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Clinical Review | Clinician's Corner

Pregnancy and Fertility Following Bariatric Surgery:  A Systematic Review FREE

Melinda A. Maggard, MD, MSHS; Irina Yermilov, MD, MPH; Zhaoping Li, MD, PhD; Margaret Maglione, MPP; Sydne Newberry, PhD; Marika Suttorp, MS; Lara Hilton, BA; Heena P. Santry, MD; John M. Morton, MD, MPH; Edward H. Livingston, MD; Paul G. Shekelle, MD, PhD
[+] Author Affiliations

Author Affiliations: Rand Corporation, Santa Monica, California (Drs Maggard, Newberry, and Shekelle and Mss Maglione, Suttorp, and Hilton); Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (Drs Maggard, Yermilov, Li, and Shekelle, and Mss Maglione); VA Greater Los Angeles Healthcare System, Los Angeles, California (Drs Yermilov, Li, and Shekelle); Department of Surgery, Massachusetts General Hospital, Boston (Dr Santry); Department of Surgery, Stanford School of Medicine, Palo Alto, California (Dr Morton); and Department of Surgery, University of Texas Southwestern School of Medicine, Dallas (Dr Livingston).


JAMA. 2008;300(19):2286-2296. doi:10.1001/jama.2008.641.
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Published online

Context Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age.

Objectives To estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery.

Evidence Acquisition Search of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery.

Evidence Synthesis Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50 000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group. Findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences in neonatal outcomes were found after gastric bypass compared with nonobese controls (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported [1 study] and = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = not reported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1 study and P = .28 [1 study]). Findings were supported by 10 other studies. Studies regarding nutrition, fertility, cesarean delivery, and contraception were limited.

Conclusion Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.

Figures in this Article

Obesity has reached epidemic levels in the United States and is a leading cause of health-related disorders.114 Rates of surgical weight loss procedures have grown steeply and women account for many of these patients.15 Large numbers of women in their childbearing years may undergo bariatric surgery, which may change fertility following weight loss, alter nutritional requirements during pregnancy, or impact contraception to prevent pregnancy. Our specific goals were to estimate the incidence of bariatric surgery in women aged 18 to 45 years and perform a systematic review to assess associations of bariatric surgery on pregnancy outcomes, including maternal and neonatal outcomes, nutritional adverse events, fertility, contraception, optimal time to delay pregnancy, and surgical complications during pregnancies.

Analysis of Trends in Surgery Utilization

The Nationwide Inpatient Sample,16 a Healthcare Cost and Utilization Project data set, was used to produce national estimates of trends in bariatric surgical procedures between 1998 and 2005, the latest year for which data are available. The Nationwide Inpatient Sample is a 20% stratified sample of all inpatient stays nationally and includes data on 5 million to 8 million hospitalizations from roughly 1000 hospitals.

A comprehensive list of International Classification of Diseases, Ninth Revision procedure codes was used to identify patients who underwent bariatric surgery, accounting for changes in coding and types of procedures.17 Rates of bariatric cases were calculated for each year. We determined the number of procedures among men and women aged 18 to 45 years. Percentage change from 1998 was calculated for each subsequent year.

Literature Search

Our literature search included Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness and captured articles published between 1985 and February 2008. Articles on bariatric surgery, including laparoscopic adjustable gastric banding (LAGB), vertical-banded gastroplasty (VBG), Roux-en-Y gastric bypass (gastric bypass), and biliopancreatic diversion/duodenal switch (BPD), were included. We used various search terms for each procedure (eg, Roux-en-Y gastric bypass: gastric bypass, RYGB, laparoscopic gastric bypass, and open gastric bypass). We also searched for fertility, contraception, pregnancy, weight management, neonatal outcomes, and nutritional deficiencies.

Study Inclusion

The literature search included review articles, randomized controlled trials, observational studies, and case reports. To be included, studies had to be an original research article and discuss 1 of the procedures and fertility or pregnancy outcomes. Two reviewers (M.A.M. and Z. L.) reviewed each study. Disagreements were resolved by consensus.

Data Abstraction and Synthesis of Results

Study results were abstracted into data tables. Because of heterogeneity in the patients, interventions, and outcomes, data pooling was not possible. Therefore, we summarized the data narratively. Outcomes included maternal pregnancy outcomes (gestational diabetes, hypertension, preeclampsia, cesarean delivery, nutritional deficiencies, surgical complications, and maternal weight gain), neonatal outcomes (premature delivery, birth weight, macrosomia, and perinatal mortality), fertility, the optimal time between surgery and pregnancy, and contraception efficacy.

Because we found no randomized trials, our evidence consisted of observational studies. We discriminated between studies based on how cases and comparison groups were identified. We considered a study less prone to bias, and consequently gave it more emphasis, if it enrolled a consecutive or random sample of surgery cases or pregnancies and used a concurrent comparison group that consisted of consecutive, random, or matched patients or pregnancies. Data presented herein included all cohort studies with a comparison group. Studies without a comparison group, case series, and case reports were used for descriptions of surgical complications or rare adverse events or to provide additional information about our study questions. Nutritional outcomes included both cohort and case series studies. A RAND biostatistician performed the statistical analyses (M.S.).

Incidence of Bariatric Surgery Among Women of Reproductive Age

The incidence of bariatric surgery in the United States increased by 800% between 1998 and 2005 (from 12 480 to 113 500 cases). Women accounted for 83% of procedures in the 18- to 45-year age group. Between 2003 and 2005, more than 50 000 women aged 18 to 45 years underwent inpatient bariatric surgery procedures annually (49% of all bariatric surgery cases). The number of inpatient bariatric procedures decreased in 2005. Reasons for the lower surgery rate in 2005 are unknown but could include a shift to bariatric surgery in the outpatient setting, which is not captured by the Nationwide Inpatient Sample.

Description of the Studies Identified by the Literature Search

Our search identified 1102 articles, of which 260 were screened and of which 75 were included in the review (Figure). One randomized controlled trial comparing surgical procedures was treated as a case series for pregnancy outcomes. Of the 185 excluded articles, 88 did not study bariatric surgery, 60 did not study a procedure of interest or did not include pregnant women, and 37 were review articles.

Place holder to copy figure label and caption
Figure. Flow of Eligible Studies of Bariatric Surgery Among Women of Reproductive Age
Graphic Jump Location

Three cohort studies by Ducarme et al,18 Wax et al,19 and Patel et al20 compared outcomes for consecutive patients with postsurgery pregnancies (bariatric surgery group) with outcomes for consecutive nonsurgical patients (comparison group) who delivered in the same period and were matched to 1 or more characteristics (eg, body mass index [BMI, calculated as weight in kilograms divided by height in meters squared], age). Because these study designs are more rigorous, we present their results in detail.

The remaining cohort studies compared outcomes in selected pregnancies after bariatric surgery with outcomes in pregnancies before bariatric surgery (same women before surgery), selected nonobese patients, or population rates.

Risks for Pregnancies: Maternal Outcomes

Sixteen studies compared pregnancies following bariatric surgery with a comparison group.1833 The most commonly reported maternal outcomes were gestational diabetes, preeclampsia, pregnancy-induced hypertension, maternal weight gain, and cesarean delivery (Table 1).

Table Graphic Jump LocationTable 1. Observational Studies on Maternal Pregnancy Outcomes Following Bariatric Surgery

Laparoscopic Adjustable Gastric Banding. Ducarme et al18 compared the outcomes of 13 consecutive deliveries following LAGB surgery with outcomes of 414 consecutive patients who were obese (BMI ≥30) who delivered at the same practice between 2004 and 2006. Gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group than in the obese comparison group, but there were no differences in pregnancy-induced hypertension or need for labor induction. Maternal weight gain was reduced in the surgical group (5.5 vs 7.1 kg, P < .05).

Three additional LAGB studies,2123 which compared outcomes to selected obese patients who did not undergo surgery or to historical presurgery pregnancies, also found lower rates of gestational diabetes, preeclampsia, and maternal weight gain, but in addition found lower rates of pregnancy-induced hypertension in the bariatric surgery group. One study21 reported that outcome rates for the surgery group approached rates in the community. The findings were supported by 6 case series that reported low rates of these maternal outcomes in pregnancies following LAGB.3439

Gastric Bypass. Two cohort studies reported on maternal outcomes following gastric bypass.19,20 Both reported on consecutive deliveries following bariatric surgery in a single practice. Wax et al19 compared outcome rates for the bariatric surgery group with a comparison group consisting of the next 2 consecutive deliveries after the index case, matched for age and prior cesarean delivery. Patel et al20 compared outcomes following surgery with a comparison group consisting of the 5 consecutive nonsurgical women who delivered before and the 5 consecutive nonsurgical women who delivered after each index case, stratifying by obesity. Wax et al19 found a higher risk of pregnancy-induced hypertension in the bariatric surgery group compared with the nonsurgical comparison group. However, women with bariatric surgery were more obese than the comparison group, with 68% and 26%, respectively, having a BMI of 30 or higher (P < .001). There were no differences between the 2 groups in rates of gestational diabetes or weight gain. Patel et al20 found that rates of gestational diabetes, preeclampsia, and pregnancy-induced hypertension did not differ between the bariatric surgery and comparison cohorts.

Two additional studies compared outcomes after gastric bypass surgery with presurgery pregnancies from the same patients or with patients matched for presurgery weight, parity, and year of delivery.24,25 For all outcomes, these studies found no differences or found lower outcome rates in the bariatric surgery group compared with the control group.

Among case series on gastric bypass, only 1 study40 reported data on the maternal outcomes of interest. This study identified no occurrences of gestational diabetes (n = 100).

VBG and BPD. Two studies of maternal outcomes after VBG procedures found similar results to the cohort studies involving LAGB and gastric bypass procedures. One study28 reported low rates of gestational diabetes, pregnancy-induced hypertension, and preeclampsia among the surgery cohort and the other study27 reported a lower rate of gestational diabetes in comparison with presurgery historical pregnancies. One cohort study29 on BPD reported a lower pregnancy-induced hypertension rate among patients who had surgery.

Mixed Procedures. Two studies31,32 assessed pregnancy outcomes following a variety of bariatric procedures. One study31 compared pregnancy outcomes for 298 patients who underwent bariatric surgery with community rates and found a higher rate of gestational diabetes in the surgery group (9.4% vs 5.0%, P < .001), but no difference in preeclampsia. Importantly, obesity was more prevalent among patients who had surgery compared with the community (10.7% vs 1.2%, P < .001). A second study32 found lower rates of gestational diabetes, preeclampsia, and pregnancy-induced hypertension following surgery.

Quiz Ref IDIn conclusion, 3 matched cohort studies found that adverse maternal outcomes in pregnancies following LAGB and gastric bypass may be lower than those outcomes of obese comparison groups and may approach rates in patients who are not obese. Additional cohort studies and case series studies support these findings. Few studies have assessed pregnancy outcome rates after BPD.

Rates of Cesarean Delivery and Other Delivery Complications. Thirteen studies1820,2225,2731,33 compared cesarean delivery rates following bariatric surgery with a comparison group (eg, nonobese women, obese women, presurgery pregnancies, or the general population). Rates ranged from 0% to 65.8% for postsurgery pregnancies and from 5.6% to 64.5% for pregnancies in comparison groups (Table 1). Some studies reported lower rates of cesarean delivery after surgery, whereas other studies reported higher rates or no difference.

The 3 cohort studies did not report consistent findings. Ducarme et al18 reported an overall cesarean delivery rate after LAGB procedures that was half that of obese nonsurgical comparisons and a 0% cesarean delivery rate before start of labor. The 2 gastric bypass cohort studies found high rates of cesarean delivery in the surgery groups (>60%) that did not differ from obese comparison groups, but exceeded those rates of the nonobese groups. Cesarean delivery rates varied in the other cohort studies (Table 1). Based on these data, bariatric surgery does not appear to have a strong relationship with cesarean delivery rates.

Only 2 studies specifically reported on rates of delivery complications, such as blood loss or operative injury. These studies18,19 found no differences in delivery complications between surgery patients and comparison groups.

Neonatal Outcomes

Fourteen studies compared neonatal outcomes following bariatric surgery with a comparison group. The 4 most commonly noted outcomes were premature delivery (<37 weeks' gestation), low birth weight (<2.5 kg), macrosomia (>4.0 or >4.5 kg), and perinatal mortality (Table 2).1821,2326,28,29,3133,41

Table Graphic Jump LocationTable 2. Observational Studies on Neonatal Outcomes Following Bariatric Surgerya

Laparoscopic Adjustable Gastric Banding. Ducarme et al18 found no difference in preterm birth rates or mean birth weight after LAGB vs obese comparison group. However, rates of low birth weight (7.7% vs 10.6%, P < .05) and macrosomia (7.7% vs 14.6%, P < .05) were lower among patients who had surgery.

Another study21 found that macrosomia rates were lower among patients who had bariatric surgery than among control patients who were obese (11.4% vs 17.7%) and approached rates in the community (11.8%). Six case series3439 on LAGB procedures (n = 162) found low rates of neonatal complications, consistent with findings in the matched cohort study.

Gastric Bypass. In 2 matched cohort studies,19,20 patients who underwent gastric bypass showed no differences in premature delivery or low birth weight compared with patients who were not obese. In both studies, there were no cases of macrosomia in the patients who had surgery, whereas rates were 2.6% and 4.3% in the nonobese comparisons ( = not reported [1 study] and  = .28 [1 study]). Other cohort studies24,25 of gastric bypass found lower mean birth weight and lower macrosomia rates in the pregnancies after surgery compared with rates in the obese comparison groups.

Relatively low neonatal complication rates were also reported in 8 case series of pregnancy following gastric bypass (approximately 300 pregnancies).40,4248 However, 2 studies43,44 reported higher than expected rates of neural tube defects (1 study44 described 4 pregnancies and the other study43 3 pregnancies, of a total 110 pregnancies, resulting in infants with neural tube defects). Mothers in these cases were reported to be nonadherent with recommended vitamin supplementation.

Biliopancreatic Diversion. Neonatal outcomes following BPD were assessed in 2 cohort studies (with >150 pregnancies)29,41 (Table 2) and 4 case series.4952 One cohort study41 found no difference in preterm birth rates, but lower mean birth weight and macrosomia rates in the surgery group were found compared with controls who were obese (3 kg vs 3.5 kg, P < .001; and 7.7% vs 34.8%, P < .001, respectively). The other study29 found that after BPD, 22 of the singleton pregnancies (15.3%) were preterm deliveries compared with US estimates of 12.8% in 2005.53

A number of studies reported miscarriage and perinatal mortality rates following BPD.29,41,4952 In 1 cohort study (n = 152), miscarriage rates were approximately 20% before and after surgery and perinatal mortality was 2.6% for both groups.29 In another cohort study (n = 251),41 miscarriage rates were 21.6% before bariatric surgery vs 26.0% after bariatric surgery. The 4 case series4952 included 108 pregnancies following BPD.

Mixed Procedures. A study31 that compared pregnancy outcomes between 298 patients who underwent a variety of bariatric procedures and a nonobese comparison group found higher labor induction rates (23.8% vs 10.9%, P < .001), mean birth weights (P = .02), and macrosomia (P < .001), and no difference in perinatal mortality among women with history of bariatric procedures.

Quiz Ref IDOverall, following LAGB and gastric bypass procedures, there is no strong evidence that adverse neonatal outcome rates are higher compared with obese groups. Following BPD, adverse neonatal outcomes may be lower; however, miscarriage rates may be higher.

Nutritional Deficiencies

Dietary guidelines recommend supplementation with multivitamins and iron following bariatric surgery.54,55 Observational studies evaluating pregnancy after LAGB or gastric bypass have shown minimal evidence of nutritional adverse events; however, most monitored supplement adherence. Of 22 studies that addressed the issues of nutritional deficiencies, 13 were comparison studies or case series (Table 3) and 9 were case reports.

Table Graphic Jump LocationTable 3. Observational Studies of Nutritional Outcomes in Pregnancy Following Bariatric Surgery

Laparoscopic Adjustable Gastric Banding. One study21 of women who became pregnant after LAGB reported no nutritional problems; 84% of the 79 pregnant women reported adherence with supplementation. However, among 4 studies,23,35,37,38 approximately 19% of pregnant women had their adjustable LAGB deflated or removed for various reasons, including nausea and vomiting and patient preference.

Gastric Bypass. Gastric bypass was associated with few nutritional adverse outcomes during pregnancy (Table 3). Four studies20,25,45,47 reported low rates of anemia, ranging from 0% to 11%. Two other studies43,44 reported neural tube defects in pregnancies (6 neonates) following gastric bypass; however, none of the mothers were adherent with supplements. Four case reports5659 following gastric bypass reported nutritional deficiencies (2 had adherence and 2 did not have adherence with supplementation).

Biliopancreatic Diversion. Observational studies29,41,51,52 show that parenteral nutrition is used in approximately 20% of pregnancies following BPD. Several small case series of pregnancies following BPD reported nutritional deficiencies among women taking nutritional supplements, those not taking supplements, and some in whom adherence was unclear.49,50,6062

There are few studies of adverse nutritional outcomes in pregnancies following LAGB or gastric bypass surgeries when nutritional supplementation was maintained. Severe nutritional deficiencies requiring parenteral nutrition have been reported in pregnancies following BPD. Many, but not all, of the studies attributed the deficiency to nonadherence. Of concern were several studies of neural tube defects, particularly in neonates of women who had undergone gastric bypass and been nonadherent. However, these studies were not designed to specifically assess nutritional outcomes.

Bariatric Surgery and Fertility. We identified 6 studies27,28,31,41,63,64 that addressed fertility outcomes in patients after bariatric surgery and most of these compared pregnancy rates before and after surgery (Table 4). Three small studies27,28,41 reported improvements in fertility and 1 study63 noted no change.

Table Graphic Jump LocationTable 4. Observational Studies Reporting Fertility Outcomes for Patients Following Bariatric Surgery

One study (n = 298) found that after bariatric surgery, the need for fertility treatment in women was low (6.7%) but exceeded that of the community (2.3%, P < .001).31 Similar results were found for patients after surgery with gestational diabetes compared with a nonsurgery control population with gestational diabetes.64 Five additional case series (n = 21 to 48)22,25,35,37,52 found that infertility rates before surgery ranged from 15% to 44%.

Six studies28,50,63,6567 found evidence of normalization of hormones and menstrual cycles and lessening of polycystic ovarian syndrome following bariatric surgery. One study65 prospectively followed up 17 women who had BPD or gastic bypass surgery and found decreases in hirsutism, testosterone, androstenedione, and dehydroepiandrosterone sulfate and also found normalization of menstrual cycles, ovulation, or both in all women. A prospective case series50 of women before and after BPD surgery demonstrated normalization of hormones. The postsurgery normalization of menstrual cycles was observed in a cohort study of 109 women (P < .001).28 A retrospective survey63 reported that menstrual cycles normalized in 71.4% (95% confidence interval, 62.3%-80.5%) of 98 previously anovulatory women and that resumption of ovulation was associated with greater weight loss following surgery. Another study66 showed resolution of polycystic ovarian syndrome following gastric bypass surgery: all 24 women resumed normal menstrual cycles, 5 conceived without clomiphene, and hirsutism resolved in more than 50%. A study67 following VBG surgery (n = 38) found improvements in hormone levels and normalization of menstrual cycles among all 5 women with abnormal cycles.

Quiz Ref IDMost observations on fertility following bariatric surgery lack complete data on the total number of women attempting to get pregnant and pregnancy rates. Most studies present convenience samples of women who were able to get pregnant, in whom presurgery fertility histories were available. With these significant limitations in mind, data suggest that surgery may have a beneficial influence on fertility, which is supported by the normalization of hormones in polycystic ovarian syndrome and correction of abnormal menstrual cycles.

Contraceptive Use. No randomized trials have assessed the efficacy of contraception after bariatric surgery. Theoretical concerns exist about absorption of oral contraceptive pills in patients following a malabsorptive procedure, such as BPD. One case series50 identified 2 failures for oral contraceptive pills out of 40 women after BPD surgery. No firm conclusions can be drawn about the effectiveness of contraceptive methods following bariatric surgery.

Evidence on Time to Delay of Pregnancy After Bariatric Surgery

We identified 5 studies comparing pregnancy outcomes within the first year up to 18 months following surgery with later pregnancies. One study42 included 18 women with 21 successful pregnancies after gastric bypass surgery. Of these women, 10 conceived within 1 year after surgery. No differences were found in rates of cesarean delivery, delivery complications, low birth weight, or congenital abnormalities. Another study47 found no differences in outcomes between pregnancies within the first year following gastric bypass surgery vs pregnancies occurring more than 1 year after surgery. In a study comparing 20 pregnancies in which conception occurred within the first year after LAGB,21 maternal weight gain was lower in these early postsurgery pregnancies, birth weight was unchanged, and there were no differences in pregnancy complications or preterm deliveries. Another study68 found a higher spontaneous abortion rate among pregnancies occurring within 18 months of having BPD surgery compared with those pregnancies occurring after 18 months of having BPD surgery (31% vs 18%). In a matched cohort study, Patel et al20 stratified the postoperative cohort of 26 patients by time to conception from surgery and found that 4 women (15.4%) were pregnant within the first year, 12 (46.1%) were pregnant between 13 and 24 months, and 10 (38.5%) became pregnant after more than 2 years. Early pregnancies were associated with more preterm deliveries (50% for <12 months, 25% for 13-24 months, and 20% for ≥24 months). A study that investigated pregnancies within 2 years after gastric bypass surgery found a high rate of premature births (18%), but this study included no comparison group.45 A study of pregnancies within 2 years of LAGB surgery found spontaneous abortion rates to be 29%.36

In conclusion, few data are available to support recommendations regarding the ideal timing for pregnancies following surgery. However, there are reports of successful pregnancies within 1 or 2 years of surgery.

Surgical Complications in Pregnancies Following Bariatric Surgery

Quiz Ref IDWe identified 20 reports of complications requiring surgical intervention during pregnancy following bariatric surgery. Maternal complications included 14 bowel obstructions (11 internal hernias), 1 gastric ulcer, 4 band events, and 1 staple-line stricture.20,23,6983 Gestational age at adverse event ranged from 13 to 37 weeks (median, 26 weeks). Most women presented with nonspecific abdominal complaints and delays often occurred before therapeutic intervention. In 7 of 20 cases (35%), an emergent cesarean delivery or premature rupture of membranes occurred. Five neonates died (25%) and 10 were delivered full-term (50%). There were 3 maternal deaths (15%). The case reports indicate the potential for complications in pregnancies following bariatric surgery, including maternal and fetal death.

More than 150 000 women of reproductive age underwent bariatric procedures in the most recent 3 years for which inpatient data are available. This figure is likely an underestimate because many patients undergo outpatient bariatric surgical procedures (eg, LAGB surgery) that would not have been reported in the Nationwide Inpatient Sample. A growing number of women of child-bearing age have undergone these procedures and need information and guidance about fertility, pregnancy, and contraception.

The available evidence suggests that risks for maternal complications, such as gestational diabetes and preeclampsia, may be lower following surgically induced weight loss than the risks in obese women and may approach community rates. Similarly, neonatal complications, such as premature delivery and low birth weight, may be lower in pregnancies following bariatric surgery. Results from large cohorts of consecutive patients with pregnancies are needed to confirm these findings. The effect of bariatric surgery on need for cesarean delivery is unclear as reported rates before and after surgery vary widely between studies. Nutritional problems during pregnancy following LAGB or gastric bypass surgeries appear uncommon and many are attributed to supplement nonadherence. Studies of consecutive patients that systematically monitor adherence and nutritional status are needed. The relationship of bariatric surgery to fertility has not been well studied. Reports of normalization of sex hormones, menstrual irregularities, and improvement in polycystic ovarian syndrome following surgery suggest that fertility may improve, which would be consistent with that observed in obese women after nonsurgically induced weight loss. However, most of these studies may have selection bias, limiting their ability to reach valid conclusions. Although rare, complications of bariatric surgery can manifest during pregnancy. The most commonly reported complication is internal hernia causing bowel compromise. There is no strong evidence to guide how long to delay pregnancy following bariatric surgery. The typical recommended period is 1 year, coinciding with the end of the period of most rapid weight loss. There is no convincing evidence to support or refute concerns about the use of oral contraceptive pills following bariatric surgery.

Quiz Ref IDOur review is limited by the quality of the original studies. Three matched cohort studies assessed consecutive patients and compared these with concurrent control groups and provided the main evidence in support of our conclusions. However, sample sizes were modest (77 surgical cases and 744 comparison controls) and there may have been differences in women electing to undergo surgery compared with women who did not have surgery. Because randomized controlled trials will not be feasible for assessing pregnancy outcomes, these types of studies represent the best available evidence for assessing the effect of surgically induced weight loss on future pregnancies. However, inherent limitations in the identified studies preclude us from drawing strong conclusions. Some of these clinical questions addressed in our review, such as optimal contraception, will be best answered by randomized clinical trials or prospective cohort studies. Because clinicians must still make decisions regarding these patients, we assessed the best evidence available in an attempt to help guide clinicians.

Research is needed to better delineate the extent to which surgery and subsequent weight loss improve fertility and pregnancy outcomes. Optimizing success for contraception and producing healthy neonates following surgery will require a multidisciplinary effort by surgeons, primary care physicians, reproductive fertility specialists, obstetricians, and patients.

Corresponding Author: Melinda A. Maggard, MD, MSHS, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CHS 72-215, 10833 Le Conte Ave, Los Angeles, CA 90095 (mmaggard@mednet.ucla.edu).

Author Contributions: Dr Maggard had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Maggard, Li, Maglione, Hilton, Santry, Livingston, Shekelle.

Acquisition of data: Maggard, Yermilov, Li, Suttorp, Santry, Livingston, Shekelle.

Analysis and interpretation of data: Maggard, Yermilov, Li, Maglione, Newberry, Suttorp, Hilton, Santry, Morton, Livingston, Shekelle.

Drafting of the manuscript: Maggard, Yermilov, Li, Hilton, Santry, Shekelle.

Critical revision of the manuscript for important intellectual content: Maggard, Yermilov, Li, Maglione, Newberry, Suttorp, Santry, Morton, Livingston, Shekelle.

Statistical analysis: Maggard, Yermilov, Li, Suttorp, Hilton.

Obtained funding: Maglione, Shekelle.

Administrative, technical, or material support: Yermilov, Maglione, Newberry, Hilton.

Study supervision: Maggard, Maglione, Shekelle.

Financial Disclosures: None reported.

Funding/Support: This project was funded under contract 290-02-0003 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services to the Southern California Evidence Based Practice Center. Dr Maggard’s time was supported in part by a grant from the Robert Wood Johnson Physician Faculty Scholars program. This work was requested by the American College of Obstetricians and Gynecologists.

Role of the Sponsor: The Agency for Healthcare Research and Quality had input into the general design and conduct of evidence reviews conducted by the Evidence Based Practice Centers, but not this evidence review in specific. The sponsors were not involved in the collection, management, or analyses of the data, but did review and provide comments on the evidence report upon which this article is based.

Disclaimer: The authors of this article are responsible for its content. Statements in the article should not be construed as endorsement by the Agency for Healthcare Research and Quality or the US Department of Health and Human Services. All data used for this study are accessible for review.

Also Available: A more detailed clinical review of pregnancy and fertility following bariatric surgery will be available at http://www.ahrq.gov/downloads/pub/evidence/pdf/bariatricrep/barirep.pdf.

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PubMed   |  Link to Article
Poirier P, Giles TD, Bray GA,  et al; American Heart Association; Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism.  Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism.  Circulation. 2006;113(6):898-918
PubMed   |  Link to Article
Poirier P, Giles TD, Bray GA,  et al.  Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss.  Arterioscler Thromb Vasc Biol. 2006;26(5):968-976
PubMed   |  Link to Article
Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity.  Obes Res. 2002;10:(Suppl 2)  97S-104S
PubMed   |  Link to Article
Allison DB, Pi-Sunyer FX. Obesity treatment: examining the premises.  Endocr Pract. 1995;1(5):353-364
PubMed   |  Link to Article
American Society for Metabolic & Bariatric Surgery.  Bariatric surgical society takes on new name, new mission, and new surgery. http://www.asbs.org/Newsite07/resources/press_release_8202007.pdf. Posted August 22, 2007. Accessed October 18, 2008
Agency for Healthcare Research and Quality.  HCUP Nationwide Inpatient Sample (NIS)Rockville, MD: Healthcare Cost and Utilization Project (HCUP); 2000-2001
Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures.  JAMA. 2005;294(15):1909-1917
PubMed   |  Link to Article
Ducarme G, Revaux A, Rodrigues A, Aissaoui F, Pharisien I, Uzan M. Obstetric outcome following laparoscopic adjustable gastric banding.  Int J Gynaecol Obstet. 2007;98(3):244-247
PubMed   |  Link to Article
Wax JR, Cartin A, Wolff R, Lepich S, Pinette MG, Blackstone J. Pregnancy following gastric bypass surgery for morbid obesity: maternal and neonatal outcomes.  Obes Surg. 2008;18(5):540-544
PubMed   |  Link to Article
Patel JA, Patel NA, Thomas RL, Nelms JK, Colella JJ. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass.  Surg Obes Relat Dis. 2008;4(1):39-45
PubMed   |  Link to Article
Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding.  Obstet Gynecol. 2005;106(5 Pt 1):965-972
PubMed   |  Link to Article
Dixon JB, Dixon ME, O'Brien PE. Pregnancy after Lap-Band surgery: management of the band to achieve healthy weight outcomes.  Obes Surg. 2001;11(1):59-65
PubMed   |  Link to Article
Skull AJ, Slater GH, Duncombe JE, Fielding GA. Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes.  Obes Surg. 2004;14(2):230-235
PubMed   |  Link to Article
Richards DS, Miller DK, Goodman GN. Pregnancy after gastric bypass for morbid obesity.  J Reprod Med. 1987;32(3):172-176
PubMed
Wittgrove AC, Jester L, Wittgrove P, Clark GW. Pregnancy following gastric bypass for morbid obesity.  Obes Surg. 1998;8(4):461-464, 465-466
PubMed   |  Link to Article
Landsberger E, Ankrah Y, Segal-Isaacson CJ,  et al.  Should severly obese women complete childbearing prior to bariatric surgery? [abstract].  Am J Obstet Gynecol. 2006;195:S93
Link to Article
Bilenka B, Ben-Shlomo I, Cozacov C, Gold CH, Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity.  Acta Obstet Gynecol Scand. 1995;74(1):42-44
PubMed   |  Link to Article
Deitel M, Stone E, Kassam HA, Wilk EJ, Sutherland DJ. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery.  J Am Coll Nutr. 1988;7(2):147-153
PubMed
Friedman D, Cuneo S, Valenzano M,  et al.  Pregnancies in an 18-year follow-up after biliopancreatic diversion.  Obes Surg. 1995;5(3):308-313
PubMed   |  Link to Article
Kral JG, Biron S, Simard S,  et al.  Large maternal weight loss from obesity surgery prevents transmission of obesity to children who were followed for 2 to 18 years.  Pediatrics. 2006;118(6):e1644-e1649
PubMed   |  Link to Article
Sheiner E, Levy A, Silverberg D,  et al.  Pregnancy after bariatric surgery is not associated with adverse perinatal outcome.  Am J Obstet Gynecol. 2004;190(5):1335-1340
PubMed   |  Link to Article
Weintraub A, Levy A, Levy I, Wiznitzer A, Mazor M, Sheiner E. Downsizing gestational complications: pregnancy outcomes before and after bariatric surgery [abstract].  Am J Obstet Gynecol. 2007;197:S186
Link to Article
Heinzen M, Ismail M, Ahn J. Perinatal outcomes in women with a history of bariatric surgery [abstract].  Am J Obstet Gynecol. 2006;195:S208
Link to Article
Bar-Zohar D, Azem F, Klausner J, Abu-Abeid S. Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gestational weight gain.  Surg Endosc. 2006;20(10):1580-1583
PubMed   |  Link to Article
Weiner R, Blanco-Engert R, Weiner S, Matkowitz R, Schaefer L, Pomhoff I. Outcome after laparoscopic adjustable gastric banding: 8 years experience.  Obes Surg. 2003;13(3):427-434
PubMed   |  Link to Article
Weiss HG, Nehoda H, Labeck B, Hourmont K, Marth C, Aigner F. Pregnancies after adjustable gastric banding.  Obes Surg. 2001;11(3):303-306
PubMed   |  Link to Article
Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding.  Obstet Gynecol. 2000;95(6 Pt 1):927-930
PubMed   |  Link to Article
Martin LF, Finigan KM, Rabner JG, Greenstein RJ. Adjustable gastric banding and pregnancy [abstract].  Obes Surg. 1997;7:280-281
Jasaitis Y, Sergent F, Bridoux V, Paquet M, Marpeau L, Teniere P. Management of pregnancies after adjustable gastric banding [in French].  J Gynecol Obstet Biol Reprod (Paris). 2007;36(8):764-769
PubMed   |  Link to Article
Jester L, Wittgrove AC, Clark GW. Evaluation of pregnancy after bariatric surgery and a developmental study of the children over two years of age [abstract].  Obes Surg. 1997;7:280
Marceau P, Kaufman D, Biron S,  et al.  Outcome of pregnancies after biliopancreatic diversion.  Obes Surg. 2004;14(3):318-324
PubMed   |  Link to Article
Rand CS, Macgregor AM. Medical care and pregnancy outcome after gastric bypass surgery for obesity.  South Med J. 1989;82(10):1319-1320
PubMed   |  Link to Article
Martin L, Chavez GF, Adams MJ Jr,  et al.  Gastric bypass surgery as maternal risk factor for neural tube defects.  Lancet. 1988;1(8586):640-641
PubMed   |  Link to Article
Haddow JE, Hill LE, Kloza EM, Thanhauser D. Neural tube defects after gastric bypass.  Lancet. 1986;1(8493):1330
PubMed   |  Link to Article
Printen KJ, Scott D. Pregnancy following gastric bypass for the treatment of morbid obesity.  Am Surg. 1982;48(8):363-365
PubMed
Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity.  J Pediatr. 2001;138(4):499-504
PubMed   |  Link to Article
Dao T, Kuhn J, Ehmer D, Fisher T, McCarty T. Pregnancy outcomes after gastric-bypass surgery.  Am J Surg. 2006;192(6):762-766
PubMed   |  Link to Article
Roehrig HR, Xanthakos SA, Sweeney J, Zeller MH, Inge TH. Pregnancy after gastric bypass surgery in adolescents.  Obes Surg. 2007;17(7):873-877
PubMed   |  Link to Article
Cools M, Duval EL, Jespers A. Adverse neonatal outcome after maternal biliopancreatic diversion operation: report of nine cases.  Eur J Pediatr. 2006;165(3):199-202
PubMed   |  Link to Article
Gerrits EG, Ceulemans R, van Hee R, Hendrickx L, Totte E. Contraceptive treatment after biliopancreatic diversion needs consensus.  Obes Surg. 2003;13(3):378-382
PubMed   |  Link to Article
Adami GF, Friedman D, Cuneo S,  et al.  Intravenous nutritional support in pregnancy: experience following biliopancreatic diversion.  Clin Nutr. 1992;11(2):106-109
PubMed   |  Link to Article
Friedman D, Semino G, Gianetta E,  et al.  Aspects of pregnancy following biliopancreatic diversion (BPD) [abstract].  Int J Obes. 1989;13:599
National Center for Health Statistics.  Teen birth rate rises for first time in 15 years. http://www.cdc.gov/nchs/pressroom/07newsreleases/teenbirth.htm. Accessed May 4, 2008
Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery.  Med Clin North Am. 2007;91(3):499-514, xii
PubMed   |  Link to Article
Parkes E. Nutritional management of patients after bariatric surgery.  Am J Med Sci. 2006;331(4):207-213
PubMed   |  Link to Article
Campbell CD, Ganesh J, Ficicioglu C. Two newborns with nutritional vitamin B12 deficiency: challenges in newborn screening for vitamin B12 deficiency.  Haematologica. 2005;90(12):(suppl)  ecr45
PubMed
Martens WS II, Martin LF, Berlin CM Jr. Failure of a nursing infant to thrive after the mother's gastric bypass for morbid obesity.  Pediatrics. 1990;86(5):777-778
PubMed
Grange DK, Finlay JL. Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass.  Pediatr Hematol Oncol. 1994;11(3):311-318
PubMed   |  Link to Article
Gurewitsch ED, Smith-Levitin M, Mack J. Pregnancy following gastric bypass surgery for morbid obesity.  Obstet Gynecol. 1996;88(4 Pt 2):658-661
PubMed   |  Link to Article
St George LI, Lin D. Malabsorption in pregnancy after biliopancreatic diversion for morbid obesity.  Med J Aust. 2005;182(6):308-309
PubMed
Smets KJ, Barlow T, Vanhaesebrouck P. Maternal vitamin A deficiency and neonatal microphthalmia: complications of biliopancreatic diversion?  Eur J Pediatr. 2006;165(7):502-504
PubMed   |  Link to Article
Huerta S, Rogers LM, Li Z, Heber D, Liu C, Livingston EH. Vitamin A deficiency in a newborn resulting from maternal hypovitaminosis A after biliopancreatic diversion for the treatment of morbid obesity.  Am J Clin Nutr. 2002;76(2):426-429
PubMed
Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual patterns.  Obes Surg. 2006;16(11):1457-1463
PubMed   |  Link to Article
Sheiner E, Menes TS, Silverberg D,  et al.  Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery.  Am J Obstet Gynecol. 2006;194(2):431-435
PubMed   |  Link to Article
Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, Sancho J, San Millan JL. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery.  J Clin Endocrinol Metab. 2005;90(12):6364-6369
PubMed   |  Link to Article
Eid GM, Cottam DR, Velcu LM,  et al.  Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass.  Surg Obes Relat Dis. 2005;1(2):77-80
PubMed   |  Link to Article
Bastounis EA, Karayiannakis AJ, Syrigos K, Zbar A, Makri GG, Alexiou D. Sex hormone changes in morbidly obese patients after vertical banded gastroplasty.  Eur Surg Res. 1998;30(1):43-47
PubMed   |  Link to Article
Biron S, Hould F, Simard S, Lebel S, Marceau S, Marceau P. Birthweight after biliopancreatic diversion [abstract].  Obes Surg. 1999;9:126
Charles A, Domingo S, Goldfadden A, Fader J, Lampmann R, Mazzeo R. Small bowel ischemia after Roux-en-Y gastric bypass complicated by pregnancy: a case report.  Am Surg. 2005;71(3):231-234
PubMed
Kakarla N, Dailey C, Marino T, Shikora SA, Chelmow D. Pregnancy after gastric bypass surgery and internal hernia formation.  Obstet Gynecol. 2005;105(5 Pt 2):1195-1198
PubMed   |  Link to Article
Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for morbid obesity.  N Engl J Med. 2004;351(7):721-722
PubMed   |  Link to Article
Loar PV III, Sanchez-Ramos L, Kaunitz AM, Kerwin AJ, Diaz J. Maternal death caused by midgut volvulus after bariatric surgery.  Am J Obstet Gynecol. 2005;193(5):1748-1749
PubMed   |  Link to Article
Graubard Z, Graham KM, Schein M. Small-bowel obstruction in pregnancy after Scopinaro weight reduction operation: a case report.  S Afr Med J. 1988;73(2):127-128
PubMed
Ahmed AR, O'malley W. Internal hernia with Roux loop obstruction during pregnancy after gastric bypass surgery.  Obes Surg. 2006;16(9):1246-1248
PubMed   |  Link to Article
Bellanger DE, Ruiz JF, Solar K. Small bowel obstruction complicating pregnancy after laparoscopic gastric bypass.  Surg Obes Relat Dis. 2006;2(4):490-492
PubMed   |  Link to Article
Baker MT, Kothari SN. Successful surgical treatment of a pregnancy-induced Petersen's hernia after laparoscopic gastric bypass.  Surg Obes Relat Dis. 2005;1(5):506-508
PubMed   |  Link to Article
Fleser PS, Villalba M. Afferent limb volvulus and perforation of the bypassed stomach as a complication of Roux-en-Y gastric bypass.  Obes Surg. 2003;13(3):453-456
PubMed   |  Link to Article
Wax JR, Wolff R, Cobean R, Pinette MG, Blackstone J, Cartin A. Intussusception complicating pregnancy following laparoscopic Roux-en-Y gastric bypass.  Obes Surg. 2007;17(7):977-979
PubMed   |  Link to Article
Wang CB, Hsieh CC, Chen CH, Lin YH, Lee CY, Tseng CJ. Strangulation of upper jejunum in subsequent pregnancy following gastric bypass surgery.  Taiwan J Obstet Gynecol. 2007;46(3):267-271
PubMed   |  Link to Article
Ramirez MM, Turrentine MA. Gastrointestinal hemorrhage during pregnancy in a patient with a history of vertical-banded gastroplasty.  Am J Obstet Gynecol. 1995;173(5):1630-1631
PubMed   |  Link to Article
Weissman A, Hagay Z, Schachter M, Dreazen E. Severe maternal and fetal electrolyte imbalance in pregnancy after gastric surgery for morbid obesity: a case report.  J Reprod Med. 1995;40(11):813-816
PubMed
Erez O, Maymon E, Mazor M. Acute gastric ulcer perforation in a 35 weeks' nulliparous patient with gastric banding.  Am J Obstet Gynecol. 2004;191(5):1721-1722
PubMed   |  Link to Article
Gaudry P, Mognol P, Fortin A, Marmuse JP. Reflection on one case of acute peritonitis due to adjustable gastric banding during pregnancy.  Gynecol Obstet Fertil. 2006;34(5):407-409
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure. Flow of Eligible Studies of Bariatric Surgery Among Women of Reproductive Age
Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Observational Studies on Maternal Pregnancy Outcomes Following Bariatric Surgery
Table Graphic Jump LocationTable 2. Observational Studies on Neonatal Outcomes Following Bariatric Surgerya
Table Graphic Jump LocationTable 3. Observational Studies of Nutritional Outcomes in Pregnancy Following Bariatric Surgery
Table Graphic Jump LocationTable 4. Observational Studies Reporting Fertility Outcomes for Patients Following Bariatric Surgery

References

Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000.  JAMA. 2002;288(14):1723-1727
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Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004.  JAMA. 2006;295(13):1549-1555
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Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-2006.  JAMA. 2008;299(20):2401-2405
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Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002.  JAMA. 2004;291(23):2847-2850
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Centers for Disease Control and Prevention.  Overweight and obesity. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm. Accessed October 18, 2008
Courneya KS, Katzmarzyk PT, Bacon E. Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey.  Cancer. 2008;112(11):2475-2482
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Katzmarzyk PT, Janssen I, Ross R, Church TS, Blair SN. The importance of waist circumference in the definition of metabolic syndrome: prospective analyses of mortality in men.  Diabetes Care. 2006;29(2):404-409
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Ramos RG, Olden K. The prevalence of metabolic syndrome among US women of childbearing age.  Am J Public Health. 2008;98(6):1122-1127
PubMed   |  Link to Article
World Health Organization.  Controlling the global obesity epidemic. http://www.who.int/nutrition/topics/obesity/en. Accessed October 18, 2008
Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity.  JAMA. 2007;298(17):2028-2037
PubMed   |  Link to Article
Poirier P, Giles TD, Bray GA,  et al; American Heart Association; Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism.  Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism.  Circulation. 2006;113(6):898-918
PubMed   |  Link to Article
Poirier P, Giles TD, Bray GA,  et al.  Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss.  Arterioscler Thromb Vasc Biol. 2006;26(5):968-976
PubMed   |  Link to Article
Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity.  Obes Res. 2002;10:(Suppl 2)  97S-104S
PubMed   |  Link to Article
Allison DB, Pi-Sunyer FX. Obesity treatment: examining the premises.  Endocr Pract. 1995;1(5):353-364
PubMed   |  Link to Article
American Society for Metabolic & Bariatric Surgery.  Bariatric surgical society takes on new name, new mission, and new surgery. http://www.asbs.org/Newsite07/resources/press_release_8202007.pdf. Posted August 22, 2007. Accessed October 18, 2008
Agency for Healthcare Research and Quality.  HCUP Nationwide Inpatient Sample (NIS)Rockville, MD: Healthcare Cost and Utilization Project (HCUP); 2000-2001
Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures.  JAMA. 2005;294(15):1909-1917
PubMed   |  Link to Article
Ducarme G, Revaux A, Rodrigues A, Aissaoui F, Pharisien I, Uzan M. Obstetric outcome following laparoscopic adjustable gastric banding.  Int J Gynaecol Obstet. 2007;98(3):244-247
PubMed   |  Link to Article
Wax JR, Cartin A, Wolff R, Lepich S, Pinette MG, Blackstone J. Pregnancy following gastric bypass surgery for morbid obesity: maternal and neonatal outcomes.  Obes Surg. 2008;18(5):540-544
PubMed   |  Link to Article
Patel JA, Patel NA, Thomas RL, Nelms JK, Colella JJ. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass.  Surg Obes Relat Dis. 2008;4(1):39-45
PubMed   |  Link to Article
Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable gastric banding.  Obstet Gynecol. 2005;106(5 Pt 1):965-972
PubMed   |  Link to Article
Dixon JB, Dixon ME, O'Brien PE. Pregnancy after Lap-Band surgery: management of the band to achieve healthy weight outcomes.  Obes Surg. 2001;11(1):59-65
PubMed   |  Link to Article
Skull AJ, Slater GH, Duncombe JE, Fielding GA. Laparoscopic adjustable banding in pregnancy: safety, patient tolerance and effect on obesity-related pregnancy outcomes.  Obes Surg. 2004;14(2):230-235
PubMed   |  Link to Article
Richards DS, Miller DK, Goodman GN. Pregnancy after gastric bypass for morbid obesity.  J Reprod Med. 1987;32(3):172-176
PubMed
Wittgrove AC, Jester L, Wittgrove P, Clark GW. Pregnancy following gastric bypass for morbid obesity.  Obes Surg. 1998;8(4):461-464, 465-466
PubMed   |  Link to Article
Landsberger E, Ankrah Y, Segal-Isaacson CJ,  et al.  Should severly obese women complete childbearing prior to bariatric surgery? [abstract].  Am J Obstet Gynecol. 2006;195:S93
Link to Article
Bilenka B, Ben-Shlomo I, Cozacov C, Gold CH, Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity.  Acta Obstet Gynecol Scand. 1995;74(1):42-44
PubMed   |  Link to Article
Deitel M, Stone E, Kassam HA, Wilk EJ, Sutherland DJ. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery.  J Am Coll Nutr. 1988;7(2):147-153
PubMed
Friedman D, Cuneo S, Valenzano M,  et al.  Pregnancies in an 18-year follow-up after biliopancreatic diversion.  Obes Surg. 1995;5(3):308-313
PubMed   |  Link to Article
Kral JG, Biron S, Simard S,  et al.  Large maternal weight loss from obesity surgery prevents transmission of obesity to children who were followed for 2 to 18 years.  Pediatrics. 2006;118(6):e1644-e1649
PubMed   |  Link to Article
Sheiner E, Levy A, Silverberg D,  et al.  Pregnancy after bariatric surgery is not associated with adverse perinatal outcome.  Am J Obstet Gynecol. 2004;190(5):1335-1340
PubMed   |  Link to Article
Weintraub A, Levy A, Levy I, Wiznitzer A, Mazor M, Sheiner E. Downsizing gestational complications: pregnancy outcomes before and after bariatric surgery [abstract].  Am J Obstet Gynecol. 2007;197:S186
Link to Article
Heinzen M, Ismail M, Ahn J. Perinatal outcomes in women with a history of bariatric surgery [abstract].  Am J Obstet Gynecol. 2006;195:S208
Link to Article
Bar-Zohar D, Azem F, Klausner J, Abu-Abeid S. Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gestational weight gain.  Surg Endosc. 2006;20(10):1580-1583
PubMed   |  Link to Article
Weiner R, Blanco-Engert R, Weiner S, Matkowitz R, Schaefer L, Pomhoff I. Outcome after laparoscopic adjustable gastric banding: 8 years experience.  Obes Surg. 2003;13(3):427-434
PubMed   |  Link to Article
Weiss HG, Nehoda H, Labeck B, Hourmont K, Marth C, Aigner F. Pregnancies after adjustable gastric banding.  Obes Surg. 2001;11(3):303-306
PubMed   |  Link to Article
Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding.  Obstet Gynecol. 2000;95(6 Pt 1):927-930
PubMed   |  Link to Article
Martin LF, Finigan KM, Rabner JG, Greenstein RJ. Adjustable gastric banding and pregnancy [abstract].  Obes Surg. 1997;7:280-281
Jasaitis Y, Sergent F, Bridoux V, Paquet M, Marpeau L, Teniere P. Management of pregnancies after adjustable gastric banding [in French].  J Gynecol Obstet Biol Reprod (Paris). 2007;36(8):764-769
PubMed   |  Link to Article
Jester L, Wittgrove AC, Clark GW. Evaluation of pregnancy after bariatric surgery and a developmental study of the children over two years of age [abstract].  Obes Surg. 1997;7:280
Marceau P, Kaufman D, Biron S,  et al.  Outcome of pregnancies after biliopancreatic diversion.  Obes Surg. 2004;14(3):318-324
PubMed   |  Link to Article
Rand CS, Macgregor AM. Medical care and pregnancy outcome after gastric bypass surgery for obesity.  South Med J. 1989;82(10):1319-1320
PubMed   |  Link to Article
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