Devora Schapiro

Based on Rotation 7 Week 4 PICO

Clinical & PICO Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

Scenario: A 33 woman comes to the office for her follow up appointment after bariatric surgery. She desires several children, and wants to know what her pregnancy outcome would be after undergoing bariatric surgery.

Question:

In women who have undergone bariatric surgery what are the pregnancy outcomes for future pregnancies?

PICO Search Elements:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

P	I	C	O
Obese patients	Bariatric surgery	No surgery	Pregnancy outcomes (live, early, still birth, gestational age and gestational size)
Obese women	Sleeve gastrectomy	Medical weight loss	Fertility (ability to conceive, time to conceive)
Women	Gastric bypass surgery	No weight loss	Neonatal morbidity mortality (NICU admission)
Obese reproductive age women			Pregnancy complication (GDM, Gestational HTN)
			Perinatal morbidity (NICU admissions)

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.  This will likewise be a revision and refinement of what you have already done. A minimum of 3 search databases should be used.

Google scholar	Searched terms: pregnancy outcomes bariatric surgery. Narrowed further by timing, between 2011-2021. I narrowed further by title. Some articles discussed other outcomes of bariatric surgery and were not relevant to my outcome. Some studies looked at specific other fertility factors such as PCOS which was not my focus. I obtained 17,800 results. I sorted by most relevant.
Science direct	Searched terms: pregnancy outcomes after bariatric surgery. I narrowed by timing and title. I excluded articles that were too specific for my outcome for example I excluded a study looking at pregnancy after bariatric surgery in women with rheumatic disease. I obtained 3,238 results. I narrowed down further by most relevant.
PubMed	Searched terms: pregnancy outcome bariatric surgery. I narrowed by 10 year range, Medline journals only, and then further by title. I excluded studies that were not discussing pregnancy outcomes after bariatric surgery, I obtained a total of 1979 results. I narrowed down further by most relevant.

I found 7 articles and excluded one for having a small sample size. I chose a large cohort study, several literature reviews, and systematic reviews and meta analysis.

Articles Chosen At least 6 articles for Inclusion (please copy and paste the abstract with link):

Please pay attention to whether the articles actually address your question and whether they are the highest level of evidence available. (Be aware that the instructor may also do a search and should not be able to find better articles that you overlooked). 
If after reviewing you cannot find high quality articles, be prepared to explain the extensiveness of your search and why there aren’t any better sources available. If you are having trouble finding better sources, please reach out to the librarian or one of the instructors for help with this.

Author	Abstract
Johansson et al	BACKGROUND Maternal obesity is associated with increased risks of gestational diabetes, large-for-gestational-age infants, preterm birth, congenital malformations, and stillbirth. The risks of these outcomes among women who have undergone bariatric surgery are unclear. METHODS We identified 627,693 singleton pregnancies in the Swedish Medical Birth Register from 2006 through 2011, of which 670 occurred in women who had previously undergone bariatric surgery and for whom presurgery weight was documented. For each pregnancy after bariatric surgery, up to five control pregnancies were matched for the mother’s presurgery body-mass index (BMI; we used early-pregnancy BMI in the controls), age, parity, smoking history, educational level, and delivery year. We assessed the risks of gestational diabetes, large-for-gestational-age and small-for-gestational-age infants, preterm birth, stillbirth, neonatal death, and major congenital malformations. RESULTS Pregnancies after bariatric surgery, as compared with matched control pregnancies, were associated with lower risks of gestational diabetes (1.9% vs. 6.8%; odds ratio, 0.25; 95% confidence interval [CI], 0.13 to 0.47; P<0.001) and large-for-gestational-age infants (8.6% vs. 22.4%; odds ratio, 0.33; 95% CI, 0.24 to 0.44; P<0.001). In contrast, they were associated with a higher risk of small-for-gestational-age infants (15.6% vs. 7.6%; odds ratio, 2.20; 95% CI, 1.64 to 2.95; P<0.001) and shorter gestation (273.0 vs. 277.5 days; mean difference −4.5 days; 95% CI, −2.9 to −6.0; P<0.001), although the risk of preterm birth was not significantly different (10.0% vs. 7.5%; odds ratio, 1.28; 95% CI, 0.92 to 1.78; P=0.15). The risk of stillbirth or neonatal death was 1.7% versus 0.7% (odds ratio, 2.39; 95% CI, 0.98 to 5.85; P=0.06). There was no significant between-group difference in the frequency of congenital malformations. CONCLUSIONS Bariatric surgery was associated with reduced risks of gestational diabetes and excessive fetal growth, shorter gestation, an increased risk of small-for-gestational-age infants, and possibly increased mortality. (Funded by the Swedish Research Council and others.) Link: https://www.nejm.org/doi/full/10.1056/NEJMoa1405789
Falcone et al	Bariatric surgery (BS) is regarded to be the most effective treatment of obesity with long lasting beneficial effects including weight loss and improvement of metabolic disorders. A considerable number of women undergoing BS are at childbearing age. Although the surgery mediated weight loss has a positive effect on pregnancy outcome, the procedures might be associated with adverse outcomes as well, for example micronutrient deficiencies, iron or B12 deficiency anemia, dumping syndrome, surgical complications such as internal hernias, and small for gestational age (SGA) offspring, possibly due to maternal undernutrition. Also, there is no international consensus concerning the ideal time to conception after BS. Hence, the present narrative review intents to summarize the available literature concerning the most common challenges which arise before and during pregnancy after BS, such as fertility related considerations, vitamin and nutritional deficiencies and their adequate compensation through supplementation, altered glucose metabolism and its implications for gestational diabetes screening, the symptoms and treatment of dumping syndrome, surgical complications and the impact of BS on pregnancy outcome. The impact of different bariatric procedures on pregnancy and fetal outcome will also be discussed, as well as general considerations concerning the monitoring and management of pregnancies after BS. Whereas BS leads to the mitigation of many obesity-related pregnancy complications, such as gestational diabetes mellitus (GDM), pregnancy induced hypertension and fetal macrosomia; those procedures pose new risks which might lead to adverse outcomes for mothers and offspring, for example nutritional deficiencies, anemia, altered maternal glucose metabolism and small for gestational age children. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307154/
Akhter et al	Abstract Background Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes. Methods and findings Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (Ors) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03–1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04–1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38–1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25–1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35–0.60, p < 0.001). Ors for SGA increased (2.72, 95% CI 2.32–3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14–0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference −242.42 g, 95% CI −307.43 to −177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes. Conclusions In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684044/
Shaw et al	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 d 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. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852078/
Harreiter et al	The prevalence of obesity is growing worldwide, and strategies to overcome this epidemic need to be developed urgently. Bariatric surgery is a very effective treatment option to reduce excess weight and often performed in women of reproductive age. Weight loss influences fertility positively and can resolve hormonal imbalance. So far, guidelines suggest conceiving after losing maximum weight and thus recommend conception at least 12–24 months after surgery. As limited data of these suggestions exist, further evidence is urgently needed as well for weight gain in pregnancy. Oral glucose tolerance tests for the diagnosis of gestational diabetes mellitus (GDM) should not be performed after bariatric procedures due to potential hypoglycaemic adverse events and high variability of glucose levels after glucose load. /is challenges the utility of the usual diagnostic criteria for GDM in accurate prediction of complications. Furthermore, recommendations on essential nutrient supplementation in pregnancy and lactation in women after bariatric surgery are scarce. In addition, nutritional deficiencies or daily intake recommendations in pregnant women after bariatric surgery are not well investigated. /is review summarizes current evidence, proposes clinical recommendations in pregnant women after bariatric surgery, and highlights areas of lack of evidence and the resulting urgent need for more clinical investigations Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008727/
Waledziak et al	The purpose of this review was to analyze the literature about pregnancy after bariatric surgery. We searched for available articles on the subject from the last decade (2010 to 2020). The positive impact of bariatric surgery on the level of comorbidities and pregnancy and neonatal outcomes cannot be overrated. Weight loss after bariatric surgery reduces the incidence of obesity-related conditions in pregnancy. A pregnancy in a woman after bariatric surgery should be considered a high-risk pregnancy and taken care of by a multidisciplinary team with appropriate micronutrient and vitamin supplementation provided. Optimum time to conception should be chosen following the international recommendations. Every woman after bariatric surgery should be aware of symptoms of surgical complications and immediately contact their surgeon in case of abdominal pain Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7991924/

For the DRAFT & Final CAT (Rotations 8 & 9) – YOU WILL INCLUDE THE PARTS ABOVE AND COMPLETE THE REMAINING PARTS BELOW:

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Johansson et al (2015)	Cohort study	627,693 pregnancies with 670 of them in women with previous bariatric surgery Those who had undergone bariatric surgery had a pre-surgery weight documentedEach bariatric pregnancy had 5 matched control for the mothers pre-surgery BMI	Gestational diabetesLarge for gestational ageSmall for gestational age Length of gestation Preterm birthStillbirth/neonatal death	The results obtained showed: that pregnancies after bariatric surgery compared to the matched controls had lower risk of GDM, LGA but were at higher risk for SGA and shorter gestations (without an increased risk of preterm birth the mean difference was -4.5 days). The risk of stillbirth and neonatal death was 1.7% vs 0.7% and there was no difference between frequency of congenital malformations.	The main surgery included in this study was gastric bypass and it is difficult to conclude if these results are applicable to other types of surgeries The population in this study was mostly Caucasian and the results cannot be generalized to other races Not all factors were matched in the control and bariatric surgery group
Falcone et al (2018)	Literature review	PubMed and Medline data bases were searched for relevant studies Longitude observational studies, meta analysis, cohort studies were includedGuidelines from ACOG and Royal College of Obstetricians and gynecologists	Reproductive aspects Nutritional aspects (which is not one of my outcomes so I did not include)Gestational diabetesPre-eclampsia and other hypertensive disorders Fetal and neonatal complication	Reproductive aspects: bariatric surgery has a positive outcome on infertile anovulatory patients because it is shown to improve hyperandrogenemia and PCOS.Gestational diabetes: obesity is a risk factor for the development of GDM and is associated with adverse pregnancy outcomes. Bariatric surgery prior to pregnancy reduces the risk of GDM. One study (Galazis et al.) found the risk to be approximately half.  Preeclampsia and other hypertensive disorders: Several studies including reviews and meta analysis came to the conclusion that the risk of hypertensive disorders of pregnancy are lower after surgery although still higher than normal weight woman. Fetal and neonatal complications: They found that several studies showed increased risk of small for gestational age neonates after malabsorptive or mixed bariatric procedures, however several studies showed no statistically significant differences in SGA rates.	This review is a narrative approach as oppose to systematic review and meta analysis Inclusion criteria and study characteristics were not included in the publication
Akhter et al (2019)	Systematic review and meta analysis	searches in Medline Embase, PsycINFO, CINAHL, Scopus, google scholar. Observational studies that compared perinatal outcomes post bariatric surgery to pregnancies without prior bariatric surgery were includedA total of 33 studies with 14,880 pregnancies post bariatric surgery and 3, 979, 978 control pregnancies were included.	perinatal mortalitycongenital anomaliespreterm birth post-term birth SGA LGA NICU admission	Results found that the odds ratio (OR) was increased after all types of bariatric surgery for perinatal mortality (1.38), congenital anomalies (1.29), preterm birth (1.57), NICU admission (1.41), SGA (2.72). the OR was decreased for post term birth (0.46), LGA (0.24)	Some of the included studies had small sample sizesThey only included English studies.
Shawe et al (2019)	Literature review	A systematic review of available literatureADAPTE protocol for development of guidelines	Timing of pregnancy Clinical follow- up of pregnancy Gestational diabetes and screening	Conception interval 14 studies: Parental et al found that shorter interval to pregnancy was associated with higher risk of SGA, prematurity and NICU admission. Other studies did not find differences in gestational outcomes with interval between surgery and pregnancy Studies have shown that bariatric surgery doubles the risk of SGA infants and but it is unclear if congenital anomalies are more prevalent. They suggest additional fetal monitoring with US The risk of developing type 2 diabetes (T2DM) and GDM is reduced in women after BS when compared with women without BS matched for their preoperative BMI.	Guidelines were issued in areas where evidence was lacking based on clinical experience This was a literature review which is less rigorous than a systematic review.
Harreiter et al (2017)	Literature review	Only peer reviewed literature about bariatric surgery and pregnancy was includedMESH search terms in Pubmed database 298 articles were included	Obesity and fertility and fertility after bariatric surgeryExamination during pregnancy post bariatric surgeryGestational diabetes  Pregnancy outcome	Many women reported normalization of menstrual cycles, regular ovulation and more spontaneous contraception after bariatric surgery Monitoring during pregnancy should include nutritional deficiencies Several studies show that the prevalence of GDM decreases after bariatric surgery, studies show that oral glucose tolerance test may not be accurate in women with bariatric surgery In post bariatric surgery pregnancies there is a decreased risk of maternal complication compared to obese women without bariatric surgery intervention- including lower risks of GDM, hypertension, preeclampsia, and miscarriageStudies reported conflicting evidence on whether it is more likely to have a LGA or SGA infantMost studies reported no differences in prematurity rate and neonatal death.	Many of the studies included were small Most of the studies included were retrospective cohort studies or case reports This is not as rigid as a systematic review since it is a literature review
Waledziak et al (2020)	Literature review	Literature analyzed on the topic of pregnancy after bariatric surgery Articles searched from 2010-2020	Influence of pregnancy on long term outcomes of weight loss of bariatric surgeryTime to conceptionSurgical complications during pregnancy Pregnancy and nutritional deficiencies Impairment of fetal growth Pregnancy induced hypertension and preeclampsia Gestational diabetes Contraception	Weight loss after bariatric surgery decreases obesity related complication of pregnancy A post bariatric surgery pregnancy should be considered high risk and treated as suchPregnancy after bariatric surgery slows weight loss but eventually does not affect weight loss long termSurgical complication can mimic early pregnancy symptoms, women with abdominal pain and pregnant should not hesitate to contact the bariatric surgeon and should be educated on the importance of this Women should follow international guidelines in regard to time to conception after bariatric surgeryNutritional deficiencies may occur, women should be monitored and appropriately supplemented Most studies show decreased risk of pregnancy inducted hypertension, gestational diabetes, and large for gestational age infants, but an increased risk of IUGR and small for gestational age infants	Literature review is not as high of evidence as a meta analysis or systematic review It is a study done in PolandIt is a recent study

Conclusion(s):

Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Author	Conclusion
Johansson et al:	Bariatric surgery prior to pregnancy is associated with decreased risk of GDM, and LGA, an increased risk of SGA, shorter gestations and a slight increase in neonatal mortality
Falcone et al:	Bariatric surgery decreases the risk of GDM and therefore the pregnancy complications that result. Hypertensive disorders of pregnancy occur at lower rates in obese women who have undergone bariatric surgery. Studies disagree whether malabsorptive bariatric procedures increase the risk of SGA neonates, however some studies recommend restrictive over malabsorptive procedures in women who desire conception to avoid these complications.
Akhter et al	Bariatric surgery especially gastric bypass is associated with increased risk of certain adverse perinatal outcomes (NICU admission, SGA etc.). These women may benefit from special preconception and pregnancy nutritional support and increased fetal monitoring. Post-term birth and LGA were associated with decreased odds.
Shawe et al:	Studies disagreed whether time from pregnancy to conception affected gestation (SGA, prematurity), however it has been shown that bariatric surgery doubles the risk of SGA infants and but it is unclear if congenital anomalies are more prevalent. They suggest additional fetal monitoring with US. There is a decreased risk of T2DM and GDM in women after bariatric surgery compared to women matched with preoperative BMI. It is still important to screen them because undiagnosed GDM has poor results on the fetus.
Harreiter et al.	Overall there is a lower risk of GDM in women post bariatric surgery, however the diagnostic criteria for this patient population is not clear and requires more research. Women post bariatric surgery are at lower risk of GDM, hypertensive disorders, and C. sections. Studies disagreed whether women were at lower risk for LGA and SGA infants however most found a lower risk for LGA infants.
Waledziak et al.	Overall bariatric surgery lessens complications of pregnancy typically associated with obesity including: pregnancy induced hypertension, LGA, and GDM. There is an increased risk of IUGR and SGA infants. There is a risk for nutritional deficiencies, and this should be considered a high risk pregnancy and treated as such.

Overall conclusions: Akhter et al. is the study I weighed the strongest for my results, which showed that there is an increased risk of some perinatal outcomes such as SGA (OR of 2.72 Akhter et al, and 15.6% vs. 7.6% in the control group Johannsson et al), congenital malformations, perinatal mortality, preterm birth, and NICU admission. However they also found decreased risk of LGA (which agreed with other studies reviewed) and post term birth. Nearly all studies point to a decreased risk of GDM (1.9% risk compared to 6.8% in control according to Johansson et al) compared to women of the same BMI as the pre-surgery BMI, suggesting that bariatric surgery lessens the risk of GDM in obese women. However women who undergo bariatric surgery are still at a higher risk of GDM compared to women of normal weight and BMI. Studies also show a decreased risk of pregnancy induced hypertension (Waledziak et al reported studies had OR of preeclampsia post bariatric surgery of 0.45 and 0.2 in analyzed studies Galazis et al and Bennett et al respectively). The results suggest that managing obesity with bariatric surgery lessens certain complications of pregnancy that occur due to obesity but does not eliminate complications and in fact may lead to higher rates of other complications. It should be a risk benefit analysis discussion with women about pregnancy, and women should be monitored closely.

Clinical Bottom Line:

Please include an assessment of the following:

– Weight of the evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)

Author	Weight
Johansson et al	This was a large study with many relevant outcomes studied. This study mainly included Caucasians which was representative of the population of Sweden where it was done, however it is not representative of the population in many other countries including the US. Therefore this was not one of the studies I weighed the strongest in drawing my clinical bottom line.
Falcone et al	This was a large literature review study from 2018, I weighed it heavily because it included several important high quality studies as well as including guidelines from two major organizations for obstetric care. However it was a narrative literature review and not a systematic review or meta analysis, to draw objective guidelines from these studies findings would require systematic review or meta analysis. I therefore did not weigh it as heavy as some of my other articles.
Akhter et al	I weighed this study the strongest because it is a recent meta analysis and systematic review that was meticulous, and they had searched multiple databases.
Shawe et al	I weighed this study as a literature review with high quality evidence as it was written by experts. It did not include as many outcomes of interest as other studies I included and I took that into consideration when drawing my clinical bottom line.
Harreiter et al	I weighed this study more heavily than some of the other literature reviews because I felt that it explained the studies that they included more clearly, critiqued the outcomes of the study showing the analysis that went into publishing the paper. However it is not as high level of evidence as a meta analysis and systematic review.
Waledziak et al	I weighed this study results strongly because it is a recently published literature review, I weighed it less strongly than a meta analysis and systematic review.

– Magnitude of any effects

Author	Magnitude of effects
Johansson et al	After bariatric surgery there was lower risk of gestational diabetes (1.9% vs 6.8%) as compared to the control group. Lower risk of large for gestational age (8.6% vs 22.4%) as compared to the control group Higher risk for small for gestational age (15.6% vs. 7.6%) as compared to the control group There was a shorter gestation (mean difference of 4.5 days) which was not statistically or clinically significant Higher risk of stillbirth/neonatal death (1.7% vs. 0.7%)
Falcone et al	The risk of gestational diabetes is decreased with bariatric surgery. One study found this risk to be halved.
Akhter et al	Results found that the odds ratio (OR) was increased after all types of bariatric surgery for perinatal mortality (1.38), congenital anomalies (1.29), preterm birth (1.57), NICU admission (1.41), SGA (2.72). the OR was decreased for post term birth (0.46), LGA (0.24) after bariatric surgery compared to the control
Shawe et al	Bariatric surgery doubles the risk of SGA infants Women are at lower risk of GDM after bariatric surgery when matched with women with same BMI as their pre-surgery BMI
Harreiter et al	Israeli observational study: OR of GDM was 0.6, for hypertensive disorders OR 0.4, preeclampsia OR 0.2, anemia OR 0.7, fetal macrosomia OR 0.5 in women after bariatric surgeryFrench observational study form women after laparoscopic adjustable gastric banding compared to obese women: GDM risk was 0 vs 22.1%, preeclampsia 0 vs 3.1%, low birthweight 7.7% vs 10.6%, fetal macrosomia 7.7% vs 14.6%, C. section 15.3% vs 34.4%. American study before and after bariatric surgery found lower GDM incidence (OR 0.23), lower risk for C. section (OR 0.53) for women after a bariatric surgery
Waledziak et al	Meta analysis Galazis et al showed two fold decrease in incidence of GDM after bariatric surgery, it also showed a lower risk of pre eclampsia after bariatric surgery with an OR of 0.45Bennett et al showed an OR of preeclampsia to be 0.20

– Clinical significance (not just statistical significance)

Women who undergo bariatric surgery and who desire to become pregnant should be monitored closely and pregnancies in women post bariatric surgery should be considered high risk pregnancies. There is a decreased risk of GDM after bariatric surgery with some studies showing the risk is halved, but it does not eliminate the risk completely. Patients should still be screened for diabetes and have all the regular pre-natal care. Some suggest that additional fetal monitoring is necessary and a different screening test for diabetes might be necessary. Additionally patients should be closely monitored for nutritional deficiencies. Risk benefits analysis should be discussed with the patient including increased risk of SGA (OR 2.72 Akhter et al.) and NICU admission (OR 1.41 Akhter et al).

– Any other considerations important in weighing this evidence to guide practice  – If the evidence you retrieved was not enough to conclude an answer to the question, discuss what aspects still need to be explored and what the next studies will have to answer/provide (e.g. larger number, higher level of evidence, answer which sub-group benefits, etc)

Overall more research needs to be done on this topic. Some additional aspects that need to be explored include:

• More time to conception analysis, there are some existing studies but the results do not agree therefore meta analysis on this topic is needed.
• Meta analysis that focus on the different types of bariatric surgeries and the effects on pregnancy outcomes
• More research on monitoring fetal growth in women post bariatric surgery is needed.
• Larger studies on the effects bariatric surgery has on fertility
• Studies on how to best diagnose GDM in pregnancy after bariatric surgery as studies show that the oral glucose tolerance test may be misinterpreted in women with bariatric surgery