Pregnancy Outcomes After Bariatric Surgery: Importance of Maternal Ferritin on Birth Weight.

PURPOSE: The risks carried by pregnancy after bariatric surgery (BS) include small-for-gestational age (SGA) newborn and prematurity. However, the underlying mechanisms are not yet fully understood in pregnant women after BS. MATERIAL AND METHODS: This single-center retrospective observational cohort study includes all women with a first and single pregnancy after BS who completed at least one clinical and biological nutritional assessment during pregnancy between 2010 and 2016. The quarterly biological assessment comprised blood count, ferritin, calcium, 25OH vitamin D, parathyroid hormone, fasting glucose, albumin, prealbumin, vitamin A, vitamin B12, folic acid, and zinc. RESULTS: Among 120 pregnancies analysed, two-thirds underwent gastric bypass (Roux-en-Y and one-anastomosis) and one-third a restrictive procedure (adjustable gastric band or sleeve gastrectomy). The median [Q1-Q3] preoperative BMI was 43.8 [41.1-47.7] kg/m2 and the mean age at pregnancy was 32.6 ± 5.3 years. Weight loss and time from surgery to pregnancy were 35.1 ± 15.4 kg and 2.9 [1.3-4.5] years, respectively. Ten women (8%) gave birth prematurely, and 22 newborns (19%) were SGA. Univariate analysis shows that ferritin was significantly higher in mothers with SGA than in those without SGA (35.5 [22.3-69.5] vs. 15 [10-32] ng/ml) at third trimester of pregnancy. Women who received pre-pregnancy nutritional assessment seemed less likely to give birth to a SGA newborn (32% vs. 54%, p = 0.07). CONCLUSION: Iron supplementation should be carefully prescribed and closely monitored during pregnancy in women who have undergone BS.

Mitral valve prolapse: arrhythmic risk during pregnancy and postpartum.

BACKGROUND AND AIMS: Arrhythmic mitral valve prolapse (AMVP) is linked to life-threatening ventricular arrhythmias (VAs), and young women are considered at high risk. Cases of AMVP in women with malignant VA during pregnancy have emerged, but the arrhythmic risk during pregnancy is unknown. The authors aimed to describe features of women with high-risk AMVP who developed malignant VA during the perinatal period and to assess if pregnancy and the postpartum period were associated with a higher risk of malignant VA. METHODS: This retrospective international multi-centre case series included high-risk women with AMVP who experienced malignant VA and at least one pregnancy. Malignant VA included ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock from an implantable cardioverter defibrillator. The authors compared the incidence of malignant VA in non-pregnant periods and perinatal period; the latter defined as occurring during pregnancy and within 6 months after delivery. RESULTS: The authors included 18 women with AMVP from 11 centres. During 7.5 (interquartile range 5.8-16.6) years of follow-up, 37 malignant VAs occurred, of which 18 were pregnancy related occurring in 13 (72%) unique patients. Pregnancy and 6 months after delivery showed increased incidence rate of malignant VA compared to the non-pregnancy period (univariate incidence rate ratio 2.66, 95% confidence interval 1.23-5.76). CONCLUSIONS: The perinatal period could impose increased risk of malignant VA in women with high-risk AMVP. The data may provide general guidance for pre-conception counselling and for nuanced shared decision-making between patients and clinicians.

Pregnancy and cardiac maternal outcomes in women with inherited cardiomyopathy: interest of the CARPREG II risk score.

AIMS: Inherited cardiomyopathies are relatively rare but carry a high risk of cardiac maternal morbidity and mortality during pregnancy and postpartum. However, data for risk stratification are scarce. The new CARPREG II score improves prediction of prognosis in pregnancies associated with heart disease, though its role in inherited cardiomyopathies is unclear. We aim to describe characteristics and cardiac maternal outcomes in patients with inherited cardiomyopathy during pregnancy, and to evaluate the interest of the CARPREG II risk score in this population. METHODS AND RESULTS: In this retrospective single-centre study, 90 consecutive pregnancies in 74 patients were included (mean age 32 ± 5 years), including 28 cases of dilated cardiomyopathy (DCM), 46 of hypertrophic cardiomyopathy, 11 of arrhythmogenic right ventricular cardiomyopathy and 5 of left ventricular noncompaction, excluding peripartum cardiomyopathy. The discriminatory power of several risk scores was assessed by the area under the receiver-operating characteristic curve (AUC). Median CARPREG II score was 2 [0;3] and was higher in the DCM subgroup. A severe cardiac maternal complication was observed in 18 (20%) pregnancies, mainly driven by arrhythmia and heart failure (each event in 10 pregnancies), with 3 cardiovascular deaths. Forty-three pregnancies (48%) presented foetal/neonatal complications (18 premature delivery, 3 foetal/neonatal death). CARPREG II was significantly associated with cardiac maternal complications (P < 0.05 for all) and showed a higher AUC (0.782) than CARPREG (0.755), mWHO (0.697) and ZAHARA (0.604). CONCLUSIONS: Pregnancy in women with inherited cardiomyopathy carries a high risk of maternal cardiovascular complications. CARPREG II is the most efficient predictor of cardiovascular complications in this population.

Pregnant women with mild COVID-19 followed in community setting by telemedicine, and factors associated with unfavorable outcome.

OBJECTIVES: Few is known on pregnant women with mild COVID-19 managed in a community setting with a telemedicine solution, including their outcomes. The objective of this study is to evaluate the adverse fetal outcomes and hospitalization rates of pregnant COVID-19 outpatients who were monitored with the Covidom© telemedicine solution. METHODS: A nested study was conducted on pregnant outpatients with confirmed COVID-19, who were managed with Covidom© between March and November 2020. The patients were required to complete a standard medical questionnaire on co-morbidities and symptoms at inclusion, and were then monitored daily for 30 days after symptom onset. Adverse fetal outcome was defined as a composite of preterm birth, low birthweight, or stillbirth, and was collected retrospectively through phone contact with a standardized questionnaire. RESULTS: The study included 714 pregnant women, with a median age of 32.0 [29.0-35.0] and a median BMI of 23.8 [21.3-27.0]. The main comorbidities observed were smoking (53%), hypertension (19%). The most common symptoms were asthenia (45.6%), cough (40.3%) and headache (25.7%), as well as anosmia (28.4%) and agueusia (32.3%). Adverse fetal outcomes occurred in 64 (9%) cases, including 38 (5%) preterm births, 33 (5%) low birthweights, and 6 (1%) stillbirths. Hospitalization occurred in 102 (14%) cases and was associated with adverse fetal outcomes (OR 2.4, 95% CI 1.3-4.4). CONCLUSIONS: Our study suggests that adverse fetal outcomes are rare in pregnant women with mild COVID-19 who are monitored at home with telemedicine. However, hospitalization for COVID-19 and pregnancy-induced hypertension are associated with a higher risk of adverse fetal outcome.

Risk-Benefit Balance Associated With Obstetric, Neonatal, and Child Outcomes After Metabolic and Bariatric Surgery.

Importance: Metabolic and bariatric surgery (MBS) is the most efficient therapeutic option for severe obesity. Most patients who undergo MBS are women of childbearing age. Data in the scientific literature are generally of a low quality due to a lack of well-controlled prospective trials regarding obstetric, neonatal, and child outcomes. Objective: To assess the risk-benefit balance associated with MBS around obstetric, neonatal, and child outcomes. Design, Setting, and Participants: The study included 53 813 women on the French nationwide database who underwent an MBS procedure and delivered a child between January 2012 and December 2018. Each women was their own control by comparing pregnancies before and after MBS. Exposures: The women included were exposed to either gastric bypass or sleeve gastrectomy. Main Outcomes and Measures: The study team first compared prematurity and birth weights in neonates born before and after maternal MBS with each other. Then they compared the frequencies of all pregnancy and child diagnoses in the first 2 years of life before and after maternal MBS with each other. Results: A total of 53 813 women (median [IQR] age at surgery, 30 [26-35] years) were included, among 3686 women who had 1 pregnancy both before and after MBS. The study team found a significant increase in the small-for-gestational-age neonate rate after MBS (+4.4%) and a significant decrease in the large-for-gestational-age neonate rate (-12.6%). The study team highlighted that compared with pre-MBS births, after MBS births had fewer occurrences of gestational hypertension (odds ratio [OR], 0.16; 95% CI, 0.10-0.23) and gestational diabetes for the mother (OR, 0.39; 95% CI, 0.34-0.45), as well as fewer birth injuries to the skeleton (OR, 0.27; 95% CI, 0.11-0.60), febrile convulsions (OR, 0.39; 95% CI, 0.21-0.67), viral intestinal infections (OR, 0.56; 95% CI, 0.43-0.71), or carbohydrate metabolism disorders in newborns (OR, 0.54; 95% CI 0.46-0.63), but an elevated respiratory failure rate (OR, 2.42; 95% CI, 1.76-3.36) associated with bronchiolitis. Conclusions and Relevance: The risk-benefit balance associated with MBS is highly favorable for pregnancies and newborns but may cause an increased risk of respiratory failure associated with bronchiolitis. Further studies are needed to better assess the middle- and long-term benefits and risks associated with MBS.

Delivery decision in pregnant women rescued by ECMO for severe ARDS: a retrospective multicenter cohort study.

BACKGROUND: Although rarely addressed in the literature, a key question in the care of critically pregnant women with severe acute respiratory distress syndrome (ARDS), especially at the time of extracorporeal membrane oxygenation (ECMO) decision, is whether delivery might substantially improve the mother's and child's conditions. This multicenter, retrospective cohort aims to report maternal and fetal short- and long-term outcomes of pregnant women with ECMO-rescued severe ARDS according to the timing of the delivery decision taken before or after ECMO cannulation. METHODS: We included critically ill women with ongoing pregnancy or within 15 days after a maternal/child-rescue-aimed delivery supported by ECMO for a severe ARDS between October 2009 and August 2021 in four ECMO centers. Clinical characteristics, critical care management, complications, and hospital discharge status for both mothers and children were collected. Long-term outcomes and premature birth complications were assessed. RESULTS: Among 563 women on venovenous ECMO during the study period, 11 were cannulated during an ongoing pregnancy at a median (range) of 25 (21-29) gestational weeks, and 13 after an emergency delivery performed at 32 (17-39) weeks of gestation. Pre-ECMO PaO2/FiO2 ratio was 57 (26-98) and did not differ between the two groups. Patients on ECMO after delivery reported more major bleeding (46 vs. 18%, p = 0.05) than those with ongoing pregnancy. Overall, the maternal hospital survival was 88%, which was not different between the two groups. Four (36%) of pregnant women had a spontaneous expulsion on ECMO, and fetal survival was higher when ECMO was set after delivery (92% vs. 55%, p = 0.03). Among newborns alive, no severe preterm morbidity or long-term sequelae were reported. CONCLUSION: Continuation of the pregnancy on ECMO support carries a significant risk of fetal death while improving prematurity-related morbidity in alive newborns with no difference in maternal outcomes. Decisions regarding timing, place, and mode of delivery should be taken and regularly (re)assess by a multidisciplinary team in experienced ECMO centers.

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device. METHODS: This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021. RESULTS: During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24-40), SAPS II at 69 (56-81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30-41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55-1530) µg/kg/min, a severe left ventricular ejection fraction measured at 14 (0-40)%, and lactate at 12 (2-30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up. CONCLUSION: In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.

Change in Birth Rate Before and After Bariatric Surgery in France.

IMPORTANCE: Bariatric surgery worldwide has grown significantly over the past years and is performed, in a vast majority, in women of childbearing age. The impact of these procedures on birth rates remains largely unknown. OBJECTIVE: The main objective was to study the evolution of the birth rates in these women, before and after bariatric surgery and in comparison with women from the general population. The secondary objectives were to compare the birth rates before and after surgery according to the Body Mass Index (BMI) (BMI 40-50 versus >50 kg/m2). METHOD: Our analyses are based on a national medico-administrative database. All women of childbearing age and who had bariatric surgery between 2012 and 2016 were included, and we included all deliveries between 2012 and 2018 in this population. We compared the birth rates before and after bariatric surgery. National statistics (INSEE, Institut National de la Statistique et des Etudes Economiques) were used for comparison with women from the general population. FINDINGS: A total of 69,932 women were included between 2012 and 2016, with a median age at surgery of 33 years [27; 39]. Among them, 9391 (13%) had a BMI over 50 kg/m2 before surgery, 46,818 (67%) benefited from a sleeve gastrectomy (SG), and 23,376 (33%) from a gastric bypass (GBP). Birth rates tend to be smaller after surgery compared to before surgery for women under 27 years (OR: 0.92, CI95% [0.88; 0.96]), while being not different after 27 in both groups (OR: 1.00, CI95% [0.97; 1.03]). Birth rates of obese women who have benefited or will benefit from the bariatric surgery were higher than the general population, with a peak at a younger age, and then decline earlier than the general population. Trends were different according to BMI class. Birth rates were higher for women with BMI between 40 and 50 kg/m2 compared to women with BMI greater than 50 kg/m2 (OR=1.28, CI95% [1.21; 1.36]) before surgery while slightly lower after surgery (OR=0.95, CI95% [0.91; 0.99]). CONCLUSIONS AND RELEVANCE: We showed that birth rates after bariatric surgery were not different before and after bariatric surgery except for women under 27 years old who had a smaller birth rate. Interestingly, we observed an improvement of birth rates after surgery for women with a BMI of 50 kg/m2 or more.

Vaginal delivery of the second twin in unengaged cephalic presentation.

In accordance with women's preferences guidelines, referring to population-based and randomized trials, which recommends counseling women with vertex-first twins to attempt a vaginal delivery. Yet, the rising rates of twin caesareans are associated with the decline in skills of senior and junior obstetricians. Although noncephalic second twins have been in the focus of interest, prompt delivery of cephalic second twins can be trickier when the head does not engage. We illustrate how to avoid complications during instrumental delivery or internal podalic version and breech extraction of the second twin encouraging to start when membranes are still intact.

A Novel Partogram for Stages 1 and 2 of Labor Based on Fetal Head Station Measured by Ultrasound: A Prospective Multicenter Cohort Study.

OBJECTIVE: This study was aimed to describe continuous labor curves, including second stage, based on fetal head station. STUDY DESIGN: We performed a prospective multicenter cohort study. The inclusion criteria were women with singleton uncomplicated cephalic term pregnancies in labor, who delivered vaginally. We used a device that combines ultrasound imaging with position-tracking technology to monitor the head station noninvasively throughout labor. We collected data on demographics, labor parameters, and delivery and neonatal outcomes. RESULTS: A total of 613 women delivered vaginally, 327 (53.3%) were nulliparous, while 286 (46.7%) were multiparous. Time to delivery (TTD) diminished progressively with descent of the fetal head. When the head is engaged, the labor curve of multiparous women demonstrated a more prominent downward shift in curve as compared with nulliparous women. When comparing multipara and nullipara at engagement level, the median TTD was 1 and 1.62 hours, respectively. In 95% of women with unengaged head during the second stage, TTD of nulliparous and multiparous women were less than 3.8 and 3 hours, respectively. CONCLUSION: While current labor curves end at full dilatation, the described curves were developed throughout stages 1 and 2 of labor. The TTD, according to the station curves, shows an acceleration of labor, once passed the engagement level, especially in multiparous women.

Pregnancy issues in Takayasu arteritis.

Takayasu arteritis (TAK) is a chronic inflammatory vasculitis of unknown origin affecting large vessels, predominantly the aorta and its main branches. TAK usually affects young women and the management of pregnancy during this vasculitis may be a challenging situation. After a review of the literature, we analysed the data of 505 pregnancies in 373 TAK patients. We discuss main results to clarify if the pregnancy outcome is affected by TAK, especially during disease clinical onset or disease activity. We also discuss the potential impact of pregnancy on TAK prognosis. Disease activity of TAK appears independently associated with a poor pregnancy outcome. More than 5% of pregnant women with TAK develop a life-threatening maternal cardiovascular complication. A good control of TAK disease activity and arterial hypertension before conception and during pregnancy is critical to improve both maternal and foetal outcomes. Pregnancies in the setting of TAK should be considered high-risk, requiring a close collaboration between specialists involved in the care of TAK and obstetricians.

Correction to: Clinical Practice Guidelines for Childbearing Female Candidates for Bariatric Surgery, Pregnancy, and Post-Partum Management after Bariatric Surgery.

In the original article, due to an XML tagging error the name of Véronique Taillard was omitted from the list of members of the French Study Group for Bariatric Surgery and Maternity (the BARIA-MAT Group). The correct list is as follows.

The sexual reproductive health of women: Unfinished business in the Eastern Europe and Central Asia region.

EBCOG and ESCRH are committed to work with UNFPA- EECA Region to reduce high maternal mortality, preventing unwanted pregnancies, improving adolescent health, reducing the burden of STDs including HIV, safeguarding and protecting sexual health and achieving gender equality to achieve the objectives of ICPD 25 as agreed in Nairobi on 12th November 2019. Both organisations will provide technical assistance to support the development of country level SRH strategies to achieve these objectives as outlined in this joint position statement. We advocate policies developments for knowledge transfer from west to the east to address the unmet need for effective contraceptive methods, to reduce the rates of teenage and adolescent pregnancy rates. All this can be achieved by developing a work force fit for purpose to support the implementation of national SRH strategies. We urge upon international and national funders to work with us to develop sustainable models of care in the Eastern Europe and Central Asian Region.

Clinical Practice Guidelines for Childbearing Female Candidates for Bariatric Surgery, Pregnancy, and Post-partum Management After Bariatric Surgery.

Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.

Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement.

Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis, and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the prevention and treatment of postpartum haemorrhage as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, and transfusion medicine was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). Members of the task force assessed the quantity, quality and consistency of the published evidence, and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings, and by policy-makers in charge of decision making for the update of clinical practice in health care establishments.