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1 Graviditet och obesitaskirurgi: Vad händer med mor och foster? Kari Johansson, nutritionist, med dr Martin Neovius, docent Enheten för klinisk epidemiologi, Karolinska Institutet
2 Acknowledgement Co-authors Ingmar Näslund MD, PhD Bariatric Surgeon SOReg Sven Cnattingius MD, PhD ObGyn Nathalie Roos MD, PhD ObGyn Olof Stephansson MD, PhD ObGyn Fredrik Granath PhD Statistician Ylva Trolle MD, PhD Endocrinologist Kari Johansson PhD Nutritionist Martin Neovius PhD Epidemiologist
3 Background & Aim Obesity & Pregnancy + Preeclampsia + Gestational diabetes + Macrosomia + Preterm birth + Stillbirth Does voluntary weight loss prior to pregnancy prevent these outcomes?
4 Post Bariatric Surgery Deliveries Roos et al, BMJ 2013
5 Post Bariatric Surgery Deliveries n ALL Gastric Bypass Vertical-Banded Gastroplasty Gastric Banding 412 other gastric bypass Year of Delivery Johansson et al, NEJM 2015
6 Evidence Status Rates of many adverse maternal and neonatal outcomes may be lower [after bariatric surgery] JAMA 2008 however, further data are needed from rigorously designed studies
7 Evidence Status Pregnancy after bariatric surgery seems safe AOGS 2013 But large studies matching or adjusting for body mass index are needed to improve the surveillance of these pregnancies and to assist in preventing adverse outcomes
8 Large Studies Matching for BMI Roos et al, BMJ 2013 Johansson et al, NEJM 2015
9 Methods Nationwide Data Sources Medical Birth Register National Patient Register Scandinavian Obesity Surgery Registry (SOReg) Prescribed Drug Register Outcomes Perinatal: Maternal: Preterm Birth, Birth Weight, Mortality Gestational Diabetes, Preeclampsia
10 Methods Population-based nationwide matched cohort studies 5 comparators per bariatric surgery woman Matching factors Age BMI Smoking status Education level Parity Delivery year
11 Two Different Questions 1 Early Pregnancy BMI (Roos et al, BMJ 2013) 2 Pre-Surgery BMI (Johansson et al, NEJM 2015) How handle similar pregnant women with/without bariatric surgery history? ObGyn & Midwives Does risk differ before/after bariatric surgery? Attempt to mimic RCT
12 Results Cohort Characteristics Roos et al, BMJ 2013 Johansson et al, NEJM 2015 Year Births BMI matching Early-pregnancy BMI Pre-Surgery BMI N, births post surgery/controls 2457/12, /2356 Bariatric surgery procedure GBP 34% VBG 38% Banding 28% GBP 98% Pre-surgery BMI (surgery vs control) - 44 vs 42 Early-pregnancy BMI (surgery vs control) 30 vs vs 42
13 Weight Change Surgery to Pregnancy Johansson et al, NEJM 2015
14 Perinatal Outcomes Preterm Birth (<37 weeks of gestation) Birth weight Small for Gestational Age Large for Gestational Age Stillbirth Neonatal Death (<28 days)
15 Preterm Birth Early-Pregnancy BMI match Pre-Surgery BMI match 10% 10% 8% Bariatric Surgery History 8% Bariatric Surgery History 6% 6% P<0.001 P=0.15 4% Matched Control Group 4% Matched Control Group 2% 2% 0% no.events / total no. Bariatric Surgery Group Matched Control Group Preterm (<37 weeks) 243/ /12,379 0% no.events / total no. Bariatric Surgery Group Matched Control Group Preterm (<37 weeks) 59/ /2344 Roos et al, BMJ 2013 Johansson et al, NEJM 2015
16 Birth Weight Early-Pregnancy BMI match Pre-Surgery BMI match 10% 20% 8% 6% 15% 4% 10% 2% P<0.001 P< % P<0.001 P< % 0% no.events / total no. SGA <2SDs LGA >2SDs SGA <10perc no.events / total no. LGA >90perc Bariatric Surgery Group Matched Control Group 131/ /12, / /12,338 Bariatric Surgery Group Matched Control Group 92/ / / /2336 Roos et al, BMJ 2013 Johansson et al, NEJM 2015
17 Mortality Early-Pregnancy BMI match Pre-Surgery BMI match 2.0% 2.0% 1.5% 1.5% 1.0% 1.0% 0.5% 0.5% P=0.056 P= % P= % no.events / total no. Stillbirth Neonatal Death (<28 Days) Stillbirth+Neonatal no.events / total no. Death (<28 Days) Bariatric Surgery Group Matched Control Group 20/ /12,464 7/ /12,393 Bariatric Surgery Group Matched Control Group 10/596 17/2356 Roos et al, BMJ 2013 Johansson et al, NEJM 2015
18 Pregnancy After Bariatric Surgery Small studies Conflicting results Maggard MA et al. Pregnancy and fertility following bariatric surgery: a systematic review JAMA 2008 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? NO* * Except for LGA
19 Maternal Outcomes Women with bariatric history Gestational diabetes Preeclampsia Ducarme et al. Obstetric outcome following laparoscopic adjustable gastric banding. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2007;98:244-7 Wax et al. Pregnancy following gastric bypass surgery for morbid obesity: maternal and neonatal outcomes. Obesity surgery 2008;18:540-4 Patel et al. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2008;4:39-45 Josefsson et al. Bariatric surgery in a national cohort of women: sociodemographics and obstetric outcomes. American journal of obstetrics and gynecology 2011;205:206 e1-8 Lesko et al. Pregnancy outcomes in women after bariatric surgery compared with obese and morbidly obese controls. Obstetrics and gynecology 2012;119:547-54
20 Gestational Diabetes Pre-Surgery BMI match 10% 8% 6% 4% 2% 0% no.events / total no. Bariatric Surgery Group Matched Control Group P<0.001 Gestational Diabetes 11/ /2294 Johansson et al, NEJM 2015
21 Preeclampsia Pre-Surgery BMI match 10% 8% 6% 4% 2% 0% no.events / total no. Bariatric Surgery Group Matched Control Group P<0.001 Gestational Diabetes 10/ /2247 Abstract TOS2014
22 Pregnancy After Bariatric Surgery Small studies Conflicting results Maggard MA et al. Pregnancy and fertility following bariatric surgery: a systematic review JAMA 2008 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 YES NO* * Except for LGA
23 SUMMARY Maternal Outcomes (-) Gestational Diabetes (-) Preeclampsia Perinatal Outcomes (+/0) Preterm Birth /Preterm Birth Early-pregnancy/Pre-surgery match (+) Small for Gestational Age (-) Large for Gestational Age (0/?+) Stillbirth & Neonatal Mortality Early-pregnancy/Pre-surgery match
24 CONCLUSION Bariatric surgery has both positive and negative influences on a subsequent pregnancy Pregnancies after bariatric surgery should be viewed as high risk => Increase fetal growth and nutritional monitoring
25 appendix
26 Subgroup Analysis Roos et al, BMJ 2013
Graviditet och obesitaskirurgi:
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