Obstetrical outcome in women with endometriosis including spontaneous hemoperitoneum and bowel perforation: a systematic review

Pregnancy and Neonatal Outcomes in Women Treated for Bowel Endometriosis: A Seven-Year Single-Centre Retrospective Matched Cohort Study

Background/Objectives: Deep infiltrating endometriosis has been linked to worsened maternal and neonatal outcomes. However, reports regarding bowel endometriosis are still scanty. We aimed to evaluate pregnancy, delivery, and newborn adverse outcomes in women after laparoscopic-assisted surgery for bowel endometriosis. Methods: A single-center retrospective cohort study was conducted at a tertiary-care university hospital. From January 2015 to December 2021, pregnant women who were diagnosed and treated for bowel endometriosis were matched using a 1:3 ratio with pregnant women with no history of endometriosis. Patients were matched using the Cox proportional hazards model to determine parity, age, BMI and gestational age-adjusted relative risk (aRR) with a 95% confidence interval (CI). Co-primary outcomes were the incidence of labor abnormalities and cesarean section (CS) rate. Co-secondary outcomes were incidence of complications related to pregnancy, delivery, and newborn. Results: A total of 71 pregnancies among women treated for bowel endometriosis and 213 from healthy controls were included. Patients requiring IVF/ET for getting pregnant were in the bowel endometriosis group relative to controls (43.7% vs. 11.7%; p < 0.001). Increased risk of labor abnormalities was present for bowel endometriosis relative to controls (21.1% vs. 17.4%; p = 0.040; aRR 1.39 [95% CI 1.06-2.05]). Risk of non-cephalic fetal presentation (14.1% vs. 6.1%; p = 0.016; aRR 3.08 [95% CI 2.03-4.68]), CS rate (43.7% vs. 24.9%; p = 0.003; aRR 1.75 [95% CI 1.23-2.49]), and emergent CS rate (19.7% vs. 8.5%; p = 0.009; aRR 2.21 [95% CI 1.55-3.16]) were significantly higher in women treated for colorectal endometriosis compared with controls. Moreover, placenta previa (9.9% vs. 0.0%; p < 0.001; aRR 21.82 [95% CI 2.19-116.40]), second-trimester hemorrhage (5.6% vs. 0.9%; p = 0.017; aRR 6.00 [95% CI 1.12-32.06]), postpartum hemorrhage (15.5% vs. 3.3%; p < 0.001; aRR 4.71 [95% CI 1.90-11.70]), and the need for transfusion during labor (5.6% vs. 0.5%; p = 0.004; aRR 12.00 [95% CI 1.36-105.60]) were increased in treatments vs. controls. Concerning neonatal outcomes, an increased risk for neonatal intensive care unit admission was seen in postsurgical endometriotic women relative to healthy controls (26.0% vs. 6.9%; p < 0.001; aRR 3.75 [2.04-3.86]). Conclusions: Women treated for bowel endometriosis seem more exposed to adverse pregnancy and neonatal outcomes relative to healthy controls. However, additional prospective and comparative studies are needed to validate the available evidence.

Obstetric outcomes in women with pelvic endometriosis: a prospective cohort study

OBJECTIVE

To determine whether obstetric outcomes differ between women with endometriosis and those without, where all women undergo first-trimester screening for endometriosis.

DESIGN

A prospective observational cohort study.

SETTING

The Early Pregnancy Unit at University College London Hospital, United Kingdom.

PATIENTS

Women with a live pregnancy progressing beyond 12 weeks' gestation and concurrent endometriosis (n = 110) or no endometriosis (n = 393).

INTERVENTION

All women underwent a pelvic ultrasound examination in early pregnancy to examine for the presence of endometriosis and uterine abnormalities.

MAIN OUTCOME MEASURES

The primary outcome of interest was preterm birth, defined as delivery before 37 completed weeks' gestation. Secondary outcomes included late miscarriage, antepartum hemorrhage, placental site disorders, gestational diabetes, hypertensive disorders of pregnancy, neonates small for gestational age, mode of delivery, intrapartum sepsis, postpartum hemorrhage, and admission to the neonatal unit.

RESULTS

Women with a diagnosis of endometriosis did not have statistically significantly higher odds of preterm delivery (adjusted odds ratio [aOR] 1.85 [95% confidence interval {CI} 0.50-6.90]), but they did have higher odds of postpartum hemorrhage during cesarean section (aOR 3.64 [95% CI 2.07-6.35]) and admission of their newborn infant to the neonatal unit (aOR 3.24 [95% CI 1.08-9.73]). Women with persistent or recurrent deep endometriosis after surgery also had higher odds of placental site disorders (aOR 8.65 [95% CI 1.17-63.71]) and intrapartum sepsis (aOR 3.47 [95% CI 1.02-11.75]).

CONCLUSION

We observed that women with endometriosis do not have higher odds of preterm delivery, irrespective of their disease subtype. However, they do have higher odds of postpartum hemorrhage during the cesarean section and newborn admission to the neonatal unit.

Endometriosis-associated spontaneous major haemoperitoneum in pregnancy

Spontaneous haemoperitoneum in pregnancy (SHiP) related to endometriosis is a rare and life-threatening complication. We report a case of a patient presenting to our department with major haemoperitoneum at 23+3 weeks of gestation due to a large rectovaginal endometriotic nodule. The patient required a midline laparotomy to evacuate 1 L of haemoperitoneum and achieve haemostasis. A large rectovaginal nodule was seen bleeding and was packed with haemostatic material and a large swab. After 24 hours, the swab was removed and haemostasis was confirmed. The patient was monitored very closely by a multidisciplinary team and the pregnancy was allowed to continue to try and achieve a better outcome for the baby and at 28 weeks of gestation, a girl was delivered in good condition via caesarean section.

Endometriosis-related infertility: severe pain symptoms do not impact assisted reproductive technology outcomes

STUDY QUESTION

Do severe endometriosis-related painful symptoms impact ART live birth rates?

SUMMARY ANSWER

Severe pain symptoms are not associated with reduced ART live birth rates in endometriosis patients.

WHAT IS KNOWN ALREADY

ART is currently recognized as one of the main therapeutic options to manage endometriosis-related infertility. Presently, no data exist in the literature regarding the association between the core symptom of the disease, e.g. pain and ART reproductive outcomes.

STUDY DESIGN, SIZE, DURATION

Observational cohort study of 354 endometriosis patients, who underwent ART at a tertiary care university hospital, between October 2014 and October 2021. Diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography and magnetic resonance imaging, and histologically confirmed in women who had a previous history of endometriosis surgery (n = 127, 35.9%).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The intensity of painful symptoms related to dysmenorrhea (DM), dyspareunia (DP), noncyclic chronic pelvic pain, gastrointestinal (GI) pain, or lower urinary tract pain was evaluated using a 10-point visual analog scale (VAS), before ART. Severe pain was defined as having a VAS of 7 or higher for at least one symptom. The main outcome measure was the cumulative live birth rate (CLBR) per patient. We analyzed the impact of endometriosis-related painful symptoms on ART live births using univariable and multivariate analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Three hundred and fifty-four endometriosis patients underwent 711 ART cycles. The mean age of the population was 33.8 ± 3.7 years, and the mean duration of infertility was 3.6 ± 2.1 years. The distribution of the endometriosis phenotypes was 3.1% superficial endometriosis, 8.2% ovarian endometrioma, and 88.7% deep infiltrating endometriosis. The mean VAS scores for DM, DP, and GI pain symptoms were 6.6 ± 2.7, 3.4 ± 3.1, and 3.1 ± 3.6, respectively. Two hundred and forty-two patients (68.4%) had severe pain symptoms. The CLBR per patient was 63.8% (226/354). Neither the mean VAS scores for the various painful symptoms nor the proportion of patients displaying severe pain differed significantly between patients who had a live birth and those who had not, based on univariate and multivariate analyses (P = 0.229). The only significant factors associated with negative ART live births were age >35 years (P < 0.001) and anti-Müllerian hormone levels <1.2 ng/ml (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The diagnosis of endometriosis was based on imaging rather than surgery. This limitation is, however, inherent to the design of most studies on endometriosis patients reverting to ART first.

WIDER IMPLICATIONS OF THE FINDINGS

Rather than considering a single argument such as pain, the decision-making process for choosing between ART and surgery in infertile endometriosis patients should be based on a multitude of aspects, including the patient's choice, the associated infertility factors, the endometriosis phenotypes, and the efficiency of medical therapies in regard to pain symptoms, through an individualized approach guided by a multidisciplinary team of experts.

STUDY FUNDING/COMPETING INTEREST(S)

No funding; no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Adverse Pregnancy Outcomes Associated with Endometriosis and Its Influencing Factors

Aim

To investigate the adverse pregnancy outcomes associated with endometriosis and its influencing factors.

Methods

A total of 188 endometriosis patients who gave birth at our hospital between June 2018 and January 2021 were screened for eligibility and included in the research group, while a control group of 188 nonendometriosis women who delivered at our hospital during the same period were also included as healthy controls. Pregnancy outcomes were the key outcome measure, and the relationship between endometriosis and unfavorable pregnancy outcomes, as well as the influencing factors, were explored.

Results

There was no significant difference in the risk of adverse pregnancy events such as miscarriage, ectopic pregnancy, termination of pregnancy, and fetal death between the two groups (P > 0.05). The differences in hypertensive disorder in pregnancy, gestational diabetes, placental abruption, fetal growth restriction, and luteal support between the two groups also failed to reach the statistical standard (P > 0.05). The two groups significantly differed in terms of cesarean delivery, preterm delivery, and placenta previa (1.92 (95% CI 1.33-2.85), 2.43 (95% CI 1.05-5.58), and 4.51 (95% CI 1.23-16.50)) (P < 0.05).

Conclusion

Endometriosis is an influential factor in adverse pregnancy outcomes and results in a high risk of preterm delivery, placenta previa, and cesarean delivery in patients. Mutual interactions exist among adverse pregnancy outcomes and thus require appropriate management.

Spontaneous Hemoperitoneum in Pregnancy and Endometriosis: A New Challenge in a Known Disease

Importance

Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare life-threatening event previously associated with endometriosis. Although pregnancy is thought to improve the symptoms of endometriosis, abrupt intraperitoneal bleeding can occur, jeopardizing both maternal and fetal outcomes.

Objective

The aim of this study was to review the published information regarding SHiP pathophysiology, presentation, diagnosis, and management in a flowchart approach.

Evidence Acquisition

A descriptive review of published articles in the English-language was carried out.

Results

SHiP most commonly presents in the second half of pregnancy with a combination of abdominal pain, hypovolemia, a decline in hemoglobin level, and fetal distress. Nonspecific gastrointestinal symptoms are not uncommon. Surgical management is suitable in most scenarios and avoids complications such as recurrent bleeding and infected hematoma. Maternal outcome has improved greatly, whereas perinatal mortality remained unchanged. In addition to physical strain, SHiP was reported to have a psychosocial sequela.

Conclusions and Relevance

A high index of suspicion is required when patients present with acute abdominal pain and signs of hypovolemia. Early use of sonography contributes to narrowing down the diagnosis. Health care providers should be familiar with the SHiP diagnosis because early identification is crucial when attempting to safeguard maternal and fetal outcomes. Maternal and fetal requirements are often contradictory, creating a greater challenge in decision-making and treatment. A multidisciplinary team approach should coordinate the treatment, whenever a SHiP diagnosis is suspected.

Association between Endometriosis and Risk of Preeclampsia in Women Who Conceived Spontaneously: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the association between endometriosis and the risk of preeclampsia and other maternal outcomes in spontaneously conceived women.

DATA SOURCES

PubMed, MEDLINE, Embase, Scopus, Cochrane Library, Web of Science, and Google Scholar were systemically searched for studies published from inception to November 2021 (CRD42020198741). Observational studies published in English or French that investigated the risk of preeclampsia in women with endometriosis who conceived spontaneously were included.

METHODS OF STUDY SELECTION

A total of 610 articles were reviewed once duplicates were removed. Inclusion criteria included spontaneous conception and surgical and/or imaging ascertainment of an endometriosis diagnosis. Exclusion criteria included conception using assisted reproductive technologies, multiple pregnancies, chronic hypertension, and unclear diagnoses of endometriosis.

TABULATION, INTEGRATION, AND RESULTS

Data of selected studies were extracted, and analysis was performed on Review Manager, version 5.4. Quality assessment of included studies for potential risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies. Three cohort studies of spontaneous pregnancies were included. Endometriosis was associated with an increased risk of preeclampsia (risk ratio [RR] = 1.47, 95% CI 1.13 -1.89, p = .003; I2 = 0%; n = 3 studies). A sensitivity analysis excluding a study with adenomyosis cases yielded similar risk (RR = 1.44; 95% CI, 1.11-1.87; p = .006; I2 = 0%; n = 2 studies). Having endometriosis did not significantly increase risk of cesarean delivery (RR = 1.38; 95% CI, 0.99-1.92; p = .06; I2 = 80%; n = 2 studies) or postpartum hemorrhage (RR = 1.16; 95% CI, 0.46-2.91; p = .76; I2 = 50%; n = 2 studies).

CONCLUSION

We detected an increased risk of preeclampsia in women with endometriosis who conceived spontaneously. Endometriosis did not seem to increase the risk of cesarean delivery and postpartum hemorrhage, but the number of studies was limited, and the heterogeneity was high.

Acute endometriosis-related sigmoid perforation in pregnancy- case report

Background

An acute abdomen is an emergency that requires accurate diagnosis and prompt treatment. In pregnancy, the process is even more challenging and sometimes the radiological findings are unclear. Moreover, endometriosis- related complications are rare, especially in previously unknown endometriosis.

Case presentation

We report on a case of acute endometriosis-related sigmoid perforation during pregnancy (34 weeks of gestation) due to a previously unknown deep intestinal infiltrating endometriosis with focal ulceration of the affected colonic mucosa.

Conclusions

Despite the low relative risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).

Endometriosis and preterm birth: A Danish cohort study

INTRODUCTION

Emerging evidence shows that women with endometriosis face a higher risk of preterm birth. However, the pathways are unclear. The objective of this study is to further investigate at different gestational ages the association between endometriosis and different pathways of preterm birth including, medically indicated preterm birth, premature pre-labor rupture of membranes (PPROM), and spontaneous labor contractions.

MATERIAL AND METHODS

In this population-based cohort study we linked singleton pregnancies from the Aarhus Birth Cohort to the Danish National Patient Registry, the Danish Medical Birth Registry, the Danish National Pathology Registry and Data Bank, and the Danish in vitro fertilization registry to gather information on endometriosis status, outcomes and maternal characteristics. We investigated preterm birth before 37 completed weeks of gestation and very preterm birth before 32 completed weeks of gestation. We explored different pathways including medically indicated preterm birth defined as induction of labor with intact membranes and no prior labor contractions, PPROM defined as rupture of membranes, and spontaneous labor contractions defined as contractions with intact membranes resulting in labor.

RESULTS

We found that women with endometriosis had an increased risk of preterm birth before 37 gestational weeks overall (adjusted hazard rate [aHR] 1.6, 95% confidence interval [CI] 1.3-1.9) and very preterm birth before 32 gestational weeks (aHR 1.8, 95% CI 1.1-2.9) compared with women without endometriosis. Medically indicated preterm birth was more prominent in women with endometriosis in deliveries before 37 gestational weeks (aHR 2.4, 95% CI 1.8-3.2) whereas spontaneous labor contractions were more common before 32 gestational weeks (aHR 2.2, 95% CI 1.1-4.5) in women with endometriosis compared with women without endometriosis. Further, in the analyses restricted to women with a histologically verified diagnosis of endometriosis, the results were strengthened overall and showed that women with endometriosis had an increased risk of PPROM before 32 gestational weeks (aHR 3.49, 95% CI1.36-8.98).

CONCLUSIONS

Endometriosis was associated with both preterm and very preterm birth; however, apparently through different pathways. Women with endometriosis were more prone to have medically indicated preterm births before 37 gestational weeks and spontaneous preterm births before 32 gestational weeks compared with women without endometriosis.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Premature Birth in Women with Endometriosis: a Systematic Review and Meta-analysis

The objective of this study is to verify the association between endometriosis and preterm birth through systematic review and meta-analysis. Is there an increased risk of premature birth in women with endometriosis compared to women without this diagnosis? The databases searched were PubMed, Medline, and LILACS in order to identify all studies published up to April 2020, using the keywords (prematurity OR preterm birth OR premature birth OR premature labor OR obstetric premature labor OR preterm labor OR premature obstetric labor) AND (endometriosis OR adenomyosis OR endometrioma OR endometriomas). A manual research was also performed through the analysis of theses, book chapters, reference references, guidelines, and reviews. All published prospective cohort studies that reported the prevalence of preterm delivery among women with endometriosis, adenomyosis, or endometrioma were included, comparing it to the control group of women without such diagnoses. The random-effects model, the calculation of relative risk, and the confidence interval of 95% were used to perform the meta-analysis. Three studies involving 10,111 patients were included. Compared to women without endometriosis, women with endometriosis present an increased risk of premature birth (RR: 2.68, 95% CI [1.19; 6.02], I² = 91%). In the subgroup of women with spontaneous conception, endometriosis is also a risk factor for prematurity (RR: 3.26, 95% CI [2.09; 5.09], I² = 0%, 2 studies, 682 participants). The evidence presented suggests that women with endometriosis should be alerted to a potential risk of preterm birth. PROSPERO registration number, CRD42020189451.

Characteristics of ovarian endometrioma during pregnancy

AIM

During pregnancy, the ovarian endometrioma generally decreases in size and occasionally ruptures. We evaluated (1) whether and how ovarian-endometrioma size changes from the first trimester to the postdelivery period, and (2) the type of endometrioma more likely to rupture during pregnancy.

METHODS

During an 18-year period (2000-2018), ultrasound in the first trimester revealed ovarian endometrioma in 149 pregnant women at our tertiary institute. Among these, we subjected 138 endometriomas in 145 patients to expectant management (wait-and-watch approach during pregnancy). We compared the cyst sizes in the first trimester and the postdelivery period, and defined a >1 cm diameter size-change as a significant increase/decrease. We analyzed four patients with rupture and characterized the predictors of rupture.

RESULTS

A comparison of cyst sizes in the first trimester and the postdelivery period revealed that the size of 94 (68%), 37 (27%), and 7 ovaries (5.0%), respectively, decreased, remained unchanged, and increased; in 56 ovaries (40%), apparent cysts were no longer present. Of the 145 patients, four (2.8%) required emergency surgery for cyst rupture. Adhesion to the surroundings, an increase in cyst size, large size (diameter of ≥6 cm), and compression due to the enlarged uterus in late pregnancy were factors clinically related to rupture.

CONCLUSIONS

Approximately two-thirds of ovarian endometriomas decreased in size during pregnancy (40% disappeared), 27% remained unchanged, and only 5% increased in size. However, 2.8% of pregnant women with endometrial cysts experienced rupture. We characterized risk factors for rupture; however, clinical application requires further evaluation.

Obstetrical and Neonatal Outcomes of 3,028 Singletons Born After Advanced ART Techniques: Ejaculated Sperm Intracytoplasmic Sperm Injection, Artificial Oocyte Activation, in Vitro Maturation and Testicular Sperm Extraction

Background: To evaluate obstetrical and neonatal outcomes of singletons conceived after advanced assisted reproductive technology (ART) techniques: conventional IVF pregnancies (C-IVF), ejaculated sperm intracytoplasmic sperm injection (ICSI), assisted oocyte activation (AOA), in vitro maturation (IVM), and testicular sperm extraction (TESE).

Methods: The subjects were 3,028 singletons who were born after fresh or frozen embryo transfer. The subjects were separated into five groups: C-IVF (n = 855), ICSI (n = 1,869), AOA (n = 42), IVM (n = 32), and TESE (n = 230). We evaluated obstetrical and neonatal outcomes calculating the adjusted odds ratio (AOR) using multivariable logistic regression analyses for fresh and frozen embryos and for cleavage and blastocyst transfer. The C-IVF group was used as a background control for the ICSI group. Moreover, the TESE, AOA, and IVM groups were compared to the ICSI group to evaluate the effects of the ICSI procedure itself.

Results: The incidence of perinatal complications was significantly lower in the ICSI-fresh group (AOR = 0.29, 95% CI: 0.10–0.83, p ¡ 0.05). Regarding sex ratio, the IVM was significantly associated with sex ratio imbalance toward female in both fresh and frozen groups (AOR = 0.30, 95% CI: 0.10–0.96, AOR = 0.27, 95% CI: 0.07–0.98, p ¡ 0.05). On the other hand, there were no significant differences in preterm birth rate, low birth weight rate and congenital abnormalities rate between conventional IVF, ICSI, and the other groups.

Conclusions: There were no negative effects on obstetrical and neonatal outcomes between conventional IVF and ICSI. Although this was a limited sample size study, advanced ART technologies such as AOA, IVM, and TESE also seem to have a low risk of adverse impact on obstetrical and neonatal outcomes but may have a slight impact on sex ratio.

Endometriosis Scarring-A Potential Etiology for Spontaneous Hemoperitoneum in Pregnancy

BACKGROUND

Endometriosis is a common condition characterized by the accumulation of dense adhesions and scar tissue around the pelvic organs, which can lead to complications. Disruption of endometriotic scar tissue is rare but can lead to spontaneous intraperitoneal hemorrhage in pregnancy.

CASE

We present the case of a patient admitted for signs of labour at 40 weeks gestation. At emergency cesarean delivery for cord prolapse, the patient was found to have a massive intraperitoneal bleed. Mechanical disruption of endometriotic scar tissue during positioning for an epidural may have been the precipitating event, as the symptoms of spontaneous hemorrhage, including hypotension and pain, appeared immediately afterward.

CONCLUSION

Without the cord prolapse, cesarean delivery would have been delayed and the spontaneous hemorrhage might have been missed. This case report alerts obstetricians to have a high index of suspicion for spontaneous hemorrhage in pregnant patients with a history of advanced-stage endometriosis, as this event can be life-threatening to mother and baby.

Cecal endometriosis presenting as a term intrauterine fetal demise and gastrointestinal hemorrhage: A case report

Background

Of women diagnosed with endometriosis, 3.8–37% have bowel endometriosis. The cecum is the least common site for endometriotic implants affecting the bowel, accounting for only 3.6–6% of cases. We present a case of intrauterine fetal demise at term in which the patient was found to have gastrointestinal bleeding caused by endometriosis of the cecum.

Case

A 35-year-old woman, gravida 4, para 1, at 37 weeks and 3 days of gestation, without a known history of endometriosis but with two prior miscarriages, presented with severe anemia and intrauterine fetal demise. During delivery, melanotic stool was noted. Colonoscopic biopsy noted the source of bleeding to be a 2 cm endometriotic implant in the patient's cecum. Suppression therapy was started. Postpartum, the patient underwent laparoscopic cecectomy and pathology confirmed the diagnosis of endometriosis.

Conclusion

Hemorrhage from endometriotic implants may occur during pregnancy due to changes in the hormonal milieu. Bowel endometriosis may increase the risk of maternal hemorrhage during pregnancy, thereby increasing the risk of unfavorable pregnancy outcomes, including intrauterine fetal demise.

•

Bowel endometriosis is a risk factor for acute gastrointestinal hemorrhage in pregnant women.

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Endometriosis affecting the cecum resulting in gastrointestinal hemorrhage and intrauterine fetal demise is described.

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In the setting of severe maternal anemia, reduced uteroplacental perfusion may be exacerbated by underlying endometriosis.

Factors Affecting the Risk of Postpartum Hemorrhage in Pregnant Women in Tibet Health Facilities

BACKGROUND Postpartum hemorrhage (PPH), the leading cause of maternal death, is defined as a blood loss >500 mL within 24 h after vaginal delivery or >1000 mL within 24 h after cesarean section. This study aimed to investigate the incidence of PPH and assess its risk factors in pregnant women in Tibet to provide a reference for clinicians in this region. MATERIAL AND METHODS A total of 4796 pregnant women with gestational age ≥28 weeks who were admitted to hospitals in Tibet between December 2010 and December 2016 were involved in this study. Patient sociological and clinical data and pregnancy outcomes were collected. The related risk factors of PPH were analyzed by univariate and multivariable logistic regression. The area under the curve of the receiver operating characteristic curves was used to evaluate the effect of the PPH prediction model. RESULTS PPH occurred in 95 women, with an incidence of 1.98%. The following factors were associated with higher risk for PPH: maternal age ≥35 (odds ratio [OR]=1.96; 95% confidence interval [CI], 1.18-3.27; P=0.010), history of preterm birth (OR=2.66; 95% CI, 1.60-4.42; P<0.001), cesarean section (OR=6.69; 95% CI, 4.30-10.40; P<0.001), neonatal weight >4 kg (OR=3.92; 95% CI, 1.75-8.81; P<0.001) and occurrence of neonatal asphyxia (OR=5.52; 95% CI, 2.22-13.74; P<0.001). CONCLUSIONS Maternal age ≥35, history of preterm birth, cesarean section, newborn weight >4 kg, and neonatal asphyxia were risk factors of PPH, which can help evaluate PPH in Tibet.

Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis summarizes the evidence for the association between endometriosis and adverse pregnancy outcome, including gestational hypertension, pre-eclampsia, low birth weight, and small for gestational age, preterm birth, placenta previa, placental abruption, cesarean section, stillbirth, postpartum hemorrhage, spontaneous hemoperitoneum in pregnancy, and spontaneous bowel perforation in pregnancy. Methods: We performed the literature review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), by searches in PubMed and EMBASE, until 1 November 2020 (PROSPERO ID CRD42020213999). We included peer-reviewed observational cohort studies and case-control studies and scored them according to the Newcastle–Ottawa Scale, to assess the risk of bias and confounding. Results: 39 studies were included. Women with endometriosis had an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth, compared to women without endometriosis. These results remained unchanged in sub-analyses, including studies on spontaneous pregnancies only. Spontaneous hemoperitoneum in pregnancy and bowel perforation seemed to be associated with endometriosis; however, the studies were few and did not meet the inclusion criteria. Conclusions: The literature shows that endometriosis is associated with an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

Spontaneous Intestinal Perforation in Pregnancy from a Pre-Existing Postoperative Adhesion: A Case Report

BACKGROUND

Spontaneous intestinal perforation is rare in pregnancy. Previously described cases have been associated with endometriosis, Crohn's disease, and intestinal tuberculosis.

CASE

We describe a case of spontaneous intestinal perforation in pregnancy from a postoperative adhesion. The patient presented with multiple episodes of abdominal pain and vomiting starting at 25⁵ weeks. The diagnosis was made at 28 weeks when she presented with severe pain and abnormal fetal heart rate requiring emergency cesarean section with bowel resection.

CONCLUSION

This case demonstrates that adhesions between the bowel and uterus from prior surgery may lead to spontaneous intestinal perforation as the uterus enlarges during pregnancy. As this diagnosis can be difficult because of imaging limitations and physiologic changes of pregnancy, it should be considered in cases of unremitting abdominal pain and vomiting.

Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis

BACKGROUND

The reproductive impact of adenomyosis and endometriosis is widely researched but the extent of these impacts remains elusive. It has been demonstrated that endometriosis, in particular, is known to result in subfertility but endometriosis and adenomyosis are increasingly linked to late pregnancy complications such as those caused by placental insufficiency. At the molecular level, the presence of ectopic endometrium perturbs the endometrial hormonal, cellular, and immunological milieu, negatively influencing decidualization, placentation, and developmental programming of the embryo. It is unclear if and how such early aberrant reproductive development relates to pregnancy outcomes in endometriosis and adenomyosis.

OBJECTIVE AND RATIONALE

The aims of this systematic review and meta-analysis were to (i) investigate the association of adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes of women through both assisted reproduction and natural conception and (ii) determine whether endometriosis disease subtypes have specific impacts on different stages of the reproductive process.

SEARCH METHODS

A systematic literature review of NHS evidence electronic databases and the Cochrane database identified all comparative and observational studies between 1980 and December 2018 in any language on adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes (23 search terms used). A total of 104 papers were selected for data extraction and meta-analysis, with use of Downs and Black standardized checklist to evaluate quality and bias.

OUTCOMES

We found that endometriosis consistently leads to reduced oocyte yield and a reduced fertilization rate (FR), in line with current evidence. Milder forms of endometriosis were most likely to affect the fertilization (FR OR 0.77, CI 0.63-0.93) and earlier implantation processes (implantation rate OR 0.76, CI 0.62-0.93). The more severe disease by American Society for Reproductive Medicine staging (ASRM III and IV) influenced all stages of reproduction. Ovarian endometriosis negatively affects the oocyte yield (MD -1.22, CI -1.96, -0.49) and number of mature oocytes (MD -2.24, CI -3.4, -1.09). We found an increased risk of miscarriage in both adenomyosis and endometriosis (OR 3.40, CI 1.41-8.65 and OR 1.30, CI 1.25-1.35, respectively), and endometriosis can be associated with a range of obstetric and fetal complications including preterm delivery (OR 1.38, CI 1.01-1.89), caesarean section delivery (OR 1.98 CI 1.64-2.38), and neonatal unit admission following delivery (OR 1.29, CI 1.07-1.55).

WIDER IMPLICATIONS

Adenomyosis and the subtypes of endometriosis may have specific complication profiles though further evidence is needed to be able to draw conclusions. Several known pregnancy complications are likely to be associated with these conditions. The complications are possibly caused by dysfunctional uterine changes leading to implantation and placentation issues and therefore could potentially have far-reaching consequences as suggested by Barker's hypothesis. Our findings would suggest that women with these conditions should ideally receive pre-natal counselling and should be considered higher risk in pregnancy and at delivery, until evidence to the contrary is available. In order to expand our knowledge of these conditions and better advise on future management of these patients in reproductive and maternal medicine, a more unified approach to studying fertility and reproductive outcomes with longer term follow-up of the offspring and attention to the subtype of disease is necessary.

Pregnancy outcomes in women with history of surgery for endometriosis

OBJECTIVE

To assess the relationship between history of surgery for endometriosis and adverse obstetrical outcomes.

DESIGN

Retrospective study using prospectively recorded data.

SETTING

Referral center.

PATIENT(S)

Total of 569 women with history of surgery for endometriosis, postoperative conception, and pregnancy evolution over 22 weeks of gestation.

INTERVENTIONS(S)

Surgery for endometriosis.

MAIN OUTCOME MEASURE(S)

Small for gestational age (SGA) status of the newborn, spontaneous preterm birth (PT, before 37 weeks' gestation), and placenta previa.

RESULTS

Among 733 pregnancies included in the study, 566 deliveries were recorded (77.2%), of which 535 were singleton (72.9% of pregnancies) and 31 twins (4.2%). SGA was observed in 81 of 535 (15.1%) singleton pregnancies and in 9 of 31 (29%) twin pregnancies. PT occurred in 53 of 535 (9.9%) singleton pregnancies and in 19 of 31 (61.2%) twin pregnancies. The number of singleton and multiple pregnancies complicated by placenta previa were, respectively, 9 of 535 (1.7%) and 0 of 31. The independent factor found to relate to SGA was the absence of endometriomas; conception with the use of assisted reproductive technologies (ART) only tended toward statistical significance. Independent factors found to increase risk of PT were conception with the use of ART, body mass index >30 kg/m², and surgery of deep endometriosis infiltrating the rectum and the bladder. Independent factors associated with placenta previa were conception with the use of ART and history of stage III or IV endometriosis.

CONCLUSION(S)

The risk of SGA and PT is increased in women with a history of surgery for endometriosis, and a high rate of conception with the use of ART may jeopardize outcomes.

Endometriosis and Pregnancy: A Single Institution Experience

Endometriosis may compromise the physiological course of pregnancy. The aim of this prospective observational study was to evaluate whether endometriosis causes a higher prevalence of obstetric and neonatal complications as well as a higher risk of caesarean section and to detect a possible correlation between the presence, type, and location of endometriosis and obstetric complications, previous surgery, and pregnancy outcome, as well as the influence of pregnancy on the course of the disease. We compared two cohorts of women with spontaneous pregnancy, with and without endometriosis. Obstetric and neonatal outcomes, mode of delivery, presence, type, and location of endometriotic lesions and the effect of pregnancy on the disease were analyzed. A total of 425 pregnancies were evaluated: 145 cases and 280 controls. Patients with endometriosis showed a higher incidence of miscarriage, threatened miscarriage, threatened preterm labor, preterm delivery, placental abruption, and a higher incidence of caesarean section. A significant correlation with pregnancy-induced hypertension and preeclampsia was found in the presence of adenomyosis. No difference in fetal outcome was found. One case of hemoperitoneum during pregnancy was observed. Pregnancy in women with endometriosis carries a higher risk of obstetric complications, such as miscarriage, threatened miscarriage, preterm labor, preterm birth, and a higher caesarean section rate. Endometriosis does not seem to influence fetal well-being.

Overexpression of TGF-β enhances the migration and invasive ability of ectopic endometrial cells via ERK/MAPK signaling pathway

Endometriosis is a common gynecological disease with manifestations of endometrial-like tissue outside the uterus. Transforming growth factor-β (TGF-β) is known to facilitate a series of biological events in many cells, including migration. However, the roles of TGF-β in endometriosis still remain largely unknown. The aim of the present study was to discover the role of TGF-β1 in endometriosis development and progression and its associated mechanisms. It was demonstrated that the expression of TGF-β1 was significantly elevated in endometriosis in comparison with that in normal tissue. Overexpression of TGF-β increased the proliferation and upregulated proliferating cell nuclear antigen and cyclin D1 in endometrial stromal cells (ESCs). Furthermore, TGF-β overexpression also triggered a series of biological events occurring in ESCs, including cell migration and invasion, and activated the extracellular signal-regulated kinase (ERK)/mitogen-activated protein kinase (MAPK) signaling pathway. The inhibition of the ERK/MAPK pathway reversed the previous effects of TGF-β overexpression. Collectively, the present results indicate that overexpression of TGF-β enhances the migration and invasion of ectopic ESCs via the ERK/MAPK signaling pathway, providing theoretical evidence for the development of new treatment methods targeting the TGF-β-ERK/MAPK signaling pathway for prophylaxis of endometriosis.

Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility

BACKGROUND

The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE.

SEARCH METHODS

A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review.

OUTCOMES

The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE.

WIDER IMPLICATIONS

In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist.

Management of Small Bowel Perforation by a Bizarre Foreign Body in a 55-Year-Old Woman

Introduction

Ingestion of foreign bodies including dentures, fishbone, screw, and/or surgical devices can be a cause of morbidity, and it rarely could be fatal.

Presentation of Case

We present the first hitherto reported case of mussel shell ingestion, which caused acute abdominal pain in a 55-year-old woman. The shell pierced ileal loops, and it was found in the abdominal cavity.

Discussion

The accidental or voluntary ingestion of a foreign body is an uncommon event compared to the other causes of bowel perforation. It is fundamental to immediately remove the intestinal fluid, repair the tear, and prevent sepsis, because each delay in diagnosis can lead to a worst outcome.

Conclusion

In case of bowel perforation, it important for surgeons, who are dealing with these acute care patients, to be aware of different designs and constructions of possible foreign bodies, in order to be prepared to deal with different possible scenarios and be able to manage them properly.