EP18.10: Challenges of endometriosis beyond conception in pregnancy

Endometriosis is an inflammatory process that is mostly associated with heavy period, infertility and pelvis pain which may result in unexpected obstetrics complications. The potential complications in pregnancy are miscarriages, preterm birth, Caesarean section, APH, PET & stillbirth. The risks for miscarriages increase by 76%, prematurity by 26%, Caesarean section by 40%, ectopic pregnancy from 0.6-1.6%. The general focuses have been on infertility while women with endometriosis may have high risk pregnancies as illustrated by these two cases reported. A pt with Hx of recurrent miscarriages presented at 34wks of pregnancy with spontaneous hemoperitoneum. She presented with severe abd pain mimicking abruption. At Caesarean section a litre of blood was found within the peritoneum from a torn broad ligament with signs of endometriosis.Hemostasis was achieved by repair of the broad ligament. Baby had low APGAR with Hb of 6 and transfused with pack cell. The pt developed mild postoperative ileus. The pt however conceived spontaneously 3 yrs later and had elective Caesarean section at term. At Caesarean section the pt had extensive adhesions with part of rectus sheath adherent to the uterus was found. The pt developed large bowel obstruction postop with dilatation of the caecum which was managed conservatively. A 40year old pt with Hx of endometriosis who conceived by IVF had elective Caesarean section due to anterior placenta previa. An extensive abdominal endometriosis and difficulty reflecting the bladder peritoneum was found at Caesarean section. She sustained bladder injury which revealed extensive infiltration of the posterior wall of the bladder with endometriosis. The bladder was repaired and irrigated postop. Follow up MRI 3mths post op still showed signs of endometriosis within the pelvis and bladder. These two cases illustrated how the pathophysiology changes associated with endometriosis that can result in high risk complications during pregnancy (e.g. spontaneous hemoperitoneum and complicated placenta previa). Further development in antenatal imaging may help predictions of these challenges.