An opinion piece.

From Medical News Today:

Commentary: Obese Pregnant Women Should Gain Less Weight Than Currently Recommended

Recent recommendations by the Institute of Medicine (IOM) call for women who are overweight or obese to gain more weight than they should, a Saint Louis University obstetrician wrote in a January commentary for Obstetrics & Gynecology.

Joined by several colleagues, Raul Artal, M.D., chair of the department of obstetrics, gynecology and women’s health at Saint Louis University who has conducted extensive research on weight gain during pregnancy, did not endorse the IOM’s May 2009 recommendation. The IOM, a non-governmental, independent, nonprofit organization, provides advice that is designed to improve health to national decision makers and the public.

“The recently published IOM recommendations for gestational weight gain are virtually identical to those published in 1990 with one exception: obese women are now recommended to gain 11 – 20 pounds compared to the previous recommendations of at least 15 pounds,” Artal said.

“Recommending a single standard of weight gain for all obese classes is of concern since higher BMI levels are associated with more severe medical conditions and have long-term adverse health implications.”

Artal recommended obese women eat a nutrient-rich diet of between 2,000 and 2,500 calories a day, which would cause them to cap their weight gain at 10 pounds, and in some cases, lose weight.

Under a doctor’s guidance, he said, obese pregnant women can safely engage in physical activities and modify their diets to successfully limit their weight gain with no harmful effects on the fetus.

When obese women reduce the amount of weight they gain, they also cut their risk of developing complications such as gestational diabetes and preeclampsia. By contrast, obese women who gain too much weight increase their risk of developing these conditions who affect both mother and fetus.

Artal called excessive weight gain during pregnancy a significant contributor to the obesity epidemic.

“Excessive gestational weight gain has been implicated in an intergenerational vicious cycle of obesity as overweight and obese mothers give birth to big daughters who are more likely to become obese themselves and deliver large infants,” he said.

Pregnancy is an ideal time for women who are obese to exercise and watch what they eat, Artal added. These lifestyle changes are safe and carry benefits that last long after they have given birth, Artal added.

“Similar to smoking cessation programs, pregnancy provides a unique and ideal opportunity for behavior modifications given high motivation and enhanced access to medical supervision,” he said.

“Limited weight gain in obese pregnant women has the added potential for setting the foundation for a healthier lifestyle over a woman’s lifespan.”

Artal led the team of obstetricians who drafted the American College of Obstetricians and Gynecologists’ guidelines for exercise during pregnancy. He was joined in writing the commentary by Charles Lockwood, M.D., chair of the department of obstetrics, gynecology and reproductive sciences at Yale University School of Medicine and Haywood Brown, M.D., chair of obstetrics and gynecology at Duke University Medical Center.

Popularly known as “The Green Journal,” Obstetrics & Gynecology is the official publication of the American College of Obstetricians and Gynecologists.

Established in 1836, Saint Louis University School of Medicine has the distinction of awarding the first medical degree west of the Mississippi River. The school educates physicians and biomedical scientists, conducts medical research, and provides health care on a local, national and international level. Research at the school seeks new cures and treatments in five key areas: cancer, infectious disease, liver disease, aging and brain disease and heart/lung disease.

Source: Saint Louis University Medical Center

Wow.  No wonder my pregnancies sucked. I was fat AND I couldn’t sleep.

From Medscape:

High BMI, Lack of Sleep Linked to Need for Migraine Treatment During Pregnancy

NEW YORK (Reuters Health) Dec 25 – A high pre-pregnancy body mass index (BMI) and a lack of sleep predict whether women will need migraine medications during pregnancy, new research shows.

An estimated 20%-80% of women report migraines during pregnancy, study co-author Dr. Katerina Nezvalova-Henriksen, of the University of Oslo, Norway, and colleagues write in the December issue of Cephalalgia.

“Many migraineurs may experience an exacerbation of their symptoms at the beginning of the first trimester,” the team notes. “Consequently, these women may require pharmacotherapy during this period, which also corresponds to the most vulnerable period of fetal development.”

To narrow down which women were likely to need migraine medications during pregnancy, Dr. Nezvalova-Henriksen and her colleagues analyzed the newest available data from the Norwegian Mother and Child Cohort Study. That effort is an observational, prospective cohort study of 60,435 pregnant women recruited between 1999 and 2006 and conducted by the Norwegian Institute of Public Health.

Overall, 3840 (5.7%) women reported having a migraine during the first 5 months of pregnancy. Of these, 2525 (72.6%) reported using migraine medications during pregnancy.

About 76% of women who reported migraine both prior to and during pregnancy reported using a migraine agent during pregnancy, compared with 51.8% who reported migraine during pregnancy only.

The most common migraine agents used included non-narcotic analgesics (54.1%) and triptans (25.4%).

After adjusting for sociodemographic factors and comorbidities, sleep duration <5 h (odds ratio, OR, 1.5), pre-pregnancy BMI > 25.0 kg/m squared (OR 1.3), and being on sick leave (OR 1.3) were associated with the use of migraine medications during pregnancy.

By contrast, women who reported acute musculoskeletal pain of the back, neck, and/or shoulder were less likely to use migraine medications during pregnancy (OR 0.6).

When it came to particular types of migraine medications, young mothers and those who had more than child were less likely to use triptans, while those who stopped taking serotonin-selective reuptake inhibitors and beta-receptor agonists prescribed before pregnancy were more likely to use triptans.

“Many women need drug treatment for migraine during pregnancy, and the choice of pharmacotherapy during this period may be influenced by maternal sociodemographic factors and comorbidities,” the authors conclude.

Cephalalgia 2009;29:1267-1276.

Another benefit to breastfeeding

On December 21, 2009, in Pregnancy after WLS, by Andrea

While most of my readers are post-RNYers, I know that some are going to be Banders or VSGers — ones that don’t have an automatic “cure” or “remission” to diabetes due to the intestinal switch done from RNY or DS.  So I’m including this for any Banders or VSGers that might decide to get pregnant at some point.

I couldn’t nurse my two kiddos post op, wish I could have — but there’s nothing to say that those who have had surgery cannot and here is more reason to do so.

From Medscape:

Breast-Feeding May Protect the Mother From Metabolic Syndrome

Laurie Barclay, MD

December 17, 2009 — Breast-feeding may protect the nursing mother from the metabolic syndrome, according to the results of a prospective, observational cohort study reported in the December 3 Online First issue of Diabetes.

“The Metabolic Syndrome is a clustering of risk factors related to obesity and metabolism that strongly predicts future diabetes and possibly, coronary heart disease during midlife and early death for women,” lead author Erica Gunderson, PhD, from Kaiser Permanente’s Division of Research in Oakland, California, said in a news release. “Because the Metabolic Syndrome affects about 18 to 37 percent of U.S. women between ages 20-59, the childbearing years may be a vulnerable period for its development. Postpartum screening of risk factors for diabetes and heart disease may offer an important opportunity for primary prevention.”

The multicenter, population-based US cohort used for this study consisted of 1399 nulliparous women (39% black, aged 18 – 30 years) enrolled in the ongoing Coronary Artery Risk Development in Young Adults Study. Participants were free of the metabolic syndrome at baseline from 1985 to 1986 and before subsequent pregnancies. At 7, 10, 15, and/or 20 years after baseline, participants were re-examined, and National Cholesterol Education Program criteria were used to identify incident cases of metabolic syndrome.

The investigators used complementary log-log models to estimate relative hazards of incident metabolic syndrome among time-dependent lactation duration categories by gestational diabetes mellitus, after adjustment for age, race, study center, time-dependent parity, baseline body mass index, components of the metabolic syndrome, education, smoking, and physical activity.

Of 704 parous women, 84 had gestational diabetes and 620 did not. During 9993 person-years, there were 120 incident cases of metabolic syndrome, yielding an overall crude incidence rate of 12.0 per 1000 person-years (10.8 for nongestational diabetes and 22.1 for gestational diabetes). Increasing duration of lactation was associated with lower crude incidence rates of metabolic syndrome from 0 to 1 month through 9 months or more of breast-feeding (P < .001).

“The findings indicate that breastfeeding a child may have lasting favorable effects on a woman’s risk factors for later developing diabetes or heart disease,” Dr. Gunderson said.

Risk reductions associated with longer duration of lactation were greater among women with gestational diabetes (fully adjusted relative hazards range, 0.14 – 0.56; P = .03) vs those without gestational diabetes (fully adjusted relative hazards range, 0.44 – 0.61; P = .03).

Limitations of this study include observational design and possible residual confounding.

“Longer duration of lactation was associated with lower incidence of the metabolic syndrome years post-weaning among women with a history of GDM [gestational diabetes mellitus] and without GDM controlling for preconception measurements, BMI [body mass index], socio-demographic and lifestyle traits,” the study authors conclude. “Further investigation is needed to elucidate the mechanisms through which lactation may influence women’s cardiometabolic risk profiles, and whether lifestyle modifications, including lactation duration, may affect development of coronary heart disease and type 2 diabetes, particularly among high-risk groups such as women with a history of GDM.”

The National Institutes of Health (the National Heart, Lung, and Blood Institute; the National Institute of Diabetes, Digestive and Kidney Diseases) and the American Diabetes Association supported this study. The study authors have disclosed no relevant financial relationships.

Diabetes. Published online December 3, 2009. Abstract

Full Title: Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy

November 2008

View or download Report

Structured Abstract

Context: The use of bariatric surgery for treating severe obesity has increased dramatically over the past 10 years; about half of patients who undergo these procedures are women of reproductive age. This report was commissioned to measure the incidence of bariatric surgery in this population and review the evidence on the impact of bariatric surgery on fertility and subsequent pregnancy.

Objectives: To measure the incidence of contemporary bariatric surgery procedures in women age 18-45 and to assess its impact on fertility, contraception, prepregnancy risk factors, and pregnancy outcomes, including those of neonates.

Data Sources and Study Selection: We used the Nationwide Inpatient Sample (NIS), a national sample of over 1,000 hospitals, to measure the trend in the number of women of reproductive age who underwent bariatric procedures from 1998-2005. We searched numerous electronic databases, including MEDLINE® and Embase, for potentially relevant studies involving bariatric surgery (gastric bypass, laparoscopic adjustable gastric band, vertical-banded gastroplasty, biliopancreatic diversion), and consequent fertility, contraception, pregnancy, weight management, maternal outcomes, neonatal outcomes, and nutritional deficiencies. We scanned reference lists for additional relevant articles and contacted experts in the fields of bariatric surgery and obstetrics/gynecology (OB/GYN).

Of 223 screened articles, we accepted 57 that reported on fertility following surgery (19 articles), contraception use/recommendations (11), maternal weight or nutrition management (28), maternal outcomes including morbidity and mortality (48), cesarean-section rates (16), and neonatal outcomes (44). These articles included reports on gastric bypass, both open and laparoscopic (27 articles), laparoscopic adjustable band (15), biliopancreatic diversion (16), and vertical-banded gastroplasty (6). Studies could contribute to one or more analyses.

We found one case-control study and the observational data accepted included 12 cohort studies, 21 case series, and 23 individual case reports.

Data Extraction: We abstracted information about study design, fertility history, fertility outcomes, prepregnancy weight loss, nutritional management, outcomes following pregnancy, and adverse events (during pregnancy) related to surgery.

Data Synthesis: Nationally representative data showed a six-fold increase in bariatric surgery inpatient procedures from 1998 to 2005. Women age 18-45 accounted for about half of the patients undergoing bariatric surgery; over 50,000 have these procedures as inpatients annually. An unknown number have outpatient bariatric procedures.

We identified one case-control study that directly addressed some of the key questions, but no randomized controlled trials or prospective cohort studies, which would be the strongest study designs to answer questions about effectiveness, risk and prognosis. Consequently, all of our conclusions are limited by the available data, and are cautious.

The evidence suggests that bariatric surgery results in improved fertility; the strongest evidence is in women with the polycystic ovarian syndrome, where biochemical studies showing normalization of hormones after surgery support case series data. Observational studies (retrospective cohorts and case series) suggest that fertility improves following bariatric procedures and weight loss; similar to that seen when obese women lose weight through nonsurgical means. There is almost no evidence on post-surgical contraceptive efficacy or use. Research is needed to determine whether differences in absorption, particularly for oral contraceptives, affect contraceptive efficacy.

Nutrient deficiencies were reported in infants born to women who underwent procedures that resulted in malabsorption, as well as women who did not take prenatal vitamins or had difficulty with their own nutrition (i.e., from chronic vomiting). Literature suggests that gastric bypass and laparoscopic adjustable band procedures confer only minimal, if any, increased risk of nutritional or congenital problems if supplemental vitamins are taken and maternal nutrition is otherwise adequate. Biliopancreatic diversion has an appreciable risk for nutritional problems in some patients.

Women who have undergone bariatric surgery may have less risk than obese women for certain pregnancy complications such as gestational diabetes, preeclampsia, and pregnancy-induced hypertension. There is no evidence that cesarean section rates and delivery complications are higher in the post-surgery group, but data are limited.

Conclusions: Weight loss procedures are being performed more frequently to treat morbid obesity, with a six-fold increase over a recent 7-year time span; almost half of all patients are women of reproductive age. The level of evidence on fertility, contraception, and pregnancy outcomes is limited to observational studies. Data suggest that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic adjustable band and gastric bypass as long as adequate maternal nutrition and vitamin supplementation are maintained. There is no evidence that delivery complications are higher in post-surgery pregnancies.

Pregnancy after WLS

On December 15, 2009, in Pregnancy after WLS, by Andrea

From the March of Dimes:

Pregnancy After Weight-Loss Surgery

In the last few years, weight-loss surgery has become more common. Celebrities such as Carnie Wilson and Al Roker have spoken publicly about having these operations and their reasons for doing so. The number of women in their childbearing years having this surgery is rising.How Is the Surgery Done?
The most common weight-loss surgery is called  “gastric bypass.” In this operation, the surgeon staples the stomach across the top and leaves a small pouch that can hold only a small amount of food. Then the surgeon cuts a part of the intestine and sews it onto the pouch. This procedure limits the patient’s ability to absorb calories from food.

Effects on Pregnancy
Early reports of women who became pregnant after weight-loss surgery warned of possible complications. Problems included bleeding in the woman’s stomach or intestines, anemia and limited growth of the baby in the uterus.

More recent studies are more reassuring. They suggest that weight-loss surgery may help protect obese women and their babies from these health problems during pregnancy:

For Women Who Are Thinking About Weight-Loss Surgery and May Get Pregnant in the Future

  • Weight-loss surgery is not for everyone who is overweight. It is for people who are extremely obese and who have health problems as a result.
  • Because weight-loss surgery is still fairly new, we know very little about the long-term effects of this surgery.
  • Talk to your health care providers, including the medical professional who will deliver your baby. Learn about the risks and benefits of weight-loss procedures. Risks include gallstones, bleeding ulcers, and even death. Be sure you are well informed before your make your decision.

For Women Who Have Had Weight-Loss Surgery

  • Since you will lose weight rapidly right after surgery, avoid getting pregnant for 12-18 months after your operation. Rapid weight loss may deprive a fetus of the nutrients it needs to grow and be healthy.
  • Talk to your health care provider before you get pregnant.
  • Be aware of your need for vitamins and minerals. Weight-loss operations can result in low levels of iron, folate, vitamin B12 and calcium. All of these are needed for a healthy pregnancy. Pregnant women who have had weight-loss surgery may need to take vitamin pills.
  • Some women have a type of weight-loss surgery that uses a gastric band. This band is used to make a small pouch for food in the upper part of the stomach. If you have a gastric band, speak to your surgeon, preferably before you get pregnant. The surgeon may need to adjust the band for pregnancy.

This article is based, in part, on Committee Opinion 315 (September 2005) produced by the American College of Obstetricians and Gynecologists (ACOG).

December 2005

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