902 GebFra Science Endometriosis-associated Maternal Pregnancy Complications – Case Report and Literature Review Maternale Endometriose-assoziierte Schwangerschaftskomplikationen – Fallbericht und Literaturübersicht Authors J. Petresin, J. Wolf, S. Emir, A. Müller, A. S. Boosz Affiliation Frauenklinik, Städtisches Klinikum, Karlsruhe Key words Abstract Zusammenfassung l" endometriosis ! ! l" pregnancy The incidence of endometriosis is increasing. Par- Durch die zunehmende Inzidenz der Endometri- l" complication ticularly during pregnancy and labour, clinicians ose muss, trotz des geringen relativen Risikos, ge- l" delivery should be alert to possible endometriosis-associ- rade während Schwangerschaft und Entbindung l" decidualization l" intraabdominal bleeding ated complications or complications of previous bei diesen Patientinnen an eine Komplikation endometriosis treatment, despite a low relative durch Endometriose oder vorherige Therapie ge- Schlüsselwörter risk. In addition to an increased rate of early mis- dacht werden. Neben einer erhöhten Abortrate in l" Endometriose carriage, complications such as spontaneous bow- der Frühschwangerschaft werden in der Literatur l" Schwangerschaft el perforation, rupture of ovarian cysts, uterine Komplikationen wie spontane Darm- und Ovari- l" Komplikation l" Hämoperitoneum rupture and intraabdominal bleeding from decid- alzystenruptur, Uterusruptur sowie intraabdomi- ualised endometriosis lesions or previous surgery nale Blutungen durch dezidualisierte Endome- are described in the literature. Unfavourable neo- trioseherde oder vorangegangene Operationen natal outcomes have also been discussed. We re- beschrieben. In der Literatur wird sogar ein un- port on an irreducible ovarian torsion in the 16th günstigeres neonatales Outcome diskutiert. Wir week of pregnancy following extensive endome- berichten über eine nicht mehr detorquierbare Deutsche Version unter: triosis surgery, and an intraabdominal haemor- Stieldrehung in der 16. SSW nach ausgedehnter http://dx.doi.org/ rhage due to endometriosis of the bowel in the Endometrioseoperation und eine intraabdomina- 10.1055/s-0042-101026 29th week of pregnancy. le Blutung bei Darmendometriose in der 29. SSW. Introduction sis [2]. The same study, with a study population of ! 5375 patients, found increased risk of placenta Endometriosis is a chronic disease that affects 4– praevia (OR 2.24), antenatal haemorrhage of un- 30% of all women of child-bearing age. The preva- certain cause (OR 1.67) and postpartum haemor- lence is even higher among women with infertili- rhage (OR 1.26) [2]. received 21.10. 2015 revised 12.1.2016 ty (up to 50%) [1]. Dysmenorrhea is the main clin- Endometriosis does not always regress during accepted 17.1.2016 ical symptom of the disease, which is character- pregnancy. Endometrial decidualisation in partic- ised by the presence of endometrial cells outside ular is responsible for many of the complications Bibliography of the uterus. Endometriosis commonly occurs occurring during pregnancy. Increased progester- DOI http://dx.doi.org/ 10.1055/s-0042-101026 superficially in the peritoneal membrane howev- one production is causative [3]. The risk of endo- Geburtsh Frauenheilk 2016; 76: er it can also infiltrate deeply into e.g. the bladder, metriosis complications is particularly high in the 902–905 © Georg Thieme rectum and other bowel segments. Serious ma- second half of pregnancy and during labour. Verlag KG Stuttgart · New York · ternal pregnancy complications mostly occur in Risks described in the literature include sponta- ISSN 0016‑5751 association with this deeply infiltrating form of neous intraabdominal haemorrhage, uterine rup- Correspondence the disease. ture, bowel perforation, endometriosis cyst perfo- Dr. med. After data adjustment for age and gestational age ration and ovarian torsion in the presence of ovar- Alexander Stephan Boosz Städtisches Klinikum women with endometriosis have tubal pregnan- ian endometrioma. Frauenklinik cies almost three times more often (odds ratio Moltkestraße 90 2.7 [95% confidence interval 1.09–6.72]), and al- 76133 Karlsruhe – alexander.boosz@ most twice as many miscarriages (1.76 [1.44 klinikum-karlsruhe.de 2.15]) compared to women without endometrio- Petresin J et al. Endometriosis-associated Maternal Pregnancy… Geburtsh Frauenheilk 2016; 76: 902–905 Case Report 903 Fig. 2 Case 1 – postoperative status, left pelvic wall: The left adnex has been removed. Excision was performed at the ovarian suspensory ligament (at bottom left of picture) and the ovarian ligament (top right). to the pelvic wall and sigmoid colon. After adhesiolysis and mobi- lisation of the sigmoid a necrotic adnexal torsion was found (l" Fig. 1a and b). Detorsion was unsuccessful. The left broad liga- ment had evidently been broken through, and the left adnex was twisted 3 times on its long axis both in the region of the ovarian suspensory ligament and the ovarian ligament (l" Fig. 1a). Be- cause of the adnexal enlargement it was not possible to perform detorsion through the defect in the broad ligament. A left adnex- Fig. 1a and baCase 1 – left adnexal torsion: The mass is twisted three ectomy was thus performed (l" Fig. 2). The patient was dis- times on its long axis between the ovarian suspensory ligament and the charged home on the 4th postoperative day after an uneventful ovarian ligament. Detorsion was impossible due to the size of the mass. The postoperative course. Fetal ultrasound before discharge was nor- surgical instrument on the left is in the previously fenestrated broad liga- mal, the patient delivered via repeat caesarean section in the ment. b Case 1 – haemorrhagic left adnex: Haemorrhagic infarction sec- 39th week of gestation. ondary to torsion. The surface is ruptured on attempted detorsion with blunt instruments. Case 2 ! Case 1 This 25-year-old patient was admitted at 27 + 1 weeks gestation ! with vaginal bleeding and preterm labour. On history she was A 33-year-old patient (gravida III, para I) had previously had ex- noted to have had a laparoscopic endometriosis operation in tensive endometriosis surgery in 2009. Amongst other proce- 2011 and a previous appendicectomy. At laparoscopy in an exter- dures she had had an extensive peritonectomy for peritoneal en- nal centre endometriosis was noted between the rectum and dometriosis. She subsequently underwent unsuccessful fertility posterior uterine wall but left in situ since consent to treat it op- treatment. She ultimately fell pregnant naturally in 2011 and eratively was lacking. the child was born in 2012 by caesarean section without compli- Initially placental abruption was suspected, however this was not cation. Her subsequent pregnancy, the one in question, was also confirmed and RDS prophylaxis with celestan as well as tocolysis natural. with fenoterol bolus was carried out. Ultrasound, laboratory pa- The patient presented to us from an external hospital at 15 + 4 rameters and repeated CTGs showed no abnormalities. The pa- weeks gestation with severe left-sided lower abdominal pain that tientʼs symptoms improved under tocolysis and on the third day had been present for 3 days. Ultrasound showed an adnexal mass of admission had completely resolved, including the bleeding. measuring approx. 60 × 40 mm. Symptoms improved with con- CTG and cervical findings were persistently normal and she was servative management, and an expectant approach with analge- discharged. sia was agreed on with the patient. After 2 days the patientʼs At 28 + 2 weeks gestation she presented again, this time as an symptoms had not yet resolved and she was transferred to our emergency, again with unusually heavy vaginal bleeding. The hospital. On ultrasound the adnexal mass was found to have cervical length was 27 mm without funneling. She was admitted grown to a diameter of approx. 80 mm, the structure appearing and tocolysis commenced with a partusisten bolus. On ultra- mostly haemorrhagic. Under suspicion of a progressively enlarg- sound there was again no evidence of placental abruption. The ing, haemorrhagic ovarian cyst with persistent symptoms the de- following day the patient was noted to have extremely severe ab- cision was made to perform a laparoscopy. dominal pain that made micturition impossible. There was still Intraoperatively the uterus was appropriately enlarged for the no ultrasound evidence of placental abruption and both fetal pregnancy and the right adnex was normal. The left adnex was heart rate and doppler indices were normal. Clinical signs were obviously enlarged, with black discolouration, and was adherent however suggestive of peritonitis, with extreme abdominal pain Petresin J et al. Endometriosis-associated Maternal Pregnancy… Geburtsh Frauenheilk 2016; 76: 902–905 904 GebFra Science and muscular defence, circulatory instability and raised CRP. At study on the incidence of haemoperitoneum in pregnancy is a this point vaginal bleeding had stopped. The patientʼs condition retrospective analysis of 800 women from a period of 5 years. was considered life-threatening and in the presence of recurrent The study describes three women (0.38%) with significant intra- vaginal bleeding of unknown cause the decision was made to abdominal bleeding during the third trimester due to endome- perform a caesarean section despite the early gestation. Since triosis [7]. There are also a few reports of stillbirths [8] and early the aetiology of the acute abdomen was unknown it was decided neonatal deaths [9] due to fulminant haemoperitoneum causing