{"paper_id":"4f5c3b12-88d2-45f2-8c27-6c1c54f2816c","body_text":"ORIGINAL ARTICLE\nDelivery and pregnancy outcome in women with bowel resection\nfor deep endometriosis: a retrospective cohort study\nSilvia Baggio1 & Paola Pomini1 & Alessandro Zecchin1 & Simone Garzon1 & Cecilia Bonin1 &\nLorenza Santi2 & Anna Festi1 & Massimo Piergiuseppe Franchi1\nReceived: 25 April 2015 / Accepted: 9 June 2015 / Published online: 20 June 2015\n# Springer-V erlag Berlin Heidelberg 2015\nAbstract Endometriosis affects women in reproductive age\nand can involve bowel in 6 –12 % of the patients. In case of\nbowel occlusion or deep pain, radical laparoscopic\nendometriosic surgery associated with bowel resection is rec-\nommended. The purpose of this study was to analyze the\nconception rate, the obstetric complications, and the pregnan-\ncy outcome. This is a retrospective study; we investigated 51\npatients with deep endometriosis who underwent surgical\ntreatment with bowel resection during the period between\n2000 and 2007. Among the 30 patients who gave birth to at\nleast one live child after surgery, we considered only the first\npregnancy following bowel resection and we investigated the\nincidence of pregnancy disorders, the gestational age at deliv-\nery, the baby birth weight, and the complications related to the\ndifferent ways of delivery. We compared the results with a\ncontrol group of 93 patients with no previous abdominal sur-\ngery. The whole group of 51 patients tried to conceive after\nsurgery, and 30 women had at least one pregnancy with the\nbirth of an alive baby. Considering only the first pregnancies\nafter surgery, 6 (20 %) experienced gestational hypertensive\ndisorders, 3 (10 %) had placenta previa, 6 (20 %) had preterm\nbirth (<37 weeks), and 1 patient (3.3 %) gestational diabetes.\nIn this group, the average newborn weight was 3000±545 g.\nCompared with the control group, women with previous bow-\nel resection for deep endometriosis had a higher risk of\nhypertensive disorders ( p<0.05), placenta previa ( p<0.05),\nand lower newborn weight ( p<0.05), while the association\nwith preterm birth and gestational diabetes was not statistical-\nly significant. These patients experience 12 vaginal deliveries\n(40 %) and 18 caesarean sections (60 %). Comparing with the\ncaesarean rate in the control group (29.03 %), the incidence of\ncaesarean section in the study population was substantially\nhigher ( p<0.01) with 33.3 % of the sections performed be-\ncause of previous bowel surgery. No differences in severe\ncomplication rates were observed between vaginal and caesar-\nean deliveries (ns). Complete removal of endometriosis with\nbowel segmental resection seems to improve the pregnancy\nrate, but in this group, there is an increased incidence of hy-\npertensive disorders, placenta previa, and lower newborn\nweight. Despite the small number of patients, we do not ob-\nserve more complications in the vaginal group than in the\ncaesarean group, so we hypothesize the previous radical sur-\ngery should not influence the way of delivery.\nKeywords Endometriosis . Bowel resection . Pregnancy\nIntroduction\nEndometriosis is characterized by the presence of the endo-\nmetrial glands and stroma outside the uterine cavity. It primar-\nily affects women of fertile age and represents a relevant clin-\nical issue as it causes severe abdominal pain [ 1, 2] and infer-\ntility [2, 3].\nEndometriosis is classified depending on location, extent\nand depth of implants, presence and severity of adhesions, and\npresence and size of ovarian endometriomas.\nThe incidence of bowel implants among women with en-\ndometriosis is between 6 and 12 % [ 4–7]. The most affected\nsites are the rectum and recto-sigmoid junction, which account\n* Silvia Baggio\nsilvia.baggio1@gmail.com\n1 Department of Obstetrics and Gynaecology, University of V erona,\nPiazzale L.A. Scuro 10, 37134 V erona, Italy\n2 Department of Endocrinology, University of V erona, Piazzale L.A.\nScuro 10, 37134 V erona, Italy\nGynecol Surg (2015) 12:279–285\nDOI 10.1007/s10397-015-0901-9\n\n\nf o ru pt o9 3%[ 8–10] of all intestinal endometriosis lesions.\nWhen this kind of lesion is associated with deep pain, stenosis,\nor massive bowel involvement, the recommended approach is\nthe complete excision of deep endometriosis with bowel re-\nsection [11]. In these last years, many authors have reported\ndifferent surgical procedures to remove endometriosis nodules\nfrom bowel like the shaving technique that consists in the\nexcision of nodule after its complete resection from the rectum\nwithout resection [ 12]. Bowel endometriosis removal let the\npatient have a reliable and persistent relief of pain symptoms\nand improvement of quality of life [ 13–22] and leads to a\nbetter fertility and pregnancy rate [23].\nConsidering the young age of women who undergo this\nradical surgery, and the related fertility improvement, the aims\nof our study were to analyze the obstetric complications and\nthe outcome of the pregnancies conceived after surgery and to\nevaluate if there is a recommended way of delivery conscious\nof short- and long-term complications related to a bowel seg-\nmental resection.\nMethods\nFrom July 1996 to February 2007, 329 infertile women with\nsevere endometriosis underwent laparoscopic surgery treat-\nment at the Gynecology and Obstetrics Department of the\nOspedale Sacro Cuore (Negrar, Italy).\nIn our study, we analyze only the 77 patients who had a\ncolorectal segmental resection. The indications for radical sur-\ngery with bowel resection were severe pelvic pain refractory\nto medical treatments and/or severe bowel stenosis caused by\nendometriosis implants.\nIn our Unit, in case of deep endometriosis with muscularis\ninvolvement, the treatment of choice is bowel segmental re-\nsection. The shaving technique is performed if the\nendometriotic nodule involves only the serosa.\nIn all cases, surgery was performed by laparoscopy. Each\nprocedure was performed using a 10-mm laparoscope in the\numbilical position and three 5-mm trocars. After an accurate\ncheck of the pelvic and abdominal organs, adnexal adhesions,\nwhen present, were sectioned with micro-scissors. Where\nendometriomas were present, steeping and temporary ovarian\nsuspension was performed. Complete excision of all visible\nendometriosis lesions from healthy tissue was obtained using\n5-mm bipolar scissors according to the technique described by\nRedwine [ 24]. Pre- and post-operative management has al-\nready been reported in previous studies [ 21, 25, 26]. The in-\ntestinal surgery was performed by a colorectal surgeon with a\nT–T colorectal anastomosis. All women were clinically eval-\nuated at 1 month, 6 months 1 year up to 4 years after surgery,\nand all findings were recorded in a specific database.\nIn this retrospective study, data about history, surgery, com-\nplications, and follow-up were obtained from database and\nmedical records, while data concerning obstetric outcomes\nwere updated contacting the 77 patients between July and\nAugust 2013.\nOnly 51 of 77 patients who underwent bowel resection\nwere considered in our study; 26 patients were not\ncontactable. Among the patients who conceived after surgery,\nwe retrieved data from medical records about conception,\ncomplications during pregnancy, gestational age at delivery,\nbirth weight, way of delivery, indications (caesarean section),\nand possible complications. Previous caesarean delivery was\nconsidered an obstetric indication. We collected the same ob-\nstetric data from a population without endometriosis who de-\nlivered in January and February 2007 in our Unit (control\ngroup) to compare the incidence of obstetric complications\nand the way of delivery in the two groups. The control group\nincluded 92 women with good health, no previous caesarean\nsection or bowel surgery, regular menstrual cycle, no dysmen-\norrhea, no dyspareunia, no dyschezia, and normal gynecolog-\nical evaluation before the conception. Subjects with medical\nconditions, previous bowel surgery, or suspicion of endome-\ntriosis were excluded.\nStatistics\nAll statistical analysis was carried out with a SPSS 21.0 soft-\nware. Continuous variables were expressed as arithmetic\nmean+SD; in case of asymmetric quantitative variables, the\nindicators were associated with the median, maximum, and\nminimal values. Categorical variables were expressed as dis-\ntributions of absolute or relative frequencies. The distribution\nof conceptions and deliveries during follow-up was studied\nwith the Kaplan–Meier curves. The chi-square test and Fisher\nexact test were used to compare data obtained by cross tabs.\nStatistical significance was declared at p<0.05 .\nResults\nDemographic data were similar in the case and control group\npopulation; none had previous caesarean section, and they did\nnot differ in age and gestational age at delivery (Table 1).\nPregnancies\nAfter surgery, all patients tried to conceive and 38 (70.37 %)\nobtained at least one pregnancy with a total of 68 pregnancies.\nSpontaneous miscarriage was observed in 19/68 (23.53 %)\nand ectopic pregnancy in 2/68 (2.94 %). The remaining 47/\n68 (73.53 %) had ongoing pregnancies with a live child\ndelivery.\nIn summary, 30 patients had at least one ongoing pregnan-\ncy with delivery, in particular, 14/30 (46.6 %) had one\n280 Gynecol Surg (2015) 12:279–285\n\npregnancy, 15/30 (50 %) had two pregnancies, and one patient\n(3.3 %) had 3 ongoing pregnancies.\nBefore radical surgery with bowel resection, only 2/51\n(3.9 %) patients had an ongoing pregnancy with a live child\ndelivery, even if 32/51 (62.7 %) were trying to conceive for\nmore than 1 year, while after surgery 30/51 (58.8 %). This\ndifference is statistically significant (p<0.00 1).\nConception\nMost of the ongoing pregnancies with delivery were obtained\nspontaneously (71 %), while 14/47 (29 %) were obtained with\nin vitro fertilization (IVF). The mean age at the first concep-\ntion was 30.1 years (d.s. 3.2). Spontaneous pregnancies had a\nmean interval from surgery of 13.8 months (d.s. 14.1) and a\nmedian of 9 months, with a minimum interval of 0 month and\na maximum of 53 months. Pregnancies obtained with IVF had\na mean interval of 26.8 months (d.s. 21.4) and a median of\n22 months, with a minimum interval of 6 and a maximum of\n85 months.\nGestational age and fetal growth\nWe considered only the first pregnancy with the birth of a live\nchild. The mean gestational age at delivery was 38.10 weeks\n(d.s. 2.25), with a median of 38 weeks, a minimum gestational\nage of 33 weeks, and a maximum of 42.\nSix of thirty pregnancies (20 %) ended with a preterm de-\nlivery (before 37 weeks), with a mean gestational age of\n34.62 weeks (d.s. 1.21). Among these pregnancies, 1 ended\nbecause of a preterm labor with consequent vaginal delivery\nduring the 36th week without any complications, while 5 had\ncaesarean delivery with a mean gestational age of 34.40 weeks\n(d.s. 1.14). The indications of these caesarean sections were\ndifferent; 2 were performed at 35 and 36 weeks after the di-\nagnosis of labor because of the previous bowel resection, to\nprotect the anastomosis, 1 for breech presentation and prema-\nture rupture of membranes at 34 weeks, 1 for severe IUGR\n(<5 % percentile) and Doppler velocimetry alterations at\n34 weeks, and 1 for twin pregnancy and preterm labor at\n33 weeks of gestation. Excluding the twin newborns, the mean\nweight at birth was 3000 g (d.s. 545) with a median of 3100 g,\na minimum weight of 1900 g, and a maximum of 3880 g.\nIn the control group the mean gestational age at the delivery\nwas 38.3 weeks (d.s. 3.3), with a median of 37.9 weeks, a\nminimum gestational age of 27 weeks and a maximum of\n41.6 weeks.\nThirteen of 93 pregnancies (14 %) ended with a preterm\ndelivery (before 37 weeks), with a mean gestational age of\n33.2 weeks (d.s. 3.8). The newborn mean weight at birth\nwas 3287 g (d.s. 671) with a median of 3365 g, a minimum\nweight of 540 g, and a maximum of 4300 g.\nPregnancy complications\nIn the case group, 6/30 pregnancies (20 %) were complicated\nby hypertensive disorders (gestational hypertension and pre-\neclampsia, with one case of severe eclampsia). Only one preg-\nnancy (3 %) was complicated by diabetes mellitus. The abnor-\nmal placentation complicated 3 pregnancies (10 %); in partic-\nular, 2 pregnancies presented placenta previa (all obtained\nwith IVF) and one placental flow alterations.\nIn the control group, 5/93 pregnancies (5.4 %) were com-\nplicated by hypertensive disorders while 10/93 (10.8 %) were\ncomplicated by diabetes mellitus. Abnormal placentation\ncomplicated 2 pregnancies (2.2 %); in particular, 1 pregnancy\npresented placenta previa (1.1 %) and 1 (1.1 %) placental flow\nalterations.\nDelivery\nAmong the 30 pregnancies in the case group, there were 12\nvaginal deliveries (40 %) and 18 caesarean deliveries (60 %).\nNo significant difference was observed in the two groups\nconcerning the interval time between surgery and delivery\n(p=0.9). Dividing the 18 caesarean deliveries into two groups\nbased on the indications, 10 (55.6 %) had an obstetric indica-\ntion, while 8 (44.4 %) were performed to protect the colon-\nrectal anastomosis, to prevent bowel perforation in this minor\nresistance point, in particular during labor expulsive stage\nwhen there is the maximum increase of abdominal pressure.\nIn the study population, vaginal deliveries were mainly\ncomplicated by minor injuries: first or second degree perineal\nlaceration (50 %), episiotomy (16.6 %), and manual removal\nof placenta (8.3 %). Only one vaginal delivery (8.3 %),\n10 months after surgery, was severely complicated with a wide\nlaceration of the cervix, vagina, and rectum at the level of the\nsuture of the previous bowel resection. The patient had a re-\nconstructive surgery, without long-term complications.\nRegarding caesarean deliveries, only two were severely\ncomplicated (11.1 %). The first case, 33 months after the rad-\nical surgery, presented a severe adhesion syndrome and devel-\noped severe intra-operative uterine bleeding and was admitted\nto ICU. In the second case, 24 months after bowel surgery, the\nTa bl e 1 Demographic characteristics of case and control patients\nCase Control p\nNumber of patients 51 93\nAge (years) 30.9±3.3 30.7±4.0 N.S.\nGestational age (w) 38.1±2.2 38.3±3.3 N.S.\nHypertension/preeclampsia 20 % 5.4 % <0.05\nAbnormal placentation 10 % 2.2 % <0.05\nNeonatal weight (g) 3000±545 3287±671 <0.05\nNS no significative, W weeks\nGynecol Surg (2015) 12:279–285 281\n\ndiffuse adhesions between the uterus and bladder determined\na large full-thickness bladder incidental laceration with recon-\nstructive urological surgery. The patient developed urine re-\ntention with intermittent self-catheterization.\nIn the control group, there were 27/93 (29.03 %) caesarean\nsections and 66/93 (70.07 %) vaginal deliveries. The compli-\ncations during vaginal deliveries were first or second degree\nperineal laceration (45.4 %), episiotomy (18.2 %), and\ntracheloraffia (1.5 %). There were no urinary tract injuries\nduring the caesarean sections in the control group, but 2 pa-\ntients (7.4 %) had severe intra-operative bleeding with neces-\nsity of blood transfusion in one case (3.7 %).\nDiscussion\nMany studies have demonstrated the close relationship be-\ntween endometriosis and infertility and the improvement of\nthe pregnancy rate and pelvic pain after radical surgery [ 16,\n18, 19, 23, 27, 28]. In particular, among women with bowel\nendometriosis, articles in lite rature confirm that the post-\noperative fertility rate is improved if segmental bowel resec-\ntion is performed (Table 2).\nStepniewska et al. [ 23] reported a cumulative pregnancy\nrate of 35 % after bowel surgery in infertile women; Darai\n[27] reported 5 pregnancies in 12 infertile patients (42 %),\nand Kavallaris [ 16] reported 8 pregnancies in 15 infertile\nwomen (47 %) with previous bowel surgery. Our study shows\na statistical significant improvement of pregnancy rate in in-\nfertile woman, after bowel surgery for endometriosis with the\nhighest pregnancy rate, 70.4 % after surgery versus 3.9 %\nbefore (p<0. 01).\nThe cumulative pregnancy rate is 50 % at 9 months for\nspontaneous conceptions and at 16 months for conceptions\nobtained with artificial reproductive techniques (ART), which\nis comparable to the results obtained by other authors [ 29].\nThis confirms that the maximum fertility rate is immediately\nafter surgery considering both spontaneous and ART pregnan-\ncies (Fig. 1).\nDonnez et al. reported an important increase of pregnancy\nrate after shaving technique too (57 %) [ 12]. Whether one\ntechnique is better than the other or not in terms of pain relief,\nfertility, and short- and long-term complications is still con-\ntroversial, and it often depends on the surgeon and its experi-\nence. The high pregnancy rate observed after surgery both\nwith bowel resection and shaving approach suggests that the\nincrease in fertility is more likely to be related to the removal\nof the endometriotic disease rather than a specific surgical\ntechnique.\nAlthough fertility after bowel surgery has been wide stud-\nied, outcome and way of delivery of the pregnancies obtained\nafter this surgery have only been considered in few papers.\nIn a study including more than 1.4 million singleton births,\nStephansson et al. [30] observed that endometriosis was asso-\nciated with preterm birth, preeclampsia, and placental\ncomplications.\nIn our study, the mean gestational age at delivery was\n38.16 weeks and 20 % of deliveries were before 37 weeks.\nConsidering that the rate of preterm delivery in the general\npopulation is 10 %, and in the control group 14 %, we ob-\nserved a significant increase in the risk of preterm birth in the\ncase population (p=0.005). Moreover, in women with previ-\nous bowel surgery, the newborn weight at birth was signifi-\ncantly lower than the control group ( p=0. 04).\nAnother important finding is the incidence of hypertensive\ndisorders during pregnancy in our population (20 %) which,\ncompared with the rate of hypertension/preeclampsia in the\ncontrol group population (5.4 %), confirms that women oper-\nated for deep endometriosis had a higher risk to develop this\ndisorder (p=0.024). This is in contrast with the results report-\ned by Brosen et al. [ 31], who showed a decrease in risk of\npreeclampsia in women with endometriosis.\nV ercellini et al. [32] in his study did not detect any partic-\nular findings with regard to the incidence of hypertension,\npreeclampsia, preterm birth, and abruption placenta, but he\nfound an incidence of 3.7 % of placenta previa in women with\nendometriosis, more than 10 times the figure of 0.3 % reported\nin the general population.\nOur study confirms this increased risk of placenta previa\nwith an incidence of 6.6 % in the case population and only\n1.1 % in the control group (p=0.045). This risk in women with\nendometriosis is probably related to abnormal endometrial\nreceptivity and a subsequent alteration in placentation, but\nfurther data are needed.\nNo significant differences were observed in the incidence\nof diabetes (p=\n0.19) between the case and the control groups.\nBesides the obstetric outcome, there is another fundamental\npoint to analyze regarding women who undergo bowel resec-\ntion for deep endometriosis, the way of delivery.\nThere are no studies in literature that focus on this issue,\nand there is no common consensus. In our study, 60 % of\ndeliveries were caesarean sections and 33.3 % were performed\nbecause of previous bowel surgery. In control group, the cae-\nsarean rate was clearly lower, 29.3 %. Refusing to perform an\nintestinal resection in a symptomatic patient who desires a\nchild, persuaded that pregnancy hormones would solve the\nsituation, is not the way to avoid caesarean sections, and\nsometimes, it could be dangerous. There are studies in litera-\nture that show the existence of a specific entity of deep endo-\nmetriosis reacting differently to the hormonal environment of\na pregnancy and responsible of severe bowel complications\nduring the third trimester of pregnancy, like perforations or\nintestinal occlusions [ 33]. To find if there is a safer way to\ndeliver after bowel surgery, in this pilot study, we decided to\ncompare complication incidence after vaginal and caesarean\n282 Gynecol Surg (2015) 12:279–285\n\ndelivery in the two groups. In the case population, vaginal\ndeliveries were mainly complicated by minor injuries; only\none vaginal delivery (8.3 %) was severely complicated with\na laceration of the rectum at the level of the suture of the\nprevious bowel resection. Among the patients who underwent\ncaesarean section, two had severe complications (11.1 %). In\nconclusion, our results show no difference in complications in\nwomen with bowel endometriosis who had a vaginal birth or a\ncaesarean section (p=0.8) and no differences in complications\nduring caesarean or vaginal delivery comparing the case and\ncontrol group ( p=0.09). More studies with larger population\nare needed to confirm these preliminary results.\nIn literature, we found some studies that analyze the way of\ndelivery in women who underwent ileal pouch-anal anasto-\nmosis (IP AA) for chronic ulcerative colitis. The condition of\nthese populations and the case group is similar; they are young\nwomen looking for pregnancy, who undergo abdominal sur-\ngery and intestine resection, with consequent risk of massive\nadhesions and the presence of a rectal/anal point of minor\nresistance, dangerous with the increased abdominal pressure\nduring delivery.\nMany retrospective studies have documented that the\npouch function in women with IPAA during labor and\nTa bl e 2 Studies regarding the fertility outcome after bowel resection for intestinal endometriosis, compared with the conducted study\nStudy No. of patients No. of infertile\npatients\nsearching\noffspring\nObtained\npregnancies\nLength of\nfollow-up\nafter surgery\nSurgical treatment Other\nconsiderations\nNote\nDarai 2005 34 (colorectal\nendometriosis)\n12 5\n(PR=42 %)\n24 months\n(mean FU),\nmin 6 months\nLPS segmental\nintestinal\nresection\nPR in the\nwhole\ngroup =\n45%\n(10/22)\n9 spontaneous\npregnancies, 3 with\nIVF\nThomassin\n2004\n27 (colorectal\nendometriosis)\n8 2 15 months\n(mean FU), range\n3–22 months\nSegmental\nintestinal\nresection: 25\nLPS, 2 LPT\n4 pregnancies\nin the whole\ngroup\n(4/27)\nAll spontaneous\npregnancies\nFleisch\n2005\n23 (infiltrative\nendometriosis\nof bowel\nor bladder)\n4 2 45±18 months LPT, 22 segmental\nresections\n4 pregnancies\nin the whole\ngroup\n(4/17)\nOnly a pregnancy\nobtained with IVF,\nother 3 were\nspontaneous\nKavallaris\n2003\n50\n(rectal\nendometriosis)\n17 searching\noffspring\n(38 infertile\nPZ)\n8\n(PR=47 %)\n32 months LPS, segmental\nintestinal\nresection\n3e a r l y\nabortion,\nnon-EP\n2 pregnancies after\nIVF, others were\nspontaneous\nPossover\n2000\n34 (segmental\nintestinal\nresection)\n15 8\n(PR=53 %)\n16 months\n(mean FU)\nVia vaginal\nresection\nlaparoscopically\nassisted\nAll patients\nwith\nprimary\ninfertility\nStepniewska\n2009\n60 (bowel\nendometriosis)\n48 17\n(PR=35 %)\n26.9 months\n(mean FU)\nLPS, segmental\nintestinal\nresection\nPR compared\nwith no\nresection\nsurgery\nPR improved by\ni\nntestinal resection\nwhen there are\nlesions\nOur study 54 (bowel\nendometriosis)\n54 33\n(PR=61 %)\nMean 113 months\n(d.s. 16), range\n68–153, median\n113\nLPS, segmental\nintestinal\nresection\n50 pregnancies\nwith\nnewborns\n36 spontaneous\n(71.43 %), 14 with\nIVF e IUI (28.57 %)\nFig. 1 Time distribution (months from surgery) of the first pregnancy\nconceptions (Kaplan–Meier). Dashed lineshows the 50 % of conceptions\nafter surgery. Black: total conceptions; blue: spontaneous conceptions;\nred: conceptions with reproductive technique\nGynecol Surg (2015) 12:279–285 283\n\ndelivery is well preserved. Hanloser et al. [34] used the Mayo\nClinic database to evaluate delivery outcomes in women after\nIP AA, and they found no increases in pouch complications or\nfunctional problems in those who had vaginal birth rather than\ncaesarean section. Among the women who had vaginal deliv-\nery before and after IPAA, no differences were found\nconcerning the duration of labor or labor complication rates\npre-IP AA versus post-IPAA in the same women. Studies by\nJuhasz et al. [35] and Ravid et al. [36] echo the same findings.\nA 2005 report from Cleveland Clinic [ 37] concluded that\nrecommendation for vaginal delivery should be cautious be-\ncause it found a major incidence of sphincter defects in wom-\nen with an IP AA who had a vaginal delivery versus those who\nhad a caesarean section. A 2007 review of literature confirmed\nthat vaginal delivery places all women at risk of sphincter\ninjury (in the general population, the incidence is 0.3 %) in\nparticular if compared with caesarean section, but it\nunderlined that there is no evidence to suggest that this risk\nis greater in women with an IP AA [38].\nThe review of literature regarding IP AA confirms the re-\nsults of our study; there is no contraindication to vaginal de-\nlivery for women who undergo bowel resection for deep en-\ndometriosis as ACOG recommended [ 39]. In these women,\nthe way of delivery should be chosen considering only obstet-\nrical concerns. In fact, the Committee of Obstetric Practice\nbelieves that in the absence of maternal or fetal indications\nfor caesarean delivery, a plan for vaginal delivery is safe and\nappropriate with a shorter maternal hospitalization, lower in-\nfection rates, fewer anesthetic complications, and lower risk of\nrespiratory problems for the infant. Moreover, the presence of\nendometriosis increases the risk of surgery complications dur-\ning caesarean section, in particular lower urinary tract injury,\noften related to bladder adhesions high up on the lower uterine\nsegment. Previous caesarean section and severe endometriosis\nwith bladder-uterine localizations are the major risk factors for\nbladder injury during caesarean section [40].\nTo reduce the incidence of the worst complications during\nlabor and vaginal delivery in women with previous bowel\nresection, we think it would be interesting to study if there is\na safe time interval between surgery and delivery. In our study,\nthe rectum laceration during labor was in the patient with the\nsmallest interval between surgery and delivery (10 months),\nmaybe too short for a correct healing. On the other hand, it is\nwell known that the best period to conceive is the closest to\nsurgery, so waiting too much could be unfavorable.\nFurther studies may be necessary to evaluate if there is a\nsafe interval of time to wait after bowel resection to conceive\nwithout an important reduction of the pregnancy rate.\nCompliance with ethical standards All procedures followed were in\naccordance with the ethical standards of the responsible committee on\nhuman experimentation (institutional and national) and with the 1964\nHelsinki Declaration and its later amendments or comparable ethical\nstandards.\nConflict of interest The authors declare that they have no competing\ninterests.\nInformed consent Informed consent was obtained from all individual\nparticipants included in the study.\nReferences\n1. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ\n(1991) Suggestive evidence that pelvic endometriosis is a progres-\nsive disease, whereas deeply infiltrating endometriosis is associated\nwith pelvic pain. Fertil Steril 55:759–65\n2. Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B,\nBréart G (2002) Relation between pain symptoms and the anatomic\nlocation of deep infiltrating endometriosis. Fertil Steril 78:719–26\n3. Pouly JL, Drolet J, Canis M, Boughazine S, Mage G, Bruhat MA\net al (1996) Laparoscopic treatment of symptomatic endometriosis.\nHum Reprod 11(Suppl 3):67–88\n4. Macafee CH, Greer HL (1960) Intestinal endometriosis. A report of\n29 cases and a survey of the literature. J Obstet Gynaecol Br Emp\n67:539–55\n5. Weed JC, Ray JE (1987) Endometriosis of the bowel. Obstet\nGynecol 69:727–30\n6. Jerby BL, Kessler H, Falcone T, Milsom JW (1999) Laparoscopic\nmanagement of colorectal endometriosis. Surg Endosc 13:1125–8\n7. Chapron C, Fauconnier A, Dubuisson JB, Barakat H, Vieira M,\nBréart G (2003) Deep infiltrating endometriosis: relation between\nseverity of dysmenorrhoea and extent of disease. Hum Reprod 18:\n760–6\n8. Coronado C, Franklin RR, Lotze EC, Bailey HR, V aldés CT (1990)\nSurgical treatment of symptomatic colorectal endometriosis. Fertil\nSteril 53:411–6\n9. Bailey HR, Ott MT , Hartendorp P (1994) Aggressive surgical man-\nagement for advanced colorectal endometriosis. Dis Colon Rectum\n37:747–53\n10. Tran KT, Kuijpers HC, Willemsen WN, Bulten H (1996) Surgical\ntreatment of symptomatic rectosigmoid endometriosis. Eur J Surg\n162:139–41\n11. Wattiez A, Puga M, Albornoz J, Faller E (2013) Surgical strategy in\nendometriosis. Best Pract Res Clin Obstet Gynaecol 27:381–92\n12. Donnez J, Squifflet J (2010) Complications, pregnancy and recur-\nrence in a prospective series of 500 patients operated on by the\nshaving technique for deep rectovaginal endometriotic nodules.\nHum Reprod 25:1949–1958\n13. Canis M, Botchorishvili R, Slim K, Pezet D, Pouly JL, Wattiez A\net al (1996) [Bowel endometriosis. Eight cases of colorectal resec-\ntion]. J Gynecol Obstet Biol Reprod (Paris) 25:699–709\n14. Duepree HJ, Senagore AJ, Delaney CP , Marcello PW, Brady KM,\nFalcone T (2002) Laparoscopic resection of deep pelvic endome-\ntriosis with rectosigmoid involvement. J Am Coll Surg 195:754–8\n15. Abbott JA, Hawe J, Clayton RD, Garry R (2003) The effects and\neffectiveness of laparoscopic excision of endometriosis: a prospec-\ntive study with 2-5 year follow-up. Hum Reprod 18:1922–7\n16. Kavallaris A, Köhler C, Kühne -Heid R, Schneider A (2003)\nHistopathological extent of rectal invasion by rectovaginal endo-\nmetriosis. Hum Reprod 18:1323–7\n17. Ford J, English J, Miles W A, Giannopoulos T (2004) Pain, quality\nof life and complications foll owing the radical resection of\nrectovaginal endometriosis. BJOG 111:353–6\n284 Gynecol Surg (2015) 12:279–285\n\n18. Thomassin I, Bazot M, Detchev R, Barranger E, Cortez A, Darai E\n(2004) Symptoms before and after surgical removal of colorectal\nendometriosis that are assessed by magnetic resonance imaging and\nrectal endoscopic sonography. Am J Obstet Gynecol 190:1264–71\n19. Fleisch MC, Xafis D, De Bruyne F, Hucke J, Bender HG, Dall P\n(2005) Radical resection of invasive endometriosis with bowel or\nbladder involvement —long-term results. Eur J Obstet Gynecol\nReprod Biol 123:224–9\n20. Dubernard G, Piketty M, Rouzier R, Houry S, Bazot M, Darai E\n(2006) Quality of life after laparoscopic colorectal resection for\nendometriosis. Hum Reprod 21:1243–7\n21. Landi S, Mereu L, Pontrelli G, Stepniewska A, Romano L, Tateo S\net al (2008) The influence of adenomyosis in patients\nlaparoscopically treated for deep endometriosis. J Minim Invasive\nGynecol 15:566–70\n22. Ferrero S, Anserini P , Abbamonte LH, Ragni N, Camerini G,\nRemorgida V (2009) Fertility after bowel resection for endometri-\nosis. Fertil Steril 92:41–6\n23. Stepniewska A, Pomini P , Bruni F, Mereu L, Ruffo G, Ceccaroni M\net al (2009) Laparoscopic treatment of bowel endometriosis in in-\nfertile women. Hum Reprod 24:1619–25\n24. Redwine DB (2004) Surgical management of endometriosis.\nMartin Dunitz, Taylor & Francis, New Y ork, USA\n25. Landi S, Ceccaroni M, Perutelli A, Allodi C, Barbieri F, Fiaccavento\nA et al (2006) Laparoscopic nerve-sparing complete excision of\ndeep endometriosis: is it feasible? Hum Reprod 21:774–81\n26. Mereu L, Ruffo G, Landi S, Barbieri F, Zaccoletti R, Fiaccavento A\net al (2007) Laparoscopic treatment of deep endometriosis with\nsegmental colorectal resection: short-term morbidity. J Minim\nInvasive Gynecol 14:463–9\n27. Daraï E, Marpeau O, Thomassin I, Dubernard G, Barranger E,\nBazot M (2005) Fertility after laparoscopic colorectal resection\nfor endometriosis: preliminary results. Fertil Steril 84:945–50\n28. Possover M, Diebolder H, Plaul K, Schneider A (2000)\nLaparascopically assisted vaginal resection of rectovaginal endo-\nmetriosis. Obstet Gynecol 96:304–7\n29. Chapron C, Fritel X, Dubuisson JB (1999) Fertility after laparo-\nscopic management of deep endometriosis infiltrating the\nuterosacral ligaments. Hum Reprod 14:329–32\n30. Stephansson O, Kieler H , Granath F, Falconer H (2009)\nEndometriosis, assisted reproduction technology, and risk of ad-\nverse pregnancy outcome. Hum Reprod 24:2341–7\n31. Brosens I, Brosens JJ, Fusi L, Al-Sabbagh M, Kuroda K,\nBenagiano G (2012) Risks of adverse pregnancy outcome in endo-\nmetriosis. Fertil Steril 98:30–5\n32. V ercellini P , Parazzini F, Pietropaolo G, Cipriani S, Frattaruolo MP ,\nFedele L (2012) Pregnancy outcome in women with peritoneal,\novarian and rectovaginal endometriosis: a retrospective cohort\nstudy. BJOG 119:1538–43\n33. Setubal A, Sidiropoulou Z, Torgal M, Casal E (2014) Bowel com-\nplications of deep endometriosis during pregnancy or in vitro fer-\ntilization. Fertil Steril 101(2):442–6\n34. Hahnloser D, Pemberton JH, Wolff BG, Larson D, Harrington J,\nFarouk R et al (2004) Pregnancy and delivery before and after ileal\npouch-anal anastomosis for inflammatory bowel disease: immedi-\nate and long-term consequences and outcomes. Dis Colon Rectum\n47:1127–35\n35. Juhasz ES, Fozard B, Dozois RR, Ilstrup DM, Nelson H (1995)\nIleal pouch-anal anastomosis function following childbirth. An ex-\ntended evaluation. Dis Colon Rectum 38:159–65\n36. Ravid A, Richard CS, Spencer LM, O'Connor BI, Kennedy ED,\nMacRae HM et al (2002) Pregnancy, delivery, and pouch function\nafter ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon\nRectum 45:1283–8\n37. Remzi FH, Gorgun E, Bast J, Schroeder T, Hammel J,\nPhilipson E et al (2005) V aginal delivery after ileal pouch-\nanal anastomosis: a word of caution. Dis Colon Rectum 48:\n1691–9\n38. Cornish J, Tan E, Teare J, Teoh TG, Rai R, Clark SK et al (2007) A\nmeta-analysis on the influence of inflammatory bowel disease on\npregnancy. Gut 56:830–7\n39\n. American College of Obstetricians and Gynecologists (2013)\nACOG committee opinion no. 559: cesarean delivery on maternal\nrequest. Obstet Gynecol 121:904–7\n40. Phipps MG, Watabe B, Clemons JL, Weitzen S, Myers DL (2005)\nRisk factors for bladder injury during cesarean delivery. Obstet\nGynecol 105:156–60\nGynecol Surg (2015) 12:279–285 285","source_license":"CC0","license_restricted":false}