A 33-year-old woman comes to the office to discuss possible bariatric surgery. The patient has a history of morbid obesity that has not responded to dietary modification and exercise. She has no other chronic medical conditions and has had no previous surgeries. The patient does not use tobacco, alcohol, or illicit drugs. She is considering pregnancy after her bariatric surgery. Blood pressure is 130/80 mm Hg and pulse is 86/min. BMI is 42 kg/m². The remainder of the physical examination is unremarkable. Which of the following is the most appropriate statement regarding pregnancy after bariatric surgery?

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Explanation: Failure to sustain weight loss with lifestyle modifications often leads to serious long-term health conditions. Bariatric surgery is indicated to assist with weight loss for patients in obesity class II (BMI ≥35 kg/m²) with at least 1 comorbidity (eg, diabetes mellitus, hypertension, sleep apnea) or for those in class III (BMI ≥40 kg/m²). Bariatric surgery is recommended in reproductive-age women as it reduces the risk of long-term adverse health consequences and reduces several obstetric complications (eg, preeclampsia, gestational diabetes mellitus) (Choice B). Bariatric surgery Due to caloric restriction and malabsorption associated with bariatric surgery procedures, patients often have folate, iron, and B₁₂ deficiency that can affect fetal outcomes (eg, neural tube defects, preterm delivery). Therefore, patients are recommended to delay pregnancy for at least a year after bariatric surgery to achieve weight loss goals and stabilize nutritional status (Choice E). During this period, a non-oral form of contraception (eg, intrauterine device, implant) is recommended due to decreased absorption rates with oral contraceptives. ₁₂ Following the 1-year delay after surgery and normalization of BMI, rates of fetal anomalies and fetal demise (stillbirth) are similar to the general population and pregnancy can be attempted. However, in patients who become pregnant, vitamin supplementation and serial fetal growth ultrasounds are recommended as patients may be at increased risk of fetal growth restriction. (Choice A) Bariatric surgery does not increase miscarriage rates. Nonsurgical weight loss has been shown to decrease rates of early pregnancy loss. (Choice C) Bariatric surgery is not an indication for cesarean delivery. Educational objective: Bariatric surgery is recommended to reduce long-term health consequences in obese women who have failed to achieve weight loss with lifestyle modifications. After bariatric surgery, it is recommended that pregnancy be delayed for at least a year to optimize weight loss and stabilize nutritional status. References: Obesity and reproduction: a committee opinion. (http://www.ncbi.nlm.nih.gov/pubmed/26434804) Obesity, pregnancy complication, and birth outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/23074004)

A 33-Year-Old Woman Comes to the Office to Discuss Possible