Interpretation
This study demonstrated higher risk of preterm birth, low birth weight,
gestational hypertension, placenta previa, placenta abruption, and
cesarean section in women who underwent non-obstetric abdominal surgery
during pregnancy compared to pregnant women who did not. This result is
consistent with previous large studies.2-4,13,14 A
Swedish study of 2 million pregnancies suggested increased risk for
fetuses of pregnant women who underwent surgery to weigh <2500
g, to be delivered before 37 weeks, and to have an increased incidence
of growth restriction compared with the total
population.3 Although the risk associated with
non-obstetric surgery is relatively low, surgical operations were
associated with additional stillbirth (1 per 287 surgery), preterm
delivery (1 per 31 surgery), LBW (1 per 39 surgery), and C/S (1 per 25
surgery) according to a cohort study of 6.5 million pregnancies in
England.4 In a Taiwanese registry-based study of
150,000 pregnancies, non-obstetric surgery during pregnancy was
associated with higher risk of spontaneous abortion (4.23% vs. 2.43%,
adjusted odd ratio [aOR]:1.53; 95% CI: 1.01–2.31),
pre-eclampsia/eclampsia (2.60% vs. 1.01%, aOR: 2.35; 95% CI:
1.30–4.23), gestational diabetes (2.38% vs. 0.69%, aOR: 3.12; 95%
CI: 1.69–5.78), prematurity (9.06 vs. 4.90%, aOR: 3.31; 95% CI:
2.54–4.31), and cesarean section (43.55% vs. 33.76%, aOR: 1.41; 95%
CI: 1.17–1.71).13
In this study, although the laparoscopic group tended to have a lower
risk of fetal complications than the laparotomy group, there was no
significant difference between the groups. However, in the pregnant
women who underwent ovarian resection, the risk of LBW was significantly
increased in the laparotomy group. The effect and safety of laparoscopic
surgery on pregnancy have been discussed for many years. In 1997, a
Swedish health registry study suggested that there was no difference in
birth weight, gestational duration, growth restriction, infant survival,
or fetal malformations for patients undergoing laparoscopy versus
laparotomy in singleton pregnancies between 4 and 20 weeks of gestation.
A recent Japanese registry study showed that laparoscopic surgery had
advantages in short-term fetal adverse events, incidence of blood
transfusion, operative time, and hospital stay.12However, there are some limitations to these studies. Since the Swedish
study was conducted 20 years ago, the results of the study were limited
for evaluating the impact of laparoscopic surgery on pregnancy. In
addition, there were very few laparoscopic surgeries during the second
or third trimester. The Japanese study was a recent study that used a
large national database, which had an advantage of performing propensity
matching to correct for possible confounders such as age, BMI,
gestational age at surgery, smoking, operative procedure, emergent
maternal transport, emergent surgery within 2 days of admission, and the
average ratio of laparoscopies to laparotomies performed at each
hospital. However, LBW, which is a major complication of surgery during
pregnancy, and preterm birth were not identified in the Japanese study.
Moreover, the risk of multiple obstetric complications such as
gestational hypertension, gestational diabetes, and C/S that have been
associated with surgery during pregnancy was not assessed. On the other
hand, in our study, the overall incidence of preterm birth and LBW was
evaluated using the National Health Screening Program for Infants and
Children (NHSP-IC). Obstetric complications such as gestational
hypertension, GDM, PPH, placental abruption, placenta previa, C/S, and
length of hospital stay after surgery were also evaluated in this study.
There was a significant difference in risk of fetal complications
according to the time of surgery during pregnancy. Comparison between
the laparoscopy and open groups indicated that there was no significant
difference in fetal and obstetric complications, although there was a
tendency for increased risk of preterm birth and LBW. However, there was
no increased risk of obstetric and fetal complications, including
premature birth and LBW, in women who underwent laparoscopic surgery
more than 6 months before delivery. This is consistent with the results
of previous studies. In a systematic review of 12,452 pregnancies,
surgery in the first trimester did not appear to increase major birth
defects.15 In a Taiwanese registry study, deliveries
that were associated with non-obstetric surgery in the third trimester
had a 3.79-fold (95% CI, 1.20–11.96) increase in OR compared to those
with surgery in the first trimester.13
This study showed that hospital stay in the laparoscopy group was
statistically significantly shorter than that in the laparotomy group.
This is one of the great advantages of laparoscopic surgery and has also
been reported in several studies. According to the Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines, benefits of
laparoscopy during pregnancy appear similar to those in non-pregnant
patients including less postoperative pain, less postoperative ileus,
decreased length of hospital stays, and faster return to
work.5 A Japanese registry study also showed that the
laparoscopy group had a significantly shorter hospital stay (9.2 vs. 5.9
days, p <.001) compared with the laparotomy
group.12