Finally, a little more guidance about pregnancy after weight loss surgery.
Source: Medscape from ACOG
The American College of Obstetricians and Gynecologists (ACOG) has
issued a practice bulletin to summarize the risks for obesity in
pregnancy and outcomes of pregnancy after bariatric surgery as well as
to provide recommendations for management during pregnancy and delivery
after bariatric surgery. The new guidelines are published in the June
issue of Obstetrics & Gynecology.
"Obesity is associated with reduced fertility primarily as a result
of oligo-ovulation and anovulation," write Michelle A. Kominiarek, MD,
and colleagues from the ACOG. "The increased risks for gestational
diabetes, preeclampsia, cesarean delivery, and infectious morbidity
associated with obesity are well established....Obese patients are more
likely to be admitted earlier in labor, need labor induction, require
more oxytocin, and have longer labor."
To identify pertinent articles published in the English language
between January 1975 and November 2008, the guidelines authors searched
the MEDLINE database, the Cochrane Library, and ACOG's own internal
resources and documents. The reviewers gave priority to articles
reporting findings from original research and also consulted review
articles and commentaries, but they did not consider abstracts of
research presented at symposia and scientific conferences. Using the
method outlined by the US Preventive Services Task Force, the reviewers
evaluated the identified studies for methodologic quality.
Recommendations from professional societies including ACOG and the
National Institutes of Health were also reviewed. Reference lists from
identified articles were used to help identify additional studies. When
reliable research findings were not available, the reviewers used
expert opinions from obstetrician-gynecologists as a basis for their
Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:
• Because pregnancy rates after bariatric surgery in adolescents are
twice that in the general adolescent population, contraceptive
counseling is especially important in these patients.
• Administration of hormonal contraception by nonoral routes should
be considered in patients with a significant malabsorption component
after bariatric surgery because these patients have an increased risk
for oral contraception failure.
• Testing drug levels may be necessary for medications in which a
therapeutic drug level is critical to ensure a therapeutic effect.
Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:
• There should be a high index of suspicion for gastrointestinal
tract surgical complications when pregnant women who have had bariatric
procedures present with significant abdominal symptoms.
• Bariatric surgery should not be performed with the intention of
treating infertility, although fertility may improve in association
with rapid postoperative weight loss.
• Bariatric surgery in and of itself does not mandate cesarean
delivery, although the rate of cesarean delivery in these patients may
• Despite the lack of consensus regarding the treatment of pregnant
patients who have had an adjustable gastric banding procedure, it is
suggested that these patients have early consultation with a bariatric
• For patients who have had bariatric surgery that may be associated
with malabsorption and/or dumping syndrome, alternative testing for
gestational diabetes should be considered.
• After conception, consultation with a nutritionist may facilitate
adherence to dietary regimens and allow the patient to cope with the
physiologic changes of pregnancy.
• For women who have had bariatric surgery, a wide-spectrum
assessment for micronutrient deficiencies should be considered at the
beginning of pregnancy.
As a proposed performance measure, the guidelines authors suggest
documentation of counseling regarding weight gain and nutrition in
Additional points made by the authors of the practice bulletin include the following:
• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.
• Waiting 12 to 24 months after bariatric surgery before conceiving
may be helpful to avoid exposing the fetus to an environment of rapid
maternal weight loss and to allow the patient to achieve full weight
• If pregnancy occurs earlier than 12 to 24 months after bariatric
surgery, closer surveillance of maternal weight and nutritional status,
including ultrasound for serial monitoring of fetal growth, may be
beneficial and should be considered.
• After bariatric surgery, there is a reduced risk for hypertension,
pregestational diabetes, gestational diabetes, and preeclampsia, as
well as of large-for-gestational-age infants and macrosomia.
• After bariatric surgery, the risk for premature rupture of
membranes is increased, but the risk for preterm delivery, congenital
anomalies, and perinatal death is not increased.
"As the rate of obesity increases, it is becoming more common for
providers of women's health care to encounter patients who are either
contemplating or have had operative procedures for weight loss, also
known as bariatric surgery," the guidelines authors write. "The
counseling and management of patients who become pregnant after
bariatric surgery can be complex. Although pregnancy outcomes generally
have been favorable after bariatric surgery, nutritional and surgical
complications can occur and some of these complications can result in
adverse perinatal outcomes."
Obstet Gynecol. 2009;113:1405-1413.