Graviditet och obesitaskirurgi:

Transcription

1 Graviditet och obesitaskirurgi: Vad händer med mor och foster? Kari Johansson, PhD, nutritionist Enheten för klinisk epidemiologi, Karolinska Institutet

2 Acknowledgement Co-authors Sven Cnattingius MD, PhD ObGyn Fredrik Granath PhD Statistician Kari Johansson PhD Nutritionist Martin Neovius PhD Epidemiologist Ingmar Näslund MD, PhD Bariatric Surgeon SOReg Nathalie Roos MD, PhD ObGyn Olof Stephansson MD, PhD ObGyn Ylva Trolle MD, PhD Endocrinologist Funding Swedish Scientific Research Council TOS Early-Career Research Grant 2013 Karolinska Institutet Strategic Young Scholar Neovius Johansson Neovius

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 Pregnancies n ALL Gastric Bypass Vertical-Banded Gastroplasty Gastric Banding 412 other gastric bypass Year of Delivery

5 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

6 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

7 Large studies matching for BMI (early-pregnancy BMI) Bmj 2013

8 Large studies matching for BMI (pre-surgery BMI) NEJM 26 Feb 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, Fetal Growth, Mortality Gestational Diabetes, Preeclampsia

10 Methods Population-based nationwide matched cohort studies 5 comparator deliveries per delivery after bariatric surgery 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 Perinatal Outcomes Preterm Birth (<37 weeks of gestation) Intrauterine Growth Small for Gestational Age Large for Gestational Age Stillbirth Neonatal Death (<28 days)

14 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

15 Fetal Growth 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

16 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

17 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

18 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

19 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

20 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

21 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

22 No-Brainer?

23 Extrapolate No-Brainer REAL WORLD (-) Gestational Diabetes (-) Preeclampsia (-) Large for Gestational Age YES (-) Preterm Birth NO (+) (-) Stillbirth & Neonatal Death NO (+/0)

24 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

25 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