In the personal statements of medical students applying for obstetrics and gynecology residencies, many comment that the combination of both medical and surgical care is a primary driver of their choice of specialty. The increasing emphasis on putting the "M" back in maternal-fetal medicine is another example of commitment by obstetrician-gynecologists to provide the full scope of care for women. To do so, we must be prepared to care for the complications faced by women who are currently obese or who have undergone bariatric surgery before pregnancy. Data from the National Health Interview Survey show that 30.4% of U.S. adults are obese, exceeding 30% for the first time. 1 With rates of obesity this high, we will no doubt see increasing numbers of women with prior bariatric surgery. In this month's issue, in a case series and systematic review of 52 women, Vannevel et al explore a relatively common and possibly lethal complication of Roux-en-Y surgery-internal herniation.The nonspecific symptoms and signs of pregnant women with internal herniation were commonly associated with delay in diagnosis in the patients in this review, about 4% of whom died. Vannevel reminds us how important it is to think of a broad differential diagnosis to include bariatric surgery complications when an afebrile woman in her third trimester who has had prior bariatric surgery presents with vague pain, nausea, vomiting, and a normal white count. It is reasonable to consider consulting our surgical colleagues in such cases; they can help us to consider the whole picture and avoid maternal mortality and morbidity.Sometimes it is what we don't know that is critical to providing excellent care. This article helps to close this gap going forward so we can continue to provide informed surgical and medical care for pregnant women.
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