Connect the Dots.

Connect the Dots—November 2017 Jenny Underwood,

MD, MSc,

Alecia Fields,

DO,

Erin M. Conway,

1. Contraception and Conception After Bariatric Surgery Obstet Gynecol 2017;130:979–87

Preconception obesity is a significant risk factor for many perinatal problems. The obese gravid patient is at higher risk for pregestational and gestational diabetes and hypertension, cesarean delivery, fetal anomalies, macrosomia, and neonatal complications, among other issues. Preconception weight management with bariatric surgery is often recommended for women who are severely obese or who have comorbidities. Recommendations to delay conception for 12–18 months after bariatric surgery are based on findings of higher rates of poor fetal growth, nutritional deficits, and perinatal complications with conceptions earlier than this. The Longitudinal Assessment of Bariatric Surgery-2 is a 10-hospital prospective cohort study of adults undergoing firsttime bariatric surgery.1 Menke et al (see page 979) report carefully collected data on pregnancy intendedness and contraceptive use among 740 women who underwent bariatric surgery between 2005 and 2009. Within the first year after surgery, about 53% of women were abstinent or consistently used contraception, and about 47% either were inconsistent contraceptors or actively tried to conceive. By the second year, the rate of attempted conception increased from about 5% to 13%. The authors report a low rate of intrauterine device use (6.4%) in the first year. During the first 18 months, there were 42.3 conceptions per 1,000 women-years. Obesity is a major public health concern, and for obese reproductive-age women, it is important to recognize the potential effects on the fetus, not only during pregnancy but owing to in utero programming. Attaining a lower preconception weight is a benefit to both mother and her fetus and neonate. Bariatric surgery is an important and increasingly common modality for preconception weight “Connect the Dots” begins with a brief comment on an article from an issue of Obstetrics & Gynecology selected by the Editor-in-Chief. The next author “connects” a piece that relates in some way to the synopsis she/he received. She/ he then sends her/his “connection” only to the next author. The three authors making connections are members of the ACOG Junior Fellow Congress Advisory Council. (Photo of Nancy Chescheir is courtesy of the Central Association of Obstetricians and Gynecologists, 2016.). Financial Disclosure The authors did not report any potential conflicts of interest. © 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/17

VOL. 130, NO. 5, NOVEMBER 2017

MD,

and Nancy C. Chescheir,

MD

control. The current study suggests that improved counseling about family planning methods with consultation by obstetrician–gynecologists (ob-gyns) may be beneficial to women who plan to conceive after bariatric surgery. Nancy C. Chescheir, MD University of North Carolina, Chapel Hill, North Carolina

REFERENCE 1. Menke MN, King WC, White GE, Gosman GG, Courcoulas AP, Dakin GF, et al. Contraception and conception after bariatric surgery. Obstet Gynecol 2017;130:979–87.

2. Is Bariatric Surgery an Option for Women With Gynecologic Cancer? Examining Weight Loss Counseling Practices and Training Among Gynecologic Oncology Providers Gynecol Oncol 2014;134:540–5

By 2030, the Centers for Disease Control and Prevention predicts that obesity in the United States will increase from one-in-three persons today to one-in-two persons. Common cancers that women will face (breast, bowel, gynecologic) are associated with obesity; indeed, endometrial cancer is 2 to 4 times more common in obese compared to nonobese women. In a study by Neff et al,1 a 49-question online survey, answered by 454 (30%) members of the Society of Gynecologic Oncology, explored willingness to initiate weight loss discussions; training to counsel patients on weight loss options, including bariatric surgery; and level of comfort managing weight loss. Clinical obesity (body mass index [BMI, calculated as weight (kg)/[height (m)]2] greater than 30) was reported in more than one half of the patient population served by 58% of respondents. The 11% of health care providers who had received formal training were comfortable discussing weight loss (correlation coefficient, r50.11; P5.04), whereas those who reported no training were more concerned about insulting their patients. Unfortunately, by the time patients are being treated by gynecologic oncologists, the opportunity to reduce their risk of cancer is past. This article, nonetheless, is important to all women’s health care providers, generalists and subspecialists alike, because it highlights areas for improvement. Training in weight loss counseling and management gives providers comfort initiating discussion and recommending a weight-management plan. Closing the gap in knowledge about weight loss strategies and collaboration with bariatric specialists will improve weight-control outcomes and thereby

Underwood et al

Connect the Dots.

Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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reduce the consequences of obesity, including endometrial and other weight-associated cancers in women. Jenny Underwood, MD, MSc Henry Ford Hospital/Wayne State University, Detroit, Michigan

obstetrician’s comfort, knowledge, and practice patterns. Obes Surg 2017;27:2354–9.

4. Bariatric Surgery and Risk of Postoperative Endometrial Cancer: A Systematic Review and Meta-analysis Surg Obes Relat Dis 2015;11:949–55

REFERENCE 1. Neff R, McCann GA, Carpenter KM, Cohn DE, Noria S, Mikami D, et al. Is bariatric surgery an option for women with gynecologic cancer? Examining weight loss counseling practices and training among gynecologic oncology providers. Gynecol Oncol 2014;134:540–5.

3. Pregnancy After Bariatric Surgery: National Survey of Obstetrician’s Comfort, Knowledge, and Practice Patterns Obes Surg 2017;27:2354–9

The percentage of obese women in the United States continues to rise. Among women 20 years old and older, 18.8% are classified as grade 2 or 3 obese, with BMIs of 35 or greater.1 Despite the benefits of bariatric surgery, there is an increased risk of preterm birth and small-for-gestational-age neonates among this group of pregnant women. Approximately 80% of patients undergoing bariatric surgery are women of reproductive age. Given the increasing prevalence of pregnant women who have undergone bariatric surgery and the additional pregnancy risk factors, it is important that ob-gyns understand current recommendations for caring for this population. A recent survey by Smid et al2 looked to examine obstetricians’ comfort, knowledge, and practice patterns in caring for pregnant women after bariatric surgery based on published American College of Obstetricians and Gynecologists’ guidelines. This survey included 106 respondents comprised of ob-gyns across practice settings. Overall, 83% reported that they felt very or somewhat comfortable caring for pregnant women after bariatric surgery. Although 66% correctly identified the increased risk of small-for-gestational-age neonates, only 13% were able to correctly identify all of the recommended nutritional laboratory values and 26% reported that they did not know the recommendation regarding medication use. Many ob-gyns report feeling comfortable caring for pregnant women after bariatric surgery and are aware of the increased perinatal risks, however knowledge gaps remain present. To improve the quality of care for this growing population, targeted efforts to increase health care provider knowledge are recommended.

The prevalence of obesity is rising in both developed and developing countries. An increased risk of endometrial cancer has been linked to obesity in many studies. The proposed mechanisms for this are the secretion of growth factors and cytokines, such as insulin-like growth factor-1 and leptin, which play a role in low-grade chronic inflammation and increased levels of sex hormones such as estrogen. Bariatric surgery is used to treat obesity in patients with BMIs greater than 35 and related comorbidities or BMIs greater than 40 after weight loss failure. Bariatric surgery and the subsequent weight loss has been associated with reduction in cardiovascular risk factors and cancer in women but not in men. One study showed an increased risk of colorectal cancer after bariatric surgery.1 The study by Upala and Sanguankeo was a systematic review and meta-analysis that aimed to assess the risk of endometrial cancer in obese patients after bariatric surgery compared with obese women in a control group.2 The authors searched published randomized clinical trials, nonrandomized trials, and observational studies related to bariatric surgery and endometrial cancer. The inclusion criteria were obese women older than 18 years who underwent Roux-en-Y gastric bypass, gastric band, vertical banded gastroplasty, and biliopancreatic diversion. A total of 890,110 obese participants were included in the meta-analysis. Of these, 42,550 underwent bariatric surgery. There were 12,102 new cancer cases, 11,847 of which were in the control group (no bariatric surgery). In the analysis of studies that specifically reported endometrial cancer risk, a total of 19,624 obese patients underwent bariatric surgery, with 56 new cases of endometrial cancer after surgery. Meta-analysis revealed that the pooled risk ratio of endometrial cancer in the bariatric surgery group compared with the control group was 0.43, providing evidence that bariatric surgery reduced the risk of endometrial cancer by about 60% in obese patients. Erin M. Conway, MD Saint Barnabas Medical Center, Livingston, New Jersey

Alecia Fields, DO University of Rochester Medical Center, Rochester, New York

REFERENCES

REFERENCE 1. National Center for Health Statistics. Health, United States, 2016: with chartbook on long-term trends in health. Hyattsville (MD): National Center for Health Statistics; 2017. 2. Smid MC, Dotters-Katz SK, Mcelwain CA, Volckmann ET, Schulkin J, Stuebe AM. Pregnancy after bariatric surgery: national survey of

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Connect the Dots.

1. Derogar M, Hull MA, Kant P, Ostlund M, Lu Y, Lagergren J. Increased risk of colorectal cancer after obesity surgery. Ann Surg 2013;258:983–8. 2. Upala S, Sanguankeo A. Bariatric surgery and risk of postoperative endometrial cancer: a systematic review and meta-analysis. Surg Obes Relat Dis 2015;11:949–55.

OBSTETRICS & GYNECOLOGY

Copyright Ó by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Connect the Dots-November 2017.

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