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