Primiparous singleton women with endometriosis have an increased risk of preterm birth: Meta-analyses

Pregnancy Outcomes and Obstetrical Complications of Twin Pregnancies with Endometriosis: A Single-Center Cohort Study

PURPOSE

There are many studies regarding the increased relationship between pregnancy outcomes of singleton with endometriosis. However, there was limited evidence of twin pregnancies with endometriosis. This study aimed to compare the pregnancy outcomes and complications in twin pregnancies with or without endometriosis in a single institution.

MATERIALS AND METHODS

From January 2011 to July 2022, a retrospective analysis of twin pregnancies was conducted. The endometriosis group included patient with histological or visual confirmation before pregnancy or during cesarean section. Pregnancy outcomes and complications were compared between the two groups.

RESULTS

Out of 1714 patients examined, 127 (7.4%) were included in the endometriosis group. Maternal body mass index (BMI) was lower in the endometriosis group (p<0.001). There were no significant differences in maternal age, mode of conception, chorionicity, and pregnancy outcomes, such as gestational age at delivery (p=0.835) and the preterm birth rate (p=0.579). The endometriosis group had a significantly higher rate of obstetrical complication: small for gestational age (SGA) <10% (p=0.029). However, after adjustment for BMI, the endometriosis group showed no statistical significance in obstetrical complications, including SGA (adjusted odds ratio, 1.568; 95% confidence interval, 0.984-2.499; p=0.059).

CONCLUSION

Twin pregnancies with endometriosis were not related to adverse effects on pregnancy outcomes and obstetrical complications. To confirm these outcomes, further large prospective studies are required.

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.

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.

Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020)

Aims The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society for Gynaecology and Obstetrics (OEGGG) and the Swiss Society for Gynaecology and Obstetrics (SGGG) was to provide consensus-based recommendations for the diagnosis and treatment of endometriosis based on an evaluation of the relevant literature. Methods This S2k guideline represents the structured consensus of a representative panel of experts with different professional backgrounds commissioned by the Guideline Committee of the DGGG, OEGGG and SGGG. Recommendations Recommendations on the epidemiology, aetiology, classification, symptomatology, diagnosis and treatment of endometriosis are given and special situations are discussed.

Menstrual symptoms and risk of preterm birth: A population-based longitudinal study

OBJECTIVES

To examine the prospective association between menstrual symptoms before pregnancy and preterm birth.

METHODS

Secondary analysis of data from 14 247 young Australian women born between 1973 and 1978 who participated in a longitudinal, population-based cohort study between 1996 and 2015. Women were first surveyed at 18-23 years, and seven waves of data were collected at roughly three-yearly intervals. At each survey, women were asked about "severe period pain," "heavy periods," and "irregular periods" within the last 12 months. From 2009 onward, information on their children was collected, including birth dates and preterm birth (<37 weeks). Logistic regression using generalized estimating equations was used to examine prospective associations between self-reported menstrual symptoms before pregnancy and risk of preterm birth.

RESULTS

Data from 6615 mothers who had 12 337 live singleton births were available for analysis. Among all births, women reporting severe period pain (adjusted odds ratio [aOR] 1.34 [95% CI 1.10-1.62]) or heavy periods (1.25 [1.02-1.53]) before pregnancy had higher odds of preterm birth. However, in analyses stratified by birth order, only severe period pain (2.05 [1.41-2.99]), heavy periods (1.77 [1.23-2.55]), or irregular periods (1.58 [1.10-2.28]) before a second or subsequent birth were associated with an increased risk of preterm birth.

CONCLUSIONS

Severe period pain, heavy periods, and irregular periods before a second or subsequent birth may be associated with preterm birth.

Obstetrical complications and outcome in patients with endometriosis

Endometriosis is a disease that has a profound impact on the quality of life of women, due to the associated chronic pelvic pain, dysmenorrhea, dyspareunia and infertility. However, even getting long-awaited pregnancy (often after assisted reproductive technologies), patients with endometriosis have a high risk of obstetric complications, such as miscarriage, preterm birth, preeclampsia, placental abnormalities, hemorrhage in labor, birth of small for gestational age infants, stillbirth and higher cesarean section rate. In addition, during pregnancy acute complications of endometriosis may occur, such as spontaneous hemoperitoneum, which is rare but life-threatening conditions that in most cases require surgical intervention. The mechanisms of the observed complications in pregnant women with endometriosis are not fully understood. This review presents literature data and personal considerations on the effect of endometriosis on pregnancy outcome and the occurrence of complications, as well as their possible underlined mechanisms. Based on this, we proposed ways to reduce the risk of obstetric complications in pregnant women with a history of endometriosis.

Shared Molecular Features Linking Endometriosis and Obstetric Complications

Recent epidemiological research has shown the increased risk of adverse pregnancy outcomes in women with endometriosis compared with the general population. The aim of this review is to explore common pathophysiologic mechanisms between endometriosis and obstetric complications. A computerized literature search was performed to identify relevant studies. The search covered the period between January 2008 and October 2018. One of the potential mechanisms driving the initiation and progression of endometriosis is the accumulation of a variety of epigenetic changes in endometrial cells. Epigenetic control of gene expression which is considered to be responsible for the development of endometriosis is commonly seen in patients with preeclampsia, small for gestational age (SGA), or preterm birth. DLX5 and GATA3, paternally imprinted genes, and CDKN1C, a maternally imprinted gene, were aberrantly expressed in placenta tissues of the preeclampsia; CDKN1C, the growth inhibitor gene, was upregulated in human SGA placentas; and hypomethylation of PTGER2 would be associated with preterm birth. Preeclampsia, SGA, or preterm birth may share common epigenetic alterations with endometriosis, which raises the possibility that the occurrence of two conditions might be nonrandom. To date, however, there is a lack of evidence that links endometriosis and other obstetric complications, such as postpartum hemorrhage or placental abruption, at the epigenetic level. In conclusion, epigenetic changes may be a common hallmark of two conditions: endometriosis and obstetrical complications, such as preeclampsia, SGA, or preterm birth.

Women with Endometriosis, Especially Those Who Conceived with Assisted Reproductive Technology, Have Increased Risk of Placenta Previa: Meta-analyses

BACKGROUND

Many women with endometriosis have become pregnant through assisted reproductive technology (ART), and have often experienced placenta previa (PP) during pregnancy. The objective of this study was to assess the association between women with endometriosis, especially those who conceived with ART, and the risk of PP.

METHODS

Two reviewers independently determined studies that were considered suitable for meta-analyses published in various medicine-related databases from March 1, 2004 through July 31, 2017 without language restrictions. Eight studies met the inclusion criteria, with a combined sample size of 21,930 women. Of these 21,930 pregnancies, 6,256 had endometriosis (endometriosis) and 15,674 had no endometriosis. Four of these studies included 8,161 women who conceived with ART, 1,640 of whom had endometriosis (endometriosis + ART), and 6,521 of whom did not have endometriosis. Meta-analyses were estimated with odds ratios (ORs) and 95% confidence intervals (CIs) using random effect analysis according to heterogeneity of studies.

RESULTS

These meta-analyses showed women with endometriosis (endometriosis) have an increased risk of PP (OR, 4.038; 95% CI, 2.291-7.116; P = 0.000). These results showed women who conceived with ART (endometriosis + ART), have a substantially increased risk of PP (OR, 5.543; 95% CI, 1.659-18.523; P = 0.005).

CONCLUSION

These meta-analyses demonstrate women with endometriosis have an increased risk of PP.

Endometriosis and adenomyosis are associated with increased risk of preterm delivery and a small-for-gestational-age child: a systematic review and meta-analysis

INTRODUCTION

The objective of this systematic review and meta-analysis was to evaluate the risk of preterm delivery and having a small-for-gestational-age (SGA) child in women with endometriosis and adenomyosis compared with women without these two diseases.

MATERIAL AND METHODS

Studies on endometriosis or adenomyosis and risk of preterm delivery and/or SGA infant were included. The systematic search was conducted for all published articles in PubMed and Embase published from 1950 to 2017 using specific search terms. After duplicates were removed, two authors independently reviewed all studies, initially based on title and subsequently based on abstract. Studies considered relevant were read in full text by both reviewers to identify if studies met the inclusion criteria.

RESULTS

The search found 21 studies on a total of 2 517 516 women meeting the inclusion criteria. Women with endometriosis had an increased odds of preterm delivery [odds ratio (OR) 1.47, 95% CI 1.28-1.69] and SGA infant (OR 1.26, 95% CI 1.04-1.549). Compared with endometriosis, adenomyosis implied an even higher odds of both preterm delivery (OR 3.09, 95% CI 1.88-5.09) and SGA infant (OR 3.23, 95% CI 1.71-6.09) as well.

CONCLUSIONS

Women with endometriosis or adenomyosis had a higher odds of preterm delivery and having a child that was SGA compared with women without endometriosis or adenomyosis. The odds of both adverse birth outcomes was highest among women with adenomyosis. The results suggest a closer prenatal monitoring among pregnant women with endometriosis or adenomyosis.