Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre , Rotterdam, The Netherlands.
Department of Surgery, Rijnstate, Arnhem, The Netherlands.
Hum Reprod Update. 2021 Oct 18;27(6):1030-1055. doi: 10.1093/humupd/dmab022.
Worldwide, the prevalence of obesity in women of reproductive age is increasing. Bariatric surgery is currently viewed as the most effective, long-term solution for this problem. Preconception bariatric surgery can reduce the prevalence of obesity-related subfertility and adverse maternal, pregnancy and birth outcomes. Maternal health during the periconception period is crucial for optimal gametogenesis and for embryonic and fetal development which also affects health in the later lives of both mother and offspring. Although preconception bariatric surgery improves several pregnancy outcomes, it can also increase the prevalence of pregnancy complications due to excessive and rapid weight loss. This can lead to iatrogenic malnutrition with vitamin deficiencies and derangements in metabolic and endocrine homeostasis. Thus, bariatric surgery can greatly influence periconception maternal health with consequences for reproduction, pregnancy and health in later life. However, its influence on periconception maternal health itself has never been reviewed systematically.
The aim of this review was to investigate associations between bariatric surgery and determinants of periconception maternal health such as endocrine changes, fertility, vitamin status, irregular menstrual cycles, miscarriages and congenital malformations.
Medline, Embase, PubMed, Web of Science, Google Scholar and the Cochrane databases were used for the literature search until 1 November 2020. The search strategy terms included, among others, bariatric surgery, hormones, fertility, malformations, miscarriages and vitamin status. We searched for human studies that were written in English. Abstracts, reviews, meta-analyses and conference papers were excluded. The ErasmusAGE score was used to assess the quality of the included studies.
A total of 51 articles were analysed. The mean quality score was 5 (range 2-8). After bariatric surgery, hormonal axes normalized and menstrual cycle regularity was restored, resulting in increased fertility. Overall, there were no short-term risks for reproductive outcomes such as the increased risk of miscarriages or congenital malformations. However, the risk of vitamin deficiencies was generally increased after bariatric surgery. A meta-analysis of 20 studies showed a significant decrease in infertility (risk difference (RD) -0.24, 95% confidence interval (CI) -0.42, -0.05) and menstrual cycle irregularities (RD -0.24, 95% CI -0.34, -0.15) with no difference in rates of miscarriage (RD 0.00, 95% CI -0.09, 0.10) and congenital malformations (RD 0.01, 95% CI -0.02, 0.03).
The current systematic review and meta-analysis show associations between bariatric surgery and periconception maternal health and underlines the need for providing and personalizing preconception care for women after bariatric surgery. We recommend preconception care including the recommendation of postponing pregnancy until weight loss has stabilized, irrespective of the surgery-to-pregnancy interval, and until vitamin status is normalized. Therefore, regular monitoring of vitamin status and vitamin supplementation to restore deficiencies is recommended. Furthermore, this systematic review emphasizes the need for a long-term follow-up research of these women from the periconception period onwards as well as their pregnancies and offspring, to further improve care and outcomes of these mothers and children.
在全球范围内，育龄妇女的肥胖患病率正在增加。减重手术目前被认为是解决这一问题的最有效、最持久的方法。孕前减重手术可以降低肥胖相关不孕和不良母婴、妊娠和分娩结局的发生率。受孕前期间的母体健康对于最佳配子发生以及胚胎和胎儿发育至关重要，这也会影响母婴双方以后的生活健康。尽管孕前减重手术可以改善多种妊娠结局，但它也会因过度和快速减肥而增加妊娠并发症的发生率。这可能导致医源性营养不良、维生素缺乏以及代谢和内分泌稳态的紊乱。因此，减重手术会极大地影响受孕前的母体健康，从而影响生殖、妊娠和以后的生活健康。然而，它对受孕前母体健康本身的影响从未被系统地评估过。
本综述的目的是研究减重手术与受孕前母体健康决定因素之间的关联，例如内分泌变化、生育能力、维生素状况、不规则月经周期、流产和先天畸形。
使用 Medline、Embase、PubMed、Web of Science、Google Scholar 和 Cochrane 数据库进行文献检索，截至 2020 年 11 月 1 日。搜索策略术语包括但不限于减重手术、激素、生育能力、畸形、流产和维生素状况。我们检索了用英文书写的人类研究。排除了摘要、综述、荟萃分析和会议论文。使用 ErasmusAGE 评分评估纳入研究的质量。
共分析了 51 篇文章。平均质量评分为 5 分（范围 2-8 分）。减重手术后，激素轴恢复正常，月经周期恢复规律，生育能力提高。总体而言，生殖结局如流产或先天畸形的风险没有短期增加。然而，减重手术后维生素缺乏的风险通常会增加。对 20 项研究的荟萃分析显示，不孕（风险差异 -0.24，95%置信区间 -0.42，-0.05）和月经周期不规律（风险差异 -0.24，95%置信区间 -0.34，-0.15）的发生率显著降低，但流产（风险差异 0.00，95%置信区间 -0.09，0.10）和先天畸形（风险差异 0.01，95%置信区间 -0.02，0.03）的发生率无差异。
目前的系统评价和荟萃分析显示了减重手术与受孕前母体健康之间的关联，并强调了为接受减重手术后的女性提供和个性化孕前保健的必要性。我们建议进行孕前保健，包括建议推迟怀孕，直到体重减轻稳定，而不管手术到怀孕的间隔时间，直到维生素状况正常。因此，建议定期监测维生素状况并补充维生素以恢复缺乏症。此外，本系统评价强调需要对这些女性从受孕前时期开始，以及她们的妊娠和后代进行长期随访研究，以进一步改善这些母亲和儿童的护理和结局。
