Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Search Strategy............................................................................................................................................ 2
Newcastle-Ottawa Scale - Total Scores for all included studies.............................................3
Newcastle-Ottawa Scale – Individual results for all included studies.................................5
Consistency of Direction of Effects – Studies in Primary Analysis........................................6
Forest Plots – Studies in Primary Analysis......................................................................................7
Consistency of Direction of Effects – all studies.........................................................................22
Assessment of publication bias using funnel plots – all studies..........................................24
Forest plots – all studies........................................................................................................................26
Characteristics of all included studies…………………………………………………………………36
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Search Strategy Medline Search Strategy & Summary of Results Bariatric Surgery and Pregnancyon December 12, 2016
bariatric surgery/ or gastric bypass/ or gastroplasty/ or jejunoileal bypass/ or lipectomy/ or (bariatric surger* or gastric bypass* or gastroplasty* or jejunoileal bypass* or lipectomy* or stomach bypass*).mp. or Gastroplasty/ or gastric band*.mp. or sleeve gastrectom*.mp. or BiliopancreaIc Diversion/ or bilipancreaIc adj (bypass* or diversion*) or Obesity/su [Surgery] or Obesity, Morbid/su [Surgery] or Obesity, Abdominal/su [Surgery] or Obesity, Metabolically Benign/su [Surgery]
AND
exp pregnancy/ or exp fetus/ or exp pregnancy complicaIons/ or exp infant, newborn/peripartum period/ or exp postpartum period/ or (pregnan* or obstetric* or gestaIon*).mp. or (f?etus or f?etal).mp. or newborn.mp. or (new adj1 born).mp. or neonat*.mp. or infan*.mp. or birth*.mp. or childbirth*.mp. or (labo?r or labo?rs or labo?uring or puerper* or C?esar* or episiotomy*).mp.exp fetal development/ or exp prenatal diagnosis/ or exp fetal monitoring/ or exp perinatal care/ or prenatal care/ or postnatal care/ or exp maternal health services/ or exp anesthesia, obstetrical/ or exp analgesia, obstetrical/ or exp parity/ or exp apgar score/ or exp pregnancy trimesters/ or ((forcep* or vacuum or ventouse or instrument* or vaginal) adj2 deliver*).mp. or (antepart* or ante-part* or prenat* or pre-nat* or perinat* or peri-nat* or peripart* or peri-part*).mp. or postnat*.mp. or post-nat*.mp. or postpart*.mp. or post-part*.mp. or breasTe*.mp. or obstetrics/ or maternal welfare/ or maternal mortality/ or pregnant woman/ or Pregnancy Outcome/ or exp heart rate, fetal/ or exp fetal therapies/ or exp placenta/ or exp placental funcIon tests/ or exp umbilical cord/
NOTAnimals/ not humans/
Summary of Results
All searches were conducted on December 12, 2016.
Medline 1946 to December 13, 2016 847
Embase 1947 to Week 50 1136
Cochrane To November 2016 36
Web of Science 1900 to December 13, 2016 511
PubMed (non Medline and inprocess) To December 13, 2016 86
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
TOTAL 2616
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Newcastle-Ottawa Scale - Total Scores for all included studies
StudySelection
(max 4 points)Comparability (max 2 points)
Outcome
(max 3 points) Total Score
Richards (1987)40 4 2 2 8
Marceau (2004)25 4 0 2 6
Dixon (2005)38 4 2 3 8
Patel (2008)33 4 0 2 6
Wax (2008)33 4 2 2 8
Weintraub (2008)31 4 0 3 7
Bennett (2010)34 4 1 3 8
Burke (2010)37 4 1 3 8
Lapolla (2010)36 4 1 2 7
Santulli (2010)30 4 1 2 7
Belogolovkin (2011)21 3 2 3 8
Josefsson (2011)21 4 0 3 7
Lesko (2012)28 4 2 3 9
Kjær (2013)27 4 2 3 9
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
StudySelection
(max 4 points)Comparability (max 2 points)
Outcome
(max 3 points) Total Score
Roos (2013)26 4 2 3 9
Berlac (2014)35 4 2 3 9
Shai (2014)19 4 1 3 8
Johansson (2015)20 4 2 3 9
Parker (2016)24 4 2 3 9
Feichtinger (2017)39 4 2 3 8
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Newcastle-Ottawa Scale – Individual results for all included studies
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Consistency of Direction of Effects – Studies in Primary AnalysisOutcome Pooled OR Statistical
Heterogeneity Direction of Effect Same as Pooled ORI2 Interpretation
GDM 0.21 49.4% Moderate 5 of 5 (100%)LGA 0.31 77.3% Substantial 3 of 3 (100%)Macrosomia 0.32 83.2% Substantial 5 of 5 (100%)Postpartum hemorrhage
0.32 46.8% Moderate 2 of 2 (100%)
Large babies 0.35 80.5% Substantial 6 of 6 (100%)All HTD 0.38 0% None 4 of 4 (100%)Gestational HTN 0.39 0% None 3 of 3 (100%)Pre-eclampsia 0.59 0% None 3 of 3 (100%)C-section 0.63 61.8% Substantial 3 of 4 (75%)NICU admission 1.26 76.7% Substantial 1 of 2 (50%)Malformations 1.29 63.0% Substantial 2 of 4 (50%)Neonatal deaths 1.31 58.7% Substantial 2 of 3 (66.7%)Pre-term delivery 1.33 0% None 4 of 4 (100%)Stillbirth 1.4 43.6% Moderate 2 of 4 (50%)IUGR 1.6 0% None 1 of 2 (50%)SGA 2.18 50.4% Substantial 5 of 6 (83.3%)Small babies 2.18 50.4% Substantial 5 of 6 (83.3%)For each outcome, the table shows the pooled OR, the I2, the standard interpretation of the I2, number and percentage of studies that have ORs in the same direction as the overall OR, along with a simple vote-counting summary of whether there is consistency in the direction of the individual ORs.
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Forest Plots – Studies in Primary Analysis
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ4
2 = 7.90 (P = .10), I2 = 49%
Patel (2008)Burke (2010)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
0.21 [0.15; 0.30]0.21 [0.12; 0.36]
0.27 [0.03; 2.76]0.23 [0.14; 0.37]0.06 [0.02; 0.17]0.46 [0.14; 1.49]0.25 [0.13; 0.48]
0.1 0.5 1 2 10Odds Ratio (95% CI)
GDM
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 0.32 (P = .96), I2 = 0%
Patel (2008)Weintraub (2008)Lapolla (2010)Lesko (2012)
OR (95% CI)
0.38 [0.27; 0.53]0.38 [0.27; 0.53]
0.56 [0.08; 3.65]0.38 [0.25; 0.58]0.35 [0.19; 0.65]0.46 [0.14; 1.49]
0.1 0.5 1 2 10Odds Ratio (95% CI)
AllHTD
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ2
2 = 8.83 (P = .01), I2 = 77%
Marceau (2004)Lapolla (2010)Johansson (2015)
OR (95% CI)
0.32 [0.24; 0.41]0.31 [0.17; 0.59]
0.16 [0.08; 0.29]0.61 [0.31; 1.20]0.33 [0.24; 0.45]
0.1 0.5 1 2 10Odds Ratio (95% CI)
LGA
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ4
2 = 23.87 (P < .01), I2 = 83%
Patel (2008)Burke (2010)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
0.52 [0.38; 0.70]0.32 [0.11; 0.89]
0.08 [0.00; 1.61]0.76 [0.52; 1.11]0.91 [0.34; 2.46]0.19 [0.05; 0.71]0.11 [0.05; 0.24]
0.01 0.1 1 10 100Odds Ratio (95% CI)
Macrosomia
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 25.59 (P < .01), I2 = 80%
Marceau (2004)Patel (2008)Burke (2010)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
0.40 [0.33; 0.49]0.35 [0.19; 0.62]
0.16 [0.08; 0.29]0.08 [0.00; 1.61]0.76 [0.52; 1.11]0.61 [0.31; 1.20]0.19 [0.05; 0.71]0.33 [0.24; 0.45]
0.01 0.1 1 10 100Odds Ratio (95% CI)
Large babies
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 10.08 (P = .07), I2 = 50%
Marceau (2004)Patel (2008)Weintraub (2008)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
2.13 [1.69; 2.68]2.18 [1.41; 3.38]
3.26 [1.63; 6.52]2.87 [0.28; 29.59]1.40 [0.84; 2.32]0.28 [0.03; 2.45]5.00 [1.73; 14.41]2.20 [1.64; 2.95]
0.1 0.5 1 2 10Odds Ratio (95% CI)
SGA
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ1
2 = 0.19 (P = .66), I2 = 0%
Patel (2008)Weintraub (2008)
OR (95% CI)
1.60 [0.69; 3.73]1.60 [0.69; 3.73]
0.88 [0.05; 14.90]1.70 [0.70; 4.11]
0.1 0.5 1 2 10Odds Ratio (95% CI)
IUGR
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 10.08 (P = .07), I2 = 50%
Marceau (2004)Patel (2008)Weintraub (2008)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
2.13 [1.69; 2.68]2.18 [1.41; 3.38]
3.26 [1.63; 6.52]2.87 [0.28; 29.59]1.40 [0.84; 2.32]0.28 [0.03; 2.45]5.00 [1.73; 14.41]2.20 [1.64; 2.95]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Small babies
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 0.61 (P = .89), I2 = 0%
Patel (2008)Lapolla (2010)Lesko (2012)Johansson (2015)
OR (95% CI)
1.33 [1.01; 1.75]1.33 [1.01; 1.75]
1.04 [0.30; 3.64]1.43 [0.67; 3.07]1.69 [0.79; 3.63]1.28 [0.92; 1.78]
0.5 1 2Odds Ratio (95% CI)
Pre-term delivery
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ1
2 = 1.88 (P = .17), I2 = 47%
Burke (2010)Lesko (2012)
OR (95% CI)
0.39 [0.15; 0.99]0.32 [0.08; 1.37]
0.56 [0.19; 1.65]0.12 [0.02; 0.82]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Postpartum hemorrhage
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 7.86 (P = .05), I2 = 62%
Patel (2008)Burke (2010)Lapolla (2010)Lesko (2012)
OR (95% CI)
0.56 [0.42; 0.74]0.63 [0.39; 1.02]
2.08 [0.74; 5.84]0.48 [0.32; 0.72]0.44 [0.26; 0.75]0.67 [0.36; 1.24]
0.2 0.5 1 2 5Odds Ratio (95% CI)
C-section
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ1
2 = 4.28 (P = .04), I2 = 77%
Lapolla (2010)Lesko (2012)
OR (95% CI)
1.32 [0.73; 2.37]1.26 [0.37; 4.26]
2.32 [1.05; 5.12]0.67 [0.28; 1.60]
0.2 0.5 1 2 5Odds Ratio (95% CI)
NICU admission
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 5.32 (P = .15), I2 = 44%
Marceau (2004)Patel (2008)Lesko (2012)Johansson (2015)
OR (95% CI)
1.57 [0.65; 3.80]1.40 [0.38; 5.23]
0.58 [0.07; 4.43]0.16 [0.01; 3.56]8.42 [0.92; 76.80]1.89 [0.59; 6.05]
0.01 0.1 1 10 100Odds Ratio (95% CI)
Stillbirth
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ2
2 = 4.84 (P = .09), I2 = 59%
Weintraub (2008)Burke (2010)Johansson (2015)
OR (95% CI)
1.21 [0.54; 2.73]1.31 [0.37; 4.71]
0.40 [0.11; 1.44]2.31 [0.59; 8.99]2.93 [0.57; 15.10]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Neonatal deaths
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 8.12 (P = .04), I2 = 63%
Marceau (2004)Patel (2008)Weintraub (2008)Johansson (2015)
OR (95% CI)
1.24 [0.83; 1.84]1.29 [0.61; 2.71]
1.62 [0.71; 3.73]0.28 [0.01; 7.30]2.50 [1.21; 5.15]0.72 [0.40; 1.29]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Malformations
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Consistency of Direction of Effects – all studies
Outcome Pooled OR
StatisticalHeterogeneity
Direction of Effects
I2 (%) Interpretation Same as Pooled OR
GDM 0.56 90.0 Substantial 9/16 (56%)Gestational HTN 0.59 77.3 Substantial 5/7 (71%)Pre-eclampsia 0.55 75.0 Substantial 8/9 (89%)Hypertensive disorders 0.29 58.8 Substantial 3/4(75%)AllHTD 0.50 85.8 Substantial 11/14 (79%)LGA 0.39 66.0 Substantial 9/10 (90%)Macrosomia 0.37 72.3 Substantial 8/8 (100%)Large babies 0.40 62.6 Substantial 14/15 (93%)SGA 2.09 26.1 Moderate 11/13 (85%)IUGR 2.64 0.0 None 4/4 (100%)Small babies 2.14 43.4 Moderate 12/15 (80%)Pre-term delivery 1.55 0.0 None 10/11 (91%)Postpartum hemorrhage
0.57 58.2Substantial
6/6 (100%)
C-section 0.98 81.9 Substantial 4/12 (33%)Labor induction 1.03 0.0 None 1/4 (25%)NICU admission 1.3 0.0 None 6/7 (86%)Malformations 1.1 62.3 Substantial 2/5 (40%)Stillbirth 1.5 0.0 None 5/7 (83%)Neonatal deaths 1.1 24.3 Moderate 3/6 (50%)Multiple gestations 1.1 32.8 Moderate 3/4 (75%)
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
For each outcome, the table shows the pooled OR, the I2, the standard interpretation of the I2, number and percentage of studies that have ORs in the same direction as the overall OR, along with a simple vote-counting summary of whether there is consistency in the direction of the individual ORs.
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Assessment of publication bias using funnel plots – all studies
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Forest plots – all studies
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ15
2 = 150.34 (P < .01), I2 = 90%
Richards (1987)Dixon (2005)Patel (2008)Wax (2008)Bennett (2010)Burke (2010)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Shai (2014)Johansson (2015)Parker (2015)Feichtinger (2017)
OR (95% CI)
0.92 [0.81; 1.04]0.56 [0.34; 0.91]
0.47 [0.11; 1.99]0.29 [0.10; 0.84]0.82 [0.07; 9.52]1.35 [0.22; 8.45]0.43 [0.28; 0.66]0.23 [0.15; 0.37]1.59 [0.22; 11.41]0.06 [0.02; 0.17]1.00 [0.20; 4.88]0.04 [0.00; 0.59]1.27 [0.82; 1.95]1.14 [0.75; 1.73]0.65 [0.44; 0.96]0.27 [0.14; 0.49]1.72 [1.42; 2.08]1.18 [0.62; 2.24]
0.01 0.1 1 10 100Odds Ratio (95% CI)
GDM
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ6
2 = 26.45 (P < .01), I2 = 77%
Dixon (2005)Patel (2008)Wax (2008)Bennett (2010)Lapolla (2010)Lesko (2012)Berlac (2014)
OR (95% CI)
0.54 [0.39; 0.76]0.59 [0.27; 1.28]
0.37 [0.11; 1.23]1.68 [0.10; 28.06]4.75 [1.60; 14.13]0.17 [0.08; 0.38]0.35 [0.15; 0.81]0.46 [0.17; 1.29]0.71 [0.42; 1.22]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Gestational HTN
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ8
2 = 31.95 (P < .01), I2 = 75%
Dixon (2005)Patel (2008)Bennett (2010)Lapolla (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Shai (2014)Parker (2015)
OR (95% CI)
0.81 [0.70; 0.93]0.55 [0.36; 0.83]
0.16 [0.05; 0.49]0.53 [0.05; 5.41]0.15 [0.07; 0.33]0.52 [0.24; 1.15]0.78 [0.29; 2.11]0.56 [0.28; 1.10]0.68 [0.38; 1.22]1.01 [0.63; 1.60]0.93 [0.79; 1.09]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Pre-eclampsia
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 7.29 (P = .06), I2 = 59%
Richards (1987)Weintraub (2008)Santulli (2010)Feichtinger (2017)
OR (95% CI)
0.36 [0.25; 0.51]0.29 [0.11; 0.75]
0.11 [0.04; 0.33]0.41 [0.28; 0.60]1.70 [0.17; 17.03]0.16 [0.02; 1.32]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Hypertensive disorders
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ13
2 = 91.83 (P < .01), I2 = 86%
Richards (1987)Dixon (2005)Patel (2008)Wax (2008)Weintraub (2008)Bennett (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Shai (2014)Parker (2015)Feichtinger (2017)
OR (95% CI)
0.69 [0.61; 0.78]0.50 [0.33; 0.77]
0.11 [0.04; 0.33]0.18 [0.08; 0.44]0.81 [0.14; 4.78]4.75 [1.60; 14.13]0.41 [0.28; 0.60]0.14 [0.08; 0.25]0.35 [0.19; 0.66]1.70 [0.17; 17.03]0.56 [0.26; 1.18]0.56 [0.28; 1.10]0.68 [0.46; 1.03]1.01 [0.63; 1.60]0.93 [0.79; 1.09]0.16 [0.02; 1.32]
0.1 0.5 1 2 10Odds Ratio (95% CI)
AllHTD
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ9
2 = 26.49 (P < .01), I2 = 66%
Richards (1987)Marceau (2004)Wax (2008)Josefsson (2010)Lapolla (2010)Santulli (2010)Kjaer (2013)Johansson (2015)Parker (2015)Feichtinger (2017)
OR (95% CI)
0.43 [0.37; 0.51]0.39 [0.27; 0.56]
0.32 [0.13; 0.78]0.16 [0.08; 0.29]0.39 [0.02; 8.26]1.02 [0.38; 2.78]0.61 [0.30; 1.21]0.16 [0.01; 2.83]0.31 [0.15; 0.64]0.33 [0.24; 0.44]0.60 [0.47; 0.76]0.32 [0.06; 1.61]
0.01 0.1 1 10 100Odds Ratio (95% CI)
LGA
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ7
2 = 25.23 (P < .01), I2 = 72%
Dixon (2005)Patel (2008)Wax (2008)Burke (2010)Lapolla (2010)Lesko (2012)Shai (2014)Johansson (2015)
OR (95% CI)
0.45 [0.35; 0.58]0.37 [0.20; 0.68]
0.60 [0.24; 1.47]0.22 [0.01; 4.40]0.39 [0.02; 8.26]0.73 [0.50; 1.06]0.91 [0.34; 2.46]0.21 [0.06; 0.71]0.29 [0.17; 0.50]0.11 [0.05; 0.24]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Macrosomia
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ14
2 = 37.39 (P < .01), I2 = 63%
Richards (1987)Marceau (2004)Dixon (2005)Patel (2008)Wax (2008)Burke (2010)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Shai (2014)Johansson (2015)Parker (2015)Feichtinger (2017)
OR (95% CI)
0.45 [0.39; 0.52]0.40 [0.30; 0.54]
0.32 [0.13; 0.78]0.16 [0.08; 0.29]0.60 [0.24; 1.47]0.22 [0.01; 4.40]0.39 [0.02; 8.26]0.73 [0.50; 1.06]1.02 [0.38; 2.78]0.61 [0.30; 1.21]0.16 [0.01; 2.83]0.21 [0.06; 0.71]0.31 [0.15; 0.64]0.29 [0.17; 0.50]0.33 [0.24; 0.44]0.60 [0.47; 0.76]0.32 [0.06; 1.61]
0.01 0.1 1 10 100Odds Ratio (95% CI)
Large babies
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ12
2 = 16.23 (P = .18), I2 = 26%
Richards (1987)Marceau (2004)Patel (2008)Wax (2008)Weintraub (2008)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Roos (2013)Johansson (2015)Feichtinger (2017)
OR (95% CI)
2.00 [1.74; 2.29]2.09 [1.71; 2.56]
2.08 [0.36; 11.81]3.26 [1.63; 6.53]5.48 [0.54; 55.72]0.84 [0.21; 3.47]1.36 [0.84; 2.20]2.74 [1.28; 5.88]0.28 [0.03; 2.45]1.73 [0.33; 9.12]3.93 [1.47; 10.49]2.55 [1.51; 4.33]1.77 [1.44; 2.17]2.24 [1.71; 2.93]3.25 [1.33; 7.89]
0.1 0.5 1 2 10Odds Ratio (95% CI)
SGA
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 2.23 (P = .53), I2 = 0%
Patel (2008)Weintraub (2008)Santulli (2010)Parker (2015)
OR (95% CI)
2.64 [2.14; 3.25]2.64 [2.14; 3.25]
5.12 [0.20; 130.38]1.72 [0.72; 4.13]15.38 [0.61; 389.26]2.68 [2.16; 3.32]
0.01 0.1 1 10 100Odds Ratio (95% CI)
IUGR
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ14
2 = 24.73 (P = .04), I2 = 43%
Richards (1987)Marceau (2004)Dixon (2005)Patel (2008)Wax (2008)Weintraub (2008)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Roos (2013)Johansson (2015)Parker (2015)Feichtinger (2017)
OR (95% CI)
2.15 [1.92; 2.41]2.14 [1.75; 2.63]
2.08 [0.36; 11.81]3.26 [1.63; 6.53]0.69 [0.21; 2.29]5.48 [0.54; 55.72]0.84 [0.21; 3.47]1.36 [0.84; 2.20]2.74 [1.28; 5.88]0.28 [0.03; 2.45]1.73 [0.33; 9.12]3.93 [1.47; 10.49]2.55 [1.51; 4.33]1.77 [1.44; 2.17]2.24 [1.71; 2.93]2.68 [2.16; 3.32]3.25 [1.33; 7.89]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Small babies
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ10
2 = 6.63 (P = .76), I2 = 0%
Richards (1987)Dixon (2005)Patel (2008)Wax (2008)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Roos (2013)Johansson (2015)
OR (95% CI)
1.54 [1.37; 1.74]1.54 [1.37; 1.74]
1.86 [0.51; 6.72]0.47 [0.15; 1.43]1.61 [0.51; 5.13]1.54 [0.33; 7.27]1.45 [0.78; 2.69]1.43 [0.67; 3.09]1.70 [0.17; 17.03]1.69 [0.79; 3.65]1.30 [0.84; 2.01]1.66 [1.42; 1.93]1.37 [1.00; 1.87]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Pre-term delivery
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 11.97 (P = .04), I2 = 58%
Burke (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Parker (2015)
OR (95% CI)
0.59 [0.46; 0.76]0.57 [0.36; 0.89]
0.68 [0.26; 1.80]0.39 [0.05; 3.16]0.12 [0.02; 0.93]0.93 [0.59; 1.46]0.70 [0.45; 1.09]0.36 [0.23; 0.55]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Postpartum hemorrhage
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ11
2 = 60.93 (P < .01), I2 = 82%
Richards (1987)Patel (2008)Wax (2008)Burke (2010)Josefsson (2010)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Parker (2015)Feichtinger (2017)
OR (95% CI)
1.17 [1.08; 1.27]0.98 [0.74; 1.29]
1.74 [0.68; 4.41]1.84 [0.68; 4.96]1.11 [0.38; 3.27]0.51 [0.37; 0.70]1.33 [0.84; 2.09]0.44 [0.25; 0.78]2.66 [1.00; 7.08]0.67 [0.37; 1.23]1.21 [0.94; 1.57]1.19 [0.86; 1.65]1.33 [1.20; 1.47]0.42 [0.21; 0.80]
0.2 0.5 1 2 5Odds Ratio (95% CI)
C-section
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 0.73 (P = .87), I2 = 0%
Wax (2008)Santulli (2010)Kjaer (2013)Feichtinger (2017)
OR (95% CI)
1.03 [0.81; 1.32]1.03 [0.81; 1.32]
1.00 [0.37; 2.73]0.69 [0.24; 2.01]1.07 [0.82; 1.41]0.86 [0.30; 2.51]
0.5 1 2Odds Ratio (95% CI)
Labor induction
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ6
2 = 4.83 (P = .57), I2 = 0%
Wax (2008)Lapolla (2010)Santulli (2010)Lesko (2012)Kjaer (2013)Berlac (2014)Feichtinger (2017)
OR (95% CI)
1.26 [1.02; 1.55]1.26 [1.02; 1.55]
1.18 [0.45; 3.12]2.32 [1.04; 5.16]2.57 [0.22; 29.48]0.66 [0.28; 1.55]1.22 [0.85; 1.75]1.26 [0.93; 1.70]1.37 [0.45; 4.16]
0.1 0.5 1 2 10Odds Ratio (95% CI)
NICU admission
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ4
2 = 10.60 (P = .03), I2 = 62%
Marceau (2004)Patel (2008)Wax (2008)Weintraub (2008)Johansson (2015)
OR (95% CI)
1.16 [0.79; 1.71]1.13 [0.52; 2.43]
1.62 [0.71; 3.73]0.31 [0.01; 6.78]0.21 [0.01; 3.99]2.49 [1.23; 5.06]0.67 [0.38; 1.19]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Malformations
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 3.77 (P = .58), I2 = 0%
Marceau (2004)Patel (2008)Lesko (2012)Roos (2013)Berlac (2014)Johansson (2015)Parker (2015)
OR (95% CI)
1.47 [1.06; 2.03]1.47 [1.06; 2.03]
0.58 [0.07; 4.44] 8.42 [0.92; 76.85]1.31 [0.80; 2.16]1.33 [0.22; 7.99]1.99 [0.74; 5.31]1.48 [0.87; 2.51]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Stillbirth
Source
Total (fixed effect)Total (random effects)Heterogeneity: χ5
2 = 6.60 (P = .25), I2 = 24%
Richards (1987)Weintraub (2008)Burke (2010)Kjaer (2013)Roos (2013)Johansson (2015)
OR (95% CI)
1.13 [0.68; 1.89]1.15 [0.62; 2.13]
1.00 [0.14; 7.35]0.42 [0.13; 1.33]2.31 [0.59; 8.99]0.63 [0.08; 5.22]1.08 [0.48; 2.45]3.19 [0.85; 11.93]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Neonatal deaths
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Source
Total (fixed effect)Total (random effects)Heterogeneity: χ3
2 = 4.46 (P = .22), I2 = 33%
Marceau (2004)Patel (2008)Bennett (2010)Feichtinger (2017)
OR (95% CI)
1.10 [0.67; 1.78]1.11 [0.59; 2.10]
1.82 [0.68; 4.88]3.50 [0.30; 40.65]1.17 [0.57; 2.37]0.49 [0.18; 1.31]
0.1 0.5 1 2 10Odds Ratio (95% CI)
Multiple gestations
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
Characteristics of all included studies
Study Patients
with
Surgery (n)
Patients
without
Surgery (n)
Outcomes Assessed Surgery Type BMI
Matching
Data Type
Richards (1987)40 57 57 GDM, neonatal death, pre-term
delivery, gestational HTN, LGA,
SGA, c-section
Malabsorptive
(100%
malabsorptive)
Pre-surgery
BMI
Clinical
Marceau (2004)25 251 1577 Stillbirth, LGA, SGA, multiple
gestations, miscarriages,
malformations
Malabsorptive
(100%
malabsorptive)
No matching Clinical
Dixon (2005)38 79 79 GDM, macrosomia, pre-term
delivery, pre-eclampsia,
gestational HTN, SGA
Restrictive
(100%
restrictive)
Pre-
pregnancy
BMI
Clinical
Patel (2008)33 26 254 GDM, macrosomia, stillbirth,
pre-term delivery, pre-
eclampsia, gestational HTN,
IUGR, SGA, multiple gestations,
Malabsorptive
(100%
malabsorptive)
No matching Clinical
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c-section, malformations
Wax (2008)32 38 76 GDM, macrosomia, NICU
admission, pre-term delivery,
gestational HTN, LGA, SGA,
labor induction, c-section,
malformations
Malabsorptive
(100%
malabsorptive)
No matching Clinical
Weintraub
(2008)31
507 301 GDM, macrosomia, neonatal
death, pre-eclampsia,
gestational HTN, IUGR, SGA, c-
section, malformations
Mostly
restrictive (did
not specify, just
said ‘mainly)
No matching Clinical
Bennett (2010)34 316 269 GDM, pre-eclampsia,
gestational HTN, multiple
gestations
Mostly
malabsorptive
(82%
malabsorptive)
No matching Administrative
Burke (2010)37 354 346 GDM, macrosomia, neonatal
death, postpartum hemorrhage,
Cannot tell No matching Administrative
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c-section
Lapolla (2010)36 83 978 GDM, macrosomia, NICU
admission, pre-term delivery,
pre-eclampsia, gestational HTN,
LGA, SGA, c-section
Restrictive
(100%
restrictive)
Pre-
pregnancy
BMI
Clinical
Santulli (2010)30 24 240 GDM, pre-term delivery, NICU
admission, pre-eclampsia,
IUGR, LGA, SGA, postpartum
hemorrhage, labor induction, c-
section
Malabsorptive
(100%
malabsorptive)
Pre-
pregnancy
BMI
Clinical
Belogolovkin
(2011)
293 656353 GDM, macrosomia, pre-term
delivery, pre-eclampsia, SGA, c-
section
Cannot tell No matching
(adjusted for
pre-
pregnancy
BMI)
Administrative
Josefsson (2011)21 367 188500 GDM, pre-term delivery, LGA,
SGA, c-section
Cannot tell No matching
(adjusted by
BMI
Administrative
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Bariatric Surgery and Outcomes of Pregnancy Online Supplement
category)
Lesko (2012)28 70 280 GDM, macrosomia, stillbirth,
NICU admission, pre-term
delivery, pre-eclampsia,
gestational HTN, SGA,
postpartum hemorrhage, c-
section
Mostly
malabsorptive
(86%
malabsorptive)
BOTH pre-
pregnancy
and pre-
surgery BMI
Clinical
Roos (2013)26 2562 1740140 Stillbirth, neonatal deaths, pre-
term delivery, LGA, SGA
Mostly
restrictive (65%
restrictive)
Pre-
pregnancy
BMI
Administrative
Kjær (2013)27 339 1277 GDM, neonatal deaths, NICU
admission, pre-term delivery,
pre-eclampsia, LGA, SGA,
postpartum hemorrhage, labor
induction, c-section
Mostly
malabsorptive
(84%
malabsorptive)
Pre-
pregnancy
BMI
Administrative
Berlac (2014)35 415 826 GDM, stillbirth, NICU admission,
pre-eclampsia, gestational HTN,
postpartum hemorrhage, c-
Malabsorptive
(100%
Pre-
pregnancy
Administrative
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section malabsorptive) BMI
Shai (2014)19 326 1612 GDM, macrosomia, pre-
eclampsia, c-section
Mostly
restrictive (did
not specify)
No matching Clinical
Johansson
(2015)20
596 2356 GDM, macrosomia, stillbirth,
neonatal deaths, pre-term
delivery, LGA, SGA,
malformations
Malabsorptive
(98%
malabsorptive)
Pre-surgery
BMI
Administrative
Parker (2016)24 1585 185120 GDM, stillbirth, pre-eclampsia,
IUGR, LGA, postpartum
hemorrhage, c-section
Cannot tell No matching Administrative
Feichtinger
(2017)39
76 76 GDM, NICU admission,
gestational HTN, LGA< SGA,
multiple gestations, labor
induction, c-section
Malabsorptive
(100%
malabsorptive)
Pre-
pregnancy
BMI
Clinical
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Abbreviations: BMI - body mass index; C-section - cesarean section; GDM - gestational diabetes; HTN - hypertension; IUGR -
intrauterine growth restriction; LGA - large for gestational age; NICU - neonatal intensive care unit; SGA - small for gestational
age
44