Pregnancy outcomes among women with asthma

Purpose: The purpose of this study is to examine the association between maternal asthma and pregnancy, delivery and neonatal outcomes.

Materials and methods:We carried out a retrospective cohort study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) database from 2003 to 2011. Among women who delivered during this time period, we compared pregnancy, delivery, and neonatal outcomes in asthmatics versus non-asthmatics. Multivariate logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals.

Results: In a cohort of 7,772,999 pregnant women, 223,236 (2.9%) had asthma. The prevalence of asthma-complicated pregnancies rose over the study period from 1.9% in 2003 to 3.7% in 2011 (p?Conclusions: Asthma is associated with an increase in adverse pregnancy, labor, and neonatal outcomes. Close surveillance of asthmatic patients during the prenatal period is warranted and care in a tertiary hospital is advised.     

Neonatal outcomes in pregnancies after bariatric surgery: a retrospective multi-centric cohort study in three French referral centers

Objective: To analyze short-term neonatal outcomes in pregnancies after bariatric surgery according to procedure, to the body mass index (BMI) at the beginning of the pregnancy and to the interval from surgery to conception, using a retrospective multi-centric cohort study in three French tertiary perinatal care and bariatric centers. Methods: 94 neonates in 79 women were included. Frequencies of adverse neonatal events by procedure, laparoscopic adjustable gastric banding (LAGB, n = 63) or Roux-en-Y gastric bypass (RYGB, n = 31), BMI class (72 women with BMI ≥ 30?kg/m²) and interval between surgery and conception (43 deliveries of patients who conceived during the first postoperative year) were compared with χ² tests. For parametric continuous data, t-tests or analysis of variance were used; non-parametric distributions were compared with the Wilcoxon or Kruskal–Wallis tests. Results: Significantly lower mean birth weight (2993?g vs. 3253?g; p = 0.02) was observed after RYGB and the mean Z-score for birth weight was significantly closer to 0 in neonates of the LAGB group than in those of the RYGB group. However, no significant differences were noticed regarding small-for-gestational age (32.3% vs. 17.1%; p = 0.06), umbilical arterial blood pH < 7.0 (9.7% vs. 0%; p = 0.11), low Apgar scores, perinatal mortality, and NICU admission. Neonatal outcomes according to the interval from surgery to conception or to the BMI at the beginning of the pregnancy were not significantly different. Conclusions: The short-term neonatal outcomes are basically comparable in pregnancies after RYGB than after LAGB.     

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.     

Hormone receptor expression patterns in the endometrium of asymptomatic morbidly obese women before and after bariatric surgery

Objective

Obesity increases risk for endometrial neoplasia, but neither the pathophysiology nor the effects of weight loss on the risk are well established. We attempted to characterize the molecular profile of the endometrium of asymptomatic women with morbid obesity before and following bariatric surgery-induced weight loss.

Methods

59 asymptomatic, morbidly obese women underwent endometrial sampling before bariatric surgery; 46 (78%) of these returned one year later for re-biopsy (median weight loss of 41 kg). Duplicate samples from these specimens were scored for expression of estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), and Ki-67 by two independent, blinded pathologists using an H-score [staining intensity (0–3) × (percent of tissue involved)].

Results

The prevalence of hyperplasia pre-operatively was 7% overall and 10% among patients not on an anti-estrogen. ER H-scores were similar before and after surgery overall (median 190 and 196 respectively, p = 0.82), but patients with hyperplasia had higher pre-operative H-scores (median 256, p < 0.001) and experienced greater H-score drops, than those without hyperplasia (− 112 vs + 50, p = 0.028). In two patients with persistent hyperplasia at one year, ER H-scores fell to levels that were similar to those without pathology. One patient who developed hyperplasia during the study period had a rising ER H-score. Patients with hyperplasia had higher median PR H-scores pre-operatively (284 vs 188, p = 0.01), which normalized through greater drops (75 vs 0, p = 0.053). AR H-scores dropped significantly after surgery (13 vs 2, p = 0.015), but were similar between patients with and without hyperplasia (p = 0.33). Weight loss did not affect Ki-67 proliferation index.

Conclusion

Asymptomatic morbidly obese patients have a high prevalence of occult hyperplasia, characterized by relatively high hormone receptor expression. These profiles appear to normalize with weight loss and in advance of pathologically identifiable changes. These data suggest a potential role for screening this population as well as the possibility that weight loss may be a valid treatment strategy for risk reduction.     

Bariatric surgery and associated adverse pregnancy outcomes among obese women

Objective: To evaluate whether bariatric surgery is associated with intrauterine growth restriction (IUGR).

Methods: We performed a population-based retrospective cohort study to estimate the relationship between prior bariatric surgery and adverse pregnancy outcomes. The data were collected from the 2012 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS). Pregnancies in obese women with a prior bariatric surgery were compared to those of obese women without. Outcomes of interest were pre-eclampsia, IUGR, intrauterine fetal demise, large for gestational age, postpartum hemorrhage, failed induction of labor, cesarean delivery and operative vaginal delivery. Multivariable logistic regression analysis was used to adjust for potential confounders.

Results: 186?605 obese women with singleton gestations were identified. Among these, 1585 (0.8%) women had a prior bariatric surgery. Prior bariatric surgery was associated with an increased risk of IUGR (5.7% versus 2.2%, adjusted odds ratio 2.89, 99% CI 1.55–5.39, p?<?0.0001) even after adjusting for confounding factors. No differences were seen in our other outcomes of interest.

Conclusion: Singleton gestations in obese women with a prior bariatric surgery have an increased risk of IUGR. It may be reasonable screen these pregnancies for the development of growth restriction.     

Pregnancy outcome in obese and morbidly obese gestational diabetic women

OBJECTIVE: We sought to determine whether pregnancy outcome differs between obese and morbidly obese GDM patients and to assess pregnancy outcome in association with mode of treatment and level of glycemic control. METHODS: A cohort study of 4,830 patients with gestational diabetes (GDM), treated in the same center using the same diabetic protocol, was performed. Obesity was defined as prepregnancy BMI >30 and <35 kg/m(2); morbid obesity was defined as prepregnancy BMI >or=35 kg/m(2). Well-controlled GDM was defined as mean blood glucose <105 mg/dl. Pregnancy outcome measures included the rates of large for gestational age (LGA) and macrosomic babies, metabolic complications, the need for NICU admission and/or respiratory support, rate of shoulder dystocia, and the rate of cesarean section. RESULTS: Among the GDM patients, the rates of obesity and morbid obesity were 15.7% (760 out of 4830, BMI: 32.4+/-1.6 kg/m(2)) and 11.6% (559 out of 4830, BMI: 42.6+/-2.2 kg/m(2)), respectively. No differences were found with regard to maternal age, ethnicity, gestational age at delivery or oral glucose tolerance test (OGTT) results. Moreover, similar rates of cesarean section, fetal macrosomia, shoulder dystocia, composite outcome, and metabolic complications were noted. Insulin treatment was initiated for 62% of the obese and 73% of the morbidly obese GDM patients (P<0.002). Similar rates of obese and morbidly obese patients achieved desired levels of glycemic control (63% versus 61%, respectively). In both obese and morbidly obese patients who achieved a desired level of glycemic control (<105 mg/dl), no difference was found in pregnancy outcome except that both neonatal metabolic complications and composite outcomes were more prevalent in diet-treated subjects in comparison to insulin-treated GDM patients. CONCLUSION: In obese women with GDM, pregnancy outcome is compromised regardless of the level of obesity or treatment modality.     

Obstetrical and neonatal outcomes in obese parturients

Objective.?Obstetrical risk is increased with maternal obesity. This prospective study was designed to simultaneously evaluate the outcomes in obese parturients and their newborns.

Methods.?Patients with a body mass index (BMI) ≥35 were prospectively identified and compared to an equal number of normal weight parturients. Maternal and neonatal outcome measures were compared for the peripartum and neonatal period.

Results.?We identified 580 obese parturients over a 6 month period and compared them to an equal number of normal weight parturients. The incidence of obesity in this population was 23%. Obesity was associated with increased rates of hypertension, diabetes, and cesarean section. Obese patients were more likely to develop postpartum complications. Neonatal outcomes were compared for infants ≥37 weeks gestation excluding multiple births (496 neonates in the obese group and 520 in the control group). The neonates of obese parturients were more likely to be macrosomic, have 1-minute Apgar scores of ≤7.0 and require admission to a special care unit. Sub-group analysis showed that negative outcomes for parturients and their neonates correlated with increasing BMI. Neonates born to obese diabetic parturients had the highest risk of poor outcomes.

Conclusions.?Maternal obesity confers increased risks for both the parturient and their newborn.     

Pregnancy and perinatal outcomes according to surgery to conception interval and gestational weight gain in women with previous gastric bypass

Objective: To compare perinatal and pregnancy outcomes including adherence to the Institute of Medicine’s (IOM) recommendations for gestational weight gain (GWG) in pregnant women with conception?<18 months (early group) compared to?≥18 months following gastric bypass (late group).

Methods: Retrospective cohort study comprising 71 women with gastric bypass and a singleton pregnancy presenting at Odense University Hospital, November 2007–October 2013. Data were extracted from medical records and laboratory systems. The primary outcomes were timing of pregnancy and adherence to the IOM’s recommendations for GWG. Secondary outcomes were birthweight, preterm delivery, cesarean section (CS), iron deficiency and post partum hemorrhage (PPH).

Results: Forty-three (61%) women conceived less than 18 months after gastric bypass surgery. Women in the late group had a significantly higher risk of requiring CS or receiving intravenous iron supplementation compared to the early group (57% versus 30%, p?=?0.03 and 29% versus 7%, p?=?0.02, respectively). Early conception was not significantly associated with insufficient GWG, preterm delivery or birthweight. Among 54 women with information on GWG, only 13 (24%) had an appropriate GWG.

Conclusion: The majority of pregnant women with gastric bypass did not fulfill guidelines for GWG; however, this study could not support the recommendation to postpone pregnancy.     

Pregnancy after bariatric surgery is not associated with adverse perinatal outcome

OBJECTIVE: The purpose of this study was to investigate the pregnancy outcome of patients after bariatric surgery. STUDY DESIGN: A population-based study was performed that compared all pregnancies of patients with and without previous obesity operations between the years 1988 and 2002. Stratified analyses with the Mantel-Haenszel technique and a multiple logistic regression model were performed to control for confounders. RESULTS: Of the 159210 deliveries that were performed during the study period, 298 deliveries were to patients after bariatric operations. No significant differences regarding obstetric characteristics or pregnancy outcome were noted between the open (n=159) and laparoscopic procedures (n=139). With the use of a multivariable analysis, the following conditions were associated significantly with a previous bariatric operation: previous cesarean delivery (odds ratios, 1.4; 95% confidence interval, 1.1-2.0; P=.024), fertility treatments (odds ratios, 2.3; 95% confidence interval, 1.6-3.8; P<.001), premature rupture of membranes (odds ratios, 1.9; 95% confidence interval, 1.3-2.7; P=.001), labor induction (odds ratios, 2.1; 95% confidence interval, 1.6-2.7; P<.001), fetal macrosomia (birth weight, >4 kg; odds ratios, 2.1; 95% confidence interval, 1.4-3.0; P<.001), and obesity (odds ratios, 8.8; 95% confidence interval, 6.1-12.9; P<.001). No significant differences were noted between the groups regarding other pregnancy complications such as placental abruption, placenta previa, labor dystocia, or perinatal complications (such as meconium-stained amniotic fluid, perinatal mortality, congenital malformations and low Apgar scores at 1 and 5 minutes). However, there were higher rates of cesarean delivery among the bariatric operation group (25.2% vs 12.2%; odds ratios, 2.4; 95% confidence interval, 1.9-3.1; P <.001). When controlled for possible confounders (such as previous cesarean delivery, obesity, fertility treatments, premature rupture of membranes, labor induction, diabetes mellitus, hypertensive disorders and fetal macrosomia) by the Mantel-Haenszel technique, the correlation between previous bariatric surgery and cesarean delivery remained significant. CONCLUSION: Previous bariatric surgery, although an independent risk factor for cesarean delivery, is not associated with adverse perinatal outcome.     

Pregnancy after bariatric surgery: a comprehensive review

Background Obesity continues to be a global epidemic, and strong evidence exists linking it with gestational complications such as macrosomia, hypertensive disorders of pregnancy, gestational diabetes, and cesarean section. Bariatric surgery, a highly effective treatment for obesity, may prevent such complications in subsequent pregnancies. Objective This review seeks to describe the risks and benefits of post-bariatric procedure pregnancies, in comparison to both community and obese cohorts. Results A thorough review of the literature suggests that post-surgery women are not at increased risk for poor perinatal outcomes, and moreover their risks for many obesity-related gestational complications are reduced after bariatric surgery. Data regarding fertility after bariatric surgery are quite ambiguous, however, and studies exist demonstrating both positive and negative associations between weight loss procedures and fertility. Conclusions Clinicians should be aware that data collected on this subject were often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies. Although pregnancy after bariatric surgery appears to be safe, providers should take extra care to properly monitor their post-op pregnant patients for appropriate weight gain and nourishment.     

The clinical outcomes of unplanned pregnancy in severely obese women

Objective: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies.

Methods: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥40.0?kg/m²) who delivered a baby weighing ≥500?g over 5 years 2009–2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit.

Results: Of the 650 women, the mean BMI was 43.8?kg/m², mean age was 31.6 years, and 30.0% (n?=?195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n?=?368). Compared with planned pregnancies (58.2%, n?=?378), those that were unplanned (41.8%, n?=?272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p?=?0.03) and depression (6.6% versus 3.2%, p?=?0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight?>?4.5?kg) compared with planned pregnancies (p?=?0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes.

Conclusion: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.     

Pregnancy outcomes among women with hemoglobin E trait

Objective: To compare the maternal and fetal outcomes between pregnant women complicated with hemoglobin E (HbE) trait and normal controls.

Patients and methods: A retrospective cohort study was conducted by assessment of the database of maternal–fetal medicine units from January 2003 to December 2013 to identify singleton pregnant women complicated by HbE trait. Pregnancies with medical complications or fetal anomalies were excluded. The normal controls were low-risk pregnancies and were non-carrier status for thalassemia and hemoglobinopathy.

Result: During the study period, 1073 women with HbE trait and 2146 normal controls were included. The baseline characteristics of the two groups were comparable except that the number of prenatal visit was statistically higher in study group (8.55?±?3.03 versus 7.85?±?4.33, p?=?<0.001). Most pregnancy outcomes were not significantly different. However, the rate of asymptomatic bacteriuria was minimally higher in the study group, 3.5% versus 2.3%; p?=?0.042 (relative risk 1.19; 95%CI: 0.98–1.43). Note that the rates of gestational diabetes tend to be higher in the group of HbE trait (7.6% versus 6.8%), but did not reach a statistical level.

Conclusion: The HbE trait does not significantly increase risk of common adverse pregnancy outcomes, except for minimal increase in asymptomatic bacteriuria.     

Preparing for and managing a pregnancy after bariatric surgery

The number of bariatric surgeries performed in the United States has increased exponentially. Given that most patients are female and of reproductive age, it is important for clinicians who manage women's health issues to be aware of the surgery, its long-term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with control patients. Following nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring.     

Pregnancy outcomes in women of very advanced maternal age

OBJECTIVE: To assess outcomes for pregnancies progressing beyond 20 weeks' gestation in women of very advanced maternal age. DESIGN: Retrospective cohort study. SETTING: Two tertiary level obstetric hospitals. POPULATION: Women aged 45 years or more at the time of delivery over a 10-year period from 1 January 1992 to 31 December 2001. METHODS: Information regarding maternal, pregnancy and neonatal outcomes was obtained from the medical records. For comparison, routinely collected data from the obstetric database was obtained for women aged 20-29 years. RESULTS: Seventy-seven pregnancies in 76 women aged 45 years and over were registered in the 10-year period. There were 74 liveborn singletons, two sets of liveborn twins and one set of twins stillborn at 20 weeks' gestation. Sixteen women were primiparous. Eighty-four percent of pregnancies were conceived naturally and 53% underwent prenatal chromosomal determination; 53% of women had no pre-existing medical problems, 13% had hypertensive disorders of pregnancy and 8% of women developed gestational diabetes. There were 10 preterm and six post dates deliveries. The Caesarean section rate was 49%, compared to 23% in the 20-29 years age group (P < 0.001). Ten percent of neonates were small for gestational age, and 8% were large for gestational age. Seventeen percent required admission to the special care nursery and 6% had congenital abnormalities. CONCLUSIONS: Maternal and neonatal outcomes in this series were generally good. There was a significantly increased rate of Caesarean section. Overall, this study is reassuring for women aged 45 and over who have good general health and a chromosomally normal fetus.