Objective
We sought to compare pregnancy outcome of patients who conceived during or after the first year postbariatric surgery.
Study Design
A retrospective study comparing pregnancy outcome between patients who conceived during or after the first postoperative year was conducted.
Results
The study included 104 pregnancies of patients who conceived during and 385 who conceived after the first postoperative year. Prepregnancy and predelivery body mass index were comparable between the groups. No significant differences were noted regarding hypertensive disorders (15.4% in the early vs 11.2% in the late postoperative pregnancy; P = .392); diabetes mellitus (11.5% vs 7.3%; P = .392); perinatal outcomes, such as congenital malformations (1.9% vs 1.3%; P = .485); or bariatric complications (6.7% vs 7.0%; P = .392) between the groups. Using multiple logistic regression models, controlling for confounders, the interval (in months) was not associated with pregnancy complications.
Conclusion
Patients who conceived during the first postoperative year had comparable short-term perinatal outcome compared with patients who conceived after the first postoperative year.
Obesity is a major health problem in the Western world, where it has long reached epidemic levels. Obese women have higher rates of associated medical problems, such as diabetes mellitus, hypertensive disorders, coronary heart disease, and stroke. Likewise, pregnancy outcome of obese women in general has been shown to be worse than that of women of normal body mass index (BMI), including an increased incidence of gestational diabetes, gestational hypertension and preeclampsia, fetal macrosomia, cesarean delivery (CD), and anesthesia-related complications.
Bariatric surgery is the most effective treatment for morbidly obese patients. Several studies have addressed pregnancy outcome following bariatric surgeries and suggested that these women are not at increased risk for adverse perinatal outcomes, although postoperative patients were generally provided with good prenatal care and screening for nutritional deficiencies.
Little is known about the influence of pregnancy timing on postbariatric surgery complications. Current recommendations suggest delaying pregnancy by at least 12 postoperative months to avoid gestation during the rapid weight loss stage, although this recommendation remains based on largely theoretical risks. Pregnancy during this time could lead to a malnourished fetus, due to some protein malnutrition, possibly resulting in complications such as low birthweight or malformation. This recommendation is problematic for patients experiencing infertility due to obesity who desire a pregnancy. The present study was aimed at comparing pregnancy outcome of patients who conceived during or after the first postoperative year.
Materials and Methods
A retrospective, population-based study was performed that included all pregnancies of patients following bariatric surgery. The analysis was limited to the first pregnancy after the bariatric surgery. Pregnancy outcomes, including bariatric-associated complications (eg, vomiting, dysphagia, gastric band slippage, gastric pouch dilatation, symptomatic anemia necessitating blood transfusion), were compared between patients who conceived during or after the first postoperative year. Deliveries occurred during 1988 through 2008 in the Soroka University Medical Center, the sole hospital in the Negev, the southern part of Israel, serving the entire obstetrical population. Multiple gestations were excluded from the analysis. Data were collected using all hospitalization files from the obstetric and gynecology department, as well as the surgery department, of the medical center.
The interval between the bariatric operation and pregnancy (in months) was evaluated, and information regarding the type of operation was collected (including laparoscopic gastric banding [LAGB], silastic ring vertical gastroplasty, vertical-banded gastroplasty, and Roux-en-Y gastric bypass [RGB]). The following clinical characteristics were analyzed: maternal age; BMI before the bariatric operation; prepregnancy BMI; and BMI before delivery; as well as any bariatric complications, such as gastrointestinal obstruction, gastric pouch dilatation, vomiting, diarrhea, and gastric band slippage. In addition, information was collected regarding gravidity; parity; gestational age; smoking; previous pregnancy complications, including abortions; fertility treatments; CD; chronic hypertension; hypothyroidism; hemoglobin level; and diabetes mellitus. The following obstetric risk factors were examined: hypertensive disorders (mild and severe preeclampsia, grouped together), gestational diabetes mellitus (glucose intolerance first recognized in the current pregnancy), intrauterine growth restriction (IUGR) (estimated weight <10th percentile for gestational age), premature rupture of membranes, hydramnios, oligohydramnios, and betamethasone administration. The following pregnancy and labor characteristics were assessed: labor induction and augmentation, preterm delivery (<37 weeks’ gestation), mode of delivery (partum spontaneous, instrumental, or CD), and postpartum hemorrhage (blood loss >500 mL following vaginal delivery or 1000 mL following CD during the first 24 hours). The following perinatal outcomes were collected: sex, fetal weight, umbilical artery cord pH and base excess, Apgar score at 1 and 5 minutes <7, prematurity (preterm newborns needing ventilatory support), and jaundice. The study was approved by the local ethics committee of the hospital.
Statistical analysis was performed with the SPSS software package (SPSS, Inc, Chicago, IL). Statistical significance was ascertained using the χ 2 test for differences in qualitative variables, and the analysis of variance test was applied for differences in continuous variables. Multiple logistic regression models were used to investigate the association between latency (ie, the interval in months) and pregnancy complications while controlling for possible confounders, such as maternal age and parity. P < .05 was considered statistically significant.
Results
This retrospective study included 489 deliveries: 104 deliveries of patients who conceived during the first postoperative year (mean operation to pregnancy interval of 7.0 ± 3.5 months and interval to delivery of 15.5 ± 3.7 months) and 385 deliveries of patients who conceived after the first postoperative year (mean operation to pregnancy interval of 56.7 ± 49.1 months and interval to delivery of 65.3 ± 49.2 months; P < .001). Clinical characteristics of the groups are shown in Table 1 . No significant differences were noted between the groups regarding BMI before the bariatric operations, prepregnancy BMI, and before delivery. Patients who conceived during the first postoperative year were more likely to have undergone LAGB compared with patients who conceived after the first postoperative year.
| Parameters | Interval ≤12 mo, n = 104 | Interval >12 mo, n = 385 | P value | |
|---|---|---|---|---|
| Maternal age | 30.5 ± 4.7 | 31.3 ± 5.1 | .162 | |
| BMI before surgery | 42.2 ± 5.1 | 42.6 ± 5.0 | .531 | |
| BMI before pregnancy | 32.3 ± 6.2 | 31.0 ± 6.1 | .062 | |
| BMI before labor | 35.7 ± 6.1 | 35.3 ± 6.2 | .557 | |
| Gravidity, % |
|
|
| .281 |
| Parity, % |
|
|
| .125 |
| Type of bariatric surgery performed | Laparoscopic gastric banding, % | 61.5 | 41.0 | .001 |
| SRVG, % | 28.8 | 30.4 | ||
| VBG, % | 5.8 | 14.3 | ||
| RGB, % | 3.8 | 14.0 | ||
| Chronic hypertension, % | 0 | 0.5 | .392 | |
| Pregestational diabetes mellitus, % | 1.9 | 0.5 | .198 | |
| Hypothyroidism, % | 7.7 | 6.0 | .523 | |
| Clomiphene citrate treatment, % | 4.8 | 5.7 | .719 | |
| IVF pregnancy, % | 1.9 | 1.0 | .375 | |
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