- by Molly Walker
Staff Writer, MedPage TodayJanuary 18, 2017
Action Points
Risk factors such as cervical incompetence, preterm labor, and vaginal infections were strongly associated with a pregnant woman's risk of adverse pregnancy outcomes if she underwent an appendectomy or cholecystectomy, researchers found.
Researchers led by Adam Sachs, MD, of Hartford Hospital, and colleagues, devised a scoring system to determine the risk categories for pregnant women undergoing these surgeries. Women in the highest risk group were associated with a 21.8% chance of an adverse pregnancy outcome, while women in the lowest risk group had a 2.5% chance of an adverse outcome.
Writing in JAMA Surgery, the authors said that appendectomies and cholecystectomies are the most common non-obstetric surgeries during pregnancy, the authors noted, with about 2,800 and 2,000 procedures respectively performed annually on pregnant women. They said that as prior research focused on diagnosis and surgical management of appendicitis and cholecystitis instead of pregnancy outcomes.
"Accurate maternal counseling regarding anticipated outcomes following non-obstetric surgery during pregnancy remain challenging in clinical practice," they wrote.
The authors examined the Nationwide Inpatient Sample, and used data from 19,926 women (mean age 26 years) who underwent an appendectomy or cholecystectomy during their pregnancy. Overall, there were 1,080 adverse events in 953 pregnant women.
They used this subset of the cohort to perform a multivariate analysis and derive the adjusted odds ratios for each risk factor contributing to an adverse pregnancy outcome for women undergoing these surgeries:
- Cervical incompetence (adjusted OR 24.29, 95% CI 7.48-78.81)
- Preterm labor during current pregnancy (adjusted OR 18.34, 95% CI 4.95-67.97)
- Vaginitis or vulvovaginitis (adjusted OR 5.17, 95% CI 2.19-12.23, P<0.001 for all)
The authors said that this was the first study to their knowledge that found these obstetric variables to have the strongest link with adverse obstetric outcomes following these surgeries, instead of "maternal-, surgery- or disease-related variables."
However, there were notable maternal-, surgery- or disease-related risk factors that increased odds of adverse outcomes. These included sepsis (adjusted OR 3.39, 95% CI 2.08-3.53), multiple gestations (adjusted OR 3.31, 95% CI 1.67-6.58), and open surgery (adjusted OR 3.13, 95% CI 2.59-3.78). Both open surgery and sepsis had been previously reported to increase the risk of obstetric complications during pregnancy, they wrote.
The authors then assigned points based on these individual risk factors:
- Cervical incompetence: 16 points
- Preterm labor: 15 points
- Vaginitis or vulvovaginitis: 8 points
- Multiple gestation or sepsis: 6 points
- Open surgery or peritonitis: 5 points
Probabilities of adverse obstetrical outcomes were determined by risk group score:
- ≥9 points: 21.8% probability
- 5-8 points: 8.2% probability
- ≤5 points: 2.5% probability
The authors also examined demographic risk factors associated with these two procedures, and found that both non-white race/ethnicity (adjusted OR 1.55, 95% CI 1.29-1.85, P<0.001) and Medicaid coverage (adjusted OR 1.22, 95% CI 1.02-1.46, P=0.03) were also linked to adverse obstetric outcomes.
Limitations to the study include that anesthetic modalities were not available in the data, so those factors could not be evaluated. In addition, because the study only looked at ICD-9-CM codes, the data did not include gestational age.
An accompanying editorial by Roxanne L. Massoumi, MD, and O. Joe Hines, MD, both of the University of California at Los Angeles, suggested that medical management of these conditions may be a better approach for these patients.
"Although use of antibiotics alone is less popular in patients with acute cholecystitis, treatment of uncomplicated acute appendicitis with antibiotics is a recent, promising, and debated trend," they wrote. "Given the higher surgical risk of pregnant patients secondary to their unique physiological features, nonoperative management of uncomplicated acute appendicitis might be considered in this population."
The authors disclosed no relevant financial relationships.
Massoumi and Hines disclosed no relevant financial relationships.
