Rare and acute complications of endometriosis in pregnant women

Ekaterina N. Vaulina, Н. В. Артымук, О. А. Зотова
In: Fundamental and Clinical Medicine · 2021 · vol. 6(1) , pp. 69–76 · doi:10.23946/2500-0764-2021-6-1-69-76 · W3201818355
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This review analyzed 41 publications and found that pregnancy with endometriosis carries risks of rare acute complications like hemoperitoneum, intestinal perforation, and cyst rupture, often due to hormonal changes and progesterone deficiency.

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The paper evaluates evidence from Cochrane databases and PubMed/HINARY over the past decade (2011–2021) to identify rare and acute endometriosis-related complications during pregnancy, selecting 41 publications from 126. Across the included literature, the authors describe pregnancy courses with higher complication risk, including uncommon but serious events such as hemoperitoneum, bowel perforation, appendicitis, and torsion/rupture of endometriomas, and they discuss a proposed progesterone-resistance mechanism whereby functional withdrawal during pregnancy may lead to necrosis, perforation, and unpredictable bleeding severity. Reported spontaneous hemoperitoneum associated with endometriosis is linked to hypervascularization and has been described in any gestational stage (more often the third trimester) and more frequently after IVF, with blood loss volumes ranging from 500 to 4000 mL, and mentions cases of maternal and perinatal death. The review emphasizes that limited data on these serious complications leads to underestimation and calls for further study, especially after assisted reproductive technologies. This paper is centrally about endometriosis — it specifically reviews rare acute obstetric complications of endometriosis in pregnant women.

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Abstract

Here we analysed rare and acute complications of endometriosis in pregnant women by searching Cochrane, HINARY, and PubMed databases. Keywords were “rare”, “causes”, “acute”, “complications”, “endometriosis”, and “pregnancy”. The search depth was 10 years (2011−2021). In total, we found 126 publications, 41 of which met the selection criteria. The course of pregnancy and childbirth in patients with endometriosis is insufficiently studied. Yet, it is characterised by a higher risk of complications including those rarely occurring: haemoperitoneum, intestinal perforation, appendicitis, torsion and rupture of the endometrioid cyst, and thoracic endometriosis. Because of major hormonal changes occurring during the pregnancy, endometriosis undergoes a significant progression or decidualisation. As endometrioid tissue is characterised by a resistance to progesterone, its defciency during the pregnancy can lead to necrosis, perforation of decidualised foci, and severe bleeding. Progesterone deficiency provokes hypervascularisation of the endometrioid tissue, which is the most common cause of spontaneous haemoperitoneum and most frequently occurs in the third trimester of pregnancy and after in vitro fertilisation. Pregnancy increases the risk of endometriosis-related intestinal perforation of different localisation: small intestine, caecum, appendix, and rectosigmoid colon. Limited information about the pregnancy-related complications of endometriosis leads to their underestimation, albeit they can be life-threatening and significantly impact the health of the mother and fetus. The results of this review indicate the need for the further studies of the pregnancy course in patients with endometriosis, especially after the use of assisted reproductive technology. Development of specific clinical guidelines would contribute to the efficient prevention of obstetric and perinatal complications in patients with endometriosis.
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Редкие и острые осложнения эндометриоза у беременных https://doi.org/10.23946/2500-0764-2021-6-1-69-76 Аннотация Проведена оценка информационных баз системы Cochrane, HINARY, PubMed. Keywords (слова для поиска): «rare causes of endometriosis and pregnancy» и «acute complications of endometriosis and pregnancy». Глубина поиска составила 10 лет (2011−2021 гг.). Обнаружено соответственно 43 и 83 источника. Из 126 публикаций соответствовала критериям отбора 41 публикация. Течение беременности и родов у пациенток с эндометриозом в настоящее время изучено недостаточно, характеризуется более высоким риском осложнений, среди которых встречаются достаточно редкие формы: гемоперитонеум, перфорация кишечника, аппендицит, перекрут и разрыв эндометриоидной кисты, эндометриоз органов грудной клетки. Эндометриоидные очаги при беременности претерпевают изменения под воздействием гормонов, становясь гипертрофированными или приобретая признаки децидуализации. В эндометриоидной ткани, характеризующейся устойчивостью к прогестерону, его «функциональная» отмена во время беременности может привести к некрозу, перфорации децидуализированных очагов эндометриоза и кровотечению непредсказуемой степени тяжести. Во время беременности описана обусловленная эндометриозом перфорация кишечника различных локализаций: тонкая кишка, слепая кишка, аппендикс, ректосигмоидный отдел толстого кишечника. При беременности гиперваскуляризация эндометриоидной ткани, индуцируемая низким уровнем прогестерона, является наиболее частой причиной спонтанного гемоперитонеума, который может регистрироваться в любом сроке беременности, а также в послеродовом периоде, однако возникает чаще в третьем триместре беременности и у женщин после процедуры ЭКО. В литературе при спонтанном гемоперитонеуме при беременности описан объем кровопотери от 500 до 4000 мл. Имеется информация о случаях материнской и перинатальной смертности. Ограниченные сведения об этих серьезных осложнениях приводят к их недооценке и увеличению риска для жизни и здоровья матери и плода во время беременности и родов. Результаты данного обзора свидетельствуют о необходимости дальнейшего изучения особенностей течения беременности и родов у пациенток с эндометриозом, особенно после применения вспомогательных репродуктивных технологий (ВРТ). Целесообразна разработка рекомендаций по дополнительному объему обследований и вмешательств, направленных на профилактику акушерских и перинатальных осложнений у пациенток с эндометриозом. Об авторах Е. Н. ВаулинаРоссия Ваулина Екатерина Николаевна, врач акушер-гинеколог отделения патологии беременности 650066, г. Кемерово, пр. Октябрьский, д. 22 Н. В. Артымук Россия Артымук Наталья Владимировна, доктор медицинских наук, профессор, заведующая кафедрой акушерства и гинекологии имени профессора Г.А. Ушаковой 650056, г. Кемерово, ул. Ворошилова, д. 22а О. А. 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Maniglio P, Ricciardi E, Meli F, Vitale SG, Noventa M, Vitagliano A, Valenti G, La Rosa VL, Laganà AS, Caserta D. Catamenial pneumothorax caused by thoracic endometriosis. Radiol Case Rep. 2017;13(1):81-85. https://doi.org/10.1016/j.radcr.2017.09.003 41. Эл-Джефут М., Артымук Н.В. Новое о теориях патогенеза эндометриоза. Фундаментальная и клиническая медицина. 2019;4(3):77-82 https://doi.org/10.23946/2500-0764-2019-4-3-77-82 Рецензия Для цитирования: Ваулина Е.Н., Артымук Н.В., Зотова О.А. Редкие и острые осложнения эндометриоза у беременных. Фундаментальная и клиническая медицина. 2021;6(1):69-76. https://doi.org/10.23946/2500-0764-2021-6-1-69-76 For citation: Vaulina E.N., Artymuk N.V., Zotova O.A. Rare and acute complications of endometriosis in pregnant women. Fundamental and Clinical Medicine. 2021;6(1):69-76. (In Russ.) https://doi.org/10.23946/2500-0764-2021-6-1-69-76 JATS XML

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