{"paper_id":"ba5a2d12-be78-4044-b54e-c9516d73ac4d","body_text":"JCOG. 2023;33(2):72-80\n72\nEndometriosis is a chronic inflammatory disease \ncharacterized by the presence of endometrial gland \nand stroma outside the uterine cavity.\n1 The preva-\nlence of endometriosis in reproductive women is ap-\nproximately 10%. \nEndometriosis is associated with pelvic pain in \n60-80% of cases and infertility in 30-40%. Adhesions \nand anatomical disorders due to fibrosis, endocrine \nabnormalities and immunological factors are shown \nas the causes of infertility in women with en-\ndometriosis. Pregnancy rates increase with assisted \nreproductive techniques and treatments in en-\ndometriosis cases.\n2 \nPhysical examination findings in women with \nendometriosis are variable and depend on the loca-\ntion and size of the implants.\n3 While the physical ex-\namination findings help the diagnosis, the \nexamination may also be completely normal, the nor-\nmal examination does not exclude the disease.\n4 Var-\nious biochemical markers, transabdominal and \ntransvaginal sonography, magnetic resonance imag-\ning, and computed tomography methods are various \nmethods used for the diagnosis of endometriosis. \nHowever, the definitive diagnosis is made by histo-\nlogical evaluation of a lesion biopsied during \nsurgery.\n5 \nEffect of Endometriosis on Obstetric Outcomes:  \nA Tertiary Center Experience \n     Aytaj MAHMUDOVAa,     Elifnur BİÇERb,     Burçin KARAKUŞc,     Kutsiye Pelin ÖÇALb \naClinic of Obstetrics and Gynecology, Yeni Yüzyıl University Gaziosmanpaşa Hospital, İstanbul, Türkiye \nbDepartment of Obstetrics and Gynecology, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye \ncClinic of Obstetrics and Gynecology, Çamlıca Medipol University Hospital, İstanbul, Türkiye\nABS TRACT Objective: The aim of this study is to compare the course of pregnancy in women with and without endometriosis for obstetric \ncomplications. Material and Methods: Patients applied to İstanbul University-Cerrahpasa were included in the case group, 49 patients in the \ncontrol group, and evaluated retrospectively. Early and late pregnancy complications were recorded. P<0.05 was considered stati stically sig-\nnificant. Results: A decrease in the rate of spontaneous pregnancy and a significant increase in the IVF rate were observed in the endometrio-\nsis group (p<0.05). Gestational hypertension,placental abruption, placental adhesion anomalies,premature rupture of membranes, fetal growth \nrestriction, threat of preterm birth and oligohydramnios there was no significant difference between the two groups (p>0.05). T he rate of ce-\nsarean delivery was 55.1% in the control group and 61.0% in the endometriosis group (p>0.05). Postpartum uterine atony,bladder injury dur-\ning cesarean section and requirement of postpartum blood transfusion seen in 6 (6.7%), 2(1.1%), and 1 (11.1%) patients respecti vely (p<0.05). \nNeonatal intensive care unit requirement was 39.0% and 24.4% in case and control group (p>0.05). Conclusion: Women with endometriosis \nare at higher risk for complications during pregnancy. The rates of miscarriage in the early gestational weeks, preeclampsia, p lacenta previa, \ngestational diabetes mellitus in the second and third trimesters, postpartum uterine atony, blood transfusion requirement,and s urgical compli-\ncations during cesarean section are higher in women with endometriosis. \n \nKeywords: Endometriosis; placenta; previa; preeclampsia; complications\nDOI: 10.5336/jcog.2023-95314\nCorrespondence: Elifnur BİÇER \nDepartment of Obstetrics and Gynecology, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye \nE-mail: drelifnurbicer@gmail.com  \nPeer review under responsibility of Journal of Clinical Obstetrics & Gynecology.  \nRe ce i ved: 06 Jan 2023          Ac cep ted: 12 May 2023          Available online: 18 May 2023  \n2619-9467 / Copyright © 2023 by Türkiye Klinikleri. This is an open \naccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nTurkiye Klinikleri Journal of Internal Medicine \nJournal of Clinical Obstetrics & Gynecology\nORIGINAL RESEARCH\n\nIt is thought that pregnancy positively affects en-\ndometriosis due to amenorrhea and anovulation. 6 \nHowever, with the increase in the success rates in the \ntreatment of endometriosis in recent years, the com-\nplication rates in pregnancies have also attracted at-\ntention. There are studies showing that endometriosis \nis associated with early pregnancy complications (ec-\ntopic pregnancy, abortion, abortus imminens), pla-\ncental pathologies (placenta previa, placenta \nattachment anomalies), placental abruption, preterm \nbirth threat and preterm delivery, fetal growth re-\nstriction, oligohydramnios, gestational diabetes, and \nhypertensive diseases of pregnancy.\n1,7,8 It has been re-\nported that the risk of cesarean delivery, postpartum \nhemorrhage and neonatal complications is high in \ncases with endometriosis.\n9,10 Uterine rupture, intesti-\nnal perforation, spontaneous hemoperitoneum or \nuroperitoneum are also rare obstetric complications \nrelated to endometriosis.\n11 It is not clear whether there \nis a relationship between the stage and type of the dis-\nease and the risk of developing neonatal and obstet-\nric complications.\n12 \nThe aim of this study is to examine the effects \nof endometriosis on pregnancy outcomes by com-\nparing certain characteristics of women with and \nwithout endometriosis, and to determine and evaluate \nmaternal complications because of pregnancy of en-\ndometrisis. \n MATERIAL AND METHODS \nThis study was conducted at İstanbul University-\nCerrahpaşa, Cerrahpa şa Faculty of Medicine, fol-\nlowing the necessary approval of the ethics \ncommittee (date: March 3, 2021, no: E-83045809-\n604.01.02-43516). This study is conducted based on \nthe principles of Helsinki Declaration. The informa-\ntion of the patients who applied to the obstetrics and \ngynecology clinics of İstanbul University-\nCerrahpaşa, Cerrahpa şa Faculty of Medicine, De-\npartment of Obstetrics and Gynecology between \n2015-2020 were scanned retrospectively using the \nhospital electronic database system and patient \narchive files. The files of patients with endometriosis \ndiagnosed before or during pregnancy were identi-\nfied. Informed consent was obtained from each pa-\ntient. For the case group, patients with clinical \ndiagnosis of endometriosis with ultrasound imaging, \nand for the control group, nulliparous pregnant \nwomen without a history of chronic systemic disease \nwere included in the study. \nPatients under the age of 18 and over the age of \n45, patients with a body mass index (BMI) below \n18.5 kg/m² and above 35 kg/m², patients with chronic \nsystemic diseases (chronic kidney diseases, autoim-\nmune diseases, chronic hypertensive diseases, an-\ntiphospholipid antibody syndrome and other causes \nof thrombophilia), patients with autoimmune, genetic \ndiseases, factor deficiencies, diabetes mellitus Type 1 \nand 2, multiparous patients, patients with a history of \nprevious endometriosis surgery, uterine anomalies, \nand patients with a history of previous uterine surgery \nwere not included in the study. \nFor statistical analysis, SPSS 27.0 (IBM, USA) \nprogram was used. The Kolmogorov-Smirnov test, \nindependent sample t-test, the Mann-Whitney U test, \nchi-square test, the Fischer test were used. In statisti-\ncal analysis, those with a significance level less \np<0.05 were considered significant. \n RESULTS \nIn our study, the results of 41 cases in the case group \nand 49 cases in the control group were examined. In \nTable 1, the case and control groups were examined \nabout the demographic characteristics. The mean age \nwas 27.5±4.8 years in the control group and 29.4±4.2 \nyears in the case group. Mean BMI values were \n27.2±3.7 and 27.0±3.1 in the control and case groups, \nrespectively. \nIn the endometriosis group, 23 (56.1%) of 41 \ncases were diagnosed with ultrasonography and 18 \n(43.9%) were diagnosed surgically (histopathologi-\ncally). Isolated ovarian endometrioma was seen in 34 \n(82.9%) cases, deep infiltrative endometriosis and \novarian endometrioma were observed in 6 (14.6%) \ncases, and adenomyosis was observed in 1 (2.4%) \ncase with ovarian endometrioma with ultrasound \nimaging. The mean diameter in patients with ovarian \nendometrioma was 5.1±1.7 cm. \nSpontaneous pregnancy was observed in 46 \n(93.9%) of 49 patients in the control group, and preg-\nnancy was achieved in 3 (6.1%) patients with in-\nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n73\n\nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n74\ntrauterine insemination (IUI) and in vitro fertilization \n(IVF). Of the pregnancies in the case group, 9 \n(22.0%) were IVF, 3 (7.3%) were IUI, and 29 \n(70.7%) were spontaneous pregnancies. When the \ntwo groups were statistically compared, it was found \nthat the pregnancy rate obtained by IVF was signifi-\ncantly higher in the case group, and spontaneous \npregnancies were lower (p<0.05) (\nTable 2). \nAbortion was detected in 22% of patients with \nendometriosis which was significantly higher in en-\ndometriosis group than control group (p<0.05) (\nTable \n3). \nPreeclampsia was observed in 1 (2%) patient in \nthe control group and 6 (14.6%) in the endometriosis \ngroup (p<0.05). In other words, the risk of develop-\ning preeclampsia was significantly higher in patients \nwith endometriosis. When evaluated in terms of ob-\nstetric complications such as gestational hyperten-\nsion, abruption of placenta, premature rupture of \nmembranes, growth restriction of fetus, threat of \npreterm birth, and oligohydramnios, no significant \ndifference was found in the two groups (p>0.05). No \ncase of placenta previa was observed in 49 patients in \nthe control group. Placenta previa developed in 9.8% \nof the patient group with endometriosis, and the risk \nwas higher than control group (p<0.05). Although the \nrate of placenta previa was significantly higher in cases \nwith endometriosis, no significant difference was found \nin terms of placenta attachment anomalies (p>0.05). \nPlacental adhesion anomaly was detected in 1 patient \nin the control group and in 5 patients in the case group. \nPlacenta accreta was observed in 1 patient in the control \ngroup, and 4 of the patients in the case group. Placenta \npercreta was observed in 1 case in the endometriosis \ngroup, and bladder injury was reported during cesarean \ndelivery. 22.0% of the patients with endometriosis and \n6.1% of the patients were diagnosed with gestational \ndiabetes in the control group (p<0.05). \nWhile the mean week of gestation at birth was \n38.3±2.1 in the control group, this value was \n37.2±2.2 in the endometriosis group. The median val-\nControl group Case group  \nDemographic characteristics n X±SD % n X±SD % p value  \nAge  27.5±4.8   29.4±4.2  0.064 a  \nBody mass index  27.2±3.7   27.0±3.1  0.785 b \nSmoking status 46  93.9 38  92.7 0.821 c \n3  6.1 3  7.3  \nAlcohol consumption 49  100.0 41  100.0 1.000 c \n0  0.0 0  0.0  \nGravida 1 44  89.8 31  75.6 0.129 c \n2 4  8.2 10  24.4  \n3 1  2.0 0  0.0  \nParity 0 49  100.0 41  100.0 1.000\nc \n1 0  0.0 0  0.0  \nAbortus 0 44  89.8 31  75.6 0.129 c \n1 4  8.2 10  24.4  \n2 1  2.0 0  0.0  \nTABLE 1:  Demographic characteristics of the subjects examined in the case and control groups.\naMann-Whitney U test; bt-test; cChi-squared test; SD: Standard deviation.\nControl group Case group   \n(n=49) (n=41)  \nObstetric features n % n % p value  \nIntrauterine insemination pregnancy 1 2 3 7.3 0.326 \nIn vitro fertilization pregnancy 2 4.1 9 22 0.024 \nSpontaneous pregnancy 46 93.9 29 70.7 0.008 \nSingle fetus 49 100 39 95.1 0.205 \nTwin fetuses 0 0 2 4.9  \nTABLE 2:  Pregnancy characteristics of the cases examined in \nthe case and control groups.\n\nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n75\nues were 39.0 and 38.0, respectively (p=0.009) \n(Table 4). \nWhile the mean birth weight of the babies of the \npatients was 3266.1±618.4 grams in the control \ngroup, it was 3074.8±552.8 grams in the case group \n(p>0.05). \nCesarean section rate was 55.1% in the control \ngroup, and 61.0% in endometriosis group (p>0.05). \nDue to the development of acute abdomen after en-\ndometriotic cyst rupture in 2 of the patients diagnosed \nwith endometriosis, emergency cesarean delivery was \ndecided (\nTable 4). \nComplications developed during delivery in 8 \n(19.5%) patients in the case group, and all these pa-\ntients delivered by cesarean section. Uterine atony \nwas observed in 6 patients and bladder injury was ob-\nserved in 2 patients. The risk of complications was \nsignificantly higher in patients with endometriosis \nthan in the control group (p=0.001). There was no \nneed for blood transfusion in the postpartum period in \n49 patients in the control group. However, 10 patients \nin the endometriosis group received blood transfu-\nsion (p<0.05) (\nTable 5). \nNeonatal intensive care unit (NICU) require-\nment was 39.0% and 24.4% in the case group and \ncontrol group, respectively. Mostly, the reasons for \nNICU requirement were prematurity, neonatal tran-\nsient tachypnea, and congenital malformations. Con-\ngenital malformation was observed in 6 (14.6%) \nnewborns in the case group. Of these, 2 had cleft \npalate-lip, 2 had cardiac anomaly, 1 had omphalo-\ncele, and 1 had bilateral hydronephrosis. Congeni-\ntal malformations were reported in 5 (10.2%) \nnewborns in the control group. Of these, 1 had cleft \npalate-lip, 2 had cardiac anomaly, 1 had hydrops \nfetalis, and 1 had fetal vein of galena aneurysm. \nWhen the overall malformation rates in the case \nand control groups, as well as the malformation \nsubgroups were compared, no significant statisti-\ncal difference was found. \nControl group (n=49) Case group (n=41) \nComplications  n % n % p value  \nImminent abortion 49 100.00 32 78.00 0.000  \n0 0.00 9 22.00  \nPreeclampsia 48 98.00 35 85.40 0.032  \n1 2.00 6 14.60  \nGestational hypertension 48 98.00 39 95.10 0.590  \n1 2.00 2 4.90  \nPlacental abruption 48 98.00 41 100.00 1.000  \n1 2.00 0 0.00  \nPlacenta previa 49 100.00 37 90.20 0.040  \n0 0.00 4 9.80  \nPlacental adhesion anomalies 48 98.00 36 87.80 0.054  \n1 2.00 5 12.20  \nEarly rupture of membranes 47 95.90 37 90.20 0.282  \n2 4.10 4 9.80  \nIntrauterine growth restriction 48 98.00 38 92.70 0.327  \n1 2.00 3 7.30  \nThreatened preterm labor 45 91.80 35 85.40 0.331  \n4 8.20 6 14.60  \nOligohidramniosis 44 89.80 36 87.80 0.765 \n5 10.20 5 12.20  \nGestational diabetes mellitus 46 93.90 32 78.00 0.028  \n3 6.10 9 22.00  \nTABLE 3:  Comparison of obstetric complications in the case and control groups.\n\nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n76\n DISCUSSION \nEndometriosis is a chronic inflammatory disease that \nis usually associated with infertility and pelvic pain. \nAlthough the exact etiopathogenesis is not known, \nhormonal, immunological and inflammatory changes \nhave been shown to be effective in the development \nand progression of the disease. It is also known that \nadhesions, fibrotic changes and anatomical distor-\ntions occur due to pelvic endometriosis. It is thought \nthat all these biochemical and anatomical changes ad-\nversely affect fertility, obstetric and neonatal out-\ncomes in women with endometriosis.\n1 \nIn our study, the obstetric and neonatal outcomes \nof patients with or without endometriosis who ap-\nplied to the hospital between 2015 and 2020 were \ncompared. In the cases examined in the endometrio-\nsis group, the pregnancy rate obtained by IVF was \nfound to be high (22.0% in the endometriosis group, \nwhile 4.1% in the control group). \nMiura et al. showed that, assisted reproductive \ntechnology (ART) pregnancies were found to be \nhigher in cases with endometriosis (n=80) compared \nto the control group (n=2,689), like our study \n(p<0.01).\n13 It is known that this difference between \nthe two groups is due to the relationship between en-\nControl group Case group \nBirth characteristics n X±SD % n X±SD % p value  \nGestational age at birth  38.3±2.1   37.2±2.2  0.009 \nBirth weight (g)  3266.1±618.4   3074.8±552.8  NS \nMode of delivery Vaginal delivery 22  44.9 16  39.0 NS \nCaesarean section 27  55.1 25  61.0  \nCaesarean section indicatios         \nSevere preeclampsia 0  0.0 4  16.0 NS \nPlacental abruption 1  3.7 0  0.0 NS \nCephalopelvic disproportion 14  51.9 5  20.0 NS \nFetal distress 3  11.1 0  0.0 NS \nGenital warts 2  7.4 0  0.0 NS \nTwin pregnancy 0  0.0 2  8.0 NS \nFailure to progress of delivery 1  3.7 4  16.0 NS \nOvarian cyst rupture 0  0.0 2  8.0 NS \nBreech presentation 5  18.5 4  16.0 NS \nMacrosomic fetus 1  3.7 1  4.0 NS \nPlasenta previa 0  0.0 3  12.0 NS \nTABLE 4:  Birth characteristics of the patients examined in the case and control groups.\nNS: Not significant; SD: Standard deviation.\n Control group Case group  \n n % n % p value  \nBirth complications (atonia, bladder injury) 49 100.00 33 80.50 0.001  \n0 (none) 0.00 8 19.50  \nBlood transfusion requirement 49 100.00 31 75.60 0.000  \n0 (none) 0.00 10 24.40  \nNeonatal intensive care unit requirement 39 79.60 25 61.00 0.052  \n10 20.40 16 39.00  \nNeonatal exitus 47 95.90 41 100.00 0.498  \n2 4.10 0 (none) 0.00  \nCongenital malformations 44 89.80 35 85.40 0.523  \nTABLE 5:  Comparison of postpartum maternal and neonatal complications in the case and control groups.\n\ndometriosis and infertility. The prevalence of en-\ndometriosis in infertile women was found to be 25-\n50%.\n14 \nIn our study, the abortion rate in the en-\ndometriosis group was 22.2%, and it was found to be \nhigher than the control group (p<0.05). Similar re-\nsults to our study were reported in a case-control \nstudy in which a total of 425 cases were examined. In \nthis study by Porpora et al., the data of 145 patients \nwith endometriosis in the case group and 280 patients \nin the control group were evaluated. Abortion rate \nwas reported as 5% in the endometriosis group and \n1% in the control group (p=0.036). Disruption of en-\ndometrial receptivity, remodeling of myometrial spi-\nral vessels, abnormal decidualization, and impaired \nuterine contractility has been implicated as mecha-\nnisms for abortion.\n2,15 \nIn a meta-analysis of 39 studies conducted by \nHuang et al. in 2020, the effects of endometriosis and \nadenomyosis on the risk of miscarriage were evalu-\nated, and it was shown that the risk of abortion in-\ncreased in cases with endometriosis who conceived \nspontaneously. Similarly, it has been shown that the \nrisk of miscarriage is high in cases with a diagnosis of \nendometriosis undergoing ART. In the spontaneously \nconceived group, the data could not be evaluated be-\ncause the relevant data were missing. In subgroup an-\nalyzes of the same study, women with deep pelvic \nendometriosis and superficial peritoneal endometrio-\nsis have been shown to have a higher risk of miscar-\nriage.\n16 \nIn our study, the rate of preeclampsia was found \nto be higher in the endometriosis group. The rate of \npreeclampsia was 2% in the control group and 14.6% \nin the endometriosis group (p<0.05). Gestational hy-\npertension rate was 4.9% in the endometriosis group \nand 2.0% in the control group (p>0.05). Wook Yi et \nal. mentioned that, the pregnancy processes of cases \nwith and without endometriosis were compared, and \nlike the results of our study, the rate of preeclampsia \nwas found to be higher in the endometriosis group \n(p<0.0001). In the subgroup analysis of the same \nstudy, when only singleton pregnancies were evalu-\nated, the rate of preeclampsia was found to be simi-\nlar between the two groups. The high risk of \npreeclampsia detected in the general evaluation with \nthese findings was attributed to the higher rate of \nmultiple pregnancy in endometriosis group than the \nother group, rather than the presence of endometrio-\nsis (multiple pregnancy rate was 2.02% in the con-\ntrol group, and 6.23% in the case group).\n1  \nFarland et al., in a cohort study, showed that the \nrisk of preeclampsia and, in general, hypertensive dis-\nease in pregnancy was significantly higher. Although \nthe etiology is not clear, it is thought that abnormal \nplacentation, defective angiogenesis and local in-\nflammation due to endometriosis may cause the de-\nvelopment of hypertensive diseases during pregnancy \nin patients with endometriosis.\n17 \nPlacenta previa was seen in 4 (9.8%) patients in \nthe endometriosis group,and placenta previa was not \nobserved in the control group cases (p=0.04). Pla-\ncental adhesion anomalies were observed in 5 \n(12.2%) patients in the endometriosis group and in 1 \npatient (2.0%) in the control group (p=0.054). Abla-\ntio placenta was observed in one case at 28 weeks of \ngestation (p=1.000) in the control group. \nIn a study by Chen et al., obstetric complications \nwere evaluated in patients with surgically diagnosed \nendometriosis. In this study, the risk of placenta pre-\nvia was shown to be twice as high in the en-\ndometriosis group, the rate of spontaneous abortion in \nthe obstetric history of the endometriosis group was \n30.13%, while it was 24.82% in control group \n(p=0.0076). The reason for the high rate of placenta \nprevia in endometriosis group was thought to be \nspontaneous abortion and related endometrial trau-\nmas. However, the high rate of placenta previa in en-\ndometriosis group after correction for spontaneous or \ntherapeutic abortion between the two groups showed \nthat there are additional factors in the pathogenesis.\n18 \nIn our study, the rate of premature rupture of \nmembranes was found to be 9.8% in the endometrio-\nsis group and 4.1% in the control group (p=0.282). \nThere was not any difference between the two groups \nfor the threat of preterm birth (14.6% in the en-\ndometriosis group, 8.2% in control group; p=0.331). \nThere wasn’t any significant difference between the \ntwo groups in terms of oligohydramnios (p=0.765). \nFetal growth restriction was observed in 3 patients in \nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n77\n\nthe endometriosis group and in 1 patient in the con-\ntrol group (the rates were 7.30% and 2.00%, respec-\ntively; p=0.327). \nIn a meta-analysis study conducted by Zullo et \nal., including 24 studies, preterm birth and small for \ngestational age were found to be higher in en-\ndometriosis patients. In subgroup analysis of preg-\nnancies obtained by ART with only endometriosis, \nthe increase in preterm birth was found to be high, \nbut the subgroup analysis of women with en-\ndometriosis who became pregnant spontaneously \ncould not be performed with the available data.\n8 In \nour study, while the mean week of gestation at birth \nwas 38.3±3.1 in the control group, this value was \n37.2±2.2 in the endometriosis group (p=0.009). A \nseparate subgroup analysis could not be performed \nfor deliveries <37 weeks due to the small number of \ncases examined. While the mean birth weight was \n3266.1±618.4 grams in the control group, this value \nwas 3074.8±552.8 grams in the case group (p>0.05). \nIn a study by Porpora et al., similar to the results \nof our study, it was shown that risk of premature rup-\nture of membranes, growth restriction of fetus and \noligohydramnios development is not high in cases \nwith endometriosis (p>0.05). Unlike our results, the \nrisk of preterm labor and preterm delivery was found \nto be high in endometriosis cases examined in this \nstudy. While the rate of threat of preterm birth was \nfound 9.6% for endometriosis group, it was reported \nto be 4.0% in the control group (p=0.014). The rate of \npreterm birth was 20.0% in the endometriosis group \nand 8.0% in the control group (p<0.001).\n2 The in-\ncrease in the expression of inflammatory cytokines, \nprostaglandins and metalloproteinase activation \ncauses cervical maturation, disruption of collagen, \nuterine contractions, and inflammation of the mem-\nbranes. In patients with endometriosis, these may ex-\nplain the cause of preterm labor and premature \nrupture of membranes.\n19 \nWhether there is a relationship between en-\ndometriosis and gestational diabetes mellitus (GDM) \nis controversial. While the rate of GDM was 22.0% in \nthe endometriosis group of our study, it was found to \nbe 6.1% in the control group (p=0.028). In a review \npublished in 2019 by Kobayashi et al., it was reported \nthat the risk of GDM is high.\n20 In a study conducted \nby Conti et al., in which the results of 216 primi-\nparous cases with endometriosis were examined, in-\ncreased GDM rates were found in the endometriosis \ngroup. The increased incidence of GDM is explained \nby chronic subclinical inflammation due to en-\ndometriosis.\n21 \nIn our study, no significant difference was found \nbetween two groups in terms of cesarean and normal \nvaginal delivery rates, and cesarean section indica-\ntions (p>0.05). The high rate of cesarean delivery in \nthe control group is due to the fact that our clinic is a \nreference hospital. However, only nulliparous pa-\ntients with endometriosis were included in our study. \nTherefore, placenta previa and placental adhesion \nanomalies were observed less frequently. \nIn many studies, it has been shown that the rate \nof cesarean delivery is higher in patients with en-\ndometriosis.\n1,2,9,22  Leone Roberti  Maggiore et al. \nshowed in a study that endometriosis was associated \nwith high cesarean section rates and the indications \nfor cesarean section in the endometriosis group were \nfetal distress, breech presentation and disproportion, \nrespectively.\n15 Other researchers explained the high \nrate of cesarean section in patients with endometrio-\nsis by the high rate of placental complications (pla-\ncenta previa, placental abruption, placental \nattachment anomalies) and premature birth rates.\n2 In \naddition, it is thought that patients with endometrio-\nsis prefer cesarean section to psychologically avoid \npelvic pain in vaginal delivery.\n7  \nIn our study, complications occurred at birth in \n8 (19.5%) patients in the endometriosis group, and \nall patients delivered by cesarean section. Uterine \natony was observed in 6 patients and bladder injury \nwas observed in 2 patients. Complication risk was \nhigher in patients with endometriosis (p=0.001). Post-\npartum blood transfusion was given to 10 patients in \nthe endometriosis group, and no transfusion was re-\nquired in the control group (p<0.05). Spontaneous \nhemoperitoneum developed due to cyst rupture in 2 \npatients in the endometriosis group. \nIn a case control study, Miura et al. showed that \nthe risk of postpartum hemorrhage is high in cases \nwith endometriosis, similar to the results of our study \nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n78\n\nAytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80\n79\n(p=0.04). When multivariate analysis is performed \naccording to factors that increase the risk of postpar-\ntum hemorrhage, such as pre-pregnancy maternal \nweight (BMI ≥25 kg/m\n2), maternal age ( ≥35 years), \nART, gravida number, placenta previa, and macro-\nsomia (>4,000 g), endometriosis is determined for \npostpartum hemorrhage. It was found that there was \nno independent risk factor (p=0.64).\n13 In our study, \nplacental pathology was observed in 40% of the cases \nrequiring blood transfusion. \nIn the review of Lier et al. in 2017, 44 articles \nwere examined and a total of 59 spontaneous \nhemoperitoneum cases were reported. It was reported \nthat surgery was performed in 39 cases due to mater-\nnal reasons (hemorrhagic shock, acute abdomen), \nfetal distress in 2 cases, and both of the above-men-\ntioned maternal-fetal complications. No major com-\nplications developed in two cases, one patient died, \nand in this case, the diagnosis of hemoperitoneum \ndue to endometriosis was confirmed at autopsy. The \nbleeding focus is from endometriotic implants (11/51 \ncases; 21.6%), decidualized hemorrhagic nodules \n(1/51 cases; 2.0%), ruptured utero-ovarian vessels \n(29/51 cases; 56.8%), or a combination (10/51 cases; \n19.6%). Hysterectomy had to be performed in 4/59 \ncases (6.8%). There was no correlation between the \nseverity of bleeding and the stage of endometriosis \n(p=0.43).\n23 In our study, hemoperitoneum developed \nin 1 patient at 39 th gestational week and in 1 patient \nat 33rd gestational week due to ovarian endometrioma \nrupture. Due to the development of acute abdomen in \nboth cases, emergency cesarean delivery and cystec-\ntomy were performed. \nWhen neonatal outcomes (neonatal exitus, con-\ngenital malformation, NICU requirement) were com-\npared in our study, no significant difference was \nfound between two groups (p>0.05). Porpora et al. \nreported that in their case-control study, similar to our \nresults, no correlation was found between neonatal \noutcomes and endometriosis.\n2 Lalani et al. reported \nin a systematic review and meta-analysis that in pa-\ntients with endometriosis, NICU requirement, still-\nbirth, and neonatal exitus rates were found to be \nsignificantly higher. The reason for this has been \nshown to be the high rate of preterm birth due to ob-\nstetric complications such as placental anomalies and \npreeclampsia in patients with endometriosis.\n22 \n CONCLUSION \nPregnancy carries a higher risk of obstetric compli-\ncations in cases with endometriosis. Surgical com-\nplication rates such as the threat of miscarriage in \nearly pregnancy weeks, preeclampsia, placenta pre-\nvia, risk of GDM development in the second and third \ntrimesters, postpartum uterine atony, need for blood \ntransfusion and bladder injury in cesarean delivery \nare higher in women with endometriosis. \nSource of Finance \nDuring this study, no financial or spiritual support was received \nneither from any pharmaceutical company that has a direct con-\nnection with the research subject, nor from a company that pro-\nvides or produces medical instruments and materials which may \nnegatively affect the evaluation process of this study. \nConflict of Interest \nNo conflicts of interest between the authors and / or family mem-\nbers of the scientific and medical committee members or mem-\nbers of the potential conflicts of interest, counseling, expertise, \nworking conditions, share holding and similar situations in any \nfirm. \nAuthorship Contributions \nIdea/Concept: Aytaj Mahmudova, Elifnur Biçer; Design: Burçin \nKarakuş, Kutsiye Pelin Öçal; Control/Supervision: Aytaj Mah-\nmudova; Data Collection and/or Processing: Elifnur Biçer; \nAnalysis and/or Interpretation: Burçin Karakuş; Literature Re-\nview: Aytaj Mahmudova; Writing the Article: Aytaj Mahmudova; \nCritical Review: Kutsiye Pelin Öçal; References and Fundings: \nKutsiye Pelin Öçal; Materials: Elifnur Biçer.\n\nAytaj MAHMUDOVA et al. 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