Endometriosis during pregnancy

Dr. T. ArbabzadehOb & Gyn. PerinatalogistSBMU

References:

• UpToDate

• Petresin J, et al. Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review. Geburtshilfe Frauenheilkd. 2016;76(8):902-905.

• Umberto L.et al. A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes, Human Reproduction Update, Volume 22, Issue 1, January/February 2016, Pages 70–103.

• ESHRE GUIDELINE,ENDOMETRIOSIS 2021

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Course During

Pregnancy

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• Improvement

“Pseudopregnancy” induced through hormonal therapies has a positive effect on symptoms.

Course During

Pregnancy

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• Complications:

• Adhesion formation: Intestinal obstruction and perforation

• Hemoperitoneum

• Uroperitoneum

• Acute appendicitis

• Ruptured or infected ovarian endometrioma

Mechanisms of complications ?

Course During

Pregnancy

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• Complications:

• Intestinal perforation

• Hemoperitoneum

• Uroperitoneum

• Acute appendicitis

• Ruptured or infected ovarian

endometrioma

• Mechanisms of complications ?

Obstetric Outcomes

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• Preterm birth

• Preeclampsia ?

• Gestational DM

• Cesarean delivery

• Miscarriage

• Ectopic pregnancy

• Placenta previa

• Unexplained antepartum hemorrhage

• Postpartum hemorrhage

• Stillbirth

• Low birth weight, admission to NICU, neonatal death

• Ovarian torsion

• High in the second

half of pregnancy

and during labor.

• Bowel perforation:

2× small bowel, 1× cecum, 3× appendix and 6×

rectum and sigmoid colon

• Uterine rupture:

Spontaneous

Intrapartum uterine rupture following previous

surgery

• Endometrioma:

infected, enlarged, and ruptured

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Complications in

Pregnancy

Deciduosis from

decidualized endometriosis

• Ectopic decidua is most commonly localized in the ovary, cervix, uterine serosa and the lamina propria of the salpinx.

• The peritoneal localization is uncommon.

Term ‘deciduosis’ is used to indicate two different entities:

(i) metaplasia of the sub-coelomic pluripotent mesenchymal cells under the effect of progesterone: very frequently in the ovary of term pregnancies and regressing post-partum within 4–6 weeks

(ii) The pregnancy-associated stromal decidualization of ectopic endometrium (endometriosis) that under progesterone action increases glandular epithelial secretion, stromal vascularity and edema

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• Ovarian endometriosis in

pregnancy is a rare condition

with an estimated frequency of

about 0.05–0.5%.

• Transvaginal sonography : Gold

standard imaging method.

Ovarian Endometrioma

• During pregnancy, changes in the dimension and in

the appearance of the endometriotic cyst:

52%

unchangedin 28%

20%

Ovarian Endometrioma

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• The sonographic pattern of decidualized ovarian

endometrioma:

1. ground-glass or low level echogenicity of the cyst

2. papillary projections with smooth rounded contour

3. multiple vascularization signals within the solid part with low resistance index

✿ Differentiating malignant papillations from decidualized endometriomas would be crucial to avoid unnecessary surgery during pregnancy:

Round-shaped appearance benign papillations →decidualized endometriomas

Irregular surface papillary projections → borderline malignancies.

✿ The absence of septations & growth could be a reassuring sign

Treatment

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Decidualized

ovarian

endometriosis

Expectant management vs. Surgical intervention

✿ Surgery• Cystectomy• Salpingo-oophorectomy• Laparoscopy is safe • Increased risk after 23 weeks’ gestation• Surgical approach in the late 3rd trimester shouldbe postponed until after or at the time of delivery.

Decidualized endometriomas

mimicking ovarianmalignancies

ESHRE2021

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Endometrioma in

pregnancy

• The decidualization of an endometrioma in pregnancy may in some cases resemble malignant

ovarian tumors posing a clinical diagnostic dilemma,

although the true incidence of this phenomenon is

uncertain (prevalence 0-12%).

• First-line management: serial monitoring

(with ultrasound, or MRI if necessary) and expectant

management.

• When a malignancy is suspected and surgery is

considered necessary, a minimally invasive

laparoscopic approach is recommended not later

than 23 weeks.

ESHRE2021

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Recommendation

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Decidualized

endometriosis in

extra-ovarian

sites

• Sites:PeritoneumBladderBowelDiaphragmpleura, lungs, breastskin, either intact or following surgery (scars, episiotomy)

• Becoming hypertrophic or gaining features of decidualization or mimicking carcinomatosis.

• No case of peritoneal decidualized endometriosis in pregnancy has been described.

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Cutaneous

decidualized

endometriosis

• DDX: Malignancy • Cyclical pain• Typical lesion enlargement occurring during pregnancy• Shape of the nodules with smooth rounded borders

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Decidualized

endometriosis of

the bladder

✿ Clinical Assessment:• Ultrasound:malignancy → high vascularization on color DopplerAnalysis, feeding arterial vessels seen on MRI scans and the location most commonly found at the bladder dome. benign endometriosis → vesicouterine pouch• Cystoscopy• MRI

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Thank you