Babies born to mothers who have had bariatric surgery are strikingly healthier at birth and throughout childhood than siblings who were born before their mother’s surgery, according to results from a large new study from Quebec.

Even as they grow, children mirror their mother’s metabolic health at the time of childbirth, the study suggests. If the mother’s lipid profile is good and she has a healthy weight when she delivers the baby, that child will have better metabolic

health and less likelihood of gaining weight as he or she grows compared with siblings who were born when their mother was obese.

“Some would say it’s a question of lifestyle but these findings don’t support that. These [metabolic differences between siblings] were noted at birth,” said senior author Picard Marceau, MD, PhD, a surgeon at Laval University in Quebec, Canada.

The results indicate that bariatric surgery—or the weight loss produced by bariatric surgery—dramatically alters the intrauterine environment, resulting in infants who are born at healthier weights than their siblings born before the surgery.

As they grow, these children develop fewer problems with high cholesterol, less fat deposits and less insulin resistance or signs of metabolic disorder than their siblings born before their mother’s surgery, even when the younger children are breastfed the same way and eat similar food quantity and quality as their older brothers and sisters.

Results showed that babies born after surgery carried health advantages from gestation onward compared with their older siblings. During pregnancy, the mothers experienced far fewer complications with no cases of gestational diabetes, eclampsia or hypertension; for babies born before surgery, 12 women developed gestational diabetes, nine had eclampsia and 15 were diagnosed with hypertension. At birth, the infants born after their mothers underwent bariatric surgery weighed 17% less (P<0.001) and had 86% less macrosomia (0.06) than their siblings.

As the children grew, so did the health disparity with their siblings. They were significantly less likely to become obese or severely obese, with a 75% drop in severe obesity when measured by body mass index (BMI) percentile and a 65% decline when measured by BMI z-score. Overall, the children born after their mothers had bariatric surgery had an 11% decrease in BMI percentile, an 11% drop in waist circumference over height, a 38% reduction in BMI z-score and a 20% decrease in fat content compared with their older siblings. They accumulated belly fat five times slower than their older siblings (P=0.01).

What is most striking, said researchers, is the stark contrast in metabolic conditions in children born before and after surgery. Laboratory tests showed a 30% decrease in insulin resistance, 20% decrease in triglycerides, a 12% increase in high-density lipoprotein (HDL) cholesterol and a 13% decline in the ratio of total cholesterol over HDL in the offspring born after their mother’s operation.

“Bariatric surgery before pregnancy significantly improves an obese woman’s chances of giving birth to children who don’t have obesity-related metabolic disorders,” he said.

Surgery can halt the cumulative transmission of obesity from one generation to the next, what Dr. Marceau called a “vicious cycle of obesity.”

“If we are to curb the obesity epidemic, the focus must be on pregnancies,” he said.

The study also showed that boys’ and girls’ bodies responded differently. In boys, the predominant effect was prevention of severe obesity and correction of the lipid metabolism, whereas in girls the greatest effects were improved insulin sensitivity and decreased tissue fat percentage, independent of weight loss.

 Even minimal weight loss in an obese woman can significantly improve the health of her children, said Dr. Marceau. “Pregnancy is a time for great investment in life, even if it is minimal weight loss or restrictive diets.”

One point to note is that the study pertains to patients who had undergone Bilio-pancreatic Diversion (BPD in short)– a rare operation. In India, BPD is an unusual procedure indeed, especially in vegetarians who need high amount of proteins in their diet after this operation.

Pic credit: GSN

Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:

• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.

• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.

• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.

Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:

• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.

• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.

• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.

• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.

• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.

• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.

• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.

As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.

Additional points made by the authors of the practice bulletin include the following:

• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.

• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.

• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.

• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.

• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.

“As the rate of obesity increases, it is becoming more common for providers of women’s health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery,” the guidelines authors write. “The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes.”

Obstet Gynecol. 2009;113:1405-1413.