Current Women’s Health Reviews, 2012, 8, 121-130 121 Endometriosis and Perinatal Outcome – A Systematic Review of the Literature Sevasti Masouridou*, Apostolos Mamopoulos, Georgios Mavromatidis and Vassilios Karagiannis 3rd University Department Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Medical School, 546 22 Thessaloniki, Greece Abstract: Objective: To assess any possible adverse effects of endometriosis on pregnancy outcome and complications, as well as in the postpartum period. Study Design: A systematic review of the literature. Data Sources: We searched all publications in Pubmed, Scopus and the Cochrane Library with the key words endometriosis, pregnancy outcome, preeclampsia, preterm birth, small-for gestational age babies (SGA) and postpartum. Eligibility Criteria for Selecting Studies: All studies reporting on endometriosis and perinatal outcome until December 2009. Results: According to the available bibliographic data, we found 38 reported cases of pregnancies, four being twin pregnancies, complicated by endometriosis (Table 1). Studies referring to specific pregnancy complications (preterm birth, small-for-gestational age babies, preeclampsia and postpartum complications) were limited to a total of 12 publications [61-63, 69, 75, 80, 82-86]. The few reported complications during pregnancy included hemoperitoneum and spontaneous bleeding [1, 9-21], perforations of the jejunum, appendix and sigmoid colon [22-24], urohemoperitoneum [25], deciduosis of the appendix [26], deciduosis of the omentum [27], infected endometrioma [28], hemoperitoneum and hemothorax [29], catamenial pneumothorax [30], endometriosis imitating a bladder tumor [31], decidualization mimicking ovarian malignancy [32], rupture of ovarian endometriotic cyst [23, 33], and rupture of the uterus affected by endometriosis [34] (Table 1). Data regarding the effect of endometriosis on preterm birth, small-for gestational age babies and preeclampsia, both in spontaneous pregnancies as well as in those conceived by Assisted Reproductive Techniques (ART) were conflicting. Conclusions: Symptoms of endometriosis often disappear during pregnancy. Yet, endometriosis must be included in the differential diagnosis of hemoperitoneum presenting during pregnancy or of heavy vaginal bleeding postpartum. Both maternal and fetal morbidity and mortality can be quite high and the woman’s childbearing ability might be irreversibly affected. The few available data on the association between endometriosis and preeclampsia are at present controversial. Together with the studies reporting an increased risk for preterm birth in women with endometriosis, physicians must be aware that close antenatal follow-up and early diagnosis is crucial. Postpartum manifestations of endometriosis, although extremely rare, can give rise to severe complications with a high possibility of irreversibly affecting the woman’s childbearing ability. Keywords: Endometriosis, postpartum, preeclampsia, pregnancy outcome, preterm birth, SGA (small for gestational age). INTRODUCTION sterilization (5%) [4]. Other reports have confirmed that infertile women are 6 to 8 times more likely to have Endometriosis is one of the most common gynaecologic endometriosis than fertile women [5]. The hypothesis that disorders and is found in approximately 70% of patients with endometriosis causes infertility or a decrease in fecundity chronic pelvic pain [1, 2]. Early studies suggested that 25% remains controversial. While there is a reasonable body of to 50% of infertile women have endometriosis and that 30% evidence to demonstrate an association between endo- to 50% of women with endometriosis are infertile [3]. There metriosis and infertility, a cause and effect relationship has is a higher prevalence of endometriosis in infertile women not been established [6]. (48%) compared with fertile women undergoing tubal The most common symptoms of endometriosis are pelvic pain, late onset dysmenorrhea and dyspareunia, and rd *Address correspondence to this author at 3 University Department infertility. Clinical symptoms result from implantation of Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Medical endometrial tissue on the pelvic organs. Thus, endometriosis School, 130 Egnatia str., 546 22 Thessaloniki, Greece; Tel: +306972427408; Fax: +302310230878; may result in bowel-related symptoms (e.g., tenesmus) and E-mail: [email protected] urinary tract symptoms. Physical findings associated with 1875-6581/12 $58.00+.00 © 2012 Bentham Science Publishers 122 Current Women’s Health Reviews, 2012, Vol. 8, No. 2 Masouridou et al. Table 1. Clinical Manifestations of Endometriosis During the Third Trimester of Pregnancy: Demographic Data and Pregnancy Outcome References Mean Mean Gestational ART Symptoms-Signs Fetal Transfusion History of Maternal Age Age at Delivery Outcome Endometriosis Grunewald [13] 33 28 No ALAP, HVS, HMP, Coagulation NL (VB at Yes No (Exploratory Laparotomy) term) Wu [14] 31 33 (twins) Nl/NL Chiodo [25] 22 31 No ALAP, HMU, UHMP SB PRD, FFP Yes Dubuisson [15] 36 32 SB Passos [35] 30 32 (twins) Yes SRM, VB and EMCS: FD, HMP Nl/NL No Yes 32 31 Yes ALAP, FD, HMP NL No Yes Roche [17] ? 33 (twins) ? ALAP, HVS, HMP SB/SB ? ? Bouet [29] 33 24 No ALAP, IRR, AFH, HMP, HMTHx SB ? No Katorza [1] 29 28 (twins) Yes ALAP, HVS, HMP RDS/RDS 4 IU PRC, 4 No IU FFP 31 26 Yes ALAP, HMP TOP 6 IUPRC, 8 Yes IU FFP, 10 IU CRYOPP 32 29 Yes ALAP, HMP CP ? Yes Schweitzer [81] 32 40 Yes ALAP, D, PNP, PSC NL No No Roger [16] 34 27 NL Aziz [5] 30 20 SB Ismail [12] ? 33 ? ALAP, HMP NL ? ? Leung [11] 35 33 SB Mizumoto [10] 28 28 NND Inoue [9] 37 29 ? ALAP, HMP NL ? ? Kawabara [18] No Rupture of pregnant uterus Nakatani [24] 25 26 No PA Gini [22] 23 35 No SVB, PRIF, PA NL ? No Clement [23] 28 37 No ALAP, PNP-PSC NL ? No Haufler [23] 30 6 months No Peritonitis, PJ Steinberg,Scott 8 cases No Rupture OEC [23], Noel, Brill [33], Vercellini, Anderson Poder [32] 34 30 No Decidualization mimicking NL Yes Ovarian malignancy Phupong [28] 35 35 No Infected endometrioma NL No Suspected mimicking acute appendicitis Feyereisl [31] 25 2nd trimester Imitating bladder tumor NL (term delivery) Endometriosis and Perinatal Outcome Current Women’s Health Reviews, 2012, Vol. 8, No. 2 123 Table 1. contd…. References Mean Mean Gestational ART Symptoms-Signs Fetal Transfusion History of Maternal Age Age at Delivery Outcome Endometriosis Sabatelle [19] 23 34 No ALAP, HMP SB, TAH Doyle [20] 37 34 No ALAP, HMP MD, FDeath Melody [27] 30 37 No ALAP Omentectomy Konwer [21] 39 40 No ALAP, HMP MD, SB ALAP: Acute Low Abdominal Pain, SRM: Spontaneous Rupture of Membranes HVS: Hypovolemic Shock HMP: Haemoperitoneum HMU: Haematuria, IRR: Increased Respiratory Rate, AFH: Absent Fetal Heart activity UHMP: Urohaemoperitoneum, HMTHx: Haemothorax, PNP: Pneumoperitoneum, D: Dyspnea, PSC: Perforation of Sigmoid Colon, PJ: Perforation of Jejunum, OEC: Ovarian Endometriotic Cyst EMCS: Emergency Cesarean Section, VB: Vaginal Birth FD: Fetal Distress, NL: Normal, RDS: Respiratory Distress Syndrome, NND: Neonatal Death, MD: Maternal Death, SB: Stillborn, CP: Cerebral Palsy, TOP: Termination of Pregnancy, TAH: Total Abdominal Hysterectomy, RPC: Red Packed Cells, FFP: Fresh Frozen Plasma SVB: Slight Vaginal Bleeding, PRIF: Pain in Right Iliac Fossa, PA: Perforation of Appendix ?: not mentioned endometriosis are variable and dependent on the severity 2 maternal deaths occurred in earlier years, one possible and location of the disease. Common findings include reason being the ongoing evolution of intensive care characteristic tender nodularity and tenderness of the units and rescuscitation techniques. One pregnancy was obliterated cul-de-sac, parametrial thickening, and adnexal terminated according to the parents’ request, at 26 weeks of masses. gestation after developing severe intrauterine asphyxia postoperatively. Four cases report massive transfusion. The etiology and pathophysiology of endometriosis are not well understood because of the lack of a suitable animal Studies referring to specific pregnancy complications model to study the anatomic correlates and natural history of (preterm birth, small-for-gestational age babies, preeclampsia disease. No cure exists for the disease, and treatment is and postpartum complications) were limited to a total of directed toward medical suppression, surgical excision, and twelve publications. At present , in lack of large population symptom alleviation. studies, the few available data on endometriosis and its possible adverse effects on pregnancy are conflicting. MATERIAL AND METHODS Endometriosis During Pregnancy Infertility appears to be one of the major problems in women suffering from endometriosis. Pregnancy can be The number of women with endometriosis is increasing achieved either spontaneously or, more commonly with the [2, 7]. Although severe endometriosis is commonly associated help of Assisted Reproductive Techniques (ART). There with infertility, treatment with assisted reproductive are only a few reports examining the possible association techniques, such as IVF (in vitro fertilisation), enables more between endometriosis and perinatal outcome. With the aim women with severe endometriosis to conceive [1]. It is of assessing any possible effects of endometriosis on generally believed that pregnancy “cures” endometriosis, and pregnancy outcome, we conducted a systematic review of all symptoms usually disappear during the gestational period. In relevant publications in Pubmed, Scopus and Cochrane