Article

Birth Outcomes in Obese Women After Laparoscopic Adjustable Gastric Banding

Authors:
  • Iverson Health Innovation Research Institute
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Abstract

This prospective study sought to examine the outcomes of 79 consecutive first pregnancies (> 20 weeks of gestation) in women following laparoscopic adjustable gastric banding (LAGB) for severe obesity. The 79 women are from a cohort of 1,382 consecutive patients. The prospectively collected data from 79 first pregnancies has been compared with these patients' previous penultimate pregnancies (n= 40), obstetric histories from matched severely obese subjects (n = 79), and community outcomes. The mean maternal weight gain was 9.6 +/- 9.0 kg, compared with 14.4 +/- 9.7 kg for the 40 penultimate pregnancies of women in this group (P < .001). There was no difference in birth weights: 3,397 g compared with 3,350 g for preband pregnancies, and these were consistent with normal community birth weights. The incidence of pregnancy-induced hypertension (10%) and gestational diabetes (6.3%) were comparable with community levels (12% and 5.5%) and lower than the obese cohort (38% and 19%) and these patients' penultimate pregnancies (45% and 15%). Monitoring and, if necessary, band adjustments during pregnancy provided more favorable maternal weight outcomes (P = .027). Neonatal outcomes, including stillbirths, preterm deliveries, low birth weight, and high birth weight, were consistent with community values. One woman developed anemia during pregnancy. Pregnancy outcomes after LAGB are consistent with general community outcomes rather than outcomes from severely obese women. The adjustability of the LAGB assists in achieving these outcomes. Adjustability is appealing because it allows adaptation to the altered requirements of pregnancy. II-2.

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... En effet, dans la littérature le taux de diabète gestationnel dans la population opérée varie entre 0% et 16% [12]. Cependant les études ne retrouvant aucun cas de diabète gestationnel sont des études de cohorte avec des effectifs très faibles (7 à 23 patientes) [22,24,26]. L'étude de Bar-Zohar regroupe 81 patientes et observe un taux proche du nôtre de 16% [25]. ...
... On notait 9,48% de macrosomie. Les études de cohorte retrouvent des taux très divers de macrosomie de 0 à 36% [11,24]. Le poids de naissance était significativement plus bas après chirurgie bariatrique dans les études les comparant aux grossesses antérieures (3264g +/-599 vs 3079+/-567, p<0,001) [31]. ...
... C'est également le cas pour quatre publications de la littérature [7,19,24,26]. Néanmoins, certains auteurs retrouvent des taux de complications plus élevés. Skull décrit dans sa série de 44 grossesses après anneaux gastriques, deux cas de prolapsus gastriques antérieurs à travers l'anneau [27]. ...
Thesis
L'obésité est actuellement un enjeu majeur de santé publique. La chirurgie bariatrique constitue l'une des alternatives pour permettre un amaigrissement significatif. Ainsi, le nombre de grossesses après chirurgie bariatrique est en forte augmentation. L'obstétricien est donc plus fréquemment confronté au suivi de grossesses après chirurgie bariatrique. Nous avons ainsi réalisé une étuderétrospective sur le suivi et les résultats obstétricaux après anneau gastrique ou bypass chez 55 femmes. Nous avons ainsi observé de faibles proportions de suivi pluri-disciplinaire, des taux de pathologies gravidiques relativement élevés malgré la perte de poids liée à la chirurgie bariatrique. Néanmoins aucune complicationliée à la chirurgie n'était observée. Les grossesses après anneau gastrique ou bypass nécessitent un suivi régulier strict et pluridisciplinaire afin d?observer une diminution du risque de pathologie gravidique et d'éviter toutes complications mécaniques ou carentielles.
... 4,5 The majority of previous studies on bariatric surgery before pregnancy and pre-eclampsia risk have been small and inconclusive. [6][7][8][9][10][11][12][13][14][15][16][17][18] Pooling of these studies in metaanalyses has been complicated by the use of heterogeneous control groups. Two meta-analyses 19,20 that separated the analysis by type of control group found a tendency (although not significant) of a lower risk of pre-eclampsia in the bariatric surgery group compared with both presurgery and early-pregnancy BMI-matched controls. ...
... e Analyses of preeclampsia complicated with SGA excluded stillbirths and births without data on birthweight. one study 15 found a significantly lower risk in the bariatric group compared with the pre-surgery BMI-matched control group (Table S5). These inconsistent findings may be attributed to the small sample sizes (range 70-139 in the post-bariatric surgery group) and the inclusion of various bariatric surgery procedures. ...
... ,15,16 have included a comparison group matched on pre-surgery BMI. All published studies reported a tendency of lower pre-eclampsia risk, but only ...
Article
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Objective: To investigate whether gastric bypass before pregnancy is associated with reduced risk of preeclampsia. Design: Nationwide matched cohort study. Setting: Swedish national health care. Population: 843,667 singleton pregnancies without pre-pregnancy hypertension were identified in the Swedish Medical Birth Register between 2007-2014, of which 2930 had a history of gastric bypass and a pre-surgery weight available from the Scandinavian Obesity Surgery Registry. Two matched control groups (pre-surgery and early-pregnancy BMI) were propensity score matched separately for nulliparous and parous births, to post-gastric bypass pregnancies (npre-surgery-BMI =2634:2634/ nearly-pregnancy-BMI =2766:2766) on pre-surgery/early-pregnancy BMI, diabetes status (pre-surgery/pre-conception), maternal age, early-pregnancy smoking status, educational level, height, country of birth, delivery year and history of preeclampsia. Main outcome measures: Preeclampsia categorised into any, preterm onset (<37+0 weeks), and term onset (≥37+0 weeks). Results: In post-gastric bypass pregnancies, mean pre-surgery BMI was 42.9kg/m2 and mean BMI-loss between surgery-to-early-pregnancy was 14.0kg/m2 (39kg). Post-gastric bypass pregnancies had lower risk of preeclampsia compared to pre-surgery BMI-matched controls (1.7 vs. 9.7 per 100 pregnancies; hazard ratio [HR] 0.21, 95%CI 0.15-0.28) and early-pregnancy BMI-matched controls (1.9 vs. 5.0 per 100 pregnancies; HR 0.44, 95%CI 0.33-0.60). Although relative risks for preeclampsia for post-gastric bypass pregnancies vs. pre-surgery matched controls was similar, absolute risk differences were significantly greater for nulliparous (RD -13.6 per 100 pregnancies, 95%CI -16.1 to -11.2) vs. parous women (RD -4.4 per 100 pregnancies, 95%CI -5.7 to -3.1). Conclusion: We found that gastric bypass was associated with lower risk of preeclampsia, with the largest absolute risk reduction among nulliparous women.
... 23 Dixon et al. studied 79 pregnancies after BS and reported one duodenal atresia and one stillbirth at 41 gestational weeks. 25 Due to paucity of data in this regard, more research is needed to evaluate the risk of congenital malformations as some case reports have shown increased risk of neural tube defects after BS. 26,27 There may be developmental delays in children born to women who had BS prior to their pregnancy. 27 Johansson et al. studied long-term growth, neuropsychosomatic and speech development in children born to women after BS in Brazil. ...
... 22 Speech developmental defects were seen in these children; however, this important observation requires more research and follow-up of children born after BS. 22 Patel et al. and Cools et al. reported delays in speech, visual and neurological development in children born to women after BS. 24,26 The results are presented in Table 1. There is no significant difference in premature births and premature rupture of membranes after BS compared to those who did not undergo BS. 24,25 Sheiner et al. found a positive correlation between premature rupture of membranes and BS (OR: 1.9; P = 0.001). 23 The underlying mechanism is not fully understood and needs more research to elucidate this relationship. ...
... 24 Dixon et al. reported no significant difference in birth weight between pregnancies with and without BS. 25 The timing of pregnancy after BS has not been demonstrated to have an impact on birth weight. Dao et al. reported on 34 patients who became pregnant after BS between 2001 and 2004; there was no significant difference between birth weight among 21 women Table 1: Summary of previous studies regarding obstetrical outcomes after bariatric surgery [20][21][22]23,28,30,31,34,57,59,60 Author and year of publication Significant positive changes compared to control Significant negative changes compared to control ...
Article
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Bariatric surgery (BS) is a novel treatment for weight reduction with longer lasting health benefits. This review aimed to summarise the available evidence regarding the fetomaternal outcomes and the most common challenges and complications in pregnancies following BS. Google Scholar (Google LLC, Mountain View, California, USA) and PubMed® (National Library of Medicine, Bethesda, Maryland, USA) databases were searched for articles published until December 2018. A total of 64 articles were included in this review and results showed that BS mitigates the risk of gestational diabetes mellitus, hypertensive disorders in pregnancy and fetal macrosomia. However, it can also have detrimental effects on fetomaternal health. There is paucity of data regarding small for gestational age intrauterine growth restriction, premature rupture of membranes and longterm effects on the children born to women who underwent BS. Keywords: Bariatric Surgery; Nutritional Deficiencies; Obesity; Pregnancy; Surgical Injuries.
... Promising, preliminary research from epidemiologic and retrospective bariatric surgery studies suggests that reductions in body weight before pregnancy may hold the key to the prevention of GDM recurrence [33][34][35][36][37][38][39]. Emergent research suggests that it is feasible to recruit women before pregnancy and promote significant weight loss prior to conception [40,41]. ...
... Kim et al. [48] estimated that up to half of GDM cases could be prevented by reducing prepregnancy obesity. Retrospective data from bariatric surgery populations also suggest that weight loss in women with obesity prior to pregnancy may reduce the risk of GDM and its recurrence [37,87,88] and prevent transmission of obesity to children [36]. Other observational research has shown that maternal consumption of healthy food and avoidance of unhealthy foods [89] and engagement in regular physical activity before pregnancy were independently associated with reduced risk of subsequent GDM [89]. ...
... To date, efforts to prevent GDM have focused primarily on interventions occurring during pregnancy, and these have met with limited success [54,[60][61][62][63][64][65]. Promising, preliminary research from epidemiologic and retrospective bariatric surgery studies suggests that reductions in body weight before pregnancy may hold the key to the prevention of GDM and its recurrence [33][34][35][36][37][38][39]. Emergent research suggests that it is feasible to recruit women before pregnancy and promote significant weight loss prior to conception [40,41]. ...
Article
Full-text available
Background Gestational diabetes mellitus (GDM) is associated with several maternal complications in pregnancy, including preeclampsia, preterm labor, need for induction of labor, and cesarean delivery as well as increased long-term risks of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM raises the risk for complications in offspring as well, including stillbirth, macrosomia, and birth trauma, and long-term risk of metabolic disease. One of the strongest risk factors for GDM is the occurrence of GDM in a prior pregnancy. Preliminary data from epidemiologic and bariatric surgery studies suggest that reducing body weight before pregnancy can prevent the development of GDM, but no adequately powered trial has tested the effects of a maternal lifestyle intervention before pregnancy to reduce body weight and prevent GDM recurrence. Methods The principal aim of the Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional is to determine whether a lifestyle intervention to reduce body weight before pregnancy can reduce GDM recurrence. This two-site trial targets recruitment of 252 women with overweight and obesity who have previous histories of GDM and who plan to have another pregnancy in the next 1–3 years. Women are randomized within site to a comprehensive pre-pregnancy lifestyle intervention to promote weight loss with ongoing treatment until conception or an educational control group. Participants are assessed preconceptionally (at study entry, after 4 months, and at brief quarterly visits until conception), during pregnancy (at 26 weeks’ gestation), and at 6 weeks postpartum. The primary outcome is GDM recurrence, and secondary outcomes include fasting glucose, biomarkers of cardiometabolic disease, prenatal and perinatal complications, and changes over time in weight, diet, physical activity, and psychosocial measures. Discussion The Gestational Diabetes Prevention /Prevención de la Diabetes Gestacional is the first randomized controlled trial to evaluate the effects of a lifestyle intervention delivered before pregnancy to prevent GDM recurrence. If found effective, the proposed lifestyle intervention could lay the groundwork for shifting current treatment practices towards the interconception period and provide evidence-based preconception counseling to optimize reproductive outcomes and prevent GDM and associated health risks. Trial registration ClinicalTrials.gov NCT02763150 . Registered on May 5, 2016
... In Table 2 (part B) 16 studies are presented on the associations between weight loss after bariatric surgery and HDP, PIH and PE [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]. Consisting of eight cohort studies, seven case-control studies and one cross-sectional study. ...
... One study, including almost 200 pregnancies after LAGB surgery, showed an 86% reduced risk of PIH in pregnancies of the same women before and after bariatric surgery (OR 0.14 (95% CI 0.05-0.36)) [44]. Rottenstreich et al. showed an almost fivefold reduced risk of PIH (OR 0.21 (95% CI 0.04-0.99)) in women after LSG compared to controls that were matched on pre-surgery BMI [48]. ...
... The last study compared the risk of PE before and after LAGB surgery in the same cohort of women and reported an 86% reduced risk after LAGB surgery (OR 0.14 (95% CI 0.04-0.48)) [44]. Five other studies showed no effect of bariatric surgery on the risk of PE [39,[46][47][48]50]. ...
Article
Full-text available
Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), Preeclampsia (PE), Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) and chronic hypertension, are leading causes of maternal and perinatal morbidity and mortality. Although the pathophysiology of HDP is complex, preconceptional weight reduction in obese women might reduce these complications. We conducted a systematic review and meta-analysis to investigate the effectiveness of preconceptional weight loss by lifestyle intervention or bariatric surgery in overweight and obese women and the reduction of the risk of HDP. Databases are searched until September 2019 resulting in 2547 articles: 110 full-text analysis and 29 detailed analysis. Reduced risks were shown for HDP in seven articles (n = 4381) of weight loss after lifestyle intervention or bariatric surgery (OR range 0.10–0.64), for PIH in four articles (n = 46,976) (OR range 0.14–0.79), and for PE in seven articles (n = 169,734) (OR range 0.14–0.84). The stratified analysis of weight loss after lifestyle intervention and bariatric surgery shows comparable results. The meta-analysis of 20 studies of the effectiveness of lifestyle intervention and bariatric surgery revealed reduced risks of HDP (OR 0.45 (95% CI 0.32–0.63)), PIH (OR 0.61 (95%CI 0.44–0.85)) and PE (OR 0.67 (95%CI 0.51–0.88)). Preconceptional weight loss after lifestyle intervention or bariatric surgery is effective in reducing risks of HDP, PIH and PE, and emphasizes the need to optimize weight in overweight and obese women with a child wish. More research is recommended to investigate short-term and long-term beneficial and harmful side-effects of these interventions on maternal and offspring health.
... [30][31][32] Promising, preliminary research from epidemiologic and retrospective bariatric surgery studies suggest that reductions in body weight before pregnancy may hold the key to prevention of GDM recurrence. [33][34][35][36][37][38][39] Emergent research suggests that it is feasible to recruit women before pregnancy and promote signi cant weight loss prior to conception. 40, 41 A lifestyle intervention before pregnancy in women with prior GDM may capitalize on a "teachable moment" when women appear more motivated to engage in behavior changes to prevent the recurrence of GDM in a subsequent pregnancy. ...
... 48 estimated that up to half of GDM cases could be prevented by reducing pre-pregnancy obesity. Retrospective data from bariatric surgery populations also suggest that weight loss in women with obesity prior to pregnancy may reduce the risk of GDM and its recurrence 37,87,88 and prevent transmission of obesity to children. 36 Other observational research has shown that maternal consumption of healthy food and avoidance of unhealthy foods 89 and engagement in regular physical activity before pregnancy were independently associated with reduced risk of subsequent GDM. ...
... 54, 60-65 Promising, preliminary research from epidemiologic and retrospective bariatric surgery studies suggest that reductions in body weight before pregnancy may hold the key to prevention of GDM and its recurrence. [33][34][35][36][37][38][39] Emergent research suggests that it is feasible to recruit women before pregnancy and promote signi cant weight loss prior to conception. 40,41 A lifestyle intervention before pregnancy in women with prior GDM may capitalize on a "teachable moment" when women appear more motivated to engage in behavior changes to prevent the recurrence of GDM in a subsequent pregnancy. ...
Preprint
Full-text available
Background Gestational diabetes mellitus (GDM) is associated with several maternal complications in pregnancy, including preeclampsia, preterm labor, need for induction of labor, and cesarean delivery as well as increased long-term risks of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM raises the risk for complications in offspring as well, including stillbirth, macrosomia, and birth trauma and long-term risk of metabolic disease. One of the strongest risk factors for GDM is the occurrence of GDM in a prior pregnancy. Preliminary data from epidemiologic and bariatric surgery studies suggest that reducing body weight before pregnancy can prevent development of GDM, but no adequately powered trial has tested the effects of a maternal lifestyle intervention before pregnancy to reduce body weight and prevent GDM recurrence.Methods The principal aim of Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional is to determine whether a lifestyle intervention to reduce body weight before pregnancy can reduce GDM recurrence. This two-site trial targets recruitment of 252 women with overweight and obesity who have previous histories of GDM and who plan to have another pregnancy in the next 1–3 years. Women are randomized within site to a comprehensive pre-pregnancy lifestyle intervention to promote weight loss with ongoing treatment until conception or an educational control group. Participants are assessed preconceptionally (at study entry, after 4 months, and at brief quarterly visits until conception), during pregnancy (at 26 weeks’ gestation) and at 6 weeks postpartum. The primary outcome is GDM recurrence and secondary outcomes include fasting glucose, biomarkers of cardiometabolic disease, prenatal and perinatal complications, and changes over time in weight, diet, physical activity and psychosocial measures.DiscussionGestational Diabetes Prevention /Prevención de la Diabetes Gestacional is the first randomized controlled trial to evaluate the effects of a lifestyle intervention delivered before pregnancy to prevent GDM recurrence. If found effective, the proposed lifestyle intervention could lay the groundwork for shifting current treatment practices towards the interconception period and provide evidence-based preconception counseling to optimize reproductive outcomes and prevent GDM and associated health risks.Trial registrationClinicalTrials.gov Identifier: NCT02763150
... Most studies about bariatric surgeries and its impact to pregnancy will also include foetal outcome of it [39][40][41]. Earlier comprehensive study by Karmon A et al. (2008) suggested that previous reviews failed to significantly show adverse perinatal outcome following bariatric surgeries, but data were mostly collected from adequate prenatal care and maintaining good, important micronutrient supplement prior and throughout pregnancies [42]. ...
... Obesity in pregnancy and macrocosmic baby is a well-known risk factor for increase in perinatal morbidity and mortality. Numerous observational studies have shown that reduction in BMI after bariatric surgery reduces the risk of delivering macrocosmic baby [11,26,39,43,44]. ...
... A retrospective population-based study by Sheiner E et al. (2004) that involved 298 pregnant post bariatric surgery women showed no significant increase in adverse perinatal outcome [41]. A small prospective study by Dixon JB et al. (2005) who followed up 79 pregnancies after previous laparoscopic adjustable gastric banding procedures found that the complications and adverse outcome were not higher compared to general population. It was mentioned that the effect might be due to adjustability of the procedure that adapt to the nutritional requirements for fetal growth during pregnancy [39]. ...
Article
Full-text available
Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level. Reduction of length of follicular phase of menstrual cycle was reported and contribute to improved ovulatory status. The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. There are no significant changes in composition of breast milk in postpartum women without bariatric surgery and with women whom undergone surgery although more study needed to evaluate this effect. Good prenatal care, micronutrient supplement during antenatal follow up and close supervision from expert managing this pregnancy are essential component to ensure good outcome to mothers and their newborn.
... Some clinicians advocate leaving the balloon inflated to limit food intake, reduce gestational weight gain and associated adverse perinatal outcomes [10]. Literature suggests that in pregnancies following LAGB a decreased incidence of gestational diabetes [11,12], maternal hypertension [11,12], abnormal fetal weight [13] and rates of caesarean delivery [13] can be observed in comparison with the obese control groups [11][12][13]. However, there are concerns that leaving a balloon inflated might reduce the intake of essential nutrients needed for normal fetal development and growth. ...
... Some clinicians advocate leaving the balloon inflated to limit food intake, reduce gestational weight gain and associated adverse perinatal outcomes [10]. Literature suggests that in pregnancies following LAGB a decreased incidence of gestational diabetes [11,12], maternal hypertension [11,12], abnormal fetal weight [13] and rates of caesarean delivery [13] can be observed in comparison with the obese control groups [11][12][13]. However, there are concerns that leaving a balloon inflated might reduce the intake of essential nutrients needed for normal fetal development and growth. ...
... Some clinicians advocate leaving the balloon inflated to limit food intake, reduce gestational weight gain and associated adverse perinatal outcomes [10]. Literature suggests that in pregnancies following LAGB a decreased incidence of gestational diabetes [11,12], maternal hypertension [11,12], abnormal fetal weight [13] and rates of caesarean delivery [13] can be observed in comparison with the obese control groups [11][12][13]. However, there are concerns that leaving a balloon inflated might reduce the intake of essential nutrients needed for normal fetal development and growth. ...
Article
Full-text available
Introduction and importance Obesity is a major health problem. Obese women have an increased risk of pregnancy-related complications. Weight loss before conception is associated with improved fertility rates and pregnancy outcomes. Bariatric surgery (BS), such as laparoscopic adjustable gastric banding (LAGB), was a popular option for obese women planning pregnancy. However, long-term follow-up studies indicate high rate of failure and reoperations. The work has been reported in line with the SCARE 2020 criteria. Case presentation We present a case of a 41-years-old multigravida who was diagnosed with intragastric penetration of the gastric band on the 27th week. Diagnostic laparoscopy and intraoperative esophagogastroduodenoscopy were performed. Gastric band was not removed and no other surgical interventions were performed. The patient underwent a caesarean section on the 37th week, due to the remaining risk of repeated gastric-band-related complications. Clinical discussion The management of pregnancy following LAGB has not been well defined yet. Gastric band erosion with intragastric band migration is considered to be one of the most worrisome of all LAGB-related complications. Conclusion International treatment consensus for pregnancy after BS is still missing. This case illustrates a need for practitioner to maintain a high index of suspicion of gastric-band-related complications during pregnancy. Gastric-band-related complications during pregnancy are rare with only limited number of published reports. To our knowledge, this is the first reported intragastric penetration of the gastric band in a pregnant woman, which was managed without gastric band removal during pregnancy and which had a good outcome for both, the patient and her baby.
... Some relatively small studies have examined the subject of the timing of pregnancy after BS; most of them included different time intervals between pregnancy and BS or a mixture of different BS techniques. None of the studies have found significant differences in perinatal outcomes between the early and late conception groups [17,[21][22][23][24][25][26]. ...
... A multicenter French cohort study also found that neonatal outcomes were not significantly different for different intervals between surgery and conception [32]. Dao et al. [23] included 34 pregnancies after gastric bypass surgery and Dixon et al. [22] included 79 pregnancies in women following laparoscopic adjustable gastric banding (LABG); neither study showed a significant difference in the incidences of CD, birthweight, or SGA, between the early (< 1 year) and late (> 1 year) groups. ...
... These results are in accordance with Rasteiro et al. [30]. Similarly, other studies [22,23] have shown significantly higher gestational weight gain in the late group (time threshold of 12 months). Stentebjerg et al. [29] showed that there was no significant difference in weight gain during pregnancy between study groups using a time threshold of 18 months. ...
Article
Full-text available
Aim We aimed to evaluate the effect of pregnancy timing after laparoscopic sleeve gastrectomy (LSG) on maternal and fetal outcomes. Methods Women with LSG were stratified into two groups with surgery-to-conception intervals of ≤ 18 months (early group) or > 18 months (late group). Only the first delivery after LSG was included in this study. We compared maternal characteristics, pregnancy, and neonatal outcomes and adherence to the Institute of Medicine’s (IOM) recommendations for gestational weight gain (GWG) in the two groups. Results Fifteen patients conceived ≤ 18 months after surgery, with a mean surgery-to-conception interval of 5.6 ± 4.12 months, and 29 women conceived > 18 months following LSG, with a mean surgery-to-conception interval of 32.31 ± 11.38 months, p < 0.05. There was no statistically significant difference between the two groups regarding birth weight, gestational age, cesarean deliveries (CD), preterm birth, whether their child was small or large for their gestational age, or in the need of neonatal intensive care. There was no correlation between mean weight loss from operation till conception, mean weight gain during pregnancy, and mean body mass index (BMI) at conception between birth weight in either study group. Inadequate and normal GWG was significantly higher in the early group, whereas excessive GWG was significantly higher in the late group (X², 20.780; p = < 0.001). Conclusion The interval between LSG and conception did not impact maternal and neonatal outcomes. Pregnancy after LSG was overall safe and well-tolerated.
... avant une perte de poids notable [31]. L' incidence des fausses couchesetcelledes complications de la grossesse telles que diabète, hypertension et pré- éclampsie semblent diminuer en comparaison à une groupe de femmes nettement obèses non opérées [32][33][34][35][36][37][38][39][40][41][42][43][44]. La prise pondérale normale pendant la grossesse semble également moins importante [39]. ...
... La prise pondérale normale pendant la grossesse semble également moins importante [39]. Certaines études ont trouvé une diminution des accouchements prématurés et de l'incidence des poids de naissance très bas (<2,5 kg) [32,37,39] et très élevés (macrosomie) [32,37,39,40] après pose d'un anneau gastrique ou dérivation gastrique, comparativement au collectif des obèses non opérées. Il y a cependant des indices que, suite à une diversion biliopancréatique, l'incidence des «outcomes» néonataux négatifs soit globalement plus faible, mais celle des fausses couches légèrement plus élevée [31,38,[45][46][47]. ...
... Maternal obesity may also impact offspring health, including increased risk of offspring macrosomia, future obesity, asthma, cardiovascular disease, and type 2 diabetes. Retrospective reports suggest that weight loss through bariatric surgery before pregnancy can prevent several comorbidities and also reduce the risk of obesity in offspring aged two through adulthood (Abodeely, Roye, Harrington, & Cioffi, 2008;Dixon, Dixon, & O'Brien, 2005;Kral et al., 2006). Observational research has found that women who maintain or lose weight in between pregnancies have lower risk of gestational and type 2 diabetes (Ehrlich et al., 2011;Pole & Dodds, 1999;Whiteman et al., 2011), large for gestational age infants (Getahun, Ananth, Peltier, Salihu, & Scorza, 2007), and other perinatal complications (Villamor & Cnattingius, 2006). ...
... Overall, lifestyle intervention before pregnancy appeared feasible in a community-based sample of overweight/obese women planning pregnancy. In prior research, bariatric surgery before conception significantly improves maternal and offspring outcomes (Dixon et al., 2005;Wittgrove, Jester, Wittgrove, & Clark, 1998). Findings from the current study suggest that non-surgical weight loss strategies prior to conception should also be considered. ...
Article
Pre-pregnancy obesity is a well-established risk factor for several adverse maternal and fetal outcomes, including gestational diabetes, hypertension, cesarean sections, and fetal macrosomia. Weight loss before pregnancy could help prevent such complications, but the feasibility of such an approach remains unknown. The current study examined the feasibility of a 3-month pre-pregnancy behavioral weight loss program in 12 overweight/obese women planning pregnancy. The 3 month program resulted in an average 5.4 ± 3.0 kg weight loss and significant improvements in self-monitoring, physical activity, eating and exercise self-efficacy, and healthy eating (p < 0.04). By the end of the 9 month follow-up, half of sample (n = 6) had conceived. Women reported significant increases in weekly or more frequent self-weighing (p < 0.0001), counting calories (p < 0.001), consuming fruit and vegetables (p = 0.007), and cutting out fat (p = 0.0001) and junk foods (p = 0.002). A lifestyle modification program to promote weight loss before pregnancy promoted clinically significant weight loss and appeared feasible.
... noch bevor ein ausge- prägter Gewichtsverlust erreicht wurde, nachgewiesen werden [31]. Die Abortrate sowie die Häufigkeit von schwanger- schaftsassoziierten Komplikationen wie Diabetes, Hyper- tonie und Präeklampsie scheinen im Vergleich zu nicht- operierten ausgeprägt adipösen Frauen zu sinken [32][33][34][35][36][37][38][39][40][41][42][43][44]. Der übliche Gewichtsanstieg während der Schwanger- schaft scheint ebenfalls etwas reduziert zu sein [39]. ...
... Der übliche Gewichtsanstieg während der Schwanger- schaft scheint ebenfalls etwas reduziert zu sein [39]. In einigen Studien wurde eine Reduktion der Frühgeburt- lichkeit sowie der Häufigkeit von sehr niedrigem (<2,5 kg) [32,37,39] und auch erhöhtem Geburtsgewicht (Makro- somie) [32,37,39,40] ...
... Vol. 13 The data is presented as mean ±SD. All women in the study came from the same area in Sweden and had undergone the same GBP surgery and therefore this material is a representative sample of this group of women and children. ...
... For girls born after GBP surgery, the same pattern was shown at 6 months of age. Previous study from Australian pregnant women who had previous undergone GBP did not find any differences in birth weight compared to normal community birth weights (13). ...
Article
Full-text available
Objective: More and more young obese women get pregnant after undergoing gastric bypass surgery (GBP) but little is known about weight development in their offspring. The first aim of this study was to investigate weight development of children whose mothers have undergone GBP before pregnancy and compare them to age specific reference values in Sweden. Second aim was to study the frequency of small for gestational age (SGA) in this population. Materials and methods: Weight of offspring (38 male and 28 female) where the mother had undergone GBP before pregnancy were studied from birth up to 18 months of age and compared to age-specific reference values in Sweden. Results: The boys to mothers who had undergone GBP before pregnancy weighed more than Swedish reference values at 6 months, 8.44 ± 1.18 kilogram (kg) (n = 35) vs. 7.98 ± 0.81 kg (n = 1388; p = 0.001), and less at 18 months, 11.54 ± 0.93 kg (n = 19) vs. 12.27 ± 1.19 kg (n = 862; p < 0.001). The girls to mothers who had undergone GBP before pregnancy weighed more than Swedish reference values at 6 months, 7.84 ± 1.00 kg (n = 28) vs. 7.50 ± 0.77 kg (n = 1375; p = 0.020). Frequency of SGA was 3.0%. Conclusion: No clear pattern was found concerning the short-term weight development of the children. However, studies with larger material and more follow up time must be performed.
... Simultaneously, it remains one of the few modifiable risk factors for GDM [14]. Bariatric surgery is becoming increasingly common for the achievement of weight loss [20], while the studies suggest that reductions in body weight before pregnancy may hold the key to the prevention of GDM [21,22]. This section will present the interrelation of probiotics with weight loss and insulin sensitivity among GDM women. ...
... The alteration in the gut microbiome has a pivotal role in the initiation and maintenance of obesity-related inflammation. Gut microbial metabolites can trigger innate immunity, especially LPS, through a complex process that activates the pro-inflammatory cytokines [20,34]. Furthermore, probiotic bacteria have also been shown to promote anti-inflammatory cytokine production, accelerating the inflammation phase, balancing intestinal microbial composition, and regulating immune-related cytokine expression [35,36]. ...
Article
Full-text available
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.
... Three meta-analyses on bariatric surgery and delivery outcomes reported non-significant differences for cesarean delivery and postpartum hemorrhage between women with and without a history of bariatric surgery [11][12][13]. Studies on bariatric surgery and delivery outcomes have generally been small, used heterogeneous control groups [14][15][16][17][18][19], or lacked a comparison group accounting for pre-surgery BMI [6,15,16,[18][19][20][21][22][23][24]. We have identified only 3 previous studies on delivery outcomes that included a control group matched on pre-surgery BMI [14,17,25], of which all included fewer than 140 post-surgery deliveries. ...
... Studies on bariatric surgery and delivery outcomes have generally been small, used heterogeneous control groups [14][15][16][17][18][19], or lacked a comparison group accounting for pre-surgery BMI [6,15,16,[18][19][20][21][22][23][24]. We have identified only 3 previous studies on delivery outcomes that included a control group matched on pre-surgery BMI [14,17,25], of which all included fewer than 140 post-surgery deliveries. No previous study to our knowledge has investigated obstetric anal sphincter injury (OASIS; i.e., perineal tear) in women with bariatric surgery history compared with controls. ...
Article
Full-text available
Background Obesity increases the risk of adverse delivery outcomes. Whether weight loss induced by bariatric surgery influences these risks remains to be determined. The objective was to investigate the risk of adverse delivery outcomes among post-surgery women compared with women without bariatric surgery history but with similar characteristics. Methods and findings We identified 801,443 singleton live-born term births (≥37 gestational weeks) in the Swedish Medical Birth Register between 1 January 2006 and 31 December 2013, of which 1,929 were in women with a history of bariatric surgery and a pre-surgery weight available from the Scandinavian Obesity Surgery Registry. For each post-surgery delivery, up to 5 control deliveries were matched by maternal pre-surgery BMI (early-pregnancy BMI used for controls), age, parity, smoking, education, height, country of birth, and delivery year (N post-surgery deliveries:matched controls = 1,431:4,476). The main outcome measures were mode of delivery, induction of labor, post-term pregnancy (≥42 + 0 gestational weeks), epidural analgesia, fetal distress, labor dystocia, peripartum infection, obstetric anal sphincter injury (perineal tear grade III–IV), and postpartum hemorrhage. Among the women with a history of bariatric surgery, the mean pre-surgery BMI was 42.6 kg/m², the median surgery-to-conception interval was 1.4 years, and the mean BMI loss between surgery and early pregnancy was 13.5 kg/m² (38 kg). Compared to matched control women, post-surgery women were less likely to have cesarean delivery (18.2% versus 25.0%, risk ratio [RR] 0.70, 95% CI 0.60–0.80), especially emergency cesarean (6.8% versus 15.1%, RR 0.40, 95% CI 0.31–0.51). Post-surgery women also had lower risks of instrumental delivery (5.0% versus 6.5%, RR 0.73, 95% CI 0.53–0.98), induction of labor (23.4% versus 34.0%, RR 0.68, 95% CI 0.59–0.78), post-term pregnancy (4.2% versus 10.3%, RR 0.40, 95% CI 0.30–0.53), obstetric anal sphincter injury (1.5% versus 2.9%, RR 0.46, 95% CI 0.25–0.81), and postpartum hemorrhage (4.6% versus 8.0%, RR 0.58, 95% CI 0.44–0.76). Since this study was not randomized, a limitation is the possibility of selection bias, despite our efforts using careful matching. Conclusions Bariatric-surgery-induced weight loss was associated with lower risks for adverse delivery outcomes in term births.
... 13 Another option might be to maintain band inflation to limit nutritional intake, but low gestational weight gain has been associated with intrauterine growth restriction 14 and pre-term birth. 15 Whereas there have been large observational studies and systematic reviews of pregnant women with previous bariatric surgery, 11,16,17 few have exclusively studied gastric banding, [18][19][20] and no study has compared outcomes according to band management (deflation, maintained inflation). 21 In this national cohort study, the aim was to estimate the prevalence of pregnancy after LAGB in the UK, determine how the gastric band was managed and compare maternal and perinatal outcomes according to band management. ...
Article
Full-text available
Background: With no evidence to guide management of the gastric band in pregnancy, we aim to compare outcomes according to band management. Methods: Data were collected on all women pregnant (November 2011-October 2012) following gastric banding, using the UK Obstetric Surveillance System surveillance system. We compared outcomes between band management groups and with national data. Results: Band management was variable; deflation 43.4%, inflation maintained 56.6%. The deflation group had lower risk of small for gestational age infants (no cases vs. 11.3%; risk ratio = 0.14, p = 0.05). There was greater gestational weight gain (deflation 15.4 kg, inflation 7.6 kg; adjusted p = 0.05), and perhaps higher risk of gestational hypertension (deflation 10.5%, inflation no cases; p = 0.08) in the deflation group. Other maternal outcomes were similar between management groups but overall worse than national data. Conclusions: Deflation is associated with better outcomes for babies but worse outcomes for mothers than maintained inflation.
... If a gastric band was implanted, a metabolic surgeon needs to assess a relaxation of the gastric band already in early pregnancy. In earlier studies, band migration with consequent complications (vomiting, disturbances in electrolyte and fluid balance, and band leakage) was described in nearly 29% [64]. A systematic review reported five neonatal and three maternal deaths and the necessity of acute surgical intervention in 20 cases in pregnancy with the majority of intervention due to internal hernia after RYGB [1]. ...
Article
Full-text available
The prevalence of obesity is growing worldwide, and strategies to overcome this epidemic need to be developed urgently. Bariatric surgery is a very effective treatment option to reduce excess weight and often performed in women of reproductive age. Weight loss influences fertility positively and can resolve hormonal imbalance. So far, guidelines suggest conceiving after losing maximum weight and thus recommend conception at least 12–24 months after surgery. As limited data of these suggestions exist, further evidence is urgently needed as well for weight gain in pregnancy. Oral glucose tolerance tests for the diagnosis of gestational diabetes mellitus (GDM) should not be performed after bariatric procedures due to potential hypoglycaemic adverse events and high variability of glucose levels after glucose load. This challenges the utility of the usual diagnostic criteria for GDM in accurate prediction of complications. Furthermore, recommendations on essential nutrient supplementation in pregnancy and lactation in women after bariatric surgery are scarce. In addition, nutritional deficiencies or daily intake recommendations in pregnant women after bariatric surgery are not well investigated. This review summarizes current evidence, proposes clinical recommendations in pregnant women after bariatric surgery, and highlights areas of lack of evidence and the resulting urgent need for more clinical investigations.
... In our study, the post-op time for most patients was over 12 months, which is associated with a lower occurrence nutritional deficiency and weight loss problems. In Dixon et al. and Sheiner et al., only half of the patients became pregnant during the first year post-op, but no significant differences occurred in the prevalence of complications among them and those who became pregnant after the first year post-op [14,15]. This is due to 100 and 61.5% of patients in these studies, respectively, were submitted to the adjustable gastric band (AGB) procedure, while only 3.8% of patients of Sheiner et al. were submitted to RYGB, more associated with nutritional deficiencies and greater short-term weight loss than AGB. ...
Article
Full-text available
Purpose Most patients undergoing bariatric surgery (BS) are fertile women whose postoperative (post-op) hormonal balance and weight loss increases fertility, frequently leading to pregnancy. This study aims to analyze supplementation adherence of pregnant women after BS and perinatal outcomes. Materials and Methods This retrospective study analyzed records from women after BS who consulted nutritionists at least twice during pregnancy. Each patient received nutritional guidance about vitamin and mineral supplementation and protein intake. Demographic data, body mass index (BMI), percentage of weight loss (%WL) at conception, maximum post-op BMI and %WL, post-op time at conception, supplementation adherence, biochemical data, possible gestational complications, and infant’s birth weight were collected. Results Data was obtained from 23 women (mean age 33 ± 4 years). On average, patients became pregnant 43 months after surgery. The mean preoperative BMI was 40.2 kg/m², the maximum post-op %WL was 36.6%, and the mean %WL at conception was 32.0%. No gestational intercurrence was related to biochemical data. Supplementation adherence was 34.7% for one multivitamin and 34.7% for two multivitamins; 43.5% for iron, 43.5% for omega 3, 39.1% for folic acid, 17.4% for B complex, and 60.8% for calcium. Mean infant birth weight was 3.0 kg, and it was not associated with maximum %WL, % WL at conception, and time since BS at conception. Conclusion Our data indicate satisfactory adherence to post-op micronutrient supplementation and few gestational complications following BS. Moreover, child’s birth weight was not associated with maximum %WL, %WL at conception, or time since BS.
... [73] Delaying pregnancy until 1-2 years after bariatric surgery has been recommended to avoid fetal exposure to nutritional deficiencies from rapid maternal weight loss, [74][75][76] although limited data suggest that pregnancy within the 1 st year after bariatric surgery may not necessarily increase the risk for adverse maternal or perinatal outcomes. [77][78][79] Particularly in late reproductive years, the benefits of postponing pregnancy to achieve weight loss must be balanced against the risk of declining fertility with advancing age. ...
... One of the largest studies to date evaluated the perinatal outcome of 159,210 deliveries occurring in Israel between 1988 and 2002. Of these deliveries, 298 were from women who had previously undergone bariatric surgery [54,55]. Although there was a higher rate of caesarean delivery in the bariatric surgery group (25.2 vs. 12.2%), no difference was found in perinatal mortality, congenital malformations, and Apgar scores at one and 5 min. ...
... However, their nutritional requirements during pregnancy or contraception effectiveness may be altered following BS. Obese women are advised to lose weight prior to conception, as obesity increases the risk of complications for mother and fetus, such as gestational diabetes, hypertension, preeclampsia, spontaneous miscarriage, large-for-gestational age offspring, and even fetal neurological and cardiovascular malformations [1][2][3][4]. ...
Article
Full-text available
Abstract Background: Obesity has reached epidemic levels at the global scale and is a leading cause of health-related disorders. Surgical weight reduction procedures are the last option for obese individuals but have become increasingly popular in recent years. While obesity presents specific acute and long-term risks to the pregnant woman and her offspring, the effects of bariatric surgery on pregnancy outcomes are still being evaluated. Objective: The aim of the present study was to evaluate the impact of bariatric surgery (BS) on maternal and neonatal health in the modern and rapidly developing health care system in Qatar. Design: In this population-based retrospective study, the data obtained as a part of the PEARL-Peristat Study (Perinatal Neonatal Registry) conducted in the state of Qatar is analyzed. The PEARL-Peristat Study is an ongoing cohort study based on the predesigned hospital data pertaining to mothers and their newborns. In its initial phase, the PEARL study was conducted from 2011 to 2013, while the phase discussed ion this work covered the 2017-2019 period. Results: The population of interest for the present study comprised of 16,701 mothers who gave birth to 17,155 infants at > 22 weeks of gestation during a two year period in Qatar. However, only singleton deliveries (n = 16,248) were subjected to analyses. Moreover, as the study focused on obese mothers, 1,918 women that were classified as obese formed the intervention group, while the remaining 14,015 women were treated as the control group. Among the obese mothers, 315 had bariatric surgery (BS), which was on average performed at the age of 35 (59%). Majority of BS cases pertained to Qatari citizens (79%) and nulliparous women (21.6%). Compared to non-obese women, those that were classified as obese were statistically significantly more likely to deliver via caesarean section (37.5% vs 30%, p = 0.003). In the group classified as obese, DM was noted in 23% cases, while PET, PIH, and PPH were respectively reported in 2.5%, 1.9%, and 5.9% of these patients, in line with the rates obtained for the control group. BS was offered to 16 non-obese (12.9%) and 37 overweight (29.8%) women. No statistically significant differences were, however, noted between the intervention and the control group with respect to premature delivery (p = 0.12) and still birth (1.6% vs. 0.6%, p = 0.037), LBW (15% vs. 8.3%, p = 0.001), and Apgar score < 7 at fifth minute (1.3 % vs. 0.3%, p = 0.01). None of the newborns weighed above 4.5 kg. Comparison of obese women that underwent BS with those that did not revealed that the former group had a lower risk of DM (77% vs. 53%), lower GDM (19% vs. 39%) and lower overt diabetes (3.55 vs. 6.75, p = 0.001). In addition, lower BMI at delivery was noted in this group (p = 0.001), as well as lower IOL rate, a greater number of LBW newborns (p = 0.001), and lower Apgar score at 5th minute (p = 0.04). It is also noteworthy that BS was more likely to be offered to Qatari women than to non-Qatari patients (p = 0.001). On the other hand, no statistically significant differences were noted between these groups with respect to the likelihood of premature delivery, PET, PIH, or PPH. Conclusion: Obesity remains a major health problem worldwide. However, women that have undergone bariatric surgery are still exposed to multiple health risks, including delivering low birthweight infants having babies with lower Apgar score at fifth minute, and having premature and stillborn babies. Nonetheless, BS appears to confer some desirable obstetric attributes, such as reduction in the incidence of IOL and assisted births. As bariatric surgery is a successful treatment of maternal obesity, more data is needed to determine clinical guidelines, given certain surgery-specific risks. Keywords: Bariatric Surgery; Maternal; Obesity; Outcome; Newborn; Women
... 38 Case-control studies comparing patients before and after LAGB have shown a significant reduction in co-mordities. Dixon et al. 39 in their study of 79 patients who had LAGB compared with same patients prior to surgery to 79 obese patients and found that there was less maternal weight gain during pregnancy in LAGB patients and that those who became pregnant within one year of surgery gained less weight during pregnancy. Perinatal outcomes such as stillbirth rate, preterm labour, low birth weight and macrosomia were similar to the general population. ...
Article
Bariatric surgery is highly effective for weight loss in morbid obesity. With the high prevalence of severe obesity in the developed world, and the acknowledgement of the effectiveness of these procedures by National Institute for Clinical Excellence (in the UK) and the Food and Drug Administration (in the USA), women with severe obesity will increasingly seek such treatment. As the majority of these patients are women of reproductive age, obstetricians will encounter these patients frequently during pregnancy. It is therefore important for obstetricians to gain an insight into the types of surgery performed, the potential complications, including nutritional deficiency, and appropriate management of pregnancy following weight-loss surgery. In general, bariatric surgery is associated with a reduction in obesity related complication, with no apparent increased risk of adverse perinatal outcomes.
... Other epidemiological research suggests that even modest weight losses (> 10 pounds) [108][109][110] or less weight gain [111][112][113] prior to pregnancy reduces risk of GDM development compared to women who maintain weight or gain >10 pounds. Retrospective data from bariatric surgery populations also suggest that weight loss in obese women prior to pregnancy may reduce the risk of GDM [114][115][116] and prevent transmission of obesity to children. 117 While the findings from observational studies are intriguing, no known clinical trials to date ( Table 2) have examined the effect of postpartum weight control interventions on subsequent pregnancy and maternal/child health outcomes among women with prior GDM. ...
Article
Gestational diabetes mellitus (GDM) is linked with several acute maternal health risks and long-term development of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM similarly increases offspring risk of early-life health complications and later disease. GDM recurrence is common, affecting 40 to 73% of women, and augments associated maternal/fetal/child health risks. Modifiable and independent risk factors for GDM include maternal excessive gestational weight gain and prepregnancy overweight and obesity. Lifestyle interventions that target diet, activity, and behavioral strategies can effectively modify body weight. Randomized clinical trials testing the effects of lifestyle interventions during pregnancy to reduce excessive gestational weight gain have generally shown mixed effects on reducing GDM incidence. Trials testing the effects of postpartum lifestyle interventions among women with a history of GDM have shown reduced incidence of diabetes and improved cardiovascular disease risk factors. However, the long-term effects of interpregnancy or prepregnancy lifestyle interventions on subsequent GDM remain unknown. Future adequately powered and well-controlled clinical trials are needed to determine the effects of lifestyle interventions to prevent GDM and identify pathways to effectively reach reproductive-aged women across all levels of society, before, during, and after pregnancy. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
... On the other hand, insufficient WG potentially affects fetal growth and may increase the risk for SGA infants [40]. Woman with obesity have a tendency towards excessive WG during pregnancy [40], while several studies show that BS reduces this phenomenon [41,42]. The Institute of Medicine of National Academies recommends adequate WG values during pregnancy according to preconception BMI [43]. ...
Article
Obesity is a chronic disease that presents a significant prevalence among women within childbearing age. Laparoscopic sleeve gastrectomy (LSG) is a widely used method for the treatment of obesity. Several studies have examined this operation’s impact on pregnancy outcomes with contradictory results. The aim of this systematic review was to examine the maternal and neonatal outcomes following LSG. The electronic databases of MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus as well as grey literature from inception to December 2019 were systematically reviewed. Search strategy included the terms: "sleeve", "gastrectomy" and "pregnancy". Eligibility criteria were randomized control trials, cohort studies and case series that reported on women with LSG prior to conception and maternal and neonatal outcomes. A total of 406 distinct articles were identified with nine studies included in the systematic review. A cumulative statistical analysis reported a preoperative BMI of 43.6 ± 5.0 kg/m2 while BMI at conception was 29.6 ± 4.9 kg/m2. The average weight gain during pregnancy was 8.9 kg. Preeclampsia appeared in 2.7%, gestational diabetes (GD) in 5.7% and cesarean delivery was performed at 42.5%. Small for gestational age (SGA) neonates were diagnosed in 15.8% and large for gestational age (LGA) neonates in 3.7%. Limited data exist on the subject and further prospective studies are needed to prove the exact evidence of relation between LSG and pregnancy outcomes. Initial studies show that patients with LSG patients present lower rates of GD and LGA neonates, higher rates of SGA neonates and similar rates of hypertensive disorders and prematurity when compared to non operated controls. Time interval between LSG and conception is not proven to have a statistically significant impact on maternal or neonatal outcomes.
... Significant weight loss and fertility improve-ment was observed after the application of bariatric surgery among an obese female population [44]. A significantly higher rate of cesarean section was reported among postbariatric surgery patients [45]. Reproductive function after gastric bypass surgery is characterized by a shortened follicular phase and improved female sexual function [46]. ...
Article
Full-text available
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.
Chapter
Obesity is rapidly becoming the nation’s number one health risk and bariatric surgery has become the most effective approach for sustainable weight loss and reduction of morbidities associated with obesity (Gastroenterol Hepatol. 2010;6(12):780–792). Obesity is defined as having a body mass index (BMI—calculated as weight in kilograms divided by height in meters squared) of 30 or greater (NCHS Data Brief. 2011;56:1–8). It can be further subdivided into class I obesity defined as a BMI of 30–34.9, class II obesity with a BMI of 35–39.9, and class III obesity with a BMI of 40 or greater (JAMA. 2013;309:71–823; J Am Coll Cardiol. 2013). Currently, all 50 of the US states have an obesity rate of more than 20 %. In 2013, 18 states had an obesity prevalence of 30 to <35 %, and 2 states had an obesity prevalence of 35 % or greater.
Chapter
Weight loss surgery is considered to be the most efficacious treatment for individuals with clinically severe class III obesity (BMI ≥ 40 kg/m2) or with moderate class II obesity (BMI ≥ 35–39.9 kg/m2) when accompanied by an obesity-related comorbidity. Significant improvement in multiple obesity-related comorbid conditions has been reported postoperatively, including type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, obstructive sleep apnea (OSA), and quality of life. However, long-term durability of weight loss and improvement in comorbid conditions are less certain, and weight regain has been observed. Although the causative factors of weight regain have not been well characterized, clinicians are being asked to evaluate an increasing number of patients postoperatively. This chapter will review the current information regarding weight gain following bariatric surgery and the factors associated with weight regain and present a proposed evaluation and treatment algorithm.
Chapter
Obesity can disrupt the fertility processes in both men and women by various mechanisms, chiefly including hormonal derangements on sex steroids and a dysmetabolic milieu characterized by an insulin-resistant state. In addition, low-grade inflammation and a consequent lipotoxic state may impair structural and functional mitochondrial physiology, thereby oocyte function and sperm quality in women and men, respectively. In women, obesity may also impair endometrial receptivity that became an important factor explaining the failure of assisted reproductive technologies in these women. The polycystic ovary syndrome (PCOS) is the commonest cause of anovulatory infertility in women. Obesity tends to favor the development of PCOS in adolescent girls and worsens the phenotype of adult affected women, by increasing the hyperandrogenic state and ovarian dysfunction. Moreover, it plays a major role in the development of a dysmetabolic profile. In turn, obesity reduces the potential efficacy of medical treatments of infertility in most of these women. Weight loss may conversely favor ovulation rates and pregnancy rates in these women. This short review summarizes the most important aspects of obesity-related infertility in both men and women, including those affected by PCOS.
Article
The majority of bariatric surgeries in Canada are performed in women of reproductive age. Clinicians encounter more and more often pregnancies that occur after bariatric surgeries. The appropriate management and education of women who want to conceive after bariatric surgery is still unclear due to the lack of consistent data about maternal and neonatal outcomes following bariatric surgery. Maternal obesity during pregnancy confers a higher risk for gestational diabetes, hypertensive disorders, congenital malformations, prematurity and perinatal mortality. Generally, pregnancies in severely obese women who have undergone bariatric surgery are safe, and the women are at significantly lower risk for gestational diabetes, hypertensive disorders and large-for-gestational-age neonates, but the surgery confers a higher risk for small-for-gestational-age infants and prematurity. This review aims to provide evidence from recent publications about the risks and benefits of bariatric surgeries in the context of future pregnancies.
Chapter
Obesity is a worldwide epidemic. It affects both developed and developing countries with rates that more than doubled since 1980. The prevalence of overweight and obesity increased by 28% in adults and 47% in children between 1980 and 2013. It affects people of all ages, including women of reproductive age. In the United States, more than 55% of reproductive age women are overweight or obese, over 30% are obese, and 7% are considered morbidly obese. It is estimated that about a third of women are now obese at the beginning of their pregnancy. Obesity is a known risk factor for diabetes mellitus (DM), and in pregnancy has been associated with an increased risk for the development of gestational diabetes mellitus (GDM). Other obesity-related complications of pregnancy include preeclampsia, fetal macrosomia, stillbirth, post-term pregnancy, and cesarean delivery (CD). Long-term maternal complications include higher risks for cardiovascular disease, ophthalmic disease, and even gynecological malignancies such as ovarian and breast cancer. Maternal obesity is related to neonatal complications, including higher rates of early neonatal death and even long-term sequelae leading to future metabolic syndrome in the offspring. Bariatric surgery (BS) for obese patients with DM results in the largest degree of sustained weight loss along with the largest improvement in blood glucose control. It is indicated for morbidly obese patients or obese patients with obesity-related comorbidities. From an obstetrical point of view, reaching normal pre-pregnancy weight and BMI may reduce the risk of complications in pregnancy and adverse perinatal outcomes. BS is becoming an increasingly utilized approach to achieve weight loss. It has been shown to be the most effective and durable treatment for obesity and to reduce obesity-related complications during pregnancy. This chapter addresses the impact of BS on GDM and the resulting perinatal outcomes.
Chapter
Successful management of bariatric patients involves vigilant preoperative and postoperative planning for prevention of complications. Short-and long-term consequences following Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy include a wide range of nutritional deficiencies. Risk factors for nutritional complications may include poor dietary intake, noncompliance with the postoperative regimen, or the type of surgical procedure. Because both the preoperative and postoperative prevalence of vitamin and mineral deficiency in bariatric patients are higher than the in general population, nutritional care demands an appreciation of bariatric physiology and patient behavior.
Article
Background At our medical center, female patients who have undergone bariatric surgery are advised to defer pregnancy for two years after surgery, in order to avoid the following complications and their potential consequences to the fetus: inadequate gestational weight gain, inadequate post-surgical weight loss, hyperemesis gravidarum, nutritional deficiencies, gestational diabetes (GDM), and gestational hypertension. Objectives To examine the effect of time from surgery to conception on pregnancy course and outcomes in bariatric patients. Setting University Methods We identified 73 pregnancies in 54 women who became pregnant after undergoing bariatric surgery. Surgery to conception interval was compared between pregnancies which were carried to delivery, and eight pregnancies which resulted in spontaneous abortion. Of 41 pregnancies which were carried to delivery, 26 occurred in women who had undergone surgery less than two years prior to conception (<2Y), and 15 occurred in women who had undergone surgery greater than two years prior to conception (>2Y). Gestational age at delivery, number of neonatal intensive care unit (NICU) admissions, gestational weight gain, hyperemesis gravidarum, nutritional deficiencies, GDM, and gestational hypertension during pregnancy were compared for the two groups. Results Eight patients who had spontaneous abortion had a significantly shorter time from surgery to conception. There were no significant differences between our two groups in rates of preterm deliveries, NICU admission, gestational weight gain, hyperemesis, nutritional deficiencies, GDM, or gestational hypertension. Conclusions Becoming pregnant within the first two years post bariatric surgery appears to have no effect on pregnancy course and outcomes. Women who miscarried had a significantly lower mean surgery to conception interval. These results fail to show an increased rate of pregnancy complications during the first two years after bariatric surgery.
Data
Full-text available
Trial protocol of the LIFEstyle study. (PDF)
Book
The growing 'obesity epidemic' in the Western world is of particular concern for women of childbearing age. Both short- and long-term effects are associated with obesity in pregnancy for both the mother and her offspring. The nine chapters of this book are organized according to the natural course of the association between obesity and pregnancy. The book commences with an examination of the association between obesity and general maternal health during pregnancy and in nonpregnancy. The book then addresses the complications of obesity in pregnancy, screening and treatment of diabetes, weight optimization and weight gain during pregnancy, bariatric surgery and the impact on pregnancy outcome, appropriate antenatal care, considerations for labor and delivery, postnatal care, and finally, the association between maternal obesity and long-term sequelae to the offspring. The book includes thought-provoking discussion between the Editor and other authors together with multiple choice questions - a feature in all Clinical Insights books - facilitating continued learning for established professionals and providing a useful learning tool for those seeking deeper insight into these topics.
Data
Full-text available
Research protocol as approved by the ethics committee. (PDF)
Chapter
Bariatric (metabolic) surgery has become recognized as the most definitive and successful means for the treatment of obesity and obesity‐associated medical conditions. Benefits of surgery include weight loss and either significant improvement or complete amelioration of metabolic derangements, which must be weighed against the risks of each procedure. When considering bariatric surgery for patients with obesity, clinicians should be aware of potential adverse events that may develop following surgery, as well as the marked improvement of associated diseases and risk factors, such as type 2 diabetes, hypertension, and hyperlipidemia, among many other metabolic conditions. Postoperatively, patients will need lifelong follow‐up that should include recognition of common acute emergencies as well as the adjustment of medical therapies as comorbid conditions evolve.
Chapter
Physiological and endocrine adaptations occur in the mother in response to the demands of pregnancy. These demands include support of the fetus (volume support, nutritional and oxygen supply, and clearance of fetal waste), protection of the fetus (from starvation, drugs, toxins), preparation of the uterus for labor, and protection of the mother from potential cardiovascular injury at delivery. The presence of a preexisting endocrine disorder is likely to affect the ability of the mother to adapt to the demands of pregnancy and, as a result, may influence fetal growth and development. Drugs used to treat such disorders may also affect perinatal outcome. The most common preexisting endocrine disorders that can complicate pregnancy are diabetes mellitus, thyroid dysfunction, and obesity. Less common preexisting maternal endocrine disorders include pituitary tumors, diabetes insipidus, and hyperparathyroidism. The physiological and endocrine adaptations that characterize pregnancy can also lead to the development of pregnancy-specific diseases in previously healthy women, the most common of which are gestational diabetes and disorders of the endocrine and sympathetic nervous systems associated with preeclampsia and preterm labor. This chapter is designed to review in detail the underlying pathophysiology of these pregnancy-specific diseases, as well as the effects of pregnancy on preexisting endocrine disorders. A better understanding of these conditions will improve the ability of clinicians to optimize maternal and perinatal outcome in such pregnancies.
Article
• • Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications. • • Bariatric surgery improves fertility and some pregnancy-related outcomes. • • Following bariatric surgery, pregnancy should be delayed by at least 12–18 months due to adverse pregnancy outcomes associated with rapid weight loss. • • Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy. • • After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. • • Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient’s usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.
Data
Full-text available
Research protocol as approved by the ethics committee. (PDF)
Article
The prevalence of women of child‐bearing age with obesity continues to rise at an alarming rate. This has significant implications for both the short‐term and long‐term health of mother and offspring. Given the paucity of evidence‐based literature in this field, the preconception management of women with obesity is highly variable both between institutions and around the world. This systematic review aims to evaluate studies that inform us about the role of preconception weight loss in the fertility and pregnancy outcomes of women with obesity. Current therapeutic interventions are discussed, with a specific focus on the suitability of weight loss interventions for women with obesity planning pregnancy. There are significant knowledge gaps in the current literature; these are discussed and areas for future research are explored.
Article
Background: Recommendations by the Institute of Medicine (IOM) on gestational weight gain (GWG) for women with histories of bariatric surgery have yet to be studied. Objectives: To describe GWG in women with histories of bariatric surgery and to investigate the relationship between GWG and maternal and neonatal outcomes. Study design: A bicentric retrospective study on the medical charts of pregnant women with histories of bariatric surgery who delivered between 2003 and 2017 in two level III maternity units. In accordance with IOM guidelines, GWG was classified as insufficient, adapted, or excessive. Results: At least 337 pregnancies from 264 patients were included in this study. Of these pregnancies, 154 (45.7%) occurred after gastric banding, 135 (40.1%) after Roux-en-Y gastric bypass, and 48 (14.2%) after sleeve gastrectomy. GWG was adapted in 90 of the pregnancies (26.7%), insufficient in 11 of the pregnancies (35%), and excessive in 129 of pregnancies (38.3%). Gestational age at birth was significantly lower when GWG was insufficient (37.7 ± 4.2 weeks vs. 38.8 ± 2.9 weeks for adequate GWG and 39.4 ± 1.8 weeks for excessive GWG). When compared to normal GWG, insufficient GWG was indicated to be a risk factor for preterm labor (adjusted OR, 3.05, 95% CI 1.30-7.17). When compared to excessive GWG, insufficient GWG increased the rates of small for gestational age (SGA) newborns (OR, 1.96, 95% CI 1.04-3.68), preterm labor (OR, 4.13, 95% CI 1.84-9.24), and preterm delivery (OR, 6.40, 95% CI 2.41-17.0). Conclusion: In our study, adequate GWG was associated with better obstetrical outcomes, resulting in the conclusion that IOM recommendations applied to pregnant women who had undergone bariatric surgery. Our findings suggest that the large proportion of women with insufficient GWG may account for increased rates of SGA and preterm birth.
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Background: Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes. Methods and findings: Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (ORs) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03-1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04-1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38-1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25-1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35-0.60, p < 0.001). ORs for SGA increased (2.72, 95% CI 2.32-3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14-0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference -242.42 g, 95% CI -307.43 to -177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes. Conclusions: In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age. Trial registration: PROSPERO CRD42017051537.
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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.
Article
Résumé L’issue des grossesses après chirurgie bariatrique semble favorable associant réduction de l’incidence du diabète gestationnel, des troubles hypertensifs et de la macrosomie. Néanmoins une augmentation de l’incidence des nouveaux nés de petit poids pour l’âge gestationnel et de la prématurité est constatée dans plusieurs études. Des carences nutritionnelles de sévérité variable pour la mère et le nouveau-né set des complications chirurgicales avec un pronostic conditionné par les difficultés diagnostiques sont également observées. Notre groupe de travail multidisciplinaire propose une série de recommandations élaborées selon la méthodologie de la HAS et concernent les questions suivantes: quel délai entre la chirurgie et la grossesse ? Quelle contraception ? Quel type de chirurgie pour les femmes en âge de procréer ? Quel support nutritionnel et quelle gestion des carences nutritionnelles ? Quel dépistage et quelle gestion du diabète gestationnel ? Quelle prise de poids optimale ? Comment gérer l’anneau gastrique au cours de la grossesse ? Comment prendre en charge les urgences chirurgicales, la prise en charge obstétricale et les soins spécifiques pendant la période post-partum et pour les nouveau-nés ?
Article
Approximately 250,000 individuals seek bariatric surgery each year in the USA for the long-term resolution of obesity-related comorbidities. Greater than 80% of these individuals are women and approximately half are of child-bearing age. Although there are many positive metabolic benefits that are realized through surgical weight loss for both men and women, the various long-term hormonal, molecular, nutrient, and epigenetic changes following bariatric surgery have not been evaluated for the surgical recipient or in the context of pregnancy and the offspring. Pregnancy may be a vulnerable period of time for the bariatric surgery recipient, and thoughtful consideration of pregnancy management should be taken by health care providers and recipients alike. The purpose of this review is to explore potential etiologies of some of the gestation-specific outcomes for the mother and offspring.
Chapter
In this chapter we aim to cover the impact of obesity on both male and female fertility potential and to touch upon the effect of bariatric surgery on natural and assisted reproduction. Where applicable, special reference will be made to laparoscopic sleeve gastrectomy. The impact of obesity and bariatric surgery on pregnancy will be discussed in a separate chapter.
Chapter
A large number of obese women of childbearing age are opting for bariatric surgery and require information and proper guidance regarding the effect of such surgeries on reproductive health. In this chapter we outline the safety, advantages and limitations of bariatric surgery procedures in relation to maternal and neonatal outcome. A multidisciplinary team comprising of surgeons, primary care clinicians, obstetricians, anesthetists, fertility specialists, nutritionists, psychologists, as well as patients themselves is required to ensure healthy maternal and neonatal outcomes. Women who have undergone bariatric procedures have safer pregnancy with fewer complications than those with morbid obesity, however, patients should be strongly advised to avoid getting pregnant for at least 12–18 months post this surgery. With regard to infertility, bariatric surgery should not be performed with the intention of treating infertility; however, fertility may improve with rapid postoperative weight loss.
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OBJECTIVE- To prospectively examine the effect of weight loss 1 year after laparoscopic adjustable gastric band surgery on a broad range of health outcomes in 50 diabetic subjects. RESEARCH DESIGN AND METHODS- A total of 50 (17 men, 33 women) of 51 patients with type 2 diabetes, from a total of 500 consecutive patients, were studied preoperatively and again 1 year after surgery. RESULTS - Preoperative weight and BMI (means +/- SD) were 137 +/- 30 kg and 48.2 +/- 8 kg/m(2), respectively; at 1 year, weight and BMI were 110 +/- 24 kg and 38.7 +/- 6 kg/m(2), respectively. There was significant improvement in all measures of glucose metabolism. Remission of diabetes occurred in 32 patients (64%), and major improvement of glucose control occurred in 13 patients (26%); glucose metabolism was unchanged in 5 patients (10%). HbA, was 7.8 +/- 3.2% preoperatively and 6.2 +/- 2.7% at 1 year (P < 0.001). Remission of diabetes was predicted by greater weight loss and a shorter history of diabetes (pseudo r(2) = 0.44, P < 0.001). Improvement in diabetes was related to increased insulin sensitivity and beta-cell function. Weight loss was associated with significant improvements in fasting triglyceride level, HDL cholesterol level, hypertension, sleep, depression, appearance evaluation, and health-related quality of life. Early complications occurred in 6% of patients (wound infections in 4%, respiratory support in 2%), and late complications occurred in 30% of patients (gastric prolapse in 20%, band erosion in 6%, and tubing leaks in 4%). All late complications were successfully revised surgically. CONCLUSIONS- Modem laparoscopic weight-loss surgery is effective in managing the broad range of health problems experienced by severely obese individuals with type 2 diabetes. Surgery should be considered as an early intervention.
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To determine whether prophylactic oral iron supplements (320 mg twice daily) would protect women from iron deficiency and anemia after Roux-en-Y gastric bypass. Prospective, double-blind, randomized study in which 29 patients received oral iron and 27 patients received a placebo beginning 1 month after Roux-en-Y gastric bypass. Tertiary care medical center. Complete blood cell count and serum levels of iron, total iron binding capacity, ferritin, vitamin B12, and folate were determined preoperatively and at 6-month intervals postoperatively in 56 menstruating women who had Roux-en-Y gastric bypass. Incidence of iron deficiency and other hematological abnormalities in each treatment group. Hemoglobin, hematocrit, and vitamin B12 levels were significantly decreased compared with preoperative values in both groups. Conversely, folate levels increased significantly over time in both groups. Oral iron consistently prevented development of iron deficiency in the iron group. Ferritin levels did not change significantly in the iron group. However, in placebo-treated patients, ferritin levels 2 years postoperatively were significantly decreased compared with preoperative levels. There was no difference in the incidence of anemia between the 2 groups. However, the incidence of microcytosis was substantially greater (P=.07) in placebo-treated than iron-treated patients. Prophylactic oral iron supplements successfully prevented iron deficiency in menstruating women after Roux-en-Y gastric bypass but did not consistently protect these women from developing anemia. On the basis of these results we now routinely recommend prophylactic iron supplements to menstruating women who have Roux-en-Y gastric bypass.
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It has been proposed that environmental chemicalization is responsible for the recent decline in male ratio, but these speculations are based on statistics going back only a few decades. The objective of this study was to evaluate whether Finnish long-term data are compatible with the hypothesis that the decrease in the ratio of male to female births in industrial countries is caused by environmental factors. We analyzed the sex ratio of births from the files of Statistics Finland and all live births in Finland from 1751 to 1997. Running averages of 9 years (1751-1904) or 5 years (1905-1997) were analyzed for sex ratios. Additionally, to identify potential explanations for the findings, births from 1990 to 1997 were correlated with various family parameters. We found an increase in the proportion of males from 1751 to 1920; this was followed by a decrease and interrupted by peaks in births of males during and after World War I and World War II. None of the family parameters (paternal age, maternal age, age difference of parents, birth order) could explain the time trends. The turning point of male proportion precedes the period of industrialization or the introduction of pesticides or hormonal drugs, rendering a causal association unlikely. Moreover the trends are similar to those observed in other countries with worse pollution and much greater pesticide use. Images Figure 1 Figure 2 Figure 3
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Severely obese women have higher obstetric risks and poorer neonatal outcomes. Weight loss reduces obstetric risk. The introduction of a laparoscopically-placed adjustable gastric band, a safe and effective method of weight loss, has given us the ability and responsibility to adjust the band in relation to pregnancy. Our aim was to devise a safe management plan to achieve healthy maternal weight gain (Institute of Medicine 1990) during pregnancy. In a cohort group of 650 patients to have a Lap-Band placement for severe obesity, we have reviewed the management of the band and pregnancy outcomes of all women (n=20) to complete a pregnancy (n=22) with a band in-situ. All 22 pregnancies were singleton, with no primary caesarean sections (3 for recurring indications). The mean maternal weight gain was 8.3 kg compared with 15.2 kg for the 15 previous pregnancies of women in this group (p<0.05). There was no difference in birth weights. Obstetric complications were minimal, and there were no premature or low birth weight infants. 11 of 15 subjects with active management of the band achieved a maternal weight gain within the advised range compared with only 2 of 7 prior to this. The ability to adjust gastric restriction allows optimal control of maternal weight change in pregnancy and should help avoid the risks of excessive weight change.
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To investigate homocysteine levels and their relationship with serum folate and vitamin B12 concentrations with weight loss after the Lap-Band form of gastric restrictive surgery, with the view to minimizing risk. We measured levels of fasting plasma homocysteine (tHcy), folate (serum and RBC) and vitamin B12 in two groups. The study group was 293 consecutive patients at 12 (n=192) or 24 (n=101) months review after surgery. The controls were 244 consecutive patients presenting for this surgery. The group losing weight had higher geometric mean tHcy levels: 10.4 (95% CI, 9.8-10.8) micromol/l compared with 9.2 (95% CI, 8.9-9.7) in controls (P<0.001). This occurred with higher folate levels and unchanged vitamin B12 levels. Levels of folate and B12 together explained 35% (r (2)) of the homocysteine variance in the weight loss group compared with only 9% (r (2)) in controls (P<0.001). Those taking regular multivitamin supplements had lower tHcy levels: 9.6 (9.1-10.0) micromol/l vs 12.3 (11.4-13.3) in those not taking supplements (P<0.001). A low normal plateau of tHcy levels occurred at levels of folate >15 ng/l and B12)600 ng/ml. A curvilinear relationship exists between these cofactors and tHcy levels, with the dose-response relationship shifted to the right in the weight loss group. This study shows elevated tHcy levels with weight loss, without lower serum folate or vitamin B(12) levels. There is an altered dose-response relationship with higher serum B(12) and folate levels required to maintain recommended tHcy levels. Patients losing weight have significant health benefits; however, they may be at greater risk of vascular events or fetal abnormality in association with raised tHcy levels. Multivitamin supplementation is effective in lowering tHcy levels.
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Obesity is now one of our major public health problems. Effective and acceptable treatment options are needed. The Lap-Band system is placed laparoscopically and allows adjustment of the level of gastric restriction. A prospective study of 709 severely obese patients was conducted over a 6-year period at a university-based multidisciplinary referral center. After extensive preoperative evaluation, patients with a body mass index > 35 were treated by Lap-Band placement. Close follow-up with progressive adjustment of gastric restriction continued permanently. Medical co-morbidities were monitored as part of comprehensive prospective data collection. There have been no deaths perioperatively or during follow-up. Significant perioperative adverse events occurred in 1.2% only. Reoperation has been needed for prolapse (slippage) in 12.5%, erosion of the band into the stomach in 2.8% and for tubing breaks in 3.6%. A steady progression of weight loss has occurred through the duration of the study with 52 +/- 19% EWL at 24 months (n = 333), 53 +/- 22% EWL at 36 months (n = 264), 52 +/- 24% EWL at 48 months (n = 108), 54 +/- 24% EWL at 60 months (n = 30), and 57 +/- 15% EWL at 72 months (n = 10). Major improvements have occurred in diabetes, asthma, gastroesophageal reflux, dyslipidemia, sleep apnea and depression. Quality of life as measured by Rand SF-36 shows highly significant improvement. Placement of the Lap-Band system provides safe and effective control of severe obesity. The effect on weight loss is durable and is associated with major improvement in health and quality of life. It has the potential to provide a broadly acceptable option for this common and serious disease.
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The sustainability of surgically induced weight loss implies that energy homeostasis is favorably altered. We investigated the hypothesis that laparoscopic adjustable gastric banding (LAGB) induces prolonged satiety and that plasma ghrelin is involved. Seventeen weight-stable subjects who had achieved LAGB-induced weight loss attended blind crossover breakfast tests, one with optimal band restriction and one with reduced restriction. Standardized meals were consumed (0900 h) after 14-h fasting. Satiety visual analog scales were completed hourly (0700-1100 h) before and after feeding. Blood glucose, plasma insulin, ghrelin, and leptin levels were measured. Seventeen body mass index-matched controls were tested. Optimal restriction was associated with significantly greater fasting and postprandial satiety levels than reduced restriction (P < 0.01). Glucose, insulin, ghrelin, and leptin levels did not alter between optimal and reduced restriction. LAGB subjects displayed higher ghrelin (+12%, P = 0.13) and lower glucose (-17%, P = 0.018), insulin (-33%, P = 0.016), and leptin (-32%, P = 0.05) 4-h area under the curve levels than controls. Optimal LAGB restriction increased fasting and postprandial satiety levels. This supports the hypothesis that LAGB provides prolonged satiety, present even during fasting, favorably influencing energy homeostasis. Plasma insulin, leptin, and ghrelin appeared unrelated to the satiety effect and displayed orexigenic compensatory changes. Identifying the mechanisms underlying LAGB-induced satiety may assist the understanding of human energy homeostasis and obesity.
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Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in health-related outcomes. To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity. MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews. Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity. Information about study design, procedure, population, comorbid conditions, and adverse events. The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/m2 or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/m2, data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach. Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible. Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m2 or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications.
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As the prevalence of obesity increases in the United States, concern over the association of body weight with excess mortality has also increased. To estimate deaths associated with underweight (body mass index [BMI] <18.5), overweight (BMI 25 to <30), and obesity (BMI > or =30) in the United States in 2000. We estimated relative risks of mortality associated with different levels of BMI (calculated as weight in kilograms divided by the square of height in meters) from the nationally representative National Health and Nutrition Examination Survey (NHANES) I (1971-1975) and NHANES II (1976-1980), with follow-up through 1992, and from NHANES III (1988-1994), with follow-up through 2000. These relative risks were applied to the distribution of BMI and other covariates from NHANES 1999-2002 to estimate attributable fractions and number of excess deaths, adjusted for confounding factors and for effect modification by age. Number of excess deaths in 2000 associated with given BMI levels. Relative to the normal weight category (BMI 18.5 to <25), obesity (BMI > or =30) was associated with 111,909 excess deaths (95% confidence interval [CI], 53,754-170,064) and underweight with 33,746 excess deaths (95% CI, 15,726-51,766). Overweight was not associated with excess mortality (-86,094 deaths; 95% CI, -161,223 to -10,966). The relative risks of mortality associated with obesity were lower in NHANES II and NHANES III than in NHANES I. Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category. The impact of obesity on mortality may have decreased over time, perhaps because of improvements in public health and medical care. These findings are consistent with the increases in life expectancy in the United States and the declining mortality rates from ischemic heart disease.
Article
Background: 239 pregnancies occurred in 1136 women who had undergone biliopancreatic diversion (BPD). Methods: There were 73 abortions, and 14 pregnancies are presently in their course. The 152 term pregnancies (six twins) occurred in 129 women 2-173 months (mean 42.7) after BPD. Mean age and current excess weight were 31.4 years (20-42) and 29.1% (-6.9-78.2), and mean excess weight loss was 72.9% (30.4-110.5). Results: Mean weight gain during pregnancy was 6.2 kg (-21-25). In 32 patients (21%), parenteral nutritional support was needed. In all the other patients (79%), the usual supplementations were given. Of the newborns, 122 were delivered at term (84.7%) with a mean weight of 2842.4 g (1760-4600 g) and a mean length of 48.5 cm (43-59 cm), while the 22 preterm babies (15.3%) weighed 2151.1 g (1400-3850 g) and had a length of 44.6 cm (33-56 cm). Forty infants (27.8%) were small for gestational age but 17 of them weighed more than 2500 g. Eleven twins (one abortion at 26th week) were also delivered, with a mean weight of 2088.6 g (1200-3100 g) and a mean length of 45.6 cm (35-50 cm). Delivery was spontaneous in 85 instances (56%), while vacuum extractor was used in one, and 66 cesarean sections were performed. There were two birth malformations, one infant died after surgery for meconium obstruction and two died from unknown causes. Of the 129 women, 35 had been infertile before BPD. Conclusions: Disappearance of infertility and decrease of pregnancy risk are to be considered among the beneficial effects of weight reduction following BPD.
Article
Objective: To evaluate the relationship between the time elapsed from the administration of ampicillin prophylaxis to delivery and its efficacy in interrupting intrapartum transmission of group B streptococcus. Methods: During the 12-month study period, all women who came to the Virgen de las Nieves Hospital (Granada, Spain) for delivery were screened for group B streptococcus vaginal carriage by a pigment-detection culture-based procedure. Colonized women were treated with ampicillin (2 g intravenously), and the interval between ampicillin administration and delivery was recorded. Newborns from colonized mothers also were screened to detect group B streptococcus colonization. Results: During the study period, 4525 women were admitted to the hospital for delivery and screened for group B streptococcus vaginal colonization. Group B streptococcus was detected in 543 women (12%), of whom 454 gave birth vaginally to 454 liveborn infants. Intrapartum ampicillin was given to 201 of these 454 women (44%), and 10% of the newborns from mothers who received intrapartum ampicillin prophylaxis were colonized by group B streptococcus. The relationship between timing of ampicillin administration and rate of neonatal group B streptococcal transmission was as follows: less than 1 hour before delivery, 46%; 1-2 hours, 29%; 2-4 hours, 2.9%; and more than 4 hours, 1.2%. Among the 253 mothers who received no intrapartum prophylaxis, colonization was found in 120 of their newborns (47%). Conclusion: When the time between the start of ampicillin prophylaxis and delivery is at least 2 hours, vertical transmission of group B streptococcus is minimized. (C) 1998 The American College of Obstetricians and Gynecologists
Article
Objective Severe obesity can be associated with evidence of androgen excess and insulin resistance, which are features of the metabolic and polycystic ovary syndromes (PCOS). In this study, we examined the association between clinical and biochemical features of these syndromes and assess changes with weight loss. Design A consecutive series of 107 severely obese premenopausal women presenting for obesity surgery. Measurements Pre-operative assessment included details of clinical comorbidity, anthropometric measures and biochemical measures, including fasting insulin, glucose, lipid profile and sex hormone analysis. Changes in these measures for 42 of 52 (81%) patients at 1 year post surgery are reported. Results Neck circumference and younger age were independent predictors of higher free androgen index (FAI) (combined r2 = 0·36). If neck circumference is not included, then younger age, higher body mass index and raised fasting insulin levels were all independent predictors of FAI (r2 = 0·29). Waist to hip ratio showed no predictive value (r = 0·14). Neck circumference was also a good clinical predictor of menstrual irregularity, hirsutism, infertility, insulin resistance and the PCOS. Neck circumference of less than 39, 39–42 and greater than 42 cm reflect a low, intermediate and high risk of the metabolic and PCOS syndromes in obese premenopausal women. For 42 patients who were followed for 1 year after surgery, the weight loss was associated with reduction of FAI, less insulin resistance and improved menstrual regularity and resolution of the PCOS in 11 of 12 cases. Conclusions Neck circumference is a good predictive measure of hyperinsulinaemia and raised androgens in obese premenopausal women. Weight loss following surgery improves ovarian function and vasculopathic risk.
Article
Twenty-one pregnancies (19 patients) were studied, noting the effects of previous jejunoileal bypass on perinatal sequelae. A larger percentage of SGA infants (20%) were delivered to mothers after bypass surgery. Low birthweight appears to be related to maternal hypoalbuminemia. Twelve of thirteen (92%) infants born to multiparous patients after surgery had term birthweights less than any previous term infant's birthweight prior to the procedure. Postponement of pregnancy after ileal shunt until all metabolic parameters have returned to normal (up to 36 months) is advised.
Article
Gestational diabetes mellitus (GDM) was diagnosed in 1928 of 35,253 (5.5%) tested pregnancies at the Mercy Maternity Hospital in Melbourne between 1979 and the end of 1988. Compared with women born in Australia and New Zealand, the incidence of GDM was significantly greater in women born on the Indian subcontinent (15%); in women born in Africa (9.4%), Vietnam (7.3%), Mediterranean countries (7.3%), and Egypt and Arabic countries (7.2%); and in Chinese (13.9%) and other Asian (10.9%) women. There was no significant difference for women born in the United Kingdom and northern Europe (5.2%), Oceania (5.7%), North America (4.0%), or South America (2.2%). With the World Health Organization criteria as a guide to the severity of hyperglycemia, compared with mothers born in Australia and New Zealand, there were significant increases in the incidences of the more severe grades of GDM in parturients born in the Mediterranean region, Asia, the Indian subcontinent, Egypt, and Arabic countries. The incidence of GDM increased significantly in all racial groups, rising from 3.3% during 1979-1983 to 7.5% during 1984-1988.
Article
One hundred forty patients were followed for a mean 24.2 months after gastric bypass. Postop multivitamin (MV) prophylaxis was recommended for all patients and 90 of 140 patients (64 percent) were regularly compliant. Deficiencies in iron, vitamin B-12 or folate were recognized in 88 of 140 patients (63 percent). Thirty of 45 patients (67 percent) with iron deficiency developed anemia. Forty-three of the 52 patients who did not have deficiencies were regularly taking MV vs 47 of 88 patients who developed deficiencies (P less than 0.001). MV prophylaxis was successful in preventing folate (P less than or equal to 0.05) and vitamin B-12 deficiencies (P less than or equal to 0.02) but did not prevent development of iron deficiency or subsequent anemia. There was no correlation between taking prescribed supplements and resolution of either iron deficiency of anemia. B-12 and folate supplements corrected deficiencies in 73 percent of cases. We conclude that oral MV prophylaxis is useful in preventing folate and B-12 deficiency after gastric bypass. Additional prophylactic iron supplements should be provided for women to prevent iron deficiency and associated anemia.
Article
Current recommendations for appropriate weight gain in pregnancy suggest an optimum of 120% of ideal body weight (IBW) at delivery. This represents an increase of approximately 24 pounds in the normal weight woman and even the obese patient (more than 135% IBW) is told to gain 16 pounds. Information concerning gestational weight gain in the morbidly obese woman (more than 160% IBW) has not been reported. We evaluated 40 morbidly obese pregnant women for maternal morbidity relative to gestational weight gain. No correlation was found between maternal weight gain and the development of gestational diabetes, pregnancy-induced hypertension, preeclampsia, preterm labor, premature rupture of membranes, incompetent cervix, or intrauterine growth retardation. The incidence of primary cesarean delivery was statistically greater in those women gaining more than 24 pounds (p less than 0.05). It appears that current recommendations for gestational weight gain in the morbidly obese are excessive and may result in increased maternal risk.
Article
A clinical study was undertaken to assess gynecologic-obstetric changes in morbidly obese women who lost greater than or equal to 50% of their excess weight with bariatric surgery. The 138 females (109 of reproductive age), age 35 +/- 9 SD yr, weighed 124 +/- 23 kg before surgery and 79 +/- 13 kg after weight loss had stabilized. Menstrual irregularities were present in 40.4% of premenopausal patients preoperatively; after massive weight loss, cycles were abnormal in 4.6% (p less than 0.001). Infertility problems were present preoperatively in 29.3% Of these, nine tried to conceive after weight loss and were successful. During past pregnancies, medical complications were frequent (hypertension 26.7%, pre-eclampsia 12.8%, diabetes 7.0%, and deep vein thrombosis 7.0%). After weight-loss stabilization, these obstetric complications did not occur. Incidence of urinary stress incontinence decreased from 61.2% to 11.6% (p less than 0.001). Gynecologic-obstetric changes tended to normalize after loss of massive body weight.
Article
With the aid of the national Medical Birth Registries and Discharge Registries in Denmark and Sweden it was possible to identify and study delivery outcome in 77 women who, prior to pregnancy, had undergone an intestinal bypass operation for obesity. Analysis of birth weight and pregnancy length distribution showed that infants borne by these women had an increased rate of low birth weight, short gestation, and also growth retardation. There were no distinct differences between those infants that were conceived less than 24 months or more than 24 months after operation. Only two infants had congenital malformations, none died perinatally.
Article
Of the patients undergoing gastric bypass for treatment of morbid obesity, 75 per cent are female. A common question both pre-and postoperatively concerns the advisability of a pregnancy following surgically-induced weight loss. Of all patients, 45 became pregnant on 54 occasions following gastric bypass and 46 infants were delivered. There were two spontaneous abortions (4.0%) and six early terminations of an undesired pregnancy. Seven infants were delivered prematurely. One child was born microcephalic and has developed severe retardation in both growth and development. In contrast to reports of infants born to mothers with jejunoileal bypass, 12 of the babies that were born to mothers after gastric bypass were heavier at birth than older siblings. An additional ten infants were the first born to women who had lost more than 100 pounds following gastric bypass. All but one of the women became pregnant more than six months following surgery. This corresponds to the period of maximum weight loss and reversal of menstrual abnormalities associated with massive obesity. Pregnancies were well tolerated by the mothers, with no excessive increase in weight loss or development of metabolic deficiencies. Since the gastric bypass is modeled on the Billroth II gastrectomy, additional iron supplementation was recommended during the pregnancy. While we cannot recommend pregnancy during the period of rapid weight loss in the initial postoperative period, our data indicate that neither the mother nor the developing fetus is unduly endangered by a pregnancy which develops after the period of rapid postoperative weight loss.
Article
Our purpose was to determine the association between increased gestational weight gain and birth weight outcomes for low-income women. A total of 53,541 single, live infants delivered from 1990 to 1991 to white, black, and Hispanic women in eight states were evaluated. Multiple logistic regression was used to calculate risk of low and high (> 4500 gm) birth weight, adjusting for selected factors. The association between gestational weight gain and birth weight varied by prepregnancy body mass index. Risk for low birth weight decreased with increasing weight gain for average-weight women. There was no reduction in risk for low birth weight, however, beyond weight gains of 30 to 34 pounds for overweight women and 15 to 19 pounds for very-overweight women. Risk for high birth weight, however, increased with increasing weight gain in all three groups. Very-overweight women (body mass index > 29 kg/m2) may benefit from an upper guideline of 25 pounds of weight gain to help reduce risk for high birth weight.
Article
Our purpose was to determine the impact of massive maternal obesity (weight > 300 pounds) on perioperative morbidity among patients undergoing cesarean section. A case-control study was conducted on 43 massively obese pregnant women, identified by perinatal database search, who were delivered by cesarean section between Jan. 1, 1987, and Dec. 31, 1991, at Long Beach Memorial Women's Hospital. Forty-three randomly selected patients who underwent cesarean delivery served as the control group. Medical records were abstracted for perioperative variables and compared between groups. Student t test, chi 2, and Fisher's exact statistical analysis were used where appropriate. No significant differences were observed between groups for maternal age, parity, use of prophylactic antibiotics, length of recovery room stay, or wound dehiscence. The massively obese group was observed to be at significantly increased risk for emergency cesarean section (32.6% vs 9.3%, p = 0.02), prolonged delivery interval (25.6% vs 4.6%, p = 0.01), and total operative time (48.8% vs 9.3%, p < 0.0001), blood loss > 1000 ml (34.9% vs 9.3%, p = 0.009), multiple epidural placement failures (14.0% vs 0%, p = 0.02), postoperative endometritis (32.6% vs 4.9%, p = 0.002), and prolonged hospitalization (34.9% vs 2.3%, p = 0.0003). Massively obese pregnant women undergoing cesarean section are at significantly increased risk for perioperative morbidity.
Article
This study examined the effects of massive maternal obesity on medical complications, mode of delivery, postpartum complications, and hospital confinement. In this retrospective case control study, women weighing > 300 pounds delivering from January 1, 1986, to November 1, 1991, were matched for age, race, parity, and height with lean parturient women (mean weight 160 +/- 21 pounds). Among massively obese women there was a greater incidence of chronic hypertension (p < 0.05) and diabetes (p < 0.05) than in the control group. Primary cesarean section was more frequent (p < 0.05), as was the postoperative complication of endometritis when obese patients were compared with lean women (p < 0.05). Cephalopelvic disproportion was the only indication for primary cesarean section, which occurred with greater frequency in the obese group. The postpartum hospital confinement was also significantly longer in the obese study group (p < 0.05). The gestation of a massively obese parturient woman is more frequently complicated by chronic hypertension and diabetes. Abdominal delivery for cephalopelvic disproportion is more likely, and this mode of birth is more often followed by endometritis, which results in longer hospital stays.
Article
Obesity before pregnancy is associated with an increased risk of several adverse outcomes of pregnancy. The risk profiles among lean, normal, or mildly overweight women are not, however, well established. We studied the associations between prepregnancy body-mass index (defined as the weight in kilograms divided by the square of the height in meters) and the frequency of late fetal death, early neonatal death, preterm delivery, and delivery of a small-for-gestational-age infant in a population-based cohort of 167,750 women in Sweden in 1992 and 1993. The women were categorized as follows, according to body-mass index: lean, less than 20.0; normal, 20.0 through 24.9; overweight, 25.0 through 29.9; and obese, 30.0 or more. The estimates were adjusted for maternal age, parity, smoking, education, whether the mother was living with the father, and maternal height. Among nulliparous women, the odds ratios for late fetal death were increased among women with higher body-mass-index values as compared with lean women, as follows: normal women, 2.2 (95 percent confidence interval, 1.2 to 4.1); overweight women, 3.2 (95 percent confidence interval, 1.6 to 6.2); and obese women, 4.3 (95 percent confidence interval, 2.0 to 9.3). Among parous women, only obese women had a significant increase in the risk of late fetal death (odds ratio, 2.0; 95 percent confidence interval, 1.2 to 3.3). Among nulliparous women, the risk of very preterm delivery (at < or =32 weeks' gestation) was significantly increased among obese as compared with lean women (odds ratio, 1.6; 95 percent confidence interval, 1.1 to 2.3), whereas among parous women, the risk was highest among those who were lean. The risk of delivering a small-for-gestational-age infant decreased more with increasing body-mass index among parous than among nulliparous women. Higher maternal weight before pregnancy increases the risk of late fetal death, although it protects against the delivery of a small-for-gestational-age infant.
Article
To review the literature addressing the effect of obesity on pregnancy outcomes and to identify practice and research implications. Computerized searches in Medline and CINAHL, as well as references cited in articles reviewed. Key words used in the search were as follows: pregnancy and obesity; pregnancy complications; weight gain and pregnancy; weight gain and complications; fat distribution and pregnancy and complications; and obstetrics and obesity. Articles and comprehensive works from indexed journals in the English language relevant to key words and published after 1978 were evaluated. Data were extracted and organized under the following headings: methodologic issues; physiologic adjustments; antepartum, intrapartum, postpartum and newborn outcomes; and cost. Obese pregnant women experience more gestational diabetes, neural tube defects, preeclampsia, induction, primary cesarean, and postpartum infection than pregnant women who are not obese. Pregnant women who are obese are at increased risk for certain complications during pregnancy, birth, and postpartum. Little is known about the effect that fat distribution (upper versus lower, which is influential in nonpregnant populations) has on obstetric complications. Even less is known about obese pregnant women's perceptions of risk, changes in lifestyle, functioning, health behaviors, and symptoms experienced during pregnancy.
Article
Women who suffer from morbid obesity are often infertile. If these women are able to become pregnant, they are considered high risk because of the hypertension, diabetes and other associated risk factors. Following the pregnancy is difficult due to limitations of the physical examinations. More costly ultrasound examinations are needed at a higher frequency. Bariatric surgery reduces the woman's weight and the incidence of obesity related co-morbidities. The number of pregnancies and rate of complications during those pregnancies in our post-bariatirc surgical patients were evaluated. Our group has been doing bariatric surgery since the early 1980s. We have over 2000 active patients on our current newsletter mailing list. The patients also have a series of networks through support groups. The patients are informed to contact us when they become pregnant so we may assist the obstetrician with their care. Through these various means, we have been able to identify 41 women in our patient population who have become pregnant. Using personal interview, questionnaire, and review of perinatal records, pregnancy-related risks and complications were studied. With over a 95% follow-up rate on the patients identified as having been pregnant following surgery, we found less risk of gestational diabetes, macrosomia, and cesarean section than associated with obesity. There were no patients with clinically significant anemia. Since the patients had an operation that restricts their food intake, some basic precautions should be taken when they become pregnant. With this in mind, our patients have done well with their pregnancies. The post-surgical group had fewer pregnancy-related complications than did an internally controlled group that were morbidly obese during their previous pregnancies.
Article
To determine outcomes of pregnancies of obese women who had surgical placement of an adjustable gastric band to treat obesity. We conducted two clinical trials to evaluate adjustable gastric banding that involved 359 obese women of reproductive potential (age 18-51 years), of whom 20 conceived resulting in 23 pregnancies. Specific information about pregnancies and fetal outcomes was collected from medical records and direct patient contact. Eighteen pregnancies were full term, one was an ectopic gestation, two ended in elective abortions, and two in spontaneous abortions unrelated to the womens' medical conditions. Of the 18 full-term pregnancies, 14 delivered vaginally and four by cesarean (one for prolonged fetal bradycardia, two for cephalopelvic disproportion, and one repeat cesarean for twins). The mean birth weight was 3676 g (range 2381-3912 g). Five women lost weight (range 1.8-17.6 kg) during pregnancy without obvious fetal and neonatal effects. Three women had fluid removed from their gastric bands (decreasing the mechanical constriction) to treat nausea and vomiting. Two women who had no fluid in their bands eliminated the effectiveness of the obesity treatment, resulting in excessive weight gain. Morbidly obese women who became pregnant soon after receiving an adjustable gastric band had uncomplicated pregnancies. Adjustment of the gastric band to decrease the amount of mechanical obstruction decreased nausea and vomiting, but led to excessive weight gain in two women when it was done prophylactically. Obese women at risk of pregnancy should be counseled that it might occur unexpectedly after weight loss from gastric banding unless birth control is promptly instituted.
Article
We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.
Article
Following its introduction in 1993, the LAP-BAND (INAMED Health, Santa Barbara, CA) has been used extensively across the world for the treatment of obesity, and data on safety and effectiveness are now available. This review draws on the literature and our own clinical patient base to provide an overview of the early and late problems associated with LAP-BAND placement and its effects on weight loss. It has proved to be a remarkably safe procedure. A report analyzing international data on laparoscopic adjustable gastric bands identified 3 deaths in 5,827 patients (approximately 1 in 2,000). In our series of 1,120 patients, there have been no deaths and no life-threatening perioperative complications. Significant early complications occurred in 17 (1.5%) of our patients; late problems have been more common, particularly during our early experience. Prolapse of the stomach through the band occurred in 125 (25%) of our first 500 patients but has occurred in only 28 (4.7%) of our last 600 patients. Erosion of the band into the stomach occurred in 34 patients (3%); all occurred in the first 500 patients. No erosions have occurred in the last 600 patients. Both problems are treated laparoscopically by removal and replacement. Combined international data show that weight loss after LAP-BAND placement is characterized by steady progressive weight loss over a 2- to 3-year period, followed by stable weight out to 6 years. This pattern reflects the benefit of adjustability. For the international series, the percent excess weight loss (%EWL) at 2 years has been between 52% and 65%. In our series, %EWL at 5 years and 6 years was 54% and 57%, respectively. The LAP-BAND is proving to be extremely safe, able to facilitate good weight loss, and able to maintain weight loss over time.
Article
To evaluate whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcomes. In a prospective population-based cohort study, 3,480 women with morbid obesity, defined as a body mass index (BMI) more than 40, and 12,698 women with a BMI between 35.1 and 40 were compared with normal-weight women (BMI 19.8-26). The perinatal outcome of singletons born to women without insulin-dependent diabetes mellitus was evaluated after suitable adjustments. In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal-weight mothers, there was an increased risk of the following outcomes (adjusted odds ratio; 95% confidence interval): preeclampsia (4.82; 4.04, 5.74), antepartum stillbirth (2.79; 1.94, 4.02), cesarean delivery (2.69; 2.49, 2.90), instrumental delivery (1.34; 1.16, 1.56), shoulder dystocia (3.14; 1.86, 5.31), meconium aspiration (2.85; 1.60, 5.07), fetal distress (2.52; 2.12, 2.99), early neonatal death (3.41; 2.07, 5.63), and large-for-gestational age (3.82; 3.50, 4.16). The associations were similar for women with BMIs between 35.1 and 40 but to a lesser degree. Maternal morbid obesity in early pregnancy is strongly associated with a number of pregnancy complications and perinatal conditions. II-2
Article
Severe obesity has deleterious effects on fertility and pregnancy outcomes. Although surgery is the best long-term treatment for severe obesity, there is a risk of gestational undernutrition in operated mothers because bariatric surgery reduces nutrient availability. This is a follow-up report of our initial findings regarding pregnancy and neonatal outcomes in biliopancreatic diversion (BPD) patients, with addition of a new cohort of children born to mothers after BPD. All women (n = 916) who had successfully undergone BPD in our hospital were mailed a questionnaire containing multiple-choice and essay questions concerning gynecologic and obstetric history, and pregnancy and neonatal outcomes in both preoperative and postoperative pregnancies. Patients operated between 1984 and 1995 (n = 568) were mailed an additional questionnaire regarding children's weight and height progress, and school performance. Perinatal records from our patients' obstetric clinics were also reviewed. The questionnaire was completed by 783 women (85.5%). 251 postoperative pregnancies in 132 women resulted in 166 infants by 109 mothers. 47.0% of patients who were unable to become pregnant preoperatively were successful postoperatively. 90 out of 109 women (82.6%) reported an appropriate weight gain (9.1 +/- 5.9 kg) during postoperative pregnancies. The incidence of fetal macrosomia decreased from 34.8 to 7.7%, with a concomitant increase in normal-weight babies from 62.1 to 82.7%. The elevated miscarriage rate (26.0%) in these obese women persisted after surgery. Major weight loss following BPD improves the reproductive function of severely obese women. BPD provides major beneficial effects for both mother and child, including normalization of gestational weight changes, reduction of fetal macrosomia, and normalization of the infant's birth-weight. Our results speak in favor of delaying pregnancy in obese women until after the substantial surgical weight loss has occurred.
Article
There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 2002-2003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy--the only effective treatment currently available.
Article
Laparoscopic adjustable gastric banding (LAGB) is increasingly recommended to women of reproductive age. For continued use, LAGB needs to be proven to be safe and well-tolerated during pregnancy. Maternal obesity is a well-recognized risk factor for gestational diabetes, maternal hypertension and is more likely to result in instrumental delivery or caesarean section. Weight control with the LAGB may reduce the incidence of these complications. An observational study was conducted of the LAGB in pregnancy, including a study comparing outcomes of LAGB pregnancies with previous non-LAGB pregnancies. Women who had had successful LAGB pregnancies were identified from a computerized database. A telephone questionnaire was used to collect the additional outcome data needed and was administered by an independent medical practitioner. 49 LAGB and 31 previous non-LAGB pregnancies were included. 2 LAGBs (4%) required removal during pregnancy. Mean maternal weight gain was significantly reduced in the LAGB group, 3.7 kg vs 15.6 kg (P <0.0001), with no effect on fetal weight, 3.31 vs 3.53 kg, or neonatal complications, 4% and 3%. The incidence of gestational diabetes, 8 and 27% (P =0.048), and hypertension, 8 and 22.5% (P =0.06) was significantly reduced in the LAGB group. The overall complication rate during pregnancy for LAGB was 20.4% and 52% for non-LAGB (P =0.0037) LAGB is safe and well-tolerated during pregnancy with a lower incidence of gestational diabetes and maternal hypertension. LAGB can be safely recommended to morbidly obese women of childbearing age.
  • Perlow
  • Barker