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Thank you for your thoughtful letter to the editor regarding our meta-analysis on pregnancy outcomes in women who had undergone bariatric surgery.1Kwong W. Tomlinson G. Feig D.S. Maternal and neonatal outcomes after bariatric surgery; a systematic review and meta-analysis: do the benefits outweigh the risks?.Am J Obstet Gynecol. 2018; ([Epub ahead of print])https://doi.org/10.1016/j.ajog.2018.02.003Abstract Full Text Full Text PDF Scopus (111) Google Scholar We agree that there are few studies that have looked specifically at pregnancy outcomes of patients who undergo vertical sleeve gastrectomy; therefore, your data on pregnancy outcomes in these patients are important. In your study that observed women who underwent vertical sleeve gastrectomy, you found an increase in small for gestational age (SGA) infants and, because this is a restrictive procedure, suggest that the growth restriction may be due to other causes other than malabsorption.2Rottenstreich A. Elchalal U. Kleinstern G. Beglaibter N. Khalaileh A. Elazary R. Maternal and perinatal outcomes after laparoscopic sleeve gastrectomy.Obstet Gynecol. 2018; 131: 451-456Crossref PubMed Scopus (35) Google Scholar We acknowledge that this is a possibility. Another possibility, however, is that the relative increase in SGA infants found in your study was a result of the choice of control group. The women in the control group were matched to the surgery patients by preoperative body mass index (average, 41 kg/m2) and thus were much heavier than the surgery group before pregnancy, in which the average body mass index was 28.9 kg/m2. The less obese surgery group had an inherently higher risk of SGA simply because of their weight, as evidenced by Lamminpaa et al,3Lamminpaa R. Vehvilainen-Julkunen K. Gissler M. Selander T. Heinonen S. Pregnancy outcomes of overweight and obese women aged 35 years or older: a registry-based study in Finland.Obes Res Clin Pract. 2016; 10: 133-142Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar compared with their obese counterparts. Therefore, your finding may reflect the control group that was used rather than the procedure itself. Another study that looked at pregnancy outcomes after vertical sleeve gastrectomy also found an increase in SGA in women who had a body mass index of <30 kg/m2 before pregnancy compared with women who had a body mass index of >30 kg/m2 before pregnancy (22% vs 4%; P=.05), despite both groups undergoing the procedure.4Ducarme G. Chesnoy V. Lemarie P. Koumare S. Krawczykowski D. Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients.Int J Gynecol Obstet. 2015; 130: 127-131Crossref PubMed Scopus (21) Google Scholar Regarding the timing of the pregnancy after the procedure, most studies did not include this kind of information; thus, this is a limitation of our study. The evidence, however, that pregnancy outcomes are affected by close timing of pregnancy after surgery is still controversial, and findings have been mixed, with a number of studies finding no difference in outcomes despite differences in timing of pregnancy.5Nikoline Norgaard L. Roslev Gjerris A.C. Kirkegaard I. Berlac J.F. Tabor A. Danish Fetal Medicine Research Group. Fetal growth in pregnancies conceived after gastric bypass surgery in relation to surgery-to-conception interval: a Danish national cohort study.PloS One. 2014; 9: e90317Crossref PubMed Scopus (24) Google Scholar, 6Sheiner E. Edri A. Balaban E. Levi I. Aricha-Tamir B. Pregnancy outcome of patients who conceive during or after the first year following bariatric surgery.Am J Obstet Gynecol. 2011; 1: 50.e1-50.e6Abstract Full Text Full Text PDF Scopus (106) Google Scholar It is possible that continuation of weight loss during pregnancy vs weight stability is a more important determinant of pregnancy outcome than a fixed time of pregnancy after surgery.7Mahawar K.K. Graham Y. Small P.K. Optimum time for pregnancy after bariatric surgery.Surg Obes Relat Dis. 2016; 12: 1126-1128Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Pregnancy after bariatric surgery: risks and benefitsAmerican Journal of Obstetrics & GynecologyVol. 219Issue 3PreviewIn the recent decade, bariatric surgery (BS) has become the mainstay of treatment for morbid obesity, because of its demonstrated efficacy in achieving significant weight loss and in improving obesity-related comorbidities. Up to 80% of patients who undergo BS are women of childbearing age. Because of this situation, coupled with the dramatic increase in the use of BS in the management of obesity, obstetricians are likely to encounter women who have undergone BS in their routine practice. Full-Text PDF