Fertility, Pregnancy and Lactation After Bariatric Surgery – a Consensus Statement from the OEGGG

Abstract

Bariatric surgery is recommended when other weight loss interventions, such as lifestyle modification or medications, have failed. A considerable number of women undergoing bariatric surgery are of childbearing age; hence, it is necessary to be aware of the effects of bariatric surgery on pregnancy for managing these patients. Although bariatric surgery is associated with positive effects on cardiovascular and metabolic parameters, side effects such as anaemia, the risk of developing internal hernia, altered glucose metabolism and the risk of small for gestational age offspring have to be considered. Pregnant women with a history of gastric bypass should not undergo the oral glucose tolerance test (OGTT) due to the high risk of hypoglycaemia. There are no contraindications for vaginal delivery and breastfeeding. This paper has been published as a consensus statement by the Austrian Society of Gynaecology and Obstetrics (OEGGG).

Key words

bariatric surgery - pregnancy - dumping syndrome - foetal growth restriction - glucose metabolism

^* contributed equally

• References/Literatur

• 1 Statistik Austria. BMI (Body Mass Index). Online: https://www.statistik.at/web_de/statistiken/menschen_und_gesellschaft/gesundheit/gesundheitsdeterminanten/bmi_body_mass_index/105608.html last access: 07.03.2018
• 2 Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ 2017; 356: j1
• 3 Marchi J, Berg M, Dencker A. et al. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev 2015; 16: 621-638
• 4 Best D, Avenell A, Bhattacharya S. How effective are weight-loss interventions for improving fertility in women and men who are overweight or obese? A systematic review and meta-analysis of the evidence. Hum Reprod Update 2017; 23: 681-705
• 5 Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 2009; 15: 189-201
• 6 Colquitt JL, Pickett K, Loveman E. et al. Surgery for weight loss in adults. Cochrane Database Syst Rev 2014; (08) CD003641
• 7 Fried M, Yumuk V, Oppert JM. et al. Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery. Obes Surg 2014; 24: 42-55
• 8 Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie. S3-Leitlinie: Chirurgie der Adipositas und metabolischer Erkrankungen. Online: https://www.awmf.org/leitlinien/detail/ll/088-001.html last access: 29.08.2018
• 9 Vest AR, Heneghan HM, Agarwal S. et al. Bariatric surgery and cardiovascular outcomes: a systematic review. Heart 2012; 98: 1763-1777
• 10 Schauer PR, Nor Hanipah Z, Rubino F. Metabolic surgery for treating type 2 diabetes mellitus: Now supported by the worldʼs leading diabetes organizations. Cleve Clin J Med 2017; 84 (7 Suppl. 1): S47-S56
• 11 Galazis N, Docheva N, Simillis C. et al. Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2014; 181: 45-53
• 12 Vannevel V, Jans G, Bialecka M. et al. Internal Herniation in Pregnancy After Gastric Bypass: A Systematic Review. Obstet Gynecol 2016; 127: 1013-1020
• 13 Feichtinger M, Stopp T, Hofmann S. et al. Altered glucose profiles and risk for hypoglycaemia during oral glucose tolerance testing in pregnancies after gastric bypass surgery. Diabetologia 2017; 60: 153-157
• 14 Chevrot A, Kayem G, Coupaye M. et al. Impact of bariatric surgery on fetal growth restriction: experience of a perinatal and bariatric surgery center. Am J Obstet Gynecol 2016; 214: 655.e1-655.e7
• 15 Gougeon A. Regulation of ovarian follicular development in primates: facts and hypotheses. Endocr Rev 1996; 17: 121-155
• 16 Nestler JE. Metformin for the Treatment of the Polycystic Ovary Syndrome. N Engl J Med 2008; 358: 47-54
• 17 Provost MP, Acharya KS, Acharya CR. et al. Pregnancy outcomes decline with increasing body mass index: analysis of 239,127 fresh autologous in vitro fertilization cycles from the 2008–2010 Society for Assisted Reproductive Technology registry. Fertil Steril 2016; 105: 663-669
• 18 Escobar-Morreale HF, Santacruz E, Luque-Ramírez M. et al. Prevalence of ‘obesity-associated gonadal dysfunction’ in severely obese men and women and its resolution after bariatric surgery: a systematic review and meta-analysis. Hum Reprod Update 2017; 23: 390-408
• 19 Milone M, De Placido G, Musella M. et al. Incidence of Successful Pregnancy After Weight Loss Interventions in Infertile Women: a Systematic Review and Meta-Analysis of the Literature. Obes Surg 2016; 26: 443-451
• 20 Milone M, Sosa Fernandez LM, Sosa Fernandez LV. et al. Does Bariatric Surgery Improve Assisted Reproductive Technology Outcomes in Obese Infertile Women?. Obes Surg 2017; 27: 2106-2112
• 21 Yska JP, van der Linde S, Tapper VV. et al. Influence of Bariatric Surgery on the Use and Pharmacokinetics of Some Major Drug Classes. Obes Surg 2013; 23: 819-825
• 22 Willis K, Alexander C, Sheiner E. Bariatric Surgery and the Pregnancy Complicated by Gestational Diabetes. Curr Diab Rep 2016; 16: 21
• 23 Adam S, Ammori B, Soran H. et al. Pregnancy after bariatric surgery: screening for gestational diabetes. BMJ 2017; 356: j533
• 24 Bonis C, Lorenzini F, Bertrand M. et al. Glucose Profiles in Pregnant Women After a Gastric Bypass: Findings from Continuous Glucose Monitoring. Obes Surg 2016; 26: 2150-2155
• 25 Narayanan RP, Syed AA. Pregnancy Following Bariatric Surgery – Medical Complications and Management. Obes Surg 2016; 26: 2523-2529
• 26 Rariy CM, Rometo D, Korytkowski M. Post-Gastric Bypass Hypoglycemia. Curr Diab Rep 2016; 16: 19
• 27 Devlieger R, Guelinckx I, Jans G. et al. Micronutrient levels and supplement intake in pregnancy after bariatric surgery: a prospective cohort study. PLoS One 2014; 9: e114192
• 28 Nomura RMY, Dias MCG, Igai AMK. et al. Anemia During Pregnancy after Silastic Ring Roux-en-Y Gastric Bypass: Influence of Time to Conception. Obes Surg 2011; 21: 479-484
• 29 Jans G, Matthys C, Bogaerts A. et al. Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review. Adv Nutr 2015; 6: 420-429
• 30 Kaska L, Kobiela J, Abacjew-Chmylko A. et al. Nutrition and Pregnancy after Bariatric Surgery. ISRN Obes 2013; 2013: 492060
• 31 Beard JH, Bell RL, Duffy AJ. Reproductive Considerations and Pregnancy after Bariatric Surgery: Current Evidence and Recommendations. Obes Surg 2008; 18: 1023-1027
• 32 Busetto L, Dicker D, Azran C. et al. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obes Facts 2018; 10: 597-632
• 33 American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol 2009; 113: 1405-1413
• 34 Weng TC, Chang CH, Dong YH. et al. Anaemia and related nutrient deficiencies after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis. BMJ Open 2015; 5: e006964
• 35 Fish E, Beverstein G, Olson D. et al. Vitamin D Status of Morbidly Obese Bariatric Surgery Patients. J Surg Res 2010; 164: 198-202
• 36 Wei JH, Lee WJ, Chong K. et al. High Incidence of Secondary Hyperparathyroidism in Bariatric Patients: Comparing Different Procedures. Obes Surg 2018; 28: 798-804
• 37 Chakhtoura MT, Nakhoul NN, Shawwa K. et al. Hypovitaminosis D in bariatric surgery: A systematic review of observational studies. Metabolism 2016; 65: 574-585
• 38 Zhang Q, Chen Y, Li J. et al. A meta-analysis of the effects of bariatric surgery on fracture risk. Obes Rev 2018; 19: 728-736
• 39 Mechanick JI, Youdim A, Jones DB. et al. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013; 9: 159-191
• 40 Gascoin G, Gerard M, Sallé A. et al. Risk of low birth weight and micronutrient deficiencies in neonates from mothers after gastric bypass: a case control study. Surg Obes Relat Dis 2017; 13: 1384-1391
• 41 Mbah A, Kornosky J, Kristensen S. et al. Super-obesity and risk for early and late pre-eclampsia. BJOG 2010; 117: 997-1004
• 42 Spradley FT, Palei AC, Granger JP. Increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms. Am J Physiol Regul Integr Comp Physiol 2015; 309: R1326-R1343
• 43 Spradley FT. Metabolic abnormalities and obesityʼs impact on the risk for developing preeclampsia. Am J Physiol Regul Integr Comp Physiol 2017; 312: R5-R12
• 44 World Health Organization. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. 2011. Online: http://whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf last access: 17.10.2017
• 45 Bennett WL, Gilson MM, Jamshidi R. et al. Impact of bariatric surgery on hypertensive disorders in pregnancy: retrospective analysis of insurance claims data. BMJ 2010; 340: c1662
• 46 Maggard MA, Yermilov I, Li Z. et al. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300: 2286-2296
• 47 Magdaleno R, Pereira BG, Chaim EA. et al. Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges. Arch Gynecol Obstet 2012; 285: 559-566
• 48 Vrebosch L, Bel S, Vansant G. et al. Maternal and Neonatal Outcome After Laparoscopic Adjustable Gastric Banding: a Systematic Review. Obes Surg 2012; 22: 1568-1579
• 49 Sheiner E, Willis K, Yogev Y. Bariatric Surgery: Impact on Pregnancy Outcomes. Curr Diab Rep 2013; 13: 19-26
• 50 González I, Lecube A, Rubio MÁ. et al. Pregnancy after bariatric surgery: improving outcomes for mother and child. Int J Womens Health 2016; 8: 721-729
• 51 Yi X, Li Q, Zhang J. et al. A meta-analysis of maternal and fetal outcomes of pregnancy after bariatric surgery. Int J Gynaecol Obstet 2015; 130: 3-9
• 52 Johansson K, Cnattingius S, Näslund I. et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015; 372: 814-824
• 53 Fernandez-Twinn DS, Ozanne SE. Mechanisms by which poor early growth programs type-2 diabetes, obesity and the metabolic syndrome. Physiol Behav 2006; 88: 234-243
• 54 Levy-Marchal C, Jaquet D. Long-term metabolic consequences of being born small for gestational age. Pediatr Diabetes 2004; 5: 147-153
• 55 Stephansson O, Johansson K, Näslund I. et al. Bariatric Surgery and Preterm Birth. N Engl J Med 2016; 375: 805-806
• 56 Kjær MM, Nilas L. Timing of pregnancy after gastric bypass – a national register-based cohort study. Obes Surg 2013; 23: 1281-1285
• 57 Leal-González R, De la Garza-Ramos R, Guajardo-Pérez H. et al. Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature. Int J Surg Case Rep 2013; 4: 44-47
• 58 Gudbrand C, Andreasen LA, Boilesen AE. Internal Hernia in Pregnant Women After Gastric Bypass: a Retrospective Register-Based Cohort Study. Obes Surg 2015; 25: 2257-2262
• 59 Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for morbid obesity. N Engl J Med 2004; 351: 721-722
• 60 Jans G, Devlieger R, De Preter V. et al. Bariatric Surgery Does Not Appear to Affect Womenʼs Breast-Milk Composition. J Nutr 2018; 148: 1096-1102