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      Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

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          Summary

          The objective of the study is to provide evidence‐based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow‐up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print‐friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high‐quality evidence and warrant further research. These areas are highlighted in the paper.

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          Most cited references 107

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          Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial.

          Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown. To compare Roux-en-Y gastric bypass with lifestyle and intensive medical management to achieve control of comorbid risk factors. A 12-month, 2-group unblinded randomized trial at 4 teaching hospitals in the United States and Taiwan involving 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher, body mass index (BMI) between 30.0 and 39.9, C peptide level of more than 1.0 ng/mL, and type 2 diabetes for at least 6 months. The study began in April 2008. Lifestyle-intensive medical management intervention and Roux-en-Y gastric bypass surgery. Medications for hyperglycemia, hypertension, and dyslipidemia were prescribed according to protocol and surgical techniques that were standardized. Composite goal of HbA1c less than 7.0%, low-density lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg. All 120 patients received the intensive lifestyle-medical management protocol and 60 were randomly assigned to undergo Roux-en-Y gastric bypass. After 12-months, 28 participants (49%; 95% CI, 36%-63%) in the gastric bypass group and 11 (19%; 95% CI, 10%-32%) in the lifestyle-medical management group achieved the primary end points (odds ratio [OR], 4.8; 95% CI, 1.9-11.7). Participants in the gastric bypass group required 3.0 fewer medications (mean, 1.7 vs 4.8; 95% CI for the difference, 2.3-3.6) and lost 26.1% vs 7.9% of their initial body weigh compared with the lifestyle-medical management group (difference, 17.5%; 95% CI, 14.2%-20.7%). Regression analyses indicated that achieving the composite end point was primarily attributable to weight loss. There were 22 serious adverse events in the gastric bypass group, including 1 cardiovascular event, and 15 in the lifestyle-medical management group. There were 4 perioperative complications and 6 late postoperative complications. The gastric bypass group experienced more nutritional deficiency than the lifestyle-medical management group. In mild to moderately obese patients with type 2 diabetes, adding gastric bypass surgery to lifestyle and medical management was associated with a greater likelihood of achieving the composite goal. Potential benefits of adding gastric bypass surgery to the best lifestyle and medical management strategies of diabetes must be weighed against the risk of serious adverse events. clinicaltrials.gov Identifier: NCT00641251.
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            Standards of Medical Care in Diabetes—2017 : Summary of Revisions

              (2017)
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              Trends in bariatric surgical procedures.

              The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity. To examine trends for elective bariatric surgical procedures, patient characteristics, and in-hospital complications from 1998 to 2003 in the United States. The Nationwide Inpatient Sample was used to identify bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states from 2003) using International Classification of Diseases, Ninth Revision, codes for foregut surgery with a confirmatory diagnosis of obesity or by diagnosis related group code for obesity surgery. Annual estimates and trends were determined for procedures, patient characteristics, and adjusted complication rates. Trends in bariatric surgical procedures, patient characteristics, and complications. The estimated number of bariatric surgical procedures increased from 13,365 in 1998 to 72,177 in 2002 (P<.001). Based on preliminary state-level data (1998-2003), the number of bariatric surgical procedures is projected to be 102 794 in 2003. Gastric bypass procedures accounted for more than 80% of all bariatric surgical procedures. From 1998 to 2002, there were upward trends in the proportion of females (81% to 84%; P = .003), privately insured patients (75% to 83%; P = .001), patients from ZIP code areas with highest annual household income (32% to 60%, P<.001), and patients aged 50 to 64 years (15% to 24%; P<.001). Length of stay decreased from 4.5 days in 1998 to 3.3 days in 2002 (P<.001). The adjusted in-hospital mortality rate ranged from 0.1% to 0.2%. The rates of unexpected reoperations for surgical complications ranged from 6% to 9% and pulmonary complications ranged from 4% to 7%. Rates of other in-hospital complications were low. These findings suggest that use of bariatric surgical procedures increased substantially from 1998 to 2003, while rates of in-hospital complications were stable and length of stay decreased. However, disparities in the use of these procedures, with disproportionate and increasing use among women, those with private insurance, and those in wealthier ZIP code areas should be explored further.
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                Author and article information

                Contributors
                roland.devlieger@uzleuven.be
                Journal
                Obes Rev
                Obes Rev
                10.1111/(ISSN)1467-789X
                OBR
                Obesity Reviews
                John Wiley and Sons Inc. (Hoboken )
                1467-7881
                1467-789X
                16 August 2019
                November 2019
                : 20
                : 11 ( doiID: 10.1111/obr.v20.11 )
                : 1507-1522
                Affiliations
                [ 1 ] Faculty of Health & Human Sciences University of Plymouth Devon UK
                [ 2 ] Department of Development and Regeneration KU Leuven Leuven Belgium
                [ 3 ] Department of Obstetrics and Gynaecology University Hospitals Leuven Leuven Belgium
                [ 4 ] Institute of Health and Society Newcastle University Newcastle upon Tyne UK
                [ 5 ] King's College Hospital NHS Foundation Trust London UK
                [ 6 ] Department of Nutritional Science, Faculty of Health and Medicine University of Surrey Guildford UK
                [ 7 ] Department of Endocrinology, Diabetes and Metabolic Diseases University Medical Centre Ljubljana Slovenia
                [ 8 ] Department of Upper Gastrointestinal and Bariatric Surgery Homerton University Hospital London UK
                [ 9 ] Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine Erasmus MC Rotterdam the Netherlands
                [ 10 ] Weill Cornell Medicine in Qatar Qatar Foundation, Education City Doha Qatar
                [ 11 ] Musgrove Park Hospital Taunton UK
                [ 12 ] Department of Diabetes and Metabolism, St. Bartholomew's Hospital and The Royal London Hospital Barts Health NHS Trust London UK
                [ 13 ] Israel Centre for Disease Control Ministry of Health Jerusalem Israel
                [ 14 ] Faculty of Health and Medical Sciences University of Surrey Guildford UK
                [ 15 ] Department of Clinical and Experimental Medicine University of Surrey Guildford UK
                [ 16 ] St. Richard's Hospital Bariatric Surgery Service, Chichester Western Sussex NHS Foundation Trust Chichester UK
                [ 17 ] Department of Obstetrics, Gynaecology and Reproduction St‐Augustinus Hospital Wilrijk Wilrijk Belgium
                Author notes
                [* ] Correspondence

                Roland Devlieger, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Herestraat 49, B3000 Leuven, Belgium.

                Email: roland.devlieger@ 123456uzleuven.be

                Article
                OBR12927 OBR-04-19-3891.R2
                10.1111/obr.12927
                6852078
                31419378
                © 2019 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 1, Tables: 4, Pages: 16, Words: 5510
                Product
                Funding
                Funded by: FWO Flanders , open-funder-registry 10.13039/501100003130;
                Award ID: 1803311N
                Funded by: Institute of Advanced Studies (IAS) , open-funder-registry 10.13039/501100000635;
                Categories
                Bariatric Surgery/Pregnancy
                Bariatric Surgery/Pregnancy
                Custom metadata
                2.0
                November 2019
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.1 mode:remove_FC converted:13.11.2019

                Medicine

                metabolic surgery, bariatric surgery, obstetrics, pregnancy, obesity, gynaecology

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