Obstetrical complications and outcome in patients with endometriosis

Endometriosis and risk of adverse pregnancy outcomes: a retrospective multicenter cohort study

OBJECTIVE

To investigate first, the association between endometriosis and preterm birth; second, the associations between endometriosis and preeclampsia, placenta previa, postpartum hemorrhage, stillbirth, and small-for-gestational-age infants (assessed by birthweight); and third, the risk of these adverse pregnancy outcomes with and without the use of medically assisted reproduction.

DESIGN

Multicenter retrospective cohort study.

SETTING

A total of 103 French maternity units.

PATIENTS

Deliveries by 368,935 women (377,338 infants) from 1999 through 2016.

EXPOSURE

Endometriosis, defined as a single disease entity (endometriosis and/or ademyosis) MAIN OUTCOMES MEASURES: The main outcome was the preterm birth rate (both <37 and <33 weeks). The secondary outcomes were rates of preeclampsia, placenta previa, postpartum hemorrhage, stillbirth, and small-for-gestational-age neonates.

RESULTS

Women in the endometriosis group had more frequent histories of infertility before the included pregnancy (34.7 vs. 5.0%), more hospitalizations during the pregnancy (27.4 vs. 19.8%), and more planned cesarean sections (14.0 vs. 8.7); they more often were nulliparous (51.7 vs. 43.4%). The prevalence of preterm birth at <37 weeks was 11.1% in the endometriosis group and 7.7% in the unexposed group, and for <33 weeks, it was 3.1% and 2.2%, respectively. The adjusted relative risk for confounding factors was higher in the endometriosis than the unexposed group for preterm delivery <37 weeks (1.40, 95% confidence interval, 1.18-1.67) or <33 weeks (1.53, 95% confidence interval, 1.08-2.16). For the secondary outcomes, the adjusted risk ratios for preeclampsia, placenta previa, postpartum hemorrhage, and small-for-gestational-age status of <10th and <5th percentiles were higher in the endometriosis group. The adjusted risk ratios for stillbirth and small-for-gestational-age status of <3rd percentile did not differ between the two groups, and those after stratification by medically assisted reproduction for preterm birth at <37 and <33 weeks did not differ statistically significantly between them, for the secondary outcomes, only the risk of placenta previa was higher in the medically assisted reproduction and non-medically assisted reproduction subgroups.

CONCLUSION

Pregnant women with endometriosis had higher risks of preterm birth and other poor pregnancy outcomes than women without endometriosis.

Pregnancy-related complications in patients with endometriosis in different stages

BACKGROUND

Endometriosis is one of the most common and costly diseases among women. This study was carried out to investigate pregnancy outcomes in women with endometriosis because of the high prevalence of endometriosis in reproductive ages and its effect on pregnancy-related complications outcomes.

METHODS

This was a cross-sectional study performed on 379 pregnant women with endometriosis who were referred to the endometriosis clinic of the Avicenna Infertility Treatment Center from 2014 to 2020. Maternal and neonatal outcomes were assessed for the endometriosis group and healthy mothers. The group with endometriosis was further divided into two groups: those who underwent surgery and those who either received medication alone or were left untreated before becoming pregnant. The analysis of the data was done using SPSS 18.

RESULTS

The mean age of the patients was 33.65 ± 7.9 years. The frequency of endometriosis stage (P = 0.622) and surgery (P = 0.400) in different age groups were not statistically significant. The highest rates of RIF and infertility were in stages 3 (N = 46, 17.2%) (P = 0.067), and 4 (N = 129, 48.3%) (P = 0.073), respectively, but these differences were not statistically different, and the highest rate of pregnancy with ART/spontaneous pregnancy was observed in stage 4 without significant differences (P = 0.259). Besides, the frequency of clinical/ectopic pregnancy and cesarean section was not statistically different across stages (P > 0.05). There is no significant relationship between endometriosis surgery and infertility (P = 0.089) and RIF (P = 0.232). Most of the people who had endometriosis surgery with assisted reproductive methods got pregnant, and this relationship was statistically significant (P = 0.002) in which 77.1% (N = 138) of ART and 63% (N = 264) of spontaneous pregnancies were reported in patients with endometriosis surgery. The rate of live births (59.4%) was not statistically significant for different endometriosis stages (P = 0.638). There was no stillbirth or neonatal death in this study. All cases with preeclampsia (N = 5) were reported in stage 4. 66.7% (N = 8) of the preterm labor was in stage 4 and 33.3% (N = 4) was in stage 3 (P = 0.005). Antepartum bleeding, antepartum hospital admission, preterm labor, gestational diabetes, gestational hypertension, abortion, placental complications and NICU admission were higher in stage 4, but this difference had no statistical difference.

CONCLUSION

Endometriosis is significantly correlated with infertility. The highest rates of RIF and infertility are observed in stages 3 and 4 of endometriosis. The rate of pregnancy with ART/spontaneous pregnancy, preterm labor, preeclampsia and pregnancy-related complications is higher in stage 4. Most of the people who had endometriosis surgery with assisted reproductive methods got significantly pregnant. Clinical/ectopic pregnancy, cesarean sections, and live birth were not affected by the endometriosis stages.

Investigating the risk factors for isthmocele development after cesarean delivery

BACKGROUND

Cesarean delivery rates are increasing globally, raising concerns about associated complications such as isthmocele. Isthmoceles are pouch-like defects in the anterior uterine wall at the site of a prior cesarean delivery scar.

OBJECTIVE

This study aimed to determine isthmocele prevalence, associated symptoms, and risk factors among women with a history of cesarean delivery.

STUDY DESIGN

This cross-sectional study evaluated 297 women with prior cesarean delivery using transvaginal ultrasound to screen for isthmocele. Data on demographics, pregnancy details, comorbidities, and indications for cesarean delivery were collected. Isthmocele was defined sonographically as any niche or defect at the hysterotomy site. Descriptive and comparative analyses identified factors associated with isthmocele.

RESULTS

Isthmocele prevalence was 65.3% (n=194). Abnormal vaginal bleeding was reported in 21.1% of participants, pelvic pain by 4.1% of participants, and both by 4.1% of participants. Compared to women without isthmocele, those with isthmocele were older (35.9 vs 31.6 years), had higher body mass index (26.8 vs 25.5 kg/m2), gravidity (1.8 vs 1.3), and parity (1.7 vs 1.2). Repeat cesarean delivery was more common (30.4% vs 12.6%) and elective cesarean delivery less common (33.5% vs 67.9%) among those with isthmocele.

CONCLUSION

Over half of the women with history of cesarean delivery had an isthmocele. Abnormal bleeding was common. Advanced maternal age, obesity, repeat procedures, and certain comorbidities appear to increase risk. Further research on prevention and treatment is warranted given the high prevalence.

The Impact of Endometriosis on Pregnancy

Despite the increased frequency of endometriosis, it remains one of the most enigmatic disorders regarding its effects on pregnancy. Endometriosis adversely affects both natural and assisted conception. Impaired folliculogenesis, which causes follicular dysfunction and low egg quality, as well as luteal phase problems, reduced fertilization, and abnormal embryogenesis, are some of the mechanisms advocated to explain reproductive dysfunction. There is a rising need for a comprehensive study of the potential negative consequences of this condition on pregnancy outcomes, including the postpartum period, as more women with a medical history of endometriosis become pregnant. Obstetrical complications (small for gestational age [SGA], cesarean section [CS], miscarriage, hemorrhage, low placental adhesion, and preterm delivery) are statistically elevated in women with endometriosis. Furthermore, ruptured ovarian endometrioma, appendicitis, intestinal perforation, and hemoperitoneum have been described in pregnancy. Obstetricians are largely unfamiliar with these complications, as they have not been thoroughly investigated. The development and pathogenesis of endometriosis is an important field of study and has not yet been fully elucidated. Finding these mechanisms is crucial for the development of new and more effective strategies to treat this condition. Endometriosis can have an impact on obstetric and neonatal outcomes of pregnancy, in addition to its potential effects on conception. To date, no additional monitoring is recommended for pregnancies with a history of endometriosis. However, more studies are urgently needed to assess the need for the tailored pregnancy monitoring of women with endometriosis.

The Perception of the Quality of Professional Healthcare Assistance for the Management of Endometriosis: Findings from a National Survey in Italy

(1) Background: endometriosis is included in the list of chronic and disabling pathologies. This study aimed to examine patients' points of view about the quality of care for endometriosis during the COVID-19 pandemic; (2) Methods: we conducted a survey on knowledge about endometriosis, management of endometriosis, perceived mental and physical well-being, and perceived changes in the quality of care during the pandemic; (3) Results: out of 1065 participants, 875 were included in the analysis, with an average age of 34. Overall, patients had positive perceptions of care accessibility and cleanliness (95%), but less satisfaction with visit hours (86%). Those with better physical and psychological health were more satisfied with service hours, while those treated at specialised centres were more content with cleanliness. Satisfaction with clarity was linked to specialist treatment, and perceived availability to listen correlated with age, complications, and overall health status; (4) Conclusions: patients' perspectives are crucial for patient education and advocate for specialised interdisciplinary networks to support endometriosis management and patients' well-being. These findings highlight the importance of considering patient viewpoints, particularly in the context of the COVID-19 pandemic's impact on healthcare systems and suggest a need for further research from the patient's perspective.

Pregnancy after laparoscopic surgery for endometriosis: How long should we wait? A retrospective study involving a long-term follow up at a university endometriosis center

OBJECTIVE

To find the factors that influence the time until pregnancy after laparoscopic intervention and to evaluate the proper time to start assisted reproductive therapy (ART).

METHODS

This is a retrospective analysis that includes a prospective evaluation of patients with infertility and with a diagnosis of endometriosis. A subgroup of patients who desired to be pregnant after laparoscopic intervention (102 patients) was followed up for 36-197 months after the surgery.

RESULTS

In this study, 71 (69.9%) and 60 (58.8%) of the patients achieved pregnancy and live birth, respectively. In the group of patients who became pregnant, the duration of infertility was significantly lower (2.7 ± 2.1 years vs. 4.7 ± 3.2 years). The median time until pregnancy after laparoscopic intervention was 8 months (the average was 10 months). After 38 months, no pregnancy occurred.

CONCLUSION

In the group of patients with endometriosis and infertility, the first 12 months were the optimal time for pregnancy. For women with revised American Society for Reproductive Medicine classification of endometriosis (rASRM) stages I and II, spontaneous pregnancy can probably be delayed for up to 24 months, but in patients with rASRM stages III and IV, ART may be considered after 12 months. The gynecologist must be careful about the timing of further interventions after the operation.

Influence of ovarian reserves on assisted reproductive and perinatal outcomes in patients with endometriosis: a retrospective study

Objective

To investigate the association between different ovarian reserves and reproductive and adverse perinatal outcomes in patients with endometriosis.

Design

Retrospective study.

Setting

Reproductive Medicine Center in a hospital.

Patients

Patients surgically diagnosed with endometriosis were divided into three groups according to their ovarian reserve: diminished ovarian reserve (DOR) group (n=66), normal ovarian reserve (NOR) group (n=160), and high ovarian reserve (HOR) group (n=141).

Interventions

None.

Main Outcome Measures

Live birth rate (LBR), cumulative live birth rate (CLBR), and adverse perinatal outcome for singleton live births.

Results

There were significantly higher live birth and cumulative live birth rates in endometriosis patients with NOR or HOR than in those with DOR. For adverse perinatal outcomes, patients with NOR or HOR had no significant association with preterm birth, gestational hypertension, placenta previa, fetal malformation, abruptio placentae, macrosomia, or low birth weight, except for a decreased risk of gestational diabetes mellitus.

Conclusion

Our study revealed that although patients with endometriosis with NOR and HOR had increased reproductive outcomes, patients with endometriosis with DOR had still an acceptable live birth rate and a similar cumulative live birth rate with available oocytes. Moreover, patients with NOR and HOR might not exhibit a decreased risk of abnormal perinatal outcomes, except for gestational diabetes mellitus. Multicenter prospective studies are needed to further clarify the relationship.

Endometriosis is associated with pregnancy loss: a nationwide historical cohort study

OBJECTIVE

To study whether endometriosis is associated with pregnancy loss and recurrent pregnancy loss (RPL).

DESIGN

Nationwide historical cohort study with a nested case-control analysis.

SETTING

National health registers.

PATIENT(S)

A total of 29,563 women born between 1957 and 1997 were identified in the national health registers, diagnosed with endometriosis between 1977 and 2017, and age-matched 1:10 with 295,630 women without endometriosis. The number of pregnancy losses was assessed, and data were analyzed with conditional logistic regression.

INTERVENTION(S)

Endometriosis (International Classification of Diseases, 8th Revision, 62530-62539, and International Classification of Diseases, 10th Revision, DN80.0-9).

MAIN OUTCOME MEASURE(S)

The primary outcomes of interest were the numbers of pregnancy losses categorized as 0, 1, 2, and ≥ 3 losses, unadjusted and adjusted for gravidity, and RPL. The secondary outcome measures were the predefined types of pregnancy losses. Pregnancy loss was defined as the spontaneous demise of a pregnancy until 22 weeks of gestation. Primary RPL was defined as 3 or more consecutive pregnancy losses with no prior live birth or stillbirth, and secondary RPL was defined as 1 or more births followed by 3 or more consecutive losses.

RESULT(S)

A total of 18.9%, 3.9%, and 2.1% of ever-pregnant women with endometriosis had 1, 2, and ≥ 3 pregnancy losses compared with 17.3%, 3.5%, and 1.5% of the women without endometriosis, corresponding to the odds ratios of 1.13 (95% confidence interval, 1.09-1.17), 1.18 (1.10-1.26), and 1.44 (1.31-1.59), respectively. When adjusted also for gravidity, the corresponding results were 1.37 (95% confidence interval, 1.32-1.42), 1.75 (1.62-1.89), and 2.57 (2.31-2.85), respectively. The following predefined subgroups of RPL were positively associated with endometriosis: primary; secondary; secondary after giving birth to a boy; after a complicated delivery; and ≥ 3 pregnancy losses before the age of 30 years. Six endometriosis subgroup analyses found an association between endometriosis and pregnancy loss. These analyses were women diagnosed in the 4 decades between 1977 and 2017, women with adenomyosis, and women with adenomyosis only.

CONCLUSION(S)

This nationwide cohort study found endometriosis to be associated with pregnancy loss and RPL, and the association strengthened with an increasing number of losses.

Impact of Chronic Exposure to Endometriosis on Perinatal Outcomes: Establishment of a Mouse Model

The purpose of this study was to establish a new mouse model of endometriosis that mimics real-world women’s health problems, in which women continue to be affected by endometriosis long before they wish to become pregnant, and to evaluate the impact of “chronic exposure to endometriosis” on perinatal outcome. Endometriosis was established by the intraperitoneal injection of homologous minced mouse uteri. Vehicle was injected for the control. Mating was initiated either 1 or 43 days after disease establishment (Young or Aged studies, respectively). Mice were sacrificed on 18 dpc. The number pups and resorptions were counted and pups’ body weights (BW) were measured, and the endometriosis lesion was identified and weighted. In the Young study, the number of resorptions and BW were comparable between the groups. In the Aged study, the number of resorptions was significantly higher and BW was significantly lower in endometriosis than that in control. The total weight of endometriosis lesion per dam was significantly lower in the Aged compared to the Young endometriosis group; however, not a single mouse was found to have any lesions at all. These results suggest that in addition to the presence of endometriosis per se, “chronic exposure to endometriosis” prior to pregnancy affect perinatal outcomes.

Obstetric Outcome After Surgical Treatment of Endometriosis: A Review of the Literature

A diagnosis of endometriosis is associated with increased risks of adverse pregnancy outcomes including placenta praevia and preterm birth. Some studies have also suggested associations with gestational hypertension, foetal growth restriction, gestational diabetes, perinatal death, and obstetric haemorrhage. This review aims to assess the impact of pre-pregnancy surgical treatment of endometriosis on future obstetric outcomes. A search of the Medline, Embase and PubMed electronic databases was performed to identify studies reporting pre-pregnancy surgery for endometriosis and subsequent pregnancy outcome compared to controls with unresected endometriosis. Three studies met the inclusion criteria. The studies were heterogenous in design, definition of study groups and outcome measures. All three studies were judged at critical risk of bias. Pre-pregnancy excision of endometriosis was associated with an increased risk of caesarean section in one of two studies, OR 1.72 (95% CI 1.59–1.86) and OR 1.79 (95% CI 0.69–4.64). Placenta praevia rates were also increased in one of two studies OR 2.83 (95% CI 0.56–12.31) and OR 2.04 (95% CI 1.66–2.52). One study found increased risks of preterm birth, small for gestational age, gestational hypertension, and antepartum and postpartum haemorrhage (all p &lt; 0.05) with pre-pregnancy excision of endometriosis. There is insufficient evidence examining the role of pre-pregnancy endometriosis surgery in ameliorating adverse pregnancy outcomes, and thus reliable conclusions cannot be drawn. Prospectively designed studies are needed to assess the relationship between surgical treatments for endometriosis and obstetric outcome and examine potential confounders such as comorbid adenomyosis and infertility.

The promising biological role of postbiotics derived from probiotic Lactobacillus species in reproductive health

Recent investigations have meaningfully developed our knowledge of the features of the reproductive microbiome/metabolome profile and their relations with host responses to offer an optimal milieu for the development of the embryo during the peri-implantation period and throughout pregnancy. In this context, the establishment of homeostatic circumstances in the Female Reproductive Tract (FRT), in various physiological periods, is a significant challenge, which appears the application of postbiotics can facilitate the achievement of this goal. So, currently, scientific literature confirms that postbiotics due to their antimicrobial, antiviral, and immunomodulatory properties can be considered as a novel biotherapeutic approach. Future investigation in this field will shed more translational mechanistic understanding of the interaction of the postbiotics derived from vaginal Lactobacilli with females' health and reproduction.

Chinese herbal compound prescription for Endometriosis: A protocol for systematic review and meta-analysis

BACKGROUND

Endometriosis (EMT) is one of the common diseases of women of childbearing age. EMT destroys the anatomical structure of the pelvis, which leads to abnormal ovulation and endocrine abnormalities. It also affects embryo implantation and makes patients infertile. Recently, it is confirmed that Chinese medicine also have an excellent clinical efficacy on EMT. Compared with the conventional western medicine treatment, it effectively relieve pain and other concomitant symptoms.

METHODS AND ANALYSIS

The following databases will be searched for relevant information before July 2020: PubMed, Embase, Cochrane Library, Web of Science, and CNKI.

MAJOR RESULTS

the overall effective rate, VAS score.

SECONDARY OUTCOMES

blood serum estradiol (E2), progesterone (P), Follicle-Stimulating Hormone (FSH), adverse events. Data will be collected independently by 2 researchers, and the risk of bias in meta-analysis will be evaluated according to "Cochrane Handbook for Systematic Reviews of Interventions". All data analysis will be conducted using Review Manager V.5.3. and Stata V.12.0.

RESULTS

The curative effect and safety of Chinese herbal compound prescription treatment for EMT patients will be evaluated systematically.

CONCLUSION

The systematic review of this study will summarize the currently published evidence of Chinese herbal compound prescription treatment for EMT to further guide its promotion and application.

ETHICS AND DISSEMINATION

The private information from individuals will not be published. This systematic review also will not involve endangering participant rights. Ethical approval is not required. The results may be published in a peer-reviewed journal or disseminated in relevant conferences. OPEN SCIENCE FRAMEWORK (OSF) REGISTRATION NUMBER:: https://osf.io/p5nrk.