doi:10.1111/jog.14165 J. Obstet. Gynaecol. Res.

2019

Effects of laparoscopic sleeve gastrectomy on obstetric

outcomes within 12 months after surgery

g1 , Sinem Demircan2 and Eray Çalışkan1

Cihan Karada

1 _
Okan University School of Medicine and 2Istanbul Medeniyet University School of Medicine, Department of Obstetrics and
_
Gynecology, Istanbul, Turkey

Abstract
Aim: To determine the obstetric and neonatal outcomes of pregnant patients having undergone laparoscopic
sleeve gastrectomy (LSG) in the previous 12 months.
Methods: This retrospective and observational study included 144 pregnant women: 48 had pregnancies
within 12 months after LSG (Group A), 42 became pregnant more than 1 year after surgery (Group B) and
54 obese pregnant women who had a body mass index (BMI) >30 kg/m2, were categorized as the control
group because they did not undergo surgery (Group C). The participants’ early gestational BMI, predelivery
BMI and gestational weight gain were determined and the obstetric and neonatal outcomes of the groups
were compared.
Results: The time interval from surgery to conception was 7.8  3.4 months and 25.8  13.4 months for
Groups A and B, respectively (P < 0.01). There were no significant differences in the rates of gestational
hypertension, pre-eclampsia, preterm delivery and cesarean section between the groups. The number of
patients with gestational diabetes mellitus was significantly higher in Group C than in Groups A and B
(P = 0.004). The number of large-for-gestational-age infants was higher in Group C than in Groups A and B
(P = 0.046). The number of small-for-gestational-age infants was significantly higher in Group A than in
Groups B and C (P = 0.025).
Conclusion: Pregnancy within one year after LSG is related to an increased risk of small-for-gestational-age
infants. LSG decreases the risk of gestational diabetes mellitus independent of the time interval between sur-
gery and conception.
Key words: gestational diabetes mellitus, laparoscopy, obesity, pregnancy, sleeve gastrectomy.

Introduction loss prior to pregnancy is crucial for better obstetric

Globally, obesity is a critical public healthcare prob-
lem that is becoming more frequent.1 It has also
become a serious health problem in Turkey, affecting
more than one-third of the adult population.2,3
Maternal obesity is related to adverse obstetric out-
comes, such as gestational diabetes mellitus (GDM),
hypertensive disorders of pregnancy, macrosomia,
increased rates of cesarean deliveries, preterm birth
and perinatal mortality.4,5 For this reason, weight
and neonatal outcomes. The previous few decades
have seen an increase in the number of bariatric sur-
geries being performed since it is the treatment of
choice for severe obesity and results in sustained
weight loss.6,7 Laparoscopic sleeve gastrectomy
(LSG) is a bariatric surgical technique and recently
has been applied more and preferred over other bar-
iatric surgical methods because of its safety, simplic-
ity and effectiveness with regard to sustained weight
loss over time.8–10

Received: August 28 2019.

Accepted: November 10 2019.
Correspondence: Dr Cihan Karada
_
g, Okan University Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey.
Email: cihankaradag2000@hotmail.com

© 2019 Japan Society of Obstetrics and Gynecology 1

 g et al.
C. Karada

Previous studies have shown beneficial effects of
bariatric surgery on obstetric outcomes such as
pregnancy-associated hypertensive disorders and
GDM.11 Increasing studies have focused on decreases
in adverse pregnancy outcomes after bariatric sur-
gery, and studies have reported decreased risk of
GDM, fetal macrosomia, cesarean delivery, hyperten-
sive disorders of pregnancy but an increased risk of
being small for gestational age (SGA)12–14 after sur-
gery. After bariatric surgery, the greatest weight
reduction occurs in the first 1 year,15 and during this
increased weight loss period maternal nutritional
intake effectively decreases. Some studies did not rec-
ommend pregnancy for at least 12 months after bar-
iatric surgery.11,16 However, there is no evidence that
shows increased adverse obstetric outcomes during
the first year after surgery.17–19 Furthermore, most
previous studies included different time intervals
between pregnancy and surgery along with utiliza-
tion of different surgical methods.
We aimed to investigate the obstetric and neonatal
outcomes in patients who had pregnancy during the
first year after LSG, and to detect the effects of LSG
on pregnancy outcomes.
Methods
This study was a retrospective and observational
study in Kocaeli University School of Medicine
between 2010 and 2019. Among 2978 patients who
underwent LSG (By the same surgical team and per-
formed the same surgical technical procedure), 48 had
spontaneous and unplanned pregnancies within 1 year
after the surgery (Group A) and 42 had pregnancies
more than 1 year after surgery (Group B). Likewise,
54 patients with BMI > 30 kg/m2 at the beginning of
the pregnancy (Group C) and who had delivered in
our clinic were observed retrospectively as the control
group. The study was approved by the ethics commit-
tee of Kocaeli University School of Medicine and was
conducted accordingly Declaration of Helsinki. Multi-
ple pregnancies, miscarriages and intrauterine fetal
demise were excluded from the study. Maternal age,
weight (kg) and height (m) were determined. BMI
before and after surgery, BMI at conception, BMI at
delivery, gestational weight gain and the time interval
between surgery and pregnancy (months) were calcu-
lated. BMI was calculated using the following for-
mula: weight (kg)/height2 (m). Obstetric and neonatal
outcomes of the groups were compared.
2 © 2019 Japan Society of Obstetrics and Gynecology
Pre-eclampsia was diagnosed as hypertension with
either proteinuria (≥300 mg/day) or thrombocytope-
nia, increased creatinine levels, increased liver
enzymes, pulmonary edema, epigastric pain, and
cerebral or visual symptoms; gestational hypertension
(GHT) was diagnosed as hypertension after 20 weeks
of gestation without findings and symptoms of pre-
eclampsia.20 Preterm delivery was defined as birth at
less than 37 weeks of gestation. Placental abruption
was described as full or partial detachment of a typi-
cally implanted placenta prior to birth. For the diag-
nosis of GDM21 a standard 75 g oral glucose tolerance
test (OGTT) was performed between 24th and 28th
weeks of gestation after overnight fasting (8–14 h),
0–60–120th minutes blood samples were taken to ana-
lyze serum glucose levels. After performing of the
75 g OGTT early dumping syndrome was seen in
14 patients (58%) and late dumping syndrome was
seen in four patients (16%) in Group A. For Group B
it was three (14%) and two (9%), respectively. Dump-
ing syndrome was diagnosed according to Sigstad
scoring system.22 Large-for-gestational-age (LGA)
infants were defined as those with a birthweight
above the 90th percentile, and SGA infants as those
with a birthweight below the 10th percentile, using
birth weight z-scores.23 Additionally, low birth weight
was considered if it was <2500 g and macrosomia
was considered if >4000 g.
Statistical analysis was done using IBM SPSS Sta-
tistics Version 20 (Statistical Package for Social Sci-
ence Japan Inc., Tokyo, Japan). To compare the
demographic results of Groups A, B and C
Bonferroni and Games-Howell posthoc tests were
used where appropriate. To compare the demo-
graphic results of Group A and Group B Student
t test was used. To compare the perinatal and neo-
natal results of the three groups, the chi-square test
was used. Multivariate linear regression analysis
was used to define the predictors of SGA and GDM.
All P values < 0.05 were considered as statistically
significant. Data are shown as the mean  standard
deviation of the mean.
Results
The mean age of Group A was significantly higher
than Group B and Group C (P = 0.034). The demo-
graphic data of the groups are shown in Table 1. The
mean BMI values of Group A and Group B was simi-
lar before surgery. At conception, the mean BMI value
 Effects of LSG on obstetric outcomes

Table 1 Demographic data of groups

Group A (n = 48) Group B (n = 42) Group C (n = 54) P
Age (years) 30.29  5.09†,‡ 28.80  4.72† 27.48  3.89‡ 0.034
Gravidity 2 (1–4) 1 (1–3) 1 (1–3) 0.072
Parity 1 (0–3) 1 (0–2) 1 (0–2) 0.034
Abortion 0 (0–2) 0 (0–2) 0 (0–2) 0.022
BMI (kg/m2) Before LSG 44.37  3.66 42.71  3.71 0.318
BMI (kg/m2) at conception 32.83  3.63† 28.90  2.84†,§ 31.05  3.12§ 0.028
BMI (kg/m2) at delivery 33.80  4.11‡ 32.60  3.27§ 36.67  2.83‡,§ 0.024
Weight before LSG 109.25  13.27 105.85  11.26 0.524
Weight at conception 82.58  9.51† 69.28  8.47†,§ 81.81  9.52§ 0.034
Weight at delivery 85.08  9.72†,‡ 78.76  8.1†,§ 96.22  9.54‡,§ 0.002
Weight gain during pregnancy 2.5  2.9†,‡ 9.5  3.1†,§ 14.4  3.6‡,§ 0.001
Time interval from surgery to conception 7.8  3.4 25.8  13.4 0.001
(months)
†P < 0.05 between Group A and Group B.; ‡P < 0.05 between Group A and Group C.; §P < 0.05 between Group B and Group C. and BMI,
body mass index.

was significantly lower in Group B than in Group A
(P = 0.014) and the mean BMI value of Group C was
significantly higher than Group B (P = 0.042). The
mean weight loss (36.57 kg) of participants after LSG
was significantly higher in Group B than in Group A
(26.67 kg) (P = 0.001). The mean BMI at delivery was
significantly higher in Group C than in Groups A and
B (P = 0.024). The mean weight gain during preg-
nancy was significantly lower in Group A than in
Groups B and C (P = 0.001).
The perinatal and neonatal outcomes of the groups
are shown in Table 2. The number of patients diag-
nosed with GDM was significantly higher in Group C
than in Groups A and B (P = 0.004). The number of
SGA babies was significantly higher in Group A than
in Groups B and C (P = 0.025) and the number of
LGA babies was higher in Group C than in Groups A
and B (P = 0.046).
Multivariate linear regression analysis was per-
formed to determine the predictors of SGA and GDM.
Among age, BMI at conception, interval time from
surgery to conception and weight gain during preg-
nancy which were included in the linear regression
model; interval time was shown to be significantly
and independently affecting risk of SGA (R2: 0.348;
P = 0.003). Among age, BMI at conception, interval
time from surgery to conception and weight gain dur-
ing pregnancy; BMI at conception was shown to be

Table 2 Perinatal and neonatal outcomes of the groups

Group A (n = 48) Group B (n = 42) Group C (n = 54) P
n (%) n (%) n (%)
GHT 6 (12.5%) 4 (9.5%) 4 (7.4%) 0.261
Pre-eclampsia 4 (8.3%) 4 (9.5%) 4 (7.4%) 0.695
Preterm delivery 10 (20.8%) 6 (14.3%) 8 (14.8%) 0.636
GDM 2 (4.3%)‡ 4 (9.5%)§ 16 (29.6%)‡,§ 0.004
SGA 11 (22.9%)†,‡ 5 (11.9%)† 4 (7.4%)‡ 0.025
LGA 2 (4.2%)‡ 2 (4.8%)§ 8 (14.8%)‡,§ 0.046
APGAR 1 9 (5–10) 9 (6–10) 9 (4–10) 0.648
APGAR 5 10 (7–10) 10 (8–10) 10 (6–10) 0.860
Congenital malformations 0 (0%) 0 (0%) 1 (0.5%) 0.834
Median gestational age of delivery (week) 37.9  2.5 38.3  2.4 37.5  2.5 0.476
Cesarean section 24 (50%) 20 (47.6%) 20 (37.0%) 0.212
Gender
Male 22 (46%) 22 (52%) 28 (52%)
Female 26 (54%) 20 (48%) 26 (48%)
†P < 0.05 between Group A and Group B.; ‡P < 0.05 between Group A and Group C.; §P < 0.05 between Group B and Group C. and BMI,
body mass index; GDM, gestational diabetes mellitus; GHT, gestational hypertension; LGA, large for gestational age; SGA, small for gesta-
tional age.

© 2019 Japan Society of Obstetrics and Gynecology 3

 g et al.
C. Karada

significantly and independently affecting risk of GDM
(R2: 0.306 P = 0.009).
There was no intergroup difference in cesarean
section (C/S) rates. The indications for C/S for
Group A were: maternal request (n = 12 [50%]),
cephalopelvic disproportion (n = 6 [25%]), previous
C/S (n = 4 [16%]), fetal distress (n = 2 [9%]); for
Group B: maternal request (n = 6 [30%]), previous
C/S (n = 4 [20%]), fetal distress (n = 4 [20%]),
cephalopelvic disproportion (n = 4 [20%]), mal-
presentation (n = 2 [10%]); for Group C: cephalopelvic
disproportion (n = 8 [40%]), fetal distress (n = 4
[20%]), previous C/S (n = 4 [20%]), malpresentation
(n = 2 [10%]), maternal request (n = 2 [10%]),
respectively.
Discussion
A remarkable weight reduction occurs in the course
of the first 12–18 months after LSG and this period
includes excessive risk of malnutrition for both the
mother and the fetus. After this period, the rate of
weight loss decreases.24 In this study, we compared
the perinatal and neonatal outcomes of patients who
underwent LSG and had a pregnancy during or after
the first year of the operation compared to obese con-
trols. We found an increase in the number of SGA
infants among those who had a pregnancy within the
first year of LSG and interval time from surgery to
conception seems to be the most determinative factor
for SGA. We found lower GDM and LGA rates in
patients after LSG independent of the time interval
between surgery and conception.
Women after bariatric surgery may still have a
higher risk of GDM than those with normal BMI
because of high BMI levels at the beginning of the
conception.25 Previous studies showed conflicting
results about the increased risk of developing GDM in
patients who had bariatric surgery compared to the
normal population.26–28 Johansson et al.28 reported
decreased GDM risk in pregnant women who had
undergone bariatric surgery. Sheiner et al.18 compared
the pregnancy outcomes in patients who had under-
gone bariatric surgery and had pregnancy within the
first year of surgery and found a similar rate of GDM.
In our study, we compared three groups and found a
decreased number of patients with GDM in pregnant
patients who had undergone LSG. We found no asso-
ciation between GDM risk and time interval after
LSG. According to our linear regression analysis
4 © 2019 Japan Society of Obstetrics and Gynecology
results, the main risk factor for GDM is BMI level at
conception, and our results indicate that LSG may
decrease the risk of GDM and this decrease is not
associated with the time interval between surgery and
conception.
Studies reported decreased risk of GHT and pre-
eclampsia in women who had undergone bariatric sur-
gery when compared with obese pregnant women.25,29
In a meta-analysis, Yi et al.30 reported lower rates of
hypertensive disorders in pregnant women who had
undergone bariatric surgery. Previous studies also
reported the relationship between obesity and pre-
eclampsia.31 Our study shows no significant difference
in rates of GHT and pre-eclampsia between the groups.
After LSG, irrespective of time interval to pregnancy,
women may have a similar risk of developing hyper-
tensive disorders as obese pregnant women.
Maternal obesity is a main risk factor for
macrosomia, and bariatric surgery decreases this risk
because of weight loss.26 Furthermore, deficiencies in
maternal nutrition due to caloric restriction after bariat-
ric surgery could result in SGA babies.32 Previous stud-
ies show contradictory results regarding this issue.
Galazis et al. reported increased incidence of SGA
infants after bariatric surgery.33 Similarly, Johansson
et al.28 showed a higher risk of SGA neonates after sur-
gery. In our study, we found an increase in the number
of SGA infants in patients who had pregnancy within
a year after LSG. Those who had pregnancy more than
a year after LSG did not have an increased risk of SGA
and had a risk similar to the control obese patients.
Başbu
g et al.34 showed an increased risk of SGA infants
for patients who had a pregnancy within 18 months
after LSG when compared with patients who had preg-
nancy after more than 18 months. However, Sancak
et al.19 reported no difference between the groups
before 18 months versus after 18 months regarding the
rate of SGA babies. These different results may arise
from different interval periods after LSG among the
studies. According to our results, the time interval
from surgery to conception seems to be the main risk
factor for SGA. Postsurgical process and effects of sur-
gery in early period may have negative effects on fetal
development. Weight gain during pregnancy also
could affect fetal growth, and insufficient weight gain
may cause fetal growth restriction and risk of SGA
infants35 and the increased number of SGA babies in
patients who had pregnancy during the first year of
surgery may arise from insufficient weight gain during
pregnancy.

Studies compared the rates of preterm delivery ear-
lier than 12 months and later than 12 months after
surgery and demonstrated conflicting results. Patel
et al.36 compared the obstetric outcomes after surgery
before and after 12 months, and found increased pre-
term birth rates in the early (<12 month) pregnant
group. Sheiner et al.18 found no difference in rates of
preterm births in the first year and later than first year
after surgery. In our study, we did not find increased
preterm delivery rates in patients who had undergone
LSG when compared to obese pregnant women with-
out LSG. We also did not find differences between the
patients within the first year of LSG and after the first
year of LSG.
Obesity is related with increased risk of C/S.37
After bariatric surgery, the decrease in BMI may
decrease the C/S rates.25 Ducerma et al.38 reported
decreased C/S rates in patients who had undergone
bariatric surgery than obese controls. Sancak et al.19
compared the obstetric outcomes of patients after LSG
before 18 months and later than 18 months and they
found no difference in C/S rates between the groups.
In our study, although the BMI levels of obese
patients without surgery was greater than in patients
who had undergone LSG, the C/S rates were similar
between the groups. There was also no difference in
C/S rates between the patients who had undergone
LSG in the previous 1 year and later than 1 year. It is
possible to say that after LSG the C/S rates are similar
to those of obese patients without surgery indepen-
dent of the time interval between surgery and preg-
nancy. In a meta-analysis, Yi et al.30 also found no
significant differences in C/S rates between pregnant
patients after bariatric surgery and obese pregnant
patients without surgery.
One of the main limitations in our study was the
small number of pregnancies in the groups. In our
study the age, BMI and weight values of Groups A
and B were not similar at conception and this could
affect the risk of SGA and GDM in groups. The other
limitation was the retrospective nature of the study
and it was not possible to evaluate the nutritional
deficiencies, such as iron, Vitamin D, Vitamin B12
and others. The mean time interval from surgery to
conception was only 25.8 months in our study for the
participants who became pregnant more than 1 year
after LSG, and this could be also a limitation for
determining GDM risk for this population, because
some studies reported increased weight regain rates
after 5 years from LSG,39 and longer interval after
LSG may show higher incidence of GDM than our
© 2019 Japan Society of Obstetrics and Gynecology
Effects of LSG on obstetric outcomes
findings. The strength of our study was comparing
three different groups. Thus, we can see the differ-
ences of pregnancy outcomes between the patients
who had pregnancy within 1 year after surgery and
after more than 1 year and obese patients without
surgery.
In conclusion, pregnancy within 1 year after LSG is
associated with an increased risk of SGA. The main
risk factor for SGA is time interval from LSG to con-
ception. LSG has beneficial effects on obstetric out-
comes. After LSG, the risk of GDM decreases for
patients and this decrease is not associated with the
time interval of pregnancy. The risks of pre-eclamp-
sia, GHT, preterm delivery and C/S are similar
between obese pregnant patients and patients who
had undergone LSG independent of the time interval
between surgery and conception. Further prospective
studies are needed to see the risk and reasons of SGA
in pregnant patients who have pregnancy within
1 year after LSG with a large number of participants.
Disclosure
None declared
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