Postpartum Gastrointestinal Outcomes in Patients With Endometriosis by Mode of Delivery: A Retrospective Cohort Study

Postpartum Gastrointestinal Outcomes in Patients With Endometriosis by Mode of Delivery: A Retrospective Cohort Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 27 January 2026 V1 Latest version Share on Postpartum Gastrointestinal Outcomes in Patients With Endometriosis by Mode of Delivery: A Retrospective Cohort Study Authors : SaNae Muhammad 0009-0000-9919-5044 [email protected] , Afia Oduro , Oluwatishe Ogunwo , Jetaun Booker , Rawan Elkomi , Syed Fahad Gillani , Elizabeth Beyene , and Miriam Michael Authors Info & Affiliations https://doi.org/10.22541/au.176953517.72177874/v1 166 views 101 downloads Contents Abstract Manuscript Title Authors Author Affiliations Corresponding Author Funding Conflicts of Interest Condensation Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To evaluate the association between the mode of delivery and gastrointestinal outcomes in patients with endometriosis. Design: Retrospective Cohort Study Setting: TriNetX Research Network encompassing data from 107 healthcare organizations. Population: Patients with endometriosis who underwent either cesarean or vaginal delivery. Methods: Each cohort included 16,652 patients. Propensity score matching was applied to balance age, race, BMI, and tobacco use. Primary outcomes included postoperative adhesions, fistulas, and bowel obstruction. Analyses included risk estimation, Kaplan-Meier survival curves, and recurrence assessments. Main Outcomes Measures: Postoperative adhesions, fistulas, and bowel obstruction. Results: Cesarean delivery was associated with a significantly higher risk of adhesions (9.3% vs. 4.9%; RR 1.89; HR 2.00, 95% CI 1.84–2.18, p < 0.001) and bowel obstruction (1.5% vs. 1.3%; RR 1.21; HR 1.26, 95% CI 1.05–1.51, p = 0.04). No significant difference was observed in fistula formation (0.084% vs. 0.108%, p = 0.48). Survival analysis confirmed a higher cumulative incidence of adhesions and bowel obstruction in the cesarean group. Frequency of repeated events did not differ significantly between cohorts. Conclusion: In patients with endometriosis, cesarean delivery is associated with a higher baseline risk of adhesions and bowel obstruction, especially at first birth, compared with vaginal delivery. These findings highlight the long-term surgical implications of selecting the delivery method in this population and may inform counseling and obstetric decision-making. Manuscript Title Postpartum Gastrointestinal Outcomes in Patients With Endometriosis by Mode of Delivery: A Retrospective Cohort Study Short Title: GI Outcomes in Endometriosis by Delivery Mode Authors SaNae Muhammad, BS¹, Afia Oduro, BS¹, Oluwatishe Ogunwo, BS¹, Jetaun Booker, BS¹,Rawan Elkome 2 , Syed Fahad Gillani, MD², Elizabeth Beyene, MD², Miriam Michael, MD²˒³ Author Affiliations ¹ Howard University College of Medicine, Washington, DC, USA ² Department of Internal Medicine, Howard University Hospital, Washington, DC, USA ³ Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA Corresponding Author SaNae Muhammad Howard University College of Medicine Washington, DC, USA Email: [email protected] Phone: (323) 691- 4310 ORCID: 0009-0000-9919-5044: Funding None. Conflicts of Interest The authors declare no conflicts of interest. Word count: 2289 Condensation Cesarean delivery in patients with endometriosis is associated with increased postoperative gastrointestinal morbidity compared to vaginal delivery. Abstract Objective: To evaluate the association between the mode of delivery and gastrointestinal outcomes in patients with endometriosis. Design: Retrospective Cohort Study Setting: TriNetX Research Network encompassing data from 107 healthcare organizations. Population: Patients with endometriosis who underwent either cesarean or vaginal delivery. Methods: Each cohort included 16,652 patients. Propensity score matching was applied to balance age, race, BMI, and tobacco use. Primary outcomes included postoperative adhesions, fistulas, and bowel obstruction. Analyses included risk estimation, Kaplan-Meier survival curves, and recurrence assessments. Main Outcomes Measures: Postoperative adhesions, fistulas, and bowel obstruction. Results: Cesarean delivery was associated with a significantly higher risk of adhesions (9.3% vs. 4.9%; RR 1.89; HR 2.00, 95% CI 1.84–2.18, p < 0.001) and bowel obstruction (1.5% vs. 1.3%; RR 1.21; HR 1.26, 95% CI 1.05–1.51, p = 0.04). No significant difference was observed in fistula formation (0.084% vs. 0.108%, p = 0.48). Survival analysis confirmed a higher cumulative incidence of adhesions and bowel obstruction in the cesarean group. Frequency of repeated events did not differ significantly between cohorts. Conclusion: In patients with endometriosis, cesarean delivery is associated with a higher baseline risk of adhesions and bowel obstruction, especially at first birth, compared with vaginal delivery. These findings highlight the long-term surgical implications of selecting the delivery method in this population and may inform counseling and obstetric decision-making. Funding: No external funding was received. Keywords: Cesarean Delivery; Endometriosis; Obstetric Outcomes ; Postoperative Complications; Vaginal Delivery Introduction Endometriosis is an estrogen-dependent, chronic inflammatory disease that occurs in around 10% of patients 1 . It is characterized by the growth of endometrial tissue outside of the uterus, causing cyclic pain, fibrosis, dyspareunia, infertility, and affects obstetric outcomes 2,3 . New evidence supports that patients with endometriosis experience higher rates of pregnancy complications, which include preterm labor, postpartum hemorrhage, gestational diabetes, preeclampsia, and increased cesarean delivery 4,5 . Cesarean delivery carries long-term surgical risks including adhesion formation, chronic pelvic pain, bowel dysfunction, and complications during future pelvic or abdominal surgeries; adhesion being the most common in the general population 6 . Despite these observed risks, little is understood about how endometriosis impacts postoperative outcomes of cesarean delivery. Considering that endometriosis is characterized by chronic inflammation and fibrosis, it is reasonable that patients with this disease may have a higher baseline risk of postoperative complications. 1 Despite this biologic plausibility, currently there are no clinical guidelines to inform the mode of delivery counseling for patients with endometriosis. Limited research has assessed whether the mode of delivery influences long-term gastrointestinal morbidity in endometriosis. The purpose of our study is to evaluate whether cesarean delivery in patients with endometriosis leads to a higher risk of postoperative complications compared to vaginal delivery. A more informed understanding of the relationship between endometriosis, delivery mode, and postoperative gastrointestinal morbidity is important to improve patient counseling, clinician decision making, and pre-/postoperative care. Methods This retrospective cohort study utilized the TriNetX Research Network, a global federated health research platform that aggregates de-identified electronic medical records from 107 healthcare organizations (HCOs). The network includes diagnoses, procedures, medications, laboratory values, and demographic information. The study aimed to compare postoperative outcomes in patients with endometriosis who underwent cesarean versus vaginal delivery. This study used fully de-identified data and is exempt from human subjects’ review under 45 CFR 46.104(d)(4). This study followed the STROBE guidelines for observational cohort research. Two patient cohorts were defined based on delivery method: Cesarean Delivery Cohort (Cohort 1): Included patients with any ICD-10 diagnosis code for endometriosis (N80.x) and a CPT code for cesarean delivery (59510, 59514, or 59515). Vaginal Delivery Cohort (Cohort 2): Included patients with endometriosis diagnoses and CPT codes for vaginal delivery (59400, 59409, or 59410). Patients were excluded from either cohort if they had any diagnosis indicating confounding gastrointestinal or gynecologic conditions (e.g., Crohn’s disease, adhesion, ulcerative colitis, bowel obstruction, pelvic inflammatory disease, or intestinal fistula) prior to or on the index date. Deliveries resulting in live birth or stillbirth were included, as CPT delivery codes do not differentiate delivery outcomes. The index event was defined as the date of delivery, and the observation window began one day after the index date, with no defined endpoint (allowing for long-term outcome assessment). Cohort selection and exclusion criteria are summarized in Figure 1. The primary outcomes were the occurrence of: • Adhesions (ICD-10 codes K56.51, K66.0, N73.6), • Fistulas (K63.2, N82.3, N82.4), • Bowel Obstruction (K56). Outcomes were measured across three analytical dimensions: incidence (risk analysis), time-to-event (Kaplan–Meier survival analysis), and recurrence (number of instances per patient). To reduce confounding, one-to-one propensity score matching was performed using nearest-neighbor matching without replacement. Variables included in the model were age at index, race/ethnicity, BMI, and tobacco use. After matching, each cohort included 16,652 patients with balanced baseline characteristics (standardized differences <0.1 for all covariates). All analyses were performed using TriNetX built-in statistical modules: • Risk Analysis: Calculated the proportion of patients experiencing each outcome, along with risk differences, risk ratios (RR), and odds ratios (OR) with 95% confidence intervals (CI). A two-sided z-test was used to assess significance. • Survival Analysis: Time-to-event analysis was conducted using Kaplan-Meier estimation with the log-rank test for group comparison. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards models. Proportional hazards assumption was tested. • Number of Instances Analysis: The frequency of each outcome per patient was assessed using mean, standard deviation, and median values. Group comparisons were performed using independent samples t-tests, excluding patients with zero occurrences. A p-value of <0.05 was considered statistically significant for all tests. All analyses were performed within the TriNetX Analytics platform (TriNetX, Inc.), which utilizes HIPAA-compliant de-identified data. Approval was not required due to the use of fully de-identified data. Pre-specified subgroup analyses were conducted for: Presence of CKD Entire obese cohort (BMI ≥ 30, as all patients met this criterion) Estimated outcome frequencies were stratified by subgroups to evaluate differential treatment effects. This is a retrospective cohort study using data from the TriNetX database (107 HCOs), comparing outcomes between: Cohort 1 (Cesarean Delivery): 17,440 patients (post-matching N = 16,652) Cohort 2 (Vaginal Delivery): 27,223 patients (post-matching N = 16,652) Propensity Score Matching was used to balance both cohorts on age, sex, race, tobacco use, and BMI. Post-matching: All standardized differences were <0.1, suggesting excellent balance between groups. Each cohort retained 16,652 patients, making the comparison robust and statistically powered. This study was underpowered to detect clinically meaningful differences for the development of fistulas and frequency of repeated events in cohorts, whereas analyses for adhesions and bowel obstruction were adequately powered. An alpha level of 0.05 was used, and matched cohorts of 16,652 each provided >80% power (β < 0.2) to detect effect sizes consistent with those reported in previous literature. No core outcome set was applied. Patients were not directly involved in study design due to use of de-identified data Results After matching, each cohort included 16,652 patients. Cesarean delivery was associated with a significantly higher risk of adhesions (9.3% vs. 4.9%; RR 1.89; HR 2.00, 95% CI 1.84–2.18, p < 0.001) and bowel obstruction (1.5% vs. 1.3%; RR 1.21; HR 1.26, 95% CI 1.05–1.51, p = 0.04). No significant difference was observed in fistula formation (0.084% vs. 0.108%, p = 0.48). Survival analysis confirmed a higher cumulative incidence of adhesions and bowel obstruction in the cesarean group. The frequency of repeated events did not differ significantly between cohorts. Incidence of each gastrointestinal outcome is shown in Figure 2. For adhesions, the incidence of the event was 9.3% in the cesarean cohort (1,544/16,652 and 4.9% in the vaginal cohort (818/16,652). Adhesion formation has a risk difference of + 4.4 ( 95% Cl 3.8-4.9; z=15.5; p<0.001), a risk ratio of 1.89, and an odds ratio of 1.98 (95% Cl 1.81-2.16). With a hazard ratio of 2.00 (95% Cl 1.84-2.18), the probability of remaining adhesion free at the end of follow-up was 78.4% and 88.9% for the cesarean and vaginal cohorts, respectively (log-rank χ²= 268.2; p<0.001). The frequency of adhesion events did not differ between cohorts (mean 1.72 in both; p=0.997). This indicates that cesarean delivery nearly doubles the risk of adhesion formation but does not increase in frequency of events. The incidence of fistula formation remained low in both groups, 0.084% (14/16,652) following cesarean and 0.108% (18/16,652) following vaginal (risk difference -0.02%; p=0.479) with risk and odds ratio of 0.78. The hazard ratio was 0.81 (p=0.466), the frequency of fistula episodes was similar (mean ~4.2 in both; p=0.978), and survival exceeded 99.7% in both groups (log-rank χ²=0.365; p=0.546). There were no statistically significant differences observed in risk, time to event, or recurrence. For bowel obstruction, the incidence was 1.5% after cesarean delivery (255/16,652) compared to 1.3% after vaginal delivery (211/16,652). There was a risk difference of +0.3% (z=2.05; p=0.040), odds ratio of 1.21, and recurrence frequency was similar (mean 2.81 vs 2.61; p=0.0611). With a hazard ratio of 1.26 (95% Cl 1.05-1.51), the survival probability at the end of follow-up was 94.9% among cesarean patients and 93.9% among vaginal patients (log rank χ²=6.18; p=0.013). The outcomes for all hazard ratios are shown in Figure 3. Cesarean delivery in patients with endometriosis significantly increases the risk of adhesions and bowel obstruction, but not fistulas. The hazard ratio and survival probability indicate higher cumulative risk over time. The lack of difference in event frequency (number of instances) suggests that once an event occurs, recurrence may not differ by delivery mode. Main Findings In this large, multi-institutional retrospective cohort study of patients with endometriosis, we found that cesarean delivery was associated with a significantly increased gastrointestinal morbidity. The nearly two-fold increase in adhesion risk and the 26% higher hazard of bowel obstruction underscore the lasting gastrointestinal morbidity that may follow cesarean intervention in this population. In contrast, fistula formation was rare in both groups. These results emphasize the need for careful obstetric planning in patients with known endometriosis and raise important considerations regarding long-term outcomes beyond delivery. Interpretation Studies show that women with endometriosis consistently demonstrate higher cesarean delivery rates compared to those without endometriosis, reporting a 1.5–2-fold greater risk of cesarean section in this population. This elevated risk is multifactorial, reflecting both disease-related factors and higher rates of pregnancy complications such as premature births, placenta previa, and hypertensive disorders. 4-8,9-16 The pathophysiology of endometriosis, as described in previous literature, involves retrograde menstruation, coelomic metaplasia, and, less commonly, lymphatic or vascular dissemination, leading to aberrant cellular adhesion, local estrogen production, immune dysregulation, and chronic inflammation [1-3] . Endometrial mesenchymal stem cells and epithelial progenitors contribute to lesion implantation by adhering to peritoneal surfaces, proliferating, and differentiating into ectopic tissue, while aberrant adhesion molecules, chronic inflammation, and estrogen-driven proliferation promote lesion persistence and fibrosis. [1-3] We observed that the presence of endometrial tissue, either in the bowel wall or as extrinsic masses, led to obstruction via direct luminal compromise, extrinsic compression, and adhesion formation, consistent with mechanisms described in the literature. Our data showed that a history of previous cesarean sections did not increase the frequency of recurrent adhesions and bowel obstruction once they occurred. Prior surgical literature describes that the interplay between surgical trauma, hypofibrinolytic states, and genetic predisposition may amplify the risk of postoperative adhesions and bowel complications in endometriosis. 17-21 Our findings support this framework and suggest that endometriosis itself predisposes patients to gastrointestinal morbidities, while in general population, increased risk is associated with previous surgical history, including cesarean deliveries. 18-20 The rarity of fistula formation across both delivery groups suggests that while cesarean may increase mechanical sequelae of postoperative gastrointestinal outcomes, it does not necessarily elevate the risk of direct organ-to-organ communication or perforation-related complications. This observation is supported by the literature, which notes that bowel obstruction and fistula formation are uncommon but serious sequelae of endometriosis, particularly in cases of intestinal or deep infiltrating disease. 22-23 In the clinical setting, these findings highlight the necessity of counseling patients with endometriosis on possible modes of delivery. Patients with endometriosis are 1.48 times more likely to deliver via cesarean compared to patients without, and this higher risk predisposes these patients to adhesions and bowel obstruction. Clinicians should weigh the benefits and long-term risks when recommending cesarean delivery, especially since there is an absence of formal guidelines addressing preferred delivery modes for endometriosis patients. The literature and our data suggest that when patients do not have contraindications and if it is safe, vaginal delivery should be encouraged to reduce long-term gastrointestinal morbidities. If and when cesarean delivery is recommended, it is critical that clinicians use adhesion-prevention strategies—such as meticulous surgical technique, minimization of tissue trauma, and the use of adhesion barriers or anti-adhesion agents—and maintain close postoperative follow-up to best support this patient population through their recovery. 24-29,11,13,16 Strength and Limitations This study has several notable strengths. Its large, multi-institutional sample drawn from a real-world clinical dataset enhances generalizability and captures the breadth of obstetric outcomes among patients with endometriosis across diverse care settings. The use of rigorous 1:1 propensity score matching substantially reduced baseline differences between delivery groups, strengthening internal validity and increasing confidence that observed associations reflect the delivery mode rather than underlying differences in clinical characteristics. Additionally, the exclusive reliance on objective, clinically coded outcomes minimizes subjective measurement variability and allows for standardized comparison across institutions. Despite these strengths, important limitations must be acknowledged. As a retrospective observational analysis, the study cannot establish causality, and residual or unmeasured confounding may persist despite matching. Administrative coding may introduce misclassification bias, particularly for conditions such as adhesions that may be under-recognized unless surgically evaluated. Disease-specific variables—such as stage of endometriosis, extent of pelvic involvement, prior abdominal surgeries, or indication for cesarean—were not uniformly available, limiting our ability to explore mechanistic pathways. Finally, long-term outcomes may be incompletely captured if patients sought care outside participating systems, potentially underestimating complication rates. Conclusion In conclusion, the study highlights the importance of individualized obstetric planning and shared decision-making due to increased risk of gastrointestinal complications following cesarean delivery in patients with endometriosis. Counseling should prioritize vaginal delivery when feasible, with clear communication about the increased risks associated with cesarean section. When a cesarean is indicated, proactive adhesion prevention and close postoperative surveillance are essential to mitigate long-term morbidity. Continued research aimed at clarifying biological mechanisms and refining risk-stratified management frameworks will be essential for improving long-term outcomes in this high-risk group. Contribution of Authors SM made contributions to the conception and design of the study, data acquisition, analysis and interpretation, drafted and critically revised the manuscript. AO, OO, and JB contributed to drafting and critical revision of the manuscript, and interpretation of data. RE, SFG, EB, and MM contributed to study conception and design, development of the TriNetX cohort, data acquisition and interpretation, and critically revised the manuscript. All authors approved the final version and agreed to be accountable for the work. Ethics Approval This study used fully de-identified data from the TriNetX Research Network and was exempt from institutional review board approval under 45 CFR 46.104(d)(4). Funding No external funding was received. Acknowledgements None. Disclosure of Interests The author declares no competing interests. Declarations Generative artificial intelligence (AI), specifically OpenAI’s ChatGPT, was used to assist in refining the word usage, and grammar of the manuscript. All content was reviewed, validated, and approved by the authors to ensure accuracy, originality, and adherence to ethical standards. 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Keywords delivery: assisted vaginal delivery: caesarean section endometriosis: diagnosis general obstetrics Authors Affiliations SaNae Muhammad 0009-0000-9919-5044 [email protected] Howard University Hospital View all articles by this author Afia Oduro Howard University Hospital View all articles by this author Oluwatishe Ogunwo Howard University Hospital View all articles by this author Jetaun Booker Howard University Hospital View all articles by this author Rawan Elkomi Howard University Hospital View all articles by this author Syed Fahad Gillani Howard University Hospital View all articles by this author Elizabeth Beyene Howard University Hospital View all articles by this author Miriam Michael Howard University Hospital View all articles by this author Metrics & Citations Metrics Article Usage 166 views 101 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation SaNae Muhammad, Afia Oduro, Oluwatishe Ogunwo, et al. Postpartum Gastrointestinal Outcomes in Patients With Endometriosis by Mode of Delivery: A Retrospective Cohort Study. Authorea . 27 January 2026. DOI: https://doi.org/10.22541/au.176953517.72177874/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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