Neonatal Outcomes May Be Better With Vaginal Birth After Cesarean Delivery
by Laurie Barclay & Charles Vega
June 3, 2009 — Neonates born after elective subsequent cesarean delivery have significantly higher rates of respiratory morbidity and neonatal intensive care unit (NICU) admission and longer length of hospital stay vs those with vaginal birth after cesarean (VBAC), according to the results of a retrospective cohort study reported in the June issue of Obstetrics & Gynecology.
"Controversy remains on whether a trial of labor or an elective repeat cesarean delivery is preferable for a woman with a history of cesarean delivery," write Beena D. Kamath, MD, MPH, from the University of Colorado School of Medicine in Denver, and colleagues. "Historically, concerns regarding the increased risk of uterine rupture and perinatal asphyxia in trial of labor after cesarean compared with planned repeat cesarean have swayed obstetricians away from recommending a trial of labor after cesarean delivery; however, the absolute risk of perinatal asphyxia remains small."
The goals of this study were to compare the outcomes of neonates born by elective subsequent cesarean delivery vs VBAC in women with 1 previous cesarean delivery and to compare the cost differences between these procedures. The study cohort consisted of 672 women with 1 previous cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Participants were categorized based on their intention to have an elective subsequent cesarean delivery or a VBAC, whether successful or failed. The main endpoints of the study were NICU admission and measures of respiratory morbidity.
Compared with the VBAC group, neonates born by cesarean delivery had higher NICU admission rates (9.3% vs 4.9%; P = .025). Rates of oxygen supplementation were also higher in the subsequent cesarean group for delivery room resuscitation (41.5% vs 23.2%; P < .01) and after NICU admission (5.8% vs 2.4%; P < .028). The rates of delivery room resuscitation with oxygen were lowest in neonates born by VBAC and highest in neonates delivered after failed VBAC.
Although the costs of elective subsequent cesarean delivery were significantly higher vs VBAC, the highest costs for the total birth experience were for failed VBAC, considering both delivery and NICU use.
"In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay," the study authors write.
Limitations of this study include relatively short postpartum follow-up of the mothers to determine the additional costs of postsurgical complications and insufficient data to allow estimation of costs other than those for hospital care.
"Given the increasing rates of primary cesarean delivery and the concomitant decrease in VBACs, once a woman has had a primary cesarean delivery, we must consider the risks that this places on her subsequent deliveries and subsequent neonates," the study authors conclude. "Indeed, this argues for greater selectivity in performing a cesarean delivery in the first place, and certainly a greater need for counseling before a primary elective cesarean delivery. As investigators continue to search for ways to make cesarean delivery safer, we may be better served by exploring other means for reducing overall cesarean delivery rates and recognizing our own preoccupation with the individual that will be our patient, whether it be mother or neonate."
Obstet Gynecol. 2009;113:1231-1238.
Clinical Context
The rate of cesarean delivery has reached an all-time high in the United States, and the current study provides an overview of the epidemiology of cesarean delivery. In 2006, 31.1% of all deliveries were via cesarean, and this rate was fueled by an increase in the rate of primary cesarean delivery by 60% between 1996 and 2005.
Women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery. Overall, more than half of cesarean deliveries are performed electively, before the onset of labor.
The current study examines neonatal outcomes in women with a history of primary cesarean delivery, with the primary variable being VBAC vs subsequent elective cesarean delivery.
Clinical Implications
The rate of cesarean deliveries in the United States was 31.1% in 2006, and an increase in the rate of primary cesarean deliveries was primarily responsible for this high rate. In addition, women with a primary cesarean delivery have a greater than 90% chance of having another cesarean delivery, and more than half of all cesarean deliveries are performed electively, before the onset of labor.
The current study finds that the rate of NICU admission is higher in infants delivered via elective subsequent cesarean delivery vs VBAC. Overall, elective subsequent cesarean delivery was estimated to be a more costly strategy.
article: http://cme.medscape.com/viewarticle/703772?src=cmemp
Wednesday, June 17, 2009
Tuesday, June 16, 2009
Postnatal Shopping - Rear Facing Car Seats
Rear-Facing Car Seats Advised for Children Under 4 Years of Age
From Reuters Health Information
Jun 12 - Children under 4 years of age fare better in motor vehicle accidents when they are riding in rear- rather than forward-facing car seats, according to a review published online in the British Medical Journal.
Infants are typically switched from a rear- to a forward-facing seat when they weigh 9 kilograms, which occurs at roughly 8 months of age for an average boy, study authors Dr. Elizabeth A. Watson and Dr. Michael J. Monteiro, from Royal Surrey County Hospital, Guildford, UK, note. They add, however, that growing evidence suggests it may be best to delay the switch until 4 years of age.
In Sweden, for example, it is common for children to ride in rear-facing seats until 4 years of age, and there is data that may fatalities in young forward-facing riders could have been averted with a rear-facing seat.
Similarly, an analysis of US National Highway Traffic Safety Administration data on 870 children involved in crashes from 1998 to 2003 found that through 23 months of age, better protection from all crash types was provided with rear-facing seats.
In terms of specific injuries, recent crash test results suggest that use of rear- rather than forward-facing seats affords better protection of the lower neck and chest, the authors note. In another crash simulation study, it was concluded that manufacturers should developed rear-facing seats for children up to 4 years old.
Drs. Watson and Monteiro note that in contrast to forward-facing seats, rear-facing seats provide full alignment of the head, neck, and spine, so that crash forces are dispersed over these areas rather than centered on one site.
The message for healthcare professionals, the authors state, is that they should recommend rear-facing car seats for children under 4 years of age. To fully address the issue, however, seat manufacturers and retailers need to "increase the availability of rear-facing car seats for children over 9 kg."
BMJ 2009.
From Reuters Health Information
Jun 12 - Children under 4 years of age fare better in motor vehicle accidents when they are riding in rear- rather than forward-facing car seats, according to a review published online in the British Medical Journal.
Infants are typically switched from a rear- to a forward-facing seat when they weigh 9 kilograms, which occurs at roughly 8 months of age for an average boy, study authors Dr. Elizabeth A. Watson and Dr. Michael J. Monteiro, from Royal Surrey County Hospital, Guildford, UK, note. They add, however, that growing evidence suggests it may be best to delay the switch until 4 years of age.
In Sweden, for example, it is common for children to ride in rear-facing seats until 4 years of age, and there is data that may fatalities in young forward-facing riders could have been averted with a rear-facing seat.
Similarly, an analysis of US National Highway Traffic Safety Administration data on 870 children involved in crashes from 1998 to 2003 found that through 23 months of age, better protection from all crash types was provided with rear-facing seats.
In terms of specific injuries, recent crash test results suggest that use of rear- rather than forward-facing seats affords better protection of the lower neck and chest, the authors note. In another crash simulation study, it was concluded that manufacturers should developed rear-facing seats for children up to 4 years old.
Drs. Watson and Monteiro note that in contrast to forward-facing seats, rear-facing seats provide full alignment of the head, neck, and spine, so that crash forces are dispersed over these areas rather than centered on one site.
The message for healthcare professionals, the authors state, is that they should recommend rear-facing car seats for children under 4 years of age. To fully address the issue, however, seat manufacturers and retailers need to "increase the availability of rear-facing car seats for children over 9 kg."
BMJ 2009.
Postnatal Shopping - Car Seats
Rear-Facing Car Seats Advised for Children Under 4 Years of Age
From Reuters Health Information
Jun 12 - Children under 4 years of age fare better in motor vehicle accidents when they are riding in rear- rather than forward-facing car seats, according to a review published online in the British Medical Journal.
Infants are typically switched from a rear- to a forward-facing seat when they weigh 9 kilograms, which occurs at roughly 8 months of age for an average boy, study authors Dr. Elizabeth A. Watson and Dr. Michael J. Monteiro, from Royal Surrey County Hospital, Guildford, UK, note. They add, however, that growing evidence suggests it may be best to delay the switch until 4 years of age.
In Sweden, for example, it is common for children to ride in rear-facing seats until 4 years of age, and there is data that many fatalities in young forward-facing riders could have been averted with a rear-facing seat.
Similarly, an analysis of US National Highway Traffic Safety Administration data on 870 children involved in crashes from 1998 to 2003 found that through 23 months of age, better protection from all crash types was provided with rear-facing seats.
In terms of specific injuries, recent crash test results suggest that use of rear- rather than forward-facing seats affords better protection of the lower neck and chest, the authors note. In another crash simulation study, it was concluded that manufacturers should developed rear-facing seats for children up to 4 years old.
Drs. Watson and Monteiro note that in contrast to forward-facing seats, rear-facing seats provide full alignment of the head, neck, and spine, so that crash forces are dispersed over these areas rather than centered on one site.
The message for healthcare professionals, the authors state, is that they should recommend rear-facing car seats for children under 4 years of age. To fully address the issue, however, seat manufacturers and retailers need to "increase the availability of rear-facing car seats for children over 9 kg."
BMJ 2009.
From Reuters Health Information
Jun 12 - Children under 4 years of age fare better in motor vehicle accidents when they are riding in rear- rather than forward-facing car seats, according to a review published online in the British Medical Journal.
Infants are typically switched from a rear- to a forward-facing seat when they weigh 9 kilograms, which occurs at roughly 8 months of age for an average boy, study authors Dr. Elizabeth A. Watson and Dr. Michael J. Monteiro, from Royal Surrey County Hospital, Guildford, UK, note. They add, however, that growing evidence suggests it may be best to delay the switch until 4 years of age.
In Sweden, for example, it is common for children to ride in rear-facing seats until 4 years of age, and there is data that many fatalities in young forward-facing riders could have been averted with a rear-facing seat.
Similarly, an analysis of US National Highway Traffic Safety Administration data on 870 children involved in crashes from 1998 to 2003 found that through 23 months of age, better protection from all crash types was provided with rear-facing seats.
In terms of specific injuries, recent crash test results suggest that use of rear- rather than forward-facing seats affords better protection of the lower neck and chest, the authors note. In another crash simulation study, it was concluded that manufacturers should developed rear-facing seats for children up to 4 years old.
Drs. Watson and Monteiro note that in contrast to forward-facing seats, rear-facing seats provide full alignment of the head, neck, and spine, so that crash forces are dispersed over these areas rather than centered on one site.
The message for healthcare professionals, the authors state, is that they should recommend rear-facing car seats for children under 4 years of age. To fully address the issue, however, seat manufacturers and retailers need to "increase the availability of rear-facing car seats for children over 9 kg."
BMJ 2009.
Postnatal Depression Screening
Screening at 2 Months Identifies Most Women With Postpartum Depression
by Caroline Cassels & Désirée Lie
Pediatrics. 2009;123: e982 - e988. Abstract
Medscape Psychiatry & Medical News
June 15, 2009 — Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.
EPDS (Edinburgh Postpartum Depression Scale) scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.
Screening Before 2 Months Not Useful
The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months.
However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
The authors note that if women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.
No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
Clinical Context
All new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
for Study Highlights see article:
http://cme.medscape.com/viewarticle/704382?sssdmh=dm1.486302&src=nldne
by Caroline Cassels & Désirée Lie
Pediatrics. 2009;123: e982 - e988. Abstract
Medscape Psychiatry & Medical News
June 15, 2009 — Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.
EPDS (Edinburgh Postpartum Depression Scale) scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.
Screening Before 2 Months Not Useful
The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months.
However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
The authors note that if women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.
No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
Clinical Context
All new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
for Study Highlights see article:
http://cme.medscape.com/viewarticle/704382?sssdmh=dm1.486302&src=nldne
Sunday, June 14, 2009
Obese women - should they gain weight in pregnancy?
From Reuters Health Information
New Study Questions Pregnancy Weight Gain for Obese Women
Jun 09 - Newly published research is challenging guidelines from the American College of Obstetricians and Gynecologists stating that all women, even those who are obese, should gain between 26 to 35 pounds during their pregnancy.
The Institute of Medicine has recommended a lower amount of weight gain for overweight and obese patients, about 15 pounds, but the new data suggest that even this is too much and goes on to show that these patients can safely be placed on a calorie-appropriate nutritional program.
"Women who are obese when beginning a pregnancy are, by definition, unhealthy," lead author Dr. Yvonne S. Thornton, from New York Medical College, Valhalla, said in a statement. "To say that they should gain even more weight is counter-intuitive, and our study bears that out."
The study, reported in the Journal of the National Medical Association for June, featured 232 obese pregnant women who were randomized to follow conventional "eat to appetite" prenatal nutritional guidelines or to participate in a well-balanced, monitored nutritional program involving the use of daily food diaries.
On average, women in the study group gained 11 pounds, while controls gained 31 pounds. Twenty-three subjects with extreme obesity lost weight during their pregnancy.
Contrary to what some prior researchers may have feared, use of the nutritionally monitored program did not result in any fetal deaths or any growth-restricted infants.
On the plus side, women who adhered to the nutritional regimen had fewer babies weighing over 10 pounds, fewer cesarean sections, a lower rate of gestational diabetes, and retained less weight after delivery.
"Rather than focusing on numerical endpoints with respect to weight gain, we need to focus on making (obese) women healthier by getting them to eat a well-balanced diet," Dr. Thornton emphasized.
The statement from New York Medical College notes, "The study grew out of Dr. Thornton's personal experience with obesity and pregnancy. Despite being overweight, she gained a substantial amount of weight during her first pregnancy, exacerbating her life-long battle with obesity. During her second pregnancy, she followed a well balanced diet and gained little weight, with no adverse consequences for mother or baby. Dr. Thornton observed the same pattern in her own clinical practice, leading her to question prevailing guidelines for weight gain during pregnancy."
J Nat Med
http://www.medscape.com/viewarticle/704113?sssdmh=dm1.484181&src=nldne Assoc 2009
New Study Questions Pregnancy Weight Gain for Obese Women
Jun 09 - Newly published research is challenging guidelines from the American College of Obstetricians and Gynecologists stating that all women, even those who are obese, should gain between 26 to 35 pounds during their pregnancy.
The Institute of Medicine has recommended a lower amount of weight gain for overweight and obese patients, about 15 pounds, but the new data suggest that even this is too much and goes on to show that these patients can safely be placed on a calorie-appropriate nutritional program.
"Women who are obese when beginning a pregnancy are, by definition, unhealthy," lead author Dr. Yvonne S. Thornton, from New York Medical College, Valhalla, said in a statement. "To say that they should gain even more weight is counter-intuitive, and our study bears that out."
The study, reported in the Journal of the National Medical Association for June, featured 232 obese pregnant women who were randomized to follow conventional "eat to appetite" prenatal nutritional guidelines or to participate in a well-balanced, monitored nutritional program involving the use of daily food diaries.
On average, women in the study group gained 11 pounds, while controls gained 31 pounds. Twenty-three subjects with extreme obesity lost weight during their pregnancy.
Contrary to what some prior researchers may have feared, use of the nutritionally monitored program did not result in any fetal deaths or any growth-restricted infants.
On the plus side, women who adhered to the nutritional regimen had fewer babies weighing over 10 pounds, fewer cesarean sections, a lower rate of gestational diabetes, and retained less weight after delivery.
"Rather than focusing on numerical endpoints with respect to weight gain, we need to focus on making (obese) women healthier by getting them to eat a well-balanced diet," Dr. Thornton emphasized.
The statement from New York Medical College notes, "The study grew out of Dr. Thornton's personal experience with obesity and pregnancy. Despite being overweight, she gained a substantial amount of weight during her first pregnancy, exacerbating her life-long battle with obesity. During her second pregnancy, she followed a well balanced diet and gained little weight, with no adverse consequences for mother or baby. Dr. Thornton observed the same pattern in her own clinical practice, leading her to question prevailing guidelines for weight gain during pregnancy."
J Nat Med
http://www.medscape.com/viewarticle/704113?sssdmh=dm1.484181&src=nldne Assoc 2009
Thursday, June 11, 2009
Pregnancy after bariatric surgery for obesity
ACOG Issues Guidelines on Managing Obesity in Pregnancy CME/CE
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
June 9, 2009 — 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 recommendations.
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 approach 62%.
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 surgeon.
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 pregnancy.
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 loss goals.
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.
Clinical Context
Obesity is associated with adverse outcomes of pregnancy, and the incidence in reproductive-age women has increased in the United States by 70% from 1994 to 2003. Bariatric surgery is the most effective treatment of morbid obesity for improvement of comorbidities and quality of life but has consequences for subsequent pregnancy.
This is a review of the risks associated with obesity and recommendations on care of pregnant women who have previously undergone bariatric surgery.
Study Highlights
Increased maternal body mass index increases the risk for stillbirth by 2.1 to 4.3 times and increases the risk for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity but not the risk for preterm delivery.
Bariatric surgery is available to women with a body mass index of 40 kg/m2 or higher or 35 kg/m2 or higher and other comorbidities.
The procedure may have restrictive and malabsorptive effects.
The number of bariatric procedures per year has increased from 12,480 in 1998 to 113,500 in 2005, and 80% are performed in women, with one half of them performed in women with a mean age of 40 years.
Operative complications of bariatric surgery include anastomotic leaks, bowel obstructions, internal or ventral hernias, band erosion, and band migration; all gastrointestinal tract problems occurring after surgery should be evaluated for these complications.
Dumping syndrome with associated nausea, weight loss, cramps, bloating, and distension may occur.
Rapid weight loss follows bariatric surgery with improvement in fertility, but bariatric surgery is not considered a treatment of infertility.
Women undergoing bariatric surgery are more likely to have had previous cesarean delivery (15.4% vs 10.5%; P = .006), gestational diabetes (9.4% vs 5.0%; P < .001), preeclampsia, and given birth via cesarean delivery (25.2% vs 12.2%; P < .001).
After bariatric surgery, the risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia is reduced.
Although the risk for premature rupture of membranes is increased after bariatric surgery, the risk for preterm delivery is not increased.
Some authorities recommend waiting 12 to 24 months after bariatric surgery before conceiving to minimize exposure of the fetus to rapid maternal weight loss.
Should pregnancy occur before this timeframe, closer surveillance of nutritional status is recommended.
The rate of congenital anomalies and perinatal death after bariatric surgery is not increased.
After bariatric surgery, there is a lower rate of large-for-gestational-age infants and macrosomia.
The ACOG recommends the following for women after bariatric surgery:
Contraceptive counseling is important especially for adolescents because pregnancy rates double after bariatric surgery.
Nonoral administration of hormonal contraception should be considered because of a higher failure rate with oral contraception because of malabsorption.
Medications may not be well absorbed, and testing for therapeutic levels may be indicated.
During pregnancy, there should be a high index of suspicion for gastrointestinal tract symptoms being complications of the bariatric surgery.
Counseling for weight gain and nutrition should be offered during pregnancy.
Because of dumping syndrome, an alternate method to the 50-g glucose load to screen for gestational diabetes should be considered.
Bariatric surgery is not an indication for cesarean delivery, although the rate of cesarean delivery may be as high as 62%.
There is no consensus on management of pregnant patients who have had an adjustable gastric banding procedure, but early consultation with a bariatric surgeon is recommended.
Nutrition consultation is recommended because of macronutrient and micronutrient effects of surgery because of malabsorption.
An evaluation for micronutrient deficiencies at the beginning of pregnancy should be considered.
Clinical Implications
Bariatric surgery is associated with a reduced risk for preeclampsia, hypertension, pregestational and gestational diabetes, and an increased incidence of cesarean delivery in pregnant women.
In pregnant women with a history of bariatric surgery, some of the ACOG recommendations include: contraceptive counseling for adolescents, prenatal care assessment for nutritional deficiencies, and non-oral administration of hormonal contraception.
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
June 9, 2009 — 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 recommendations.
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 approach 62%.
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 surgeon.
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 pregnancy.
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 loss goals.
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.
Clinical Context
Obesity is associated with adverse outcomes of pregnancy, and the incidence in reproductive-age women has increased in the United States by 70% from 1994 to 2003. Bariatric surgery is the most effective treatment of morbid obesity for improvement of comorbidities and quality of life but has consequences for subsequent pregnancy.
This is a review of the risks associated with obesity and recommendations on care of pregnant women who have previously undergone bariatric surgery.
Study Highlights
Increased maternal body mass index increases the risk for stillbirth by 2.1 to 4.3 times and increases the risk for gestational diabetes, preeclampsia, cesarean delivery, and infectious morbidity but not the risk for preterm delivery.
Bariatric surgery is available to women with a body mass index of 40 kg/m2 or higher or 35 kg/m2 or higher and other comorbidities.
The procedure may have restrictive and malabsorptive effects.
The number of bariatric procedures per year has increased from 12,480 in 1998 to 113,500 in 2005, and 80% are performed in women, with one half of them performed in women with a mean age of 40 years.
Operative complications of bariatric surgery include anastomotic leaks, bowel obstructions, internal or ventral hernias, band erosion, and band migration; all gastrointestinal tract problems occurring after surgery should be evaluated for these complications.
Dumping syndrome with associated nausea, weight loss, cramps, bloating, and distension may occur.
Rapid weight loss follows bariatric surgery with improvement in fertility, but bariatric surgery is not considered a treatment of infertility.
Women undergoing bariatric surgery are more likely to have had previous cesarean delivery (15.4% vs 10.5%; P = .006), gestational diabetes (9.4% vs 5.0%; P < .001), preeclampsia, and given birth via cesarean delivery (25.2% vs 12.2%; P < .001).
After bariatric surgery, the risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia is reduced.
Although the risk for premature rupture of membranes is increased after bariatric surgery, the risk for preterm delivery is not increased.
Some authorities recommend waiting 12 to 24 months after bariatric surgery before conceiving to minimize exposure of the fetus to rapid maternal weight loss.
Should pregnancy occur before this timeframe, closer surveillance of nutritional status is recommended.
The rate of congenital anomalies and perinatal death after bariatric surgery is not increased.
After bariatric surgery, there is a lower rate of large-for-gestational-age infants and macrosomia.
The ACOG recommends the following for women after bariatric surgery:
Contraceptive counseling is important especially for adolescents because pregnancy rates double after bariatric surgery.
Nonoral administration of hormonal contraception should be considered because of a higher failure rate with oral contraception because of malabsorption.
Medications may not be well absorbed, and testing for therapeutic levels may be indicated.
During pregnancy, there should be a high index of suspicion for gastrointestinal tract symptoms being complications of the bariatric surgery.
Counseling for weight gain and nutrition should be offered during pregnancy.
Because of dumping syndrome, an alternate method to the 50-g glucose load to screen for gestational diabetes should be considered.
Bariatric surgery is not an indication for cesarean delivery, although the rate of cesarean delivery may be as high as 62%.
There is no consensus on management of pregnant patients who have had an adjustable gastric banding procedure, but early consultation with a bariatric surgeon is recommended.
Nutrition consultation is recommended because of macronutrient and micronutrient effects of surgery because of malabsorption.
An evaluation for micronutrient deficiencies at the beginning of pregnancy should be considered.
Clinical Implications
Bariatric surgery is associated with a reduced risk for preeclampsia, hypertension, pregestational and gestational diabetes, and an increased incidence of cesarean delivery in pregnant women.
In pregnant women with a history of bariatric surgery, some of the ACOG recommendations include: contraceptive counseling for adolescents, prenatal care assessment for nutritional deficiencies, and non-oral administration of hormonal contraception.
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