Hypertensive disorders were fewer among women in the BS group: CHTN (7 vs 23%), gestational hypertension (2 vs 13%) and preeclampsia with severe features (7 vs 17%). Women who had BS were less likely to have CHTN (aOR 0.231 CI 95% (0.081,0.658). Furthermore, 5 of 6 women with CHTN in the BS group and 21 of 39 in the no-BS group required continued antihypertensive medication before and after delivery. Concurrently, prevalence of PCOS (23 vs 12%), OSA (18 vs 7%) and GERD (16 vs 4%) was higher in the BS group whereas the incidence of asthma (15 vs 13%), iron deficiency anemia (15 vs 7%) and post-partum hemorrhage (10 vs 8%) were similar. Among women in the BS group, median pregestational (113 vs 110 kg), median admission weight at delivery (124 vs 124 kg), excessive GWG (70 vs 74%), rates of vaginal (48 vs 41%) and cesarean deliveries (52 vs 59%) were all comparable to those of women in the no-BS group.

Neonatal outcomes for the BS and no-BS groups

Infants born to the 83 women from the BS group and the 166 infants from the no-BS group were comparable in male gender (52vs 57%), median gestational age (39 vs 39w) and late prematurity (17 vs 17%), but differed in birth weight (3117 vs 3472g), LGA (4 vs 21%), SGA (18 vs 2%) and macrosomia (4 vs 15%) (Table 2). Regression analysis showed that infants born after BS were less likely to be macrosomic (aOR 0.170 CI 95% (0.043,0.668). Fourteen infants from the BS group and 35 from the no-BS group admitted to the NICU were combined for analysis. Thirty-four of the 49 (69%) infants were transferred to the NICU directly from the delivery room, while the remaining 15 (31%) stayed with their mothers prior to transfer. Of the 49 mothers, eight had GDM, three Type 1 and thirteen Type 2 DM. Primary NICU admission diagnoses were respiratory distress (45%), hypoglycemia (22%), rule-out sepsis (12%), apnea-hypotonia-temperature instability (12%) and miscellaneous conditions (9%). Twenty-nine percent of the infants were discharged from the NICU within three days, 35% from 4-7 days and the remaining 36% later. All infants admitted to the NICU or to the Newborn Nursery and their mothers were discharged home in good condition.

Neonatal outcomes for the no-BS group according to low and high pregestational BMI

Most of the clinical and demographic characteristics of both neonatal subgroups were similar (Table 6). However, macrosomia affected 21% of infants in the high BMI group as compared to 8% of those in the low BMI group. Similar intention to BF was declared by women from either group (77 vs 73%) although intention to FF only was more common among women from the high BMI group (23 vs 10%). Coincidentally, at discharge women from the high BMI group FF exclusively to 44% of their infants as compared with 25% of those in the low BMI group. Finally, BF initiation was more prevalent among women in the low BMI as compared to those in the high BMI subgroup (75 vs 56%).

Discussion

In general, clinical and demographic features of our study population are comparable to that of other publications [9,24-26]. Our data showed that GDM rates were lower among the patients who had BS [27]. Since a glucose tolerance test to diagnose GDM in a pregnancy after BS is unreliable, the true incidence of post BS GDM is unknown [28]. Long term complications of GDM include recurrence, Type 2 DM and cardiovascular disease in the mother and obesity and glucose intolerance in the offspring [29]. It has been reported that 73% of women who experienced GDM would recur in the subsequent pregnancy and they are ten times more likely to develop Type 2 DM later [29-30]. The high prevalence of Type 2 DM observed in our study may relate to the referral population of our regional center [19]. In many cases, Type 2 DM declined a few days after BS, however, relapses are known to occur in half of the patients [31]. Germaine to our study GDM has been associated with shorter duration of BF although for women who BF longer than three months the risk of developing Type 2 DM may decrease [32].

Pregnant women with obesity are at increased risk of adverse maternal and neonatal outcomes including hypertensive diseases, diabetes, prematurity, cesarean delivery, fetal growth abnormalities and perinatal mortality [3,33]. Although BS is one of the most effective methods for substantial weight loss, a proportion of patients experience clinically significant weight regain following surgery [34]. Unfortunately, if excessive, this regained weight may be associated with recurrences of previously controlled type 2 DM, hypertension, and other obesity-related comorbidities [31,34]. The data presented here indicates that the benefits of BS on GDM and hypertensive disorders is evident even in this heterogeneous group of women with grade 3 obesity and the highest pregestational BMI. On the other hand, our data showed that the rate of GDM, CHTN and preeclampsia was higher among women with grade 3 obesity in the low and high no-BS (control) group. Unfortunately, CHTN is also often associated with obesity, superimposed preeclampsia, and diabetes [19,35-38]. In light of the above, the benefits provided by BS to women with gestational HTN, preeclampsia and CHTN reported here are very rewarding [9,26, 38-39].

Recent reports confirm that after BS, patients who had PCOS and a significant and persistent weight loss, the prevalence of menstrual irregularities, hirsutism, type 2 DM, hypertension and infertility may be significantly reduced [40-41]. The unexpected high prevalence of PCOS among women who had BS in the current study may be related to the research design where all womenhave pregestational grade 3 obesity (BMI≥40kg/m²), either due to insufficient weight loss or having substantially regained weight over time [34].

OSA is a common sleep disorder in morbidly obese adults estimated to affect up to one billion people worldwide, while among patients scheduled for BS, the prevalence was found to be 60 percent [42-43]. In our investigation, OSA was more prevalent in the BS group and it was twice as common in the high than in the low BMI subgroup.

As shown in this report, GERD although highly prevalent in adults with obesity, is also common among those who had BS. RYGB is the most effective treatment for GERD in patients with obesity for whom the reported resolution was as high as 45%, however the effect of other restrictive surgeries was not as impressive [44]. Due to the possibility that de novo GERD could occur after BS, the true prevalence of preexisting or post-BS GERD remains equivocal.

Obesity has been recognized as an important comorbidity in patients with asthma or asthma like symptoms [45]. Adults with grade 3 obesity, especially those with BMI ≥ 50kg/m² have a two and a half times higher risk of asthma as compared to adults of normal weight [45]. Of further concern is the high prevalence of asthma in children whose mothers were obese and had asthma during pregnancy [45]. Recent data showed that weight reduction triggered by BS may improve asthma outcomes or may decrease the need for asthma medications [46].

In the current study, iron deficiency anemia was found in 14% of BS and in 8% of no-BS controls women who received iron supplementation. Iron deficiencyin obese persons or individuals with Type 2 DM may be due to low absorption and poor tolerance to iron rich food [47], The prevalence of iron deficiency anemia after BS varies from 18 to 53% for RYGB and between 1 and 54% for SG [48]. SG is an alternative technique that causes less perioperative and late complications, however, long term weight results appeared to be inferior to RYGB [8,24,39]. The prevalence and changing choices of BS procedures over time that we observed are commensurate with that seen across the world [8,18,24,39].

Earlier studies of perinatal outcomes following BS showed increased rates of SGA and varying rates of LGA in infants, some associated with the type of surgery and others with the duration of BS to conception intervals [15,18, 24-25]. The higher rates of SGA and lower rates of LGA and macrosomia after BS as compared to the control (no-BS) population noted here are in line with earlier reports [8,26].

In an effort to extend BF duration the American Academy of Pediatrics and the Academy of Breastfeeding Medicine recommend exclusive BF for all healthy infants during birth hospitalization [12]. In the US in 2019 the mean in-hospital exclusive BF rate in the general population was 52.6% and for those in the most BF supportive hospitals was 64.7% [12]. In reality, these rates are quite different from the 19 to 35% range reported for women with severe obesity, pregestational diabetes, preeclampsia or CHTN [1,18-19,36,38]. Considering that the comorbidities affecting BS and no-BS women with Grade 3 obesity are similar to those described above, their low exclusive BF rates (24 vs 24%) although disappointing, were not unexpected.

Another predictor of BF duration, BF initiation (any BF) at discharge, was reported to be 83.2% in 2019 for the general US population [49]. In comparison, BF initiation rates among women with comorbidities like those described above ranged from 54 to 82%, thus the 66% BF initiation rate in the BS and no-BS reported here,although lower, were not surprising [18-19,36,38].

It is known that women who do not BF the first child are unlikely to BF the next [50]. Prior BF experience even among women with obesity and other comorbidities is also a good predictor of success in subsequent pregnancies [50-51]. It is of concern that in our study of the 58 BS and 125 no-BS women who intended to BF exclusively, only 86% and 80% respectively provided any BF to their infants at discharge. Regardless of the difficulties that led to an unsatisfactory BF experience it is up to health providers to explain, reassure, comfort, educate and encourage these women and their families to expect better outcomes in future pregnancies [51].

Besides the comorbidities described above there are several other obstacles to BF including race, advanced maternal age, smoking and public assistance that need to be recognized [52-55]. The lower prevalence of African American compared to white women undergoing BS in our study is similar to that reported by others [52]. Women of advanced age and smokers are less likely to initiate BF or to BF longer than non-smokers [53-54]. Public assistance for health care was reported for 52% in the BS and 57% in the no-BS group whereas BF initiation rate was low in both groups (63 vs 59%). In a recent publication we noted that women who received public assistance and had BS were less likely to BF exclusively (a OR 0.391, CI 95%, 0.185-0.825, respectively) [18]. Furthermore, women on public assistance are less likely to undergo BS, although they experience higher rates of obesity and related complications that could qualify them for this surgical option [55].

 A limitation of this investigation is that the definition of exclusive BF and BF initiation at discharge used here may be applicable only to women with high-risk obstetrical conditions and to the absence of follow-up information regarding BF after discharge from the hospital [18-19]. The strength of this investigation is the addition of BF as an important perinatal outcome to BS. Furthermore, the obstetrical and neonatal data presented here was obtained directly from electronic medical records and not from post-delivery maternal questionnaires.

In conclusion, although poor fetal growth remains a challenge, BS improvement on rates of hypertensive disorders and GDM even in women with higher grade 3 obesity are definite.

Regrettably, exclusive BF and BF initiation rates among women with obesity and significant comorbidities remained lower than in the general population. Learning about obstacles to BF following BS would be helpful to design special strategies if successful lactation is to be achieved.

Declarations

Authors’ contributions

All authors participated in planning and research design, data analysis and manuscript preparation - LC, Manuscript revisions - LC, CAN, MRS, MBN, BJN and SN. The author(s) read and approved the final manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Availability of data and materials

The data sets generated during and analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The Ohio State University Biomedical Science IRB approved on 05/02/2022 the continuation of the study #2010H0198 with waivers of informed consent and HIPAA research authorization. All methods were performed in accordance with the relevant guidelines and regulations of the declaration of Helsinki.

Competing interests

The Author(s) declare(s) that there is no conflict of interest.

References

1. Ramji N, Challa S, Murphy PA, Quinlan J, Crane JMG, et al. (2018) A comparison of breastfeeding rates by obesity class. J Matern Fetal Neonatal Med 31: 3021-3026.
2. ACOG Practice Bulletin #230 (2021) Obesity in pregnancy. Obstet Gynecol 137: e128-e137.
3. Langley-Evans SC, Pearce J, Ellis S (2022) Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: A narrative review. J Hum Nutr Diet 35: 250-264.
4. Welbourn R, Hollyman M, Kinsman R, Dixon J, Liem R, et al. (2019) Surgery worldwide: Baseline demographic description and one-year outcomes from the fourth IFSO global registry report 2018. Obes Surg 29: 782-795.  
5. Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, et al. (2019) Clinical practice guidelines for the perioperative nutrition, metabolic and nonsurgical support of patients undergoing bariatric procedures - 2019 update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists - Executive Summary. Endocr Pract 25:1346-1359.
6. Falcone V, Stopp T, Feichtinger M, Kiss H, Eppel W, et al. (2018) Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome. BMC Pregnancy Childbirth 18: 507.
7. Shawe J, Ceulemans D, Akhter Z, Neff K, Hart K, et al. (2019) Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care. Obes Rev 20: 15071522.  
8. Akhter Z, Rankin J, Ceulemans D, Ngongalah L, Ackroyd R, Devlieger R, et al. (2019) Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLoS Med 16:e1002866.
9. Getahun D, Fassett MJ, Jacobsen SJ, Sacks DA, Murali SB, et al. (2022) Perinatal outcomes after bariatric surgery. Am J Obstet Gynecol 226: 121.e1-e16.  
10. Steube A (2015) Associations between lactation, maternal carbohydrate metabolism, and cardiovascular health. Clin Obstet Gynecol 58: 827-839.
11. Nguyen B, Jin K, Ding D (2017) Breastfeeding and maternal cardiovascular risk factors and outcomes: A systematic review. PLoS ONE 12: e0187923.
12. Barrera CM, Beauregard JL, Nelson JM, Perrine CG (2019) Association of maternity care practices and policies with in-hospital exclusive breastfeeding in the United States. Breastfeed Med 14: 243-248.
13. JCAHO Specifications manual for national quality measures (v2015B).
14. Caplinger P, Cooney AT, Bledsoe C, Hagan P, Smith A, et al. (2015) Breastfeeding outcomes following bariatric surgery. Clinical Lactation 6: 144-150.  
15. Gascoin G, Gerard M, Sallé A, Becouarn G, Rouleau S, et al. (2017) Risk of low birth weight and micronutrient deficiencies in neonates from mothers after gastric bypass: a case control study. Surg Obes Relat Dis 13: 1384-1391.  
16. Garretto D, Kim YK, Quadro L, Rhodas RR, Pimentel V, et al. (2019) Vitamin A and β-carotene in pregnant and breastfeeding post-bariatric women in an urban population. J Perinat Med 47: 183-189.  
17. Adsit J, Hewlings SJ (2022) Impact of bariatric surgery on breastfeeding: a systematic review. Surg Obes Relat Dis 18: 117-122.
18. Cordero L, Stenger MR, Landon MB, Needleman BJ, Noria S, et al. (2023) Bariatric Surgery to Conception Intervals and Breastfeeding Initiation. Arch Pediatr 8: 244.  
19. Cordero L, Stenger MR, Landon MB, Nankervis CA (2022) Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus. BMC Pregnancy Childbirth 22: 69.  
20. ACOG Practice Bulletin #105 (2009) Bariatric surgery and pregnancy. Obstet Gynecol 113: 1405-1413.  
21. ACOG Practice Bulletin Summary #222 (2020) Gestational hypertension and preeclampsia. Obstet Gynecol 135: 1492.
22. ACOG Practice Bulletin #201 (2018) Pregestational diabetes mellitus.Obstet Gynecol 132: e228-e248.  
23. LifeCycle Project-Maternal Obesity and Childhood Outcomes Study Group Susana Santos, Hazel Inskip, Pilar Amiano, Henrique Barros, Marie-Aline Charles, et al. (2019) Association of gestational weight gain with adverse maternal and infant outcomes. JAMA 321: 17021715.
24. Rottenstreich A, Elchalal U, Kleinstern G, Beglaibter N, Khalaileh A, et al. (2018) Maternal and perinatal outcomes after laparoscopic sleeve gastrectomy. Obstet Gynecol 131: 451-456.  
25. Stephensson O, Johansson K, Söderling J, Näslund I, Neovius M, et al. (2018) Delivery outcomes in term births after bariatric surgery: Population-based matched cohort study. PLOS Med 15: e1002656.  
26. Machado BM, Blume C, Mottin C, Drehmer M, Schaan BD, et al. (2020) Neonatal outcomes of pregnancy following Roux-en-Y gastric bypass: a matched case-control study. Obes Surg 30: 2963-2970.  
27. Wong VW, Chong S, Chenn R, Jalaludin B (2019) Factors predicting recurrence of gestational diabetes in a high-risk multi-ethnic population. Aust N Z J Obstet Gynaecol 59: 831-836.  
28. Deleus E, Van der Schueren B, Devlieger R, Lannoo M, Benhalima K, et al. (2020) Glucose homeostasis, fetal growth and gestational diabetes mellitus in pregnancy after bariatric surgery: A scoping review. J Clin Med 9: 2732.  
29. Moon JH, Jang HC (2022) Gestational diabetes mellitus: Diagnostic approaches and maternal-offspring complications. Diabetes Metab 46: 3-14.  
30. Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, et al. (2020) Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ 369:m1361.  
31. Debédat J, Sokolovska N, Coupaye M, Panunzi S, Chakaroun R, et al. (2018) Long-term relapse of type 2 diabetes after Roux-en-Y gastric bypass: Prediction and clinical relevance. Diabetes Care 41: 20862095.  
32. Nguyen PTH, Binns CW, Nguyen CL, Ha AVV, Chu TK, et al. (2019) Gestational diabetes mellitus reduces breastfeeding duration: A prospective cohort study. Breastfeed Med 14: 39-45.  
33. Relph S, Guo Y, Harvey ALJ, Vieira MC, Corsi DJ, et al. (2021) Characteristics associated with uncomplicated pregnancies in women with obesity: a population-based cohort study. BMC Pregnancy Childbirth 21: 182.  
34. Noria SF, Shelby RD, Atkins KD, Nguyen NT, Gadde KM, et al. (2023) Weight regain after bariatric surgery: Scope of the problem, causes, prevention, and treatment. Curr Diab Rep 23: 31-42.  
35. Lewandowska M, Więckowska B, Sajdak S (2020) Pre-pregnancy obesity, excessive gestational weight gain, and the risk of pregnancyinduced hypertension and gestational diabetes mellitus. J Clin Med 9: 1980.  
36. Cordero L, Stenger MR, Landon MB, Nankervis CA (2021) Breastfeeding initiation among women with preeclampsia with and without severe features. J Neonatal Perinatal Med 14: 419-426.  
37. Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN, et al. (2020) Chronic hypertension in pregnancy. Am J Obstet Gynecol 222: 532541.
38. Cordero L, Stenger MR, Landon MB, Nankervis CA (2022) Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus. J Neonatal Perinatal Med 15: 171-177.  
39. Kwong W, Tomlinson G, Feig DS (2018) Maternal and neonatal outcomes after bariatric surgery; a systematic review and metaanalysis: do the benefits outweigh the risks? Am J Obstet Gynecol 218: 573-580.  
40. Tian Z, Zhang Y, Wang Y, Chang X, Zhu H, et al. (2021) Effects of bariatric surgery on patients with obesity and polycystic ovary syndrome: a meta-analysis. Surg Obes Relat Dis 17: 1399-1408. 
41. Hu L, Ma L, Xia X, Ying T, Zhou M, et al. (2022) Efficacy of bariatric surgery in the treatment of women with obesity and polycystic ovary syndrome. J Clin Endocrinol Metab 107: e3217-e3229.
42. Chen JL, Moon TS, Schumann R (2022) Bariatric surgery in patients with obstructive sleep apnea. Int Anesthesiol Clin 60: 50-58. 
43. de Raaff CAL, de Vries N, van Wagensveld (2018) Obstructive sleep apnea and bariatric surgical guidelines: summary and update. Curr Opin Anesthesiol 31: 104-109. 
44. King K, Sudan R, Bardaro S, Soriano I, Petrick AT, et al. (2021) Assessment and management of gastroesophageal reflux disease following bariatric surgery. Surg Obes Relat Dis 17: 1919-1925.  
45. Miethe S, Guarino M, Alhamdan F, Simon H, Renz H, et al. (2018) Effects of obesity on asthma: immunometabolic links. Pol Arch Intern Med 128: 469-477.  
46. Xie L, Chandrasekhar A, DeSantis SM, Almandoz JP, de la CruzMuñoz N, et al. (2023) Discontinuation and reduction of asthma medications after metabolic and bariatric surgery: A systematic review and meta-analysis. Obes Rev 24: e13527.  
47. Bjorklund G, Peana M, Pivina L, Dosa A, Aaseth J, et al. (2021) Iron deficiency in obesity and after bariatric surgery. Biomolecules 11: 613.
48. Steenakers N, Van der Schueren B, Mertens A, Lannoo M, Grauwet T, et al. (2018) Iron deficiency after bariatric surgery: what is the real problem? Proc Nutr Soc 77: 445-455.  
49. Centers for Disease Control and Prevention. Breastfeeding report card 2022. 
50. Huang Y, Ouyang Y, Redding SR (2019) Previous breastfeeding experience and its influence on breastfeeding outcomes in subsequent births: A systematic review. Women Birth 32: 303-309. 
51. Cordero L, Stenger MR, Blaney SD, Finneran MM, Nankervis CA, et al. (2020) Prior breastfeeding experience and infant feeding at discharge among women with pregestational diabetes mellitus. J Neonatal Perinatal Med 13: 563-570. 
52. Stevens DR, Taylor SN, Roberts JR, Neelon B, Newman RB, et al. (2019) Breastfeeding initiation as related to the interaction of race/ ethnicity and maternal diabetes. Breastfeed Med 14: 630-639. 
53. Shechter-Maor G, Sadeh-Mestechkin D, Paz YG, Halevy RS, Markovitch O, et al. (2020) Does parity affect pregnancy outcomes in the elderly gravida? Arch Gynecol Obstet 301: 85-91.  
54. Wolvers PJD, Ayubi O, Bruin SC, Hutten BA, Brandjes DPM, et al. (2021) Smoking behavior and beliefs about smoking cessation after bariatric surgery. Obes Surg 31: 239-249.
55. Hennings DL, Baimas-George M, Al-Quarayshi Z, Moore R, Kandil E, et al. (2018) The inequity of bariatric surgery: Publicly insured patients undergo lower rates of bariatric surgery with worse outcomes. Obes Surg 28: 44-51.