusion

The results highlighted a significant positive relationship between social capital and self-efficacy in women with GDM. Improving women’s social capital may enhance their self-efficacy in controlling GDM.

An Update on Screening Strategies for Gestational Diabetes Mellitus: A Narrative Review

Gestational diabetes mellitus (GDM) is a frequent medical complication during pregnancy. Screening and diagnostic practices for GDM are inconsistent across the world. This narrative review includes data from 87 observational studies and randomized controlled trials (RCTs), and aims to give an overview of the current evidence on screening strategies and diagnostic criteria for GDM. Screening in early pregnancy remains controversial and studies show conflicting results on the benefit of screening and treatment of GDM in early pregnancy. Implementing the one-step "International Association of Diabetes and Pregnancy Study Groups" (IADPSG) screening strategy at 24-28 weeks often leads to a substantial increase in the prevalence of GDM, without conclusive evidence regarding the benefits on pregnancy outcomes compared to a two-step screening strategy with a glucose challenge test (GCT). In addition, RCTs are needed to investigate the impact of treatment of GDM diagnosed with IADPSG criteria on long-term maternal and childhood outcomes. Selective screening using a risk-factor-based approach could be helpful in simplifying the screening algorithm but carries the risk of missing significant proportions of GDM cases. A two-step screening method with a 50g GCT and subsequently a 75g oral glucose tolerance test (OGTT) with IADPSG could be an alternative to reduce the need for an OGTT. However, to have an acceptable sensitivity to screen for GDM with the IADPSG criteria, the threshold of the GCT should be lowered from 7.8 to 7.2 mmol/L. A pragmatic approach to screen for GDM can be implemented during the COVID-19 pandemic, using fasting plasma glucose (FPG), HbA1c or even random plasma glucose (RPG) to reduce the number of OGTTs needed. However, usual guidelines and care should be resumed as soon as the COVID pandemic is controlled.

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.

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.

The 2019 Flemish consensus on screening for overt diabetes in early pregnancy and screening for gestational diabetes mellitus

Screening for gestational diabetes mellitus (GDM) is important to improve pregnancy outcomes and to prevent type 2 diabetes after pregnancy. The 'International Association of Diabetes and Pregnancy Study Groups' (IADPSG) recommends a universal one-step approach with the 75 g oral glucose tolerance test (OGTT) for screening of GDM. The IADPSG recommendation remains controversial due to the important increase in GDM prevalence and increased workload. After review of the latest evidence and based on data from the 'Belgian Diabetes in Pregnancy' study, members of the Diabetes Liga, the Flemish associations of general physicians (Domus Medica), obstetricians (VVOG), midwives (VVOB), diabetes nurse educators (BVVDV) and clinical chemists (RBSLM) have reached a new consensus on screening for GDM in Flanders. This new consensus recommends universal screening for overt diabetes when planning pregnancy or at the latest at first prenatal contact, preferably by measuring the fasting plasma glucose by using the same diagnostic criteria as in the non-pregnant state. In women with impaired fasting glycaemia, but also in normoglycemic obese women and women with a previous history of GDM, lifestyle counselling is advised with screening for GDM with a 75 g OGTT at 24 weeks. In all other women, we recommend a two-step screening strategy with a 50 g glucose challenge test (GCT) at 24 weeks followed by a 75 g OGTT when the glucose level 1 hour after the GCT ≥130 mg/dl. Diagnosis of GDM is made using the IADPSG criteria for GDM. Postpartum screening for subsequent glucose abnormalities should be advocated and organized for every woman with GDM.

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.

Micronutrient management following bariatric surgery: the role of the dietitian in the postoperative period

Bariatric surgery is increasingly being utilized to manage obesity and obesity related comorbidities, but may lead to the development of micronutrient deficiencies postoperatively. The anatomical, physiological, nutritional and behavioral reasons for micronutrient vulnerabilities are reviewed, along with recommendations for routine monitoring and replacement following surgery. The role the dietitian and their contribution in the postoperative identification, prevention and management of micronutrient vulnerabilities in bariatric patients is described. Specific considerations such as the nutritional and dietetic management of pregnant and lactating women post-bariatric surgery is also discussed.

GDM and Nutrition-Answered and Unanswered Questions-There's More Work to Do!

Gestational Diabetes Mellitus (GDM) is the commonest medical pregnancy complication, and a growing problem around the world as the obesity epidemic continues. Ways to prevent GDM are urgently required, the management of GDM still poses many unanswered questions, and the postpartum prevention of the progression of GDM to type 2 diabetes remains a challenge. With GDM, the impact of any intervention on the offspring is always a major concern. Nutritional interventions come to the fore as one of our few levers in reducing the short-term pregnancy risk and long-term cardiometabolic risks to both mother and child. This special issue reports on the relationship between several nutrients and foods and the development and management of GDM, behavioural strategies to enhance lifestyle choices, the issues raised by prior bariatric surgery and ways to screen for GDM. The work identifies further unanswered questions over nutritional strategies to reduce the impact of GDM.