{"paper_id":"c3bc71e7-10c5-481d-b8a5-4bf9885c70bf","body_text":"Pregnancy after Endometriosis: Maternal and\nNeonatal Outcomes according to the\nLocation of the Disease\nStefano Uccella, MD, PhD 1,2 Paolo Manzoni, MD 3 Antonella Cromi, MD, PhD 2 Nicola Marconi, MD 2\nBaldo Gisone, MD 2 Andrea Miraglia, MD 2 Sara Biasoli, MD 2 Pier Carlo Zorzato, MD 1\nStefania Ferrari, MD 1 Gabriele Lanzo, MD 1 Francesca Bertoli, CNM, MS 2 Vito Andrea Capozzi, MD 4\nDavide Gallina, MD 1 Massimo Agosti, MD 5 Fabio Ghezzi, MD 2\n1 Division of Obstetrics and Gynecology, Department of Maternal,\nNeonatal and Infant Medicine, Nuovo Ospedale degli Infermi, Biella,\nItaly\n2 Department of Obstetrics and Gynecology, Filippo Del Ponte\nHospital, University of Insubria, Varese, Italy\n3 Division of Pediatrics and Neonatology, Department of Maternal and\nInfant Medicine, Nuovo Ospedale degli Infermi, Biella, Italy\n4 Department of Obstetrics and Gynecology, University of Parma,\nParma, Italy\n5 Department of Neonatology and Neonatal Intensive Care Unit,\nUniversity of Insubria, Varese, Italy\nAm J Perinatol 2019;36(suppl S2):S91 –S98.\nAddress for correspondence Stefano Uccella, MD, PhD, Division of\nObstetrics and Gynecology, Depa rtment of Maternal, Neonatal and\nInfant Medicine, Nuovo Ospedale degli Infermi, Via dei Ponderanesi,\n2–13058, Ponderano, Biella, Italy (e-mail: stefucc@libero.it).\nKeywords\n► endometriosis\n► pregnancy\n► deep endometriosis\n► endometrioma\n► neonatal outcomes\n► maternal outcomes\nAbstract Objective To systematically evaluate pregnancy and labor course, obstetrical com-\nplications, and maternal and neonatal outcomes in women with endometriosis,\nstratifying according to the speci fic location of the disease.\nStudy Design We retrospectively analyzed our prospectively maintained obstetrical\ndatabase from January 2011 to August 2014 to identify all women with a previous\nhistological diagnosis of endometriosis who delivered at our institution (cases). We\ndivided the cases according to the speci fic location of the disease (deep in filtrating\nendometriosis, ovarian endometriosis, and peritoneal endometriosis). As controls, we\nidentified all unaffected women who delivered in the year 2013. To avoid the\nconfounding effect of parity, we limited our analysis to nulliparous women.\nResults A total of 118 nulliparous women with endometriosis and 1,690 nulliparous\ncontrols were identi fied. Women with endometriosis were signi ficantly older, had a\nlower body mass index, and had a higher incidence of assisted reproductive technol-\nogy. The duration of pregnancy was signi ficantly shorter among women with endo-\nmetriosis. A higher incidence of placenta previa (3.4 vs. 0.5%; p ¼ 0.006), hypertension\n(11 vs. 5.9%; p ¼ 0.04), cesarean section (41.5 vs. 24.2%; p < 0.0001), and vacuum\ndelivery (10.1 vs. 2.9%; p ¼ 0.006) was found in women with endometriosis. Neonatal\noutcomes were similar between groups. The incidence of placenta previa in patients\nwith deep endometriosis was 11.7 versus 0.5% among controls ( p < 0.0001), whereas\nin women with ovarian and peritoneal endometriosis, it was similar to the controls.\nCopyright © 2019 by Thieme Medical\nPublishers, Inc., 333 Seventh Avenue,\nNew York, NY 10001, USA.\nTel: +1(212) 584-4662.\nDOI https://doi.org/\n10.1055/s-0039-1692130.\nISSN 0735-1631.\nOriginal Article S91\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nEndometriosis is a common gynecological disease that is\ndefined as the presence of endometrial tissue in ectopic\nlocations; it typically affects women in their fertile age.\nThree different forms of the disease have been historically\ndescribed according to the invasiveness and site of the\nimplants: peritoneal disease, ovarian endometriomas, and\ndeep in filtrating endometriosis.\n1 It has been hypothesized\nthat the different anatomical locations may re flect diverse\npathogenetic mechanisms and different clinical course. 1\nRegardless of the location of the disease, the estimated\nprevalence of endometriosis has been concerningly\ndescribed to be up to 11% in the general female population, 2\nbut it dramatically increases among infertile women. 3\nAlthough it has been clearly demonstrated that endometrio-\nsis reduces fertility,\n4–7 pregnancy among women affected by\nthis disease is becoming increasingly common, thanks to\nassisted reproductive technology (ART) 8 and complex surgi-\ncal eradicative procedures. 9–17 Despite the rising rates of\npregnant women with a previous diagnosis of endometriosis\n(and in many cases also previous surgical procedures for this\ncondition), information regarding the possible effect of the\ndisease on obstetrical and neonatal outcomes is still scant.\nInitial reports described an apparently increased risk of\npreterm birth among women with endometriosis.\n18–21 An\nintriguing hypothesis linking endometriotic process and\npreterm delivery regards the possible role of in flammation,\nwith cross-reactions among cytokines, hormones and\ngrowth factors.22 A recent interesting review of the available\nliterature has concluded that complications of endometriosis\nduring pregnancy are rare and that pregnant women affected\nby this disease can be reassured on the course of the\ngestation.\n23 However, a nonnegligible increase in the like-\nlihood of placenta accrete, preterm birth, and aesarean\ndelivery has been described. 23–26\nUnfortunately, most of the available evidence relies either\non population-based studies, which used codes of the diag-\nnoses for both the mother and the newborn at the time of\ndischarge from the hospital, or on small retrospective collec -\ntions of data with conflicting results. Moreover, attention has\nbeen given almost exclusively to pregnancy and maternal\noutcomes, whereas scant data are available on the neonates.\nAt the Department of Obstetrics and Gynecology of the\nUniversity of Insubria, we have been maintaining for years\na detailed prospective collection of perinatal data (regarding\nboth the mother and the newborn) on women who deliver at\nour institution. With the aid of this valuable tool, we\ndesigned this study to systematically evaluate pregnancy\nand labor course, obstetrical complications, and maternal\nand neonatal outcomes in women with endometriosis, stra-\ntifying according to the speci fic location of the disease.\nMaterials and Methods\nThe obstetrical database of the Department of Obstetrics and\nGynecology of the University of Insubria was queried from\nJanuary 2011 to August 2014 to identify all women with a\nprevious diagnosis of endometriosis who delivered at our\ninstitution (cases). This database is a research quality dataset\nthat is designed and approved for both research and internal-\naudit purposes, is updated on a regular basis by trained\nresidents, and has thorough and accurate information\nregarding a patient ’s history, course of pregnancy, possible\nobstetrical complications, details of delivery and peripartum\nperiod, and neonatal outcomes.\nTo avoid the possible confounding effect deriving from the\ninclusion of multiparous women, we focused only on nulli-\nparous women with histologically proven endometriosis.\nThe ascertainment of the diagnosis of endometriosis and\nthe anatomical localization of the disease was conducted as\nfollows: the obstetrical database contains details of medical\nhistory of endometriosis, including the site of the lesions and\nthe treatment received (whether surgical only or surgical þ\npharmacological). For patients previously operated at our\ninstitution, a manual search of the operative charts of the\npatients was performed to con firm the diagnosis, the anato-\nmical site of the disease, the treatment performed, and the\nrAFS (revised American Fertility Society) score. Patients\noperated elsewhere were contacted by phone and were\nasked to provide the operative charts to obtain details of\ntheir disease and of the procedures performed. In case of\nuncertainty or missing histological diagnosis, and/or inaccu-\nrate description of the anatomical localization of disease,\npatients were excluded from the study.\nThe cases of women with endometriosis were then\ndivided according to the site of the lesions in the following\nmanner: (1) deep in filtrating endometriosis (with or with-\nout ovarian and peritoneal localizations), (2) ovarian endo-\nmetriomas (with or without peritoneal endometriosis),\nand (3) peritoneal endometriosis only (i.e., patients with\nonly super ficial localizations on the peritoneum and no\nother types of lesions). The control group was represented\nby all nulliparous women who delivered during the\nyear 2013 but who did not have any history of suspected\nor con firmed endometriosis. Institutional Review Board\napproval was obtained for the prospective collection of\ndata, their retrospective analysis, and collection of follow-\nup information.\nOur analysis focused on the identi fication of maternal and\nfetal/neonatal outcomes during pregnancy, in the intrapar-\ntum period, and in the postpartum period, comparing all\ncases of women affected by endometriosis versus controls\nConclusion Women with endometriosis have a higher incidence of vacuum delivery,\ncesarean section, and placenta previa com pared with unaffected women. The higher\nrisk of placenta previa is attributable exclusively to women with deep endometriosis.\nNeonatal outcomes are unaffected by the presence of the disease.\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al.S92\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nand then stratifying according to the site of the disease. To\ncorrect for the possible confounding effect of ART, we also\nperformed a subanalysis including only those patients who\nconceived spontaneously.\nStatistical Analysis\nStatistical analysis was performed using GraphPad Prism\nversion 5.00 for Windows (GraphPad Software, San Diego,\nCA). Incidence of binomial variables was analyzed for statis-\ntical signi ficance using the Fisher exact test. Regarding\ncontinuous variables, normality testing (D'Agostino and\nPearson test) was performed to determine whether data\nwere sampled from a Gaussian distribution. The Student t-\ntest and Mann –Whitney U test were used to compare con-\ntinuous parametric and nonparametric variables, respec -\ntively. A p-value of <0.05 was considered statistically\nsignificant.\nResults\nA total of 118 nulliparous women were affected by endome-\ntriosis delivered at our institution during the study period\nand were included in this analysis, and 1,690 patients were\nselected as controls. The characteristics of the cases (women\nwith endometriosis) and controls (unaffected women) are\nshown in\n►Table 1 . Women with previously histologically\nproven endometriosis were signi ficantly older, had a lower\nbody mass index (BMI), and had a higher incidence of ART\ncompared with controls. The duration of pregnancy was\nsignificantly shorter among women with endometriosis\n(p ¼ 0.0002), although the difference was only 5 days (39\nweeks and 4 days among controls vs. 38 weeks and 6 days\namong cases). Eighteen (15.3%) and 9 (7.6%) patients in the\nendometriosis group and 194 (11.5%) and 70 (4.1%) in the\ncontrol group delivered before 37 ( p ¼ 0.24) and 34\n(p ¼ 0.09) weeks of gestation, respectively. The relative\nrisk of delivering before 34 weeks of gestation was 1.81\n(95% con fidence interval: 0.95 –3.43) in the endometriosis\ngroup compared with the controls. A higher incidence of\nplacenta previa (3.4 vs. 0.5% p ¼ 0.006) and hypertension (11\nvs. 5.9%; p ¼ 0.04) was found in women affected by endo-\nmetriosis compared with controls.\n►Table 2 reports the maternal and neonatal outcomes at\ndelivery in cases and controls. Women with endometriosis\nhad a lower incidence of spontaneous labor and a higher risk\nof cesarean section and vaginal vacuum delivery compared\nwith controls. Neonatal outcomes in terms of birthweight,\nApgar score at 5 minutes, umbilical artery pH at birth,\nincidence of pH < 7, and neonatal intensive care unit\n(NICU) admissions were similar between groups.\n►Table 3 reports the comparison between the 64\npatients with ovarian endometriosis and the controls.\nPatients in the ovarian endometriosis group were signi fi-\ncantly older and had a lower BMI, a lower median gesta-\ntional age at delivery, a lower incidence of spontaneous\nonset of labor, and a higher rate of cesarean section as well\nas a vacuum delivery compared with controls. The incidence\nof placenta previa and the neonatal outcomes were similar\nbetween groups.\n►Table 4 reports the comparison between the 20 women\nwith peritoneal endometriosis and the controls. The age and\nBMI of the patients were comparable between the two\ngroups. The incidence of vacuum delivery and cesarean\nsection were signi ficantly higher, whereas the likelihood of\nTable 1 Characteristics of the cases affected by endometriosis (study group) versus unaffected controls (control group)\nParameter Study group Control group p-Value\nNo. of patients 118 1,690\nAge 34 (22 –45) 31 (15 –48) <0.0001\n/C21 35 years (%) 50 (42.4) 434 (25.7) 0.001\nBMI (kg/m\n2) 24.71 (19.69 –32.42) 26.4 (17.59 –48.87) 0.049\nAssisted reproductive\ntechnique (%)\n17 (14.4) 100 (5.9) 0.001\nMultiple fetal gestations (%) 6 (5.1) 65 (3.9) 0.46\nGestational age at delivery 38.9 (29.9 –42) 39.6 (23.3 –42.1) <0.001\nMaternal weight at delivery (kg) 70 (45.5 –98) 72 (47 –146) 0.08\nSmoking habit (%) 9 (7.6) 97 (5.7) 0.41\nPreexisting medical\ncomorbidities (%)\n1 (0.8) 12 (0.7) 0.59\nHypertension/preeclampsia (%) 13 (11) 99 (5.9) 0.04\nGDM (%) 6 (5.1) 127 (7.5) 0.46\nPlacenta previa (%) 4 (3.4) 8 (0.5) 0.006\nIUGR (%) 6 (5.1) 51 (3) 0.27\nAbbreviations: BMI, body mass index; GDM, gestational diabetes mellitus; IUGR, intrauterine growth restriction.\nNote: Bold characters highlight statistically signi ficant findings.\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al. S93\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nvaginal delivery was signi ficantly lower in patients with\nperitoneal endometriosis compared with controls; the neo-\nnatal outcomes were similar between groups.\n►Table 5 shows the comparison between the 34 women\nwith deep endometriosis compared with controls. The\npatients in the deep endometriosis group had a lower\ngestational age at birth and a higher incidence of cesarean\nsection, as well as a higher likelihood of hypertensive dis-\norders of pregnancy. The incidence of placenta previa in the\ngroup of patients with deep endometriosis was 11.7 versus\n0.5% among controls ( p < 0.0001). The birthweight, Apgar\nscore at 5 minutes, umbilical artery pH at birth, incidence of\npH < 7, and NICU admissions were similar between groups.\nThese results did not change after exclusion of patients\nwho obtained pregnancy with assisted reproductive\ntechniques.\nDiscussion\nThis study demonstrates that women who deliver after a\nprevious histological diagnosis of endometriosis are leaner,\nare older, and have a lower likelihood of spontaneous onset\nof labor and a higher incidence of cesarean section and\nvacuum delivery compared with patients without endome-\ntriosis. We also reported a higher rate of hypertensive\ndisorders of pregnancy and placenta previa in women\naffected by the disease. The observed increase in the inci-\ndence of placenta previa is attributable exclusively to the\ngroup of women affected by deep in filtrating endometriosis.\nIt is interesting to note that neonatal outcomes are not\naffected by the presence and location of endometriosis.\nAnother interesting finding of our study is the observed\ntendency (although not signi ficant) toward a higher rate of\npreterm delivery < 34 weeks of gestation among women\nwith endometriosis. Even though patients with the disease\nhave a signi ficantly shorter duration of pregnancy, the\nclinical signi ficance of this shortening appears limited\n(only 5 days in median) and therefore should not be regarded\nas a major issue in the everyday clinical practice.\nPrevious studies have already shown an association\nbetween endometriosis and some unfavorable pregnancy\noutcomes.\n18–26 However, two interesting and comprehen-\nsive reviews by Leone Roberti Maggiore et al have high-\nlighted that the risk of complications associated with\nendometriosis during pregnancy is low.\n23,24 While the avail-\nable literature suggests that there is an increased risk of\nplacenta previa, particularly in patients with deep endome-\ntriosis, pregnant women with endometriosis should be in\ngeneral reassured regarding the course of their gestation.\nFew studies, however, have focused on the possible simila-\nrities and differences among the different types and loca-\ntions of endometriosis.\n27 Moreover, while a discrete number\nof papers have focused on women ’s health, the literature is\ndevoid of information on the impact of endometriosis on the\ncourse of labor and on neonatal outcomes. Thanks to our\nsystematic and thorough collection of data, we were able to\nTable 2 Delivery outcomes: patients with endometriosis versus control group\nParameter Study group Control group p-Value\nNo. of patients 118 1,690\nSpontaneous labor (%) 56 (47.5) 997 (58.9) 0.015\nLabor induction (%) 34 (31.4) 452 (26.7) 0.67\nFailed induction (%) 10 (8.5) 86 (5.1) 0.13\nEpidural analgesia in labor (%)\na 34/89 (38.2) 659/1,469 (44.8) 0.23\nVaginal delivery (%) 69 (58.5) 1,281 (75.8) <0.0001\nVacuum delivery (%) 7 (10.1) 37 (2.9) 0.006\nCS (%) 49 (41.5) 409 (24.2) <0.0001\nCS in labor (%) 20 (16.9) 188 (11.1) 0.07\nBlood transfusion (%) 3 (2.5) 36 (2.1) 0.74\nEBL (mL) 375 (50 –3,850) 300 (50 –3,000) 0.23\nPostpartum hemorrhage (%) 21 (17.8) 413 (24.4) 0.051\nPostpartum urinary retention (%) 1 (0.9) 48 (2.8) 0.37\nPostpartum hospital stay (days) 3 (1 –8) 3 (0 –15) 0.32\nNeonatal weight at birth (grams) 3,105 (1,250 –4,090) 3,120 (400 –5,030) 0.19\nApgar at 5 min 10 (4 –10) 10 (0 –10) 0.91\nNICU admissions (%) 7 (5.9) 94 (5.6) 0.68\nUmbilical artery pH at birth 7.29 (6.97 –7.48) 7.27 (6.67 –7.45) 0.69\nAbbreviations: CS, cesarean section; EBL, estimated blood loss; NICU, neonatal intensive care unit.\nNote: Bold characters highlight statistically signi ficant findings.\naThe percentage is calculated on the total number of women who entered labor.\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al.S94\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nprovide consistent results and explore the aspects that have\nbeen less investigated.\nThe higher incidence of cesarean section observed in our\nstudy is maintained also after the exclusion of women who\nunderwent ART. The possible explanations for this observa-\ntion are dif ficult to find. While the older age and the higher\nincidence of placenta previa may obviously play a role, it\nmay be hypothesized that the possible coexistence of\nadenomyosis could be responsible for altered uterine con-\ntractility both during and before labor. However, these\nassumptions should be investigated and proven with spe-\ncific and personalized research. On the other hand, we\nobserved that there is no detrimental impact of endome-\ntriosis on the newborn ’s health, even in case of deep\nendometriosis.\nIt is interesting to note that different subtypes of endo-\nmetriosis are associated with different pregnancy out-\ncomes. In general, our findings suggest that peritoneal\nendometriosis should be regarded as the mildest expression\nof the disease even when considering the course of preg-\nnancy. On the other hand, it is well known that deep\ninfiltrating endometriosis is the most severe form of the\ndisease, with the worst symptoms and the highest tech-\nnical dif ficulty when surgical treatment is to be accom-\nplished. When dealing with pregnancy, deep endometriosis\nappears as the subtype of disease associated with the\npoorest outcomes in comparison with ovarian and perito-\nneal endometriosis.\nWe acknowledge several limitations of our study. First, the\nretrospective design may be the source of possible selection,\ndetection and reporting bias. However, we emphasize that\nour systematic collection of data considerably reduces these\npossible drawbacks. Another possible limitation of our series\nis that we did not stratify according to the radicality of the\nsurgery performed for endometriosis, particularly for deep\nendometriosis. However, it is commonly accepted that the\ncomplete removal of the disease during surgical procedures\nis associated not only with a higher risk of complications but\nalso with a signi ficant improvement in terms of fertility\nrates.\n9–11,13 Moreover, it is our policy to completely remove\nTable 3 Adnexal endometriosis versus control group\nParameter Adnexal endome triosis Control group p-Value\nNo. of patients 64 1,690\nGestational week at delivery 38.9 (30 –41.9) 39.6 (range 23.3 –42.1) 0.016\nAge 34 (26 –44) 31 (15 –48) <0.0001\nSpontaneous labor (%) 28 (43.7) 997 (58.9) 0.02\nVaginal delivery (%) 40 (62.5) 1,281 (75.7) 0.02\nVacuum delivery (%) 4 (10) 37 (2.9) 0.03\nCS (%) 24 (37.5) 409 (24.3) 0.02\nCS in labor (%) 8 (33.3) 188 (45.9) 0.29\nBMI 24.2 (19.7 –27.9) 26.4 (17.5 –48.8) 0.002\nSmoking habit (%) 7 (10.9) 97 (5.7) 0.09\nHypertension/preeclampsia (%) 7 (10.9) 99 (5.9) 0.10\nGDM (%) 2 (3.1) 127 (7.5) 0.32\nPlacenta previa 0 8 (0.5) 1.00\nEBL (mL) 375 (100 –2,000) 300 (50 –3,000) 0.18\nPostpartum hemorrhage (%) 10 (15.6) 413 (24.4) 0.13\nBlood transfusion (%) 2 (4.6) 36 (2.1) 0.64\nPostpartum urinary retention 0 48 (2.8) 0.41\nPostpartum hospital stay (days) 3 (2 –7) 3 (0 –15) 0.47\nNeonatal weight at birth 3,100 (1,350 –3,960) 3,120 (400 –5,030) 0.18\nApgar at 5 minutes 10 (5 –10) 10 (0 –10) 0.66\nNICU admissions (%) 3 (4.7) 94 (5.6) 0.76\nIUGR (%) 3 (4.6) 51 (3) 0.44\nAnalgesia (%) 22/40 (55) 659/1,281 (51.4) 0.74\nUmbilical artery pH at birth 7.3 (6.97 –7.46) 7.27 (6.67 –7.45) 0.18\nAbbreviations: BMI, body mass index; CS, cesarean section; EBL, estimated blood loss; GDM, gestational diabetes mellitus; NICU, neonatal intensiv e\ncare unit; IUGR, intrauterine growth restriction.\nNote: Bold characters highlight statistically signi ficant findings.\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al. S95\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nTable 4 Peritoneal endometriosis versus control group\nParameter Peritoneal endometriosis Control group p-Value\nNo. of patients 20 1,690\nGestational age at delivery 38.8 (29.9 –42) 39.6 (23.3 –42.1) 0.16\nMultiple fetal gestations (%) 1 (5) 65 (3.9) 0.54\nA g e( y e a r s ) 3 3 . 5( 2 6 –39) 31 (15 –48) 1.00\nSpontaneous labor (%) 9 (45) 997 (58.9) 0.25\nVaginal delivery (%) 10 (50) 1,281 (75.8) 0.02\nVacuum delivery (%) 3 (30) 37 (2.9) 0.003\nCS (%) 10 (50) 409 (24.2) 0.02\nCS in labor (%) 6 (60) 188 (45.9) 0.52\nBMI 24.62 (20.8 –28.4) 26.4 (17.5 –48.8) 0.5\nSmoking habit (%) 2 (10) 97 (5.7) 0.32\nHypertension/preeclampsia (%) 1 (5) 99 (5.9) 1.00\nGDM (%) 1 (5) 127 (7.5) 1.00\nPlacenta previa (%) 0 8 (0.5) 1.00\nEstimated blood loss (mL) 350 (50 –900) 300 (50 –3,000) 0.76\nPostpartum hemorrhage (%) 5 (25) 413 (24.4) 1.00\nBlood transfusion 0 36 (2.1) 1.00\nPostpartum urinary retention (%) 1 (5) 48 (2.8) 0.44\nPostpartum hospital stay (days) 3 (2 –4) 3 (0 –15) 0.41\nNeonatal weight (grams) 3,150 (1,250 –4,090) 3,120 (400 –5,030) 0.82\nApgar at 5 min 10 (7 –10) 10 (0 –10) 0.24\nNICU admissions (%) 1 (5) 94 (5.6) 1.00\nIUGR (%) 1 (5) 51 (3) 0.46\nEpidural analgesia in labor (%) 5 (50) 659/1,281 (51.4) 1.00\nUmbilical artery pH at birth 7.31 (7.11 –7.48) 7.27 (6.67 –7.45) 0.02\nAbbreviations: BMI, body mass index; CS, cesarean section; GDM, gesta tional diabetes mellitus; NICU, neonatal intensive care unit; IUGR,\nintrauterine growth restriction.\nNote: Bold characters highlight statistically signi ficant findings.\nTable 5 Deep endometriosis versus control group\nParameter Deep endometriosis Control group p-Value\nNo. of patients 34 1,690\nGestational age at delivery 38.6 (30 –41.6) 39.6 (23.3 –42.1) 0.002\nA g e( y e a r s ) 3 3 . 5( 2 2 –45) 31 (15 –48) 0.09\nSpontaneous labor (%) 15 (44.1) 997 (58.9) 0.11\nVaginal delivery (%) 19 (55.8) 1,281 (75.7) 0.013\nVacuum delivery (%) 0 37 (2.9) 1.000\nCS (%) 15 (44.2) 409 (24.3) 0.013\nCS in labor (%) 6 (40) 188 (45.9) 1.000\nBMI 27 (23.5 –32.4) 26.4 (17.5 –48.8) 0.54\nSmoking habit (%) 0 97 (5.7) 0.25\nHypertension/preeclampsia (%) 5 (14.7) 99 (5.9) 0.03\nGDM (%) 2 (5.8) 127 (7.5) 0.19\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al.S96\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nthe disease when surgery is indicated. As a consequence, we\nassume that almost all the patients included in this study had\noptimal removal of endometriosis at the time of surgery\nbefore the onset of pregnancy.\nIn conclusion, our analysis provides useful data on an\nappropriate and moderately optimistic counseling to preg-\nnant women previously operated for endometriosis. Our\nfindings show that although patients with deep endome-\ntriosis have a considerably higher risk of placenta previa ( /C24 1\nout of 10), the overall outcomes of pregnancy and in parti-\ncular the neonatal outcomes are in line with those of\nunaffected women.\nFunding\nNone.\nConflict of Interest\nNone declared.\nReferences\n1 Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endome-\ntriosis, and adenomyotic nodules of the rectovaginal septum are\nthree different entities. Fertil Steril 1997;68(04):585 –596\n2 Buck Louis GM, Hediger ML, Peterson CM, et al; ENDO Study\nWorking Group. Incidence of endometriosis by study population\nand diagnostic method: the ENDO study. Fertil Steril 2011;96\n(02):360–365\n3 Macer ML, Taylor HS. Endometriosis and infertility: a review of\nthe pathogenesis and treatment of endometriosis-associated\ninfertility. Obstet Gynecol Clin North Am 2012;39(04):535 –549\n4 Harb HM, Gallos ID, Chu J, Harb M, Coomarasamy A. The effect of\nendometriosis on in vitro fertilisation outcome: a systematic\nreview and meta-analysis. BJOG 2013;120(11):1308 –1320\n5 Falconer H. Pregnancy outcomes in women with endometriosis.\nSemin Reprod Med 2013;31(02):178 –182\n6 Practice Committee of the American Society for Reproductive\nMedicine. Endometriosis and infertility. Fertil Steril 2006;86(05,\nSuppl Suppl 1):S156 –S160\n7 Legendre G, Catala L, Morinière C, et al. Relationship between\novarian cysts and infertility: what surgery and when? Fertil Steril\n2014;101(03):608–614\n8 Prefumo F, Rossi AC. Endometriosis, endometrioma, and ART\nresults: current understanding and recommended practices.\nBest Pract Res Clin Obstet Gynaecol 2018;51:34 –40\n9 Uccella S, Gisone B, Serati M, et al. Functional outcomes of nerve-\nsparing laparoscopic eradication of deep in filtrating endometrio-\nsis: a prospective analysis using validated questionnaires. Arch\nGynecol Obstet 2018;298(03):639 –647\n10 Uccella S, Marconi N, Casarin J, et al. Impact of endometrio-\nsis on surgical outcomes and complications of total laparoscopic\nhysterectomy. Arch Gynecol Obstet 2016;294(04):771 –778\n11 Uccella S, Cromi A, Agosti M, et al. Fertility rates, course of\npregnancy and perinatal outcomes after laparoscopic ureterolysis\nfor deep endometriosis: a long-term follow-up study. J Obstet\nGynaecol 2016;36(06):800 –805\n12 Rausei S, Sambucci D, Spampatti S, et al. Laparoscopic treatment\nof deep in filtrating endometriosis: results of the combined\nlaparoscopic gynecologic and colorectal surgery. Surg Endosc\n2015;29(10):2904–2909\n13 Uccella S, Cromi A, Casarin J, et al. Laparoscopy for ureteral\nendometriosis: surgical details, long-term follow-up, and fertility\noutcomes. Fertil Steril 2014;102(01):160 –166\n14 Ceccaroni M, Ceccarello M, Calef fi G, et al. Total laparoscopic\nureteroneocystostomy for ureteral endometriosis: a single-center\nexperience of 160 Consecutive Patients. J Minim Invasive Gynecol\n2019;26(01):78–86\n15 Ceccaroni M, Clarizia R, Roviglione G, Ruffo G. Neuro-anatomy of\nthe posterior parametrium and surgical considerations for a\nnerve-sparing approach in radical pelvic surgery. Surg Endosc\n2013;27(11):4386–4394\n16 Ceccaroni M, Clarizia R, Bruni F, et al. Nerve-sparing laparo-\nscopic eradication of deep endometriosis with segmental\nrectal and parametrial resection: the Negrar method. A single-\ncenter, prospective, clinical trial. Surg Endosc 2012;26(07):\n2029–2045\nTable 5 (Continued )\nParameter Deep endometriosis Control group p-Value\nPlacenta previa (%) 4 (11.7) 8 (0.5) <0.0001\nEstimated blood loss (mL) 400 (50 –3,850) 300 (50 –3,000) 0.84\nPostpartum hemorrhage (%) 6 (17.6) 413 (24.4) 0.42\nBlood transfusion (%) 1 (2.9) 36 (2.1) 0.52\nEpisiotomy\nPostpartum urinary retention 0 48 (2.8) 1.00\nPostpartum hospital stay (days) 3 (1 –8) 3 (0 –15) 0.003\nNeonatal weight at birth (grams) 3,080 (1,530 –3,760) 3,120 (400 –5,030) 0.42\nApgar at 5 min 10 (4 –10) 10 (0 –10) 0.23\nNICU admissions (%) 3 (8.8) 94 () 0.42\nIUGR (%) 2 (5,8) 51 (3) 0.28\nEpidural analgesia in labor (%) 7/19 (36.8) 659/1,281 (51.4) 1.00\nUmbilical artery pH at birth 7.26 (7.01 –7.49) 7.27 (6.67 –7.45) 0.66\nAbbreviations: BMI, body mass index; CS, cesarean section; GDM, gesta tional diabetes mellitus; NICU, neonatal intensive care unit; IUGR,\nintrauterine growth restriction.\nNote: Bold characters highlight statistically signi ficant findings.\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al. S97\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\n17 Iosca S, Lumia D, Bracchi E, et al. Multislice computed tomography\nwith colon water distension (MSCT-c) in the study of intestinal and\nureteral endometriosis. Clin Imaging 2013;37(06):1061–1068\n18 Ueda Y, Enomoto T, Miyatake T, et al. A retrospective analysis of\novarian endometriosis during pregnancy. Fertil Steril 2010;94\n(01):78–84\n19 Brosens I, Brosens JJ, Fusi L, Al-Sabbagh M, Kuroda K, Benagiano G.\nRisks of adverse pregnancy outcome in endometriosis. Fertil Steril\n2012;98(01):30–35\n20 Stephansson O, Kieler H, Granath F, Falconer H. Endometriosis,\nassisted reproduction technology, and risk of adverse pregnancy\noutcome. Hum Reprod 2009;24(09):2341 –2347\n21 Fernando S, Breheny S, Jaques AM, Halliday JL, Baker G, Healy D.\nPreterm birth, ovarian endometriomata, and assisted reproduc -\ntion technologies. Fertil Steril 2009;91(02):325 –330\n22 Petraglia F, Arcuri F, de Ziegler D, Chapron C. In flammation: a link\nbetween endometriosis and preterm birth. Fertil Steril 2012;98\n(01):36–40\n23 Leone Roberti Maggiore U, Ferrero S, Mangili G, et al. A systematic\nreview on endometriosis during pregnancy: diagnosis, misdiag-\nnosis, complications and outcomes. Hum Reprod Update 2016;22\n(01):70–103\n24 Leone Roberti Maggiore U, Inversetti A, Schimberni M, Viganò P,\nGiorgione V, Candiani M. Obstetrical complications of endome-\ntriosis, particularly deep endometriosis. Fertil Steril 2017;108\n(06):895–912\n25 Zullo F, Spagnolo E, Saccone G, et al. Endometriosis and obstetrics\ncomplications: a systematic review and meta-analysis. Fertil\nSteril 2017;108(04):667 –672\n26 Chen I, Lalani S, Xie RH, Shen M, Singh SS, Wen SW. Association\nbetween surgically diagnosed endometriosis and adverse preg-\nnancy outcomes. Fertil Steril 2018;109(01):142 –147\n27 Exacoustos C, Lauriola I, Lazzeri L, De Felice G, Zupi E. Complica-\ntions during pregnancy and delivery in women with untreated\nrectovaginal deep in filtrating endometriosis. Fertil Steril 2016;\n106(05):1129–1135\nAmerican Journal of Perinatology Vol. 36 Suppl. S2/2019\nPregnancy after Endometriosis Uccella et al.S98\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.","source_license":"CC0","license_restricted":false}