Effect of Endometriosis on Obstetric Outcomes: A Tertiary Center Experience

used for the diagnosis of endometriosis. However, the definitive diagnosis is made by histo- logical evaluation of a lesion biopsied during surgery. 5 Effect of Endometriosis on Obstetric Outcomes: A Tertiary Center Experience Aytaj MAHMUDOVAa, Elifnur BİÇERb, Burçin KARAKUŞc, Kutsiye Pelin ÖÇALb aClinic of Obstetrics and Gynecology, Yeni Yüzyıl University Gaziosmanpaşa Hospital, İstanbul, Türkiye bDepartment of Obstetrics and Gynecology, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye cClinic of Obstetrics and Gynecology, Çamlıca Medipol University Hospital, İstanbul, Türkiye ABS TRACT Objective: The aim of this study is to compare the course of pregnancy in women with and without endometriosis for obstetric complications. Material and Methods: Patients applied to İstanbul University-Cerrahpasa were included in the case group, 49 patients in the control group, and evaluated retrospectively. Early and late pregnancy complications were recorded. P<0.05 was considered stati stically sig- nificant. Results: A decrease in the rate of spontaneous pregnancy and a significant increase in the IVF rate were observed in the endometrio- sis group (p<0.05). Gestational hypertension,placental abruption, placental adhesion anomalies,premature rupture of membranes, fetal growth restriction, threat of preterm birth and oligohydramnios there was no significant difference between the two groups (p>0.05). T he rate of ce- sarean delivery was 55.1% in the control group and 61.0% in the endometriosis group (p>0.05). Postpartum uterine atony,bladder injury dur- ing cesarean section and requirement of postpartum blood transfusion seen in 6 (6.7%), 2(1.1%), and 1 (11.1%) patients respecti vely (p0.05). Conclusion: Women with endometriosis are at higher risk for complications during pregnancy. The rates of miscarriage in the early gestational weeks, preeclampsia, p lacenta previa, gestational diabetes mellitus in the second and third trimesters, postpartum uterine atony, blood transfusion requirement,and s urgical compli- cations during cesarean section are higher in women with endometriosis.

Endometriosis; placenta; previa; preeclampsia; complications DOI: 10.5336/jcog.2023-95314 Correspondence: Elifnur BİÇER Department of Obstetrics and Gynecology, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, İstanbul, Türkiye E-mail: [email protected] Peer review under responsibility of Journal of Clinical Obstetrics & Gynecology. Re ce i ved: 06 Jan 2023 Ac cep ted: 12 May 2023 Available online: 18 May 2023 2619-9467 / Copyright © 2023 by Türkiye Klinikleri. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Turkiye Klinikleri Journal of Internal Medicine Journal of Clinical Obstetrics & Gynecology ORIGINAL RESEARCH It is thought that pregnancy positively affects en- dometriosis due to amenorrhea and anovulation. 6 However, with the increase in the success rates in the treatment of endometriosis in recent years, the com- plication rates in pregnancies have also attracted at- tention. There are studies showing that endometriosis is associated with early pregnancy complications (ec- topic pregnancy, abortion, abortus imminens), pla- cental pathologies (placenta previa, placenta attachment anomalies), placental abruption, preterm birth threat and preterm delivery, fetal growth re- striction, oligohydramnios, gestational diabetes, and hypertensive diseases of pregnancy. 1,7,8 It has been re- ported that the risk of cesarean delivery, postpartum hemorrhage and neonatal complications is high in cases with endometriosis. 9,10 Uterine rupture, intesti- nal perforation, spontaneous hemoperitoneum or uroperitoneum are also rare obstetric complications related to endometriosis. 11 It is not clear whether there is a relationship between the stage and type of the dis- ease and the risk of developing neonatal and obstet- ric complications. 12 The aim of this study is to examine the effects of endometriosis on pregnancy outcomes by com- paring certain characteristics of women with and without endometriosis, and to determine and evaluate maternal complications because of pregnancy of en- dometrisis.

This study was conducted at İstanbul University- Cerrahpaşa, Cerrahpa şa Faculty of Medicine, fol- lowing the necessary approval of the ethics committee (date: March 3, 2021, no: E-83045809- 604.01.02-43516). This study is conducted based on the principles of Helsinki Declaration. The informa- tion of the patients who applied to the obstetrics and gynecology clinics of İstanbul University- Cerrahpaşa, Cerrahpa şa Faculty of Medicine, De- partment of Obstetrics and Gynecology between 2015-2020 were scanned retrospectively using the hospital electronic database system and patient archive files. The files of patients with endometriosis diagnosed before or during pregnancy were identi- fied. Informed consent was obtained from each pa- tient. For the case group, patients with clinical diagnosis of endometriosis with ultrasound imaging, and for the control group, nulliparous pregnant women without a history of chronic systemic disease were included in the study. Patients under the age of 18 and over the age of 45, patients with a body mass index (BMI) below 18.5 kg/m² and above 35 kg/m², patients with chronic systemic diseases (chronic kidney diseases, autoim- mune diseases, chronic hypertensive diseases, an- tiphospholipid antibody syndrome and other causes of thrombophilia), patients with autoimmune, genetic diseases, factor deficiencies, diabetes mellitus Type 1 and 2, multiparous patients, patients with a history of previous endometriosis surgery, uterine anomalies, and patients with a history of previous uterine surgery were not included in the study. For statistical analysis, SPSS 27.0 (IBM, USA) program was used. The Kolmogorov-Smirnov test, independent sample t-test, the Mann-Whitney U test, chi-square test, the Fischer test were used. In statisti- cal analysis, those with a significance level less p<0.05 were considered significant.

In our study, the results of 41 cases in the case group and 49 cases in the control group were examined. In Table 1, the case and control groups were examined about the demographic characteristics. The mean age was 27.5±4.8 years in the control group and 29.4±4.2 years in the case group. Mean BMI values were 27.2±3.7 and 27.0±3.1 in the control and case groups, respectively. In the endometriosis group, 23 (56.1%) of 41 cases were diagnosed with ultrasonography and 18 (43.9%) were diagnosed surgically (histopathologi- cally). Isolated ovarian endometrioma was seen in 34 (82.9%) cases, deep infiltrative endometriosis and ovarian endometrioma were observed in 6 (14.6%) cases, and adenomyosis was observed in 1 (2.4%) case with ovarian endometrioma with ultrasound imaging. The mean diameter in patients with ovarian endometrioma was 5.1±1.7 cm. Spontaneous pregnancy was observed in 46 (93.9%) of 49 patients in the control group, and preg- nancy was achieved in 3 (6.1%) patients with in- Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 73 Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 74 trauterine insemination (IUI) and in vitro fertilization (IVF). Of the pregnancies in the case group, 9 (22.0%) were IVF, 3 (7.3%) were IUI, and 29 (70.7%) were spontaneous pregnancies. When the two groups were statistically compared, it was found that the pregnancy rate obtained by IVF was signifi- cantly higher in the case group, and spontaneous pregnancies were lower (p<0.05) ( Table 2). Abortion was detected in 22% of patients with endometriosis which was significantly higher in en- dometriosis group than control group (p<0.05) ( Table 3). Preeclampsia was observed in 1 (2%) patient in the control group and 6 (14.6%) in the endometriosis group (p<0.05). In other words, the risk of develop- ing preeclampsia was significantly higher in patients with endometriosis. When evaluated in terms of ob- stetric complications such as gestational hyperten- sion, abruption of placenta, premature rupture of membranes, growth restriction of fetus, threat of preterm birth, and oligohydramnios, no significant difference was found in the two groups (p>0.05). No case of placenta previa was observed in 49 patients in the control group. Placenta previa developed in 9.8% of the patient group with endometriosis, and the risk was higher than control group (p0.05). Placental adhesion anomaly was detected in 1 patient in the control group and in 5 patients in the case group. Placenta accreta was observed in 1 patient in the control group, and 4 of the patients in the case group. Placenta percreta was observed in 1 case in the endometriosis group, and bladder injury was reported during cesarean delivery. 22.0% of the patients with endometriosis and 6.1% of the patients were diagnosed with gestational diabetes in the control group (p<0.05). While the mean week of gestation at birth was 38.3±2.1 in the control group, this value was 37.2±2.2 in the endometriosis group. The median val- Control group Case group Demographic characteristics n X±SD % n X±SD % p value Age 27.5±4.8 29.4±4.2 0.064 a Body mass index 27.2±3.7 27.0±3.1 0.785 b Smoking status 46 93.9 38 92.7 0.821 c 3 6.1 3 7.3 Alcohol consumption 49 100.0 41 100.0 1.000 c 0 0.0 0 0.0 Gravida 1 44 89.8 31 75.6 0.129 c 2 4 8.2 10 24.4 3 1 2.0 0 0.0 Parity 0 49 100.0 41 100.0 1.000 c 1 0 0.0 0 0.0 Abortus 0 44 89.8 31 75.6 0.129 c 1 4 8.2 10 24.4 2 1 2.0 0 0.0 TABLE 1: Demographic characteristics of the subjects examined in the case and control groups. aMann-Whitney U test; bt-test; cChi-squared test; SD: Standard deviation. Control group Case group (n=49) (n=41) Obstetric features n % n % p value Intrauterine insemination pregnancy 1 2 3 7.3 0.326 In vitro fertilization pregnancy 2 4.1 9 22 0.024 Spontaneous pregnancy 46 93.9 29 70.7 0.008 Single fetus 49 100 39 95.1 0.205 Twin fetuses 0 0 2 4.9 TABLE 2: Pregnancy characteristics of the cases examined in the case and control groups. Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 75 ues were 39.0 and 38.0, respectively (p=0.009) (Table 4). While the mean birth weight of the babies of the patients was 3266.1±618.4 grams in the control group, it was 3074.8±552.8 grams in the case group (p>0.05). Cesarean section rate was 55.1% in the control group, and 61.0% in endometriosis group (p>0.05). Due to the development of acute abdomen after en- dometriotic cyst rupture in 2 of the patients diagnosed with endometriosis, emergency cesarean delivery was decided ( Table 4). Complications developed during delivery in 8 (19.5%) patients in the case group, and all these pa- tients delivered by cesarean section. Uterine atony was observed in 6 patients and bladder injury was ob- served in 2 patients. The risk of complications was significantly higher in patients with endometriosis than in the control group (p=0.001). There was no need for blood transfusion in the postpartum period in 49 patients in the control group. However, 10 patients in the endometriosis group received blood transfu- sion (p<0.05) ( Table 5). Neonatal intensive care unit (NICU) require- ment was 39.0% and 24.4% in the case group and control group, respectively. Mostly, the reasons for NICU requirement were prematurity, neonatal tran- sient tachypnea, and congenital malformations. Con- genital malformation was observed in 6 (14.6%) newborns in the case group. Of these, 2 had cleft palate-lip, 2 had cardiac anomaly, 1 had omphalo- cele, and 1 had bilateral hydronephrosis. Congeni- tal malformations were reported in 5 (10.2%) newborns in the control group. Of these, 1 had cleft palate-lip, 2 had cardiac anomaly, 1 had hydrops fetalis, and 1 had fetal vein of galena aneurysm. When the overall malformation rates in the case and control groups, as well as the malformation subgroups were compared, no significant statisti- cal difference was found. Control group (n=49) Case group (n=41) Complications n % n % p value Imminent abortion 49 100.00 32 78.00 0.000 0 0.00 9 22.00 Preeclampsia 48 98.00 35 85.40 0.032 1 2.00 6 14.60 Gestational hypertension 48 98.00 39 95.10 0.590 1 2.00 2 4.90 Placental abruption 48 98.00 41 100.00 1.000 1 2.00 0 0.00 Placenta previa 49 100.00 37 90.20 0.040 0 0.00 4 9.80 Placental adhesion anomalies 48 98.00 36 87.80 0.054 1 2.00 5 12.20 Early rupture of membranes 47 95.90 37 90.20 0.282 2 4.10 4 9.80 Intrauterine growth restriction 48 98.00 38 92.70 0.327 1 2.00 3 7.30 Threatened preterm labor 45 91.80 35 85.40 0.331 4 8.20 6 14.60 Oligohidramniosis 44 89.80 36 87.80 0.765 5 10.20 5 12.20 Gestational diabetes mellitus 46 93.90 32 78.00 0.028 3 6.10 9 22.00 TABLE 3: Comparison of obstetric complications in the case and control groups. Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 76

Endometriosis is a chronic inflammatory disease that is usually associated with infertility and pelvic pain. Although the exact etiopathogenesis is not known, hormonal, immunological and inflammatory changes have been shown to be effective in the development and progression of the disease. It is also known that adhesions, fibrotic changes and anatomical distor- tions occur due to pelvic endometriosis. It is thought that all these biochemical and anatomical changes ad- versely affect fertility, obstetric and neonatal out- comes in women with endometriosis. 1 In our study, the obstetric and neonatal outcomes of patients with or without endometriosis who ap- plied to the hospital between 2015 and 2020 were compared. In the cases examined in the endometrio- sis group, the pregnancy rate obtained by IVF was found to be high (22.0% in the endometriosis group, while 4.1% in the control group). Miura et al. showed that, assisted reproductive technology (ART) pregnancies were found to be higher in cases with endometriosis (n=80) compared to the control group (n=2,689), like our study (p<0.01). 13 It is known that this difference between the two groups is due to the relationship between en- Control group Case group Birth characteristics n X±SD % n X±SD % p value Gestational age at birth 38.3±2.1 37.2±2.2 0.009 Birth weight (g) 3266.1±618.4 3074.8±552.8 NS Mode of delivery Vaginal delivery 22 44.9 16 39.0 NS Caesarean section 27 55.1 25 61.0 Caesarean section indicatios Severe preeclampsia 0 0.0 4 16.0 NS Placental abruption 1 3.7 0 0.0 NS Cephalopelvic disproportion 14 51.9 5 20.0 NS Fetal distress 3 11.1 0 0.0 NS Genital warts 2 7.4 0 0.0 NS Twin pregnancy 0 0.0 2 8.0 NS Failure to progress of delivery 1 3.7 4 16.0 NS Ovarian cyst rupture 0 0.0 2 8.0 NS Breech presentation 5 18.5 4 16.0 NS Macrosomic fetus 1 3.7 1 4.0 NS Plasenta previa 0 0.0 3 12.0 NS TABLE 4: Birth characteristics of the patients examined in the case and control groups. NS: Not significant; SD: Standard deviation. Control group Case group n % n % p value Birth complications (atonia, bladder injury) 49 100.00 33 80.50 0.001 0 (none) 0.00 8 19.50 Blood transfusion requirement 49 100.00 31 75.60 0.000 0 (none) 0.00 10 24.40 Neonatal intensive care unit requirement 39 79.60 25 61.00 0.052 10 20.40 16 39.00 Neonatal exitus 47 95.90 41 100.00 0.498 2 4.10 0 (none) 0.00 Congenital malformations 44 89.80 35 85.40 0.523 TABLE 5: Comparison of postpartum maternal and neonatal complications in the case and control groups. dometriosis and infertility. The prevalence of en- dometriosis in infertile women was found to be 25- 50%. 14 In our study, the abortion rate in the en- dometriosis group was 22.2%, and it was found to be higher than the control group (p<0.05). Similar re- sults to our study were reported in a case-control study in which a total of 425 cases were examined. In this study by Porpora et al., the data of 145 patients with endometriosis in the case group and 280 patients in the control group were evaluated. Abortion rate was reported as 5% in the endometriosis group and 1% in the control group (p=0.036). Disruption of en- dometrial receptivity, remodeling of myometrial spi- ral vessels, abnormal decidualization, and impaired uterine contractility has been implicated as mecha- nisms for abortion. 2,15 In a meta-analysis of 39 studies conducted by Huang et al. in 2020, the effects of endometriosis and adenomyosis on the risk of miscarriage were evalu- ated, and it was shown that the risk of abortion in- creased in cases with endometriosis who conceived spontaneously. Similarly, it has been shown that the risk of miscarriage is high in cases with a diagnosis of endometriosis undergoing ART. In the spontaneously conceived group, the data could not be evaluated be- cause the relevant data were missing. In subgroup an- alyzes of the same study, women with deep pelvic endometriosis and superficial peritoneal endometrio- sis have been shown to have a higher risk of miscar- riage. 16 In our study, the rate of preeclampsia was found to be higher in the endometriosis group. The rate of preeclampsia was 2% in the control group and 14.6% in the endometriosis group (p0.05). Wook Yi et al. mentioned that, the pregnancy processes of cases with and without endometriosis were compared, and like the results of our study, the rate of preeclampsia was found to be higher in the endometriosis group (p<0.0001). In the subgroup analysis of the same study, when only singleton pregnancies were evalu- ated, the rate of preeclampsia was found to be simi- lar between the two groups. The high risk of preeclampsia detected in the general evaluation with these findings was attributed to the higher rate of multiple pregnancy in endometriosis group than the other group, rather than the presence of endometrio- sis (multiple pregnancy rate was 2.02% in the con- trol group, and 6.23% in the case group). 1 Farland et al., in a cohort study, showed that the risk of preeclampsia and, in general, hypertensive dis- ease in pregnancy was significantly higher. Although the etiology is not clear, it is thought that abnormal placentation, defective angiogenesis and local in- flammation due to endometriosis may cause the de- velopment of hypertensive diseases during pregnancy in patients with endometriosis. 17 Placenta previa was seen in 4 (9.8%) patients in the endometriosis group,and placenta previa was not observed in the control group cases (p=0.04). Pla- cental adhesion anomalies were observed in 5 (12.2%) patients in the endometriosis group and in 1 patient (2.0%) in the control group (p=0.054). Abla- tio placenta was observed in one case at 28 weeks of gestation (p=1.000) in the control group. In a study by Chen et al., obstetric complications were evaluated in patients with surgically diagnosed endometriosis. In this study, the risk of placenta pre- via was shown to be twice as high in the en- dometriosis group, the rate of spontaneous abortion in the obstetric history of the endometriosis group was 30.13%, while it was 24.82% in control group (p=0.0076). The reason for the high rate of placenta previa in endometriosis group was thought to be spontaneous abortion and related endometrial trau- mas. However, the high rate of placenta previa in en- dometriosis group after correction for spontaneous or therapeutic abortion between the two groups showed that there are additional factors in the pathogenesis. 18 In our study, the rate of premature rupture of membranes was found to be 9.8% in the endometrio- sis group and 4.1% in the control group (p=0.282). There was not any difference between the two groups for the threat of preterm birth (14.6% in the en- dometriosis group, 8.2% in control group; p=0.331). There wasn’t any significant difference between the two groups in terms of oligohydramnios (p=0.765). Fetal growth restriction was observed in 3 patients in Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 77 the endometriosis group and in 1 patient in the con- trol group (the rates were 7.30% and 2.00%, respec- tively; p=0.327). In a meta-analysis study conducted by Zullo et al., including 24 studies, preterm birth and small for gestational age were found to be higher in en- dometriosis patients. In subgroup analysis of preg- nancies obtained by ART with only endometriosis, the increase in preterm birth was found to be high, but the subgroup analysis of women with en- dometriosis who became pregnant spontaneously could not be performed with the available data. 8 In our study, while the mean week of gestation at birth was 38.3±3.1 in the control group, this value was 37.2±2.2 in the endometriosis group (p=0.009). A separate subgroup analysis could not be performed for deliveries 0.05). In a study by Porpora et al., similar to the results of our study, it was shown that risk of premature rup- ture of membranes, growth restriction of fetus and oligohydramnios development is not high in cases with endometriosis (p>0.05). Unlike our results, the risk of preterm labor and preterm delivery was found to be high in endometriosis cases examined in this study. While the rate of threat of preterm birth was found 9.6% for endometriosis group, it was reported to be 4.0% in the control group (p=0.014). The rate of preterm birth was 20.0% in the endometriosis group and 8.0% in the control group (p<0.001). 2 The in- crease in the expression of inflammatory cytokines, prostaglandins and metalloproteinase activation causes cervical maturation, disruption of collagen, uterine contractions, and inflammation of the mem- branes. In patients with endometriosis, these may ex- plain the cause of preterm labor and premature rupture of membranes. 19 Whether there is a relationship between en- dometriosis and gestational diabetes mellitus (GDM) is controversial. While the rate of GDM was 22.0% in the endometriosis group of our study, it was found to be 6.1% in the control group (p=0.028). In a review published in 2019 by Kobayashi et al., it was reported that the risk of GDM is high. 20 In a study conducted by Conti et al., in which the results of 216 primi- parous cases with endometriosis were examined, in- creased GDM rates were found in the endometriosis group. The increased incidence of GDM is explained by chronic subclinical inflammation due to en- dometriosis. 21 In our study, no significant difference was found between two groups in terms of cesarean and normal vaginal delivery rates, and cesarean section indica- tions (p>0.05). The high rate of cesarean delivery in the control group is due to the fact that our clinic is a

hospital. However, only nulliparous pa- tients with endometriosis were included in our study. Therefore, placenta previa and placental adhesion anomalies were observed less frequently. In many studies, it has been shown that the rate of cesarean delivery is higher in patients with en- dometriosis. 1,2,9,22 Leone Roberti Maggiore et al. showed in a study that endometriosis was associated with high cesarean section rates and the indications for cesarean section in the endometriosis group were fetal distress, breech presentation and disproportion, respectively. 15 Other researchers explained the high rate of cesarean section in patients with endometrio- sis by the high rate of placental complications (pla- centa previa, placental abruption, placental attachment anomalies) and premature birth rates. 2 In addition, it is thought that patients with endometrio- sis prefer cesarean section to psychologically avoid pelvic pain in vaginal delivery. 7 In our study, complications occurred at birth in 8 (19.5%) patients in the endometriosis group, and all patients delivered by cesarean section. Uterine atony was observed in 6 patients and bladder injury was observed in 2 patients. Complication risk was higher in patients with endometriosis (p=0.001). Post- partum blood transfusion was given to 10 patients in the endometriosis group, and no transfusion was re- quired in the control group (p<0.05). Spontaneous hemoperitoneum developed due to cyst rupture in 2 patients in the endometriosis group. In a case control study, Miura et al. showed that the risk of postpartum hemorrhage is high in cases with endometriosis, similar to the results of our study Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 78 Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 79 (p=0.04). When multivariate analysis is performed according to factors that increase the risk of postpar- tum hemorrhage, such as pre-pregnancy maternal weight (BMI ≥25 kg/m 2), maternal age ( ≥35 years), ART, gravida number, placenta previa, and macro- somia (>4,000 g), endometriosis is determined for postpartum hemorrhage. It was found that there was no independent risk factor (p=0.64). 13 In our study, placental pathology was observed in 40% of the cases requiring blood transfusion. In the review of Lier et al. in 2017, 44 articles were examined and a total of 59 spontaneous hemoperitoneum cases were reported. It was reported that surgery was performed in 39 cases due to mater- nal reasons (hemorrhagic shock, acute abdomen), fetal distress in 2 cases, and both of the above-men- tioned maternal-fetal complications. No major com- plications developed in two cases, one patient died, and in this case, the diagnosis of hemoperitoneum due to endometriosis was confirmed at autopsy. The bleeding focus is from endometriotic implants (11/51 cases; 21.6%), decidualized hemorrhagic nodules (1/51 cases; 2.0%), ruptured utero-ovarian vessels (29/51 cases; 56.8%), or a combination (10/51 cases; 19.6%). Hysterectomy had to be performed in 4/59 cases (6.8%). There was no correlation between the severity of bleeding and the stage of endometriosis (p=0.43). 23 In our study, hemoperitoneum developed in 1 patient at 39 th gestational week and in 1 patient at 33rd gestational week due to ovarian endometrioma rupture. Due to the development of acute abdomen in both cases, emergency cesarean delivery and cystec- tomy were performed. When neonatal outcomes (neonatal exitus, con- genital malformation, NICU requirement) were com- pared in our study, no significant difference was found between two groups (p>0.05). Porpora et al. reported that in their case-control study, similar to our results, no correlation was found between neonatal outcomes and endometriosis. 2 Lalani et al. reported in a systematic review and meta-analysis that in pa- tients with endometriosis, NICU requirement, still- birth, and neonatal exitus rates were found to be significantly higher. The reason for this has been shown to be the high rate of preterm birth due to ob- stetric complications such as placental anomalies and preeclampsia in patients with endometriosis. 22

Pregnancy carries a higher risk of obstetric compli- cations in cases with endometriosis. Surgical com- plication rates such as the threat of miscarriage in early pregnancy weeks, preeclampsia, placenta pre- via, risk of GDM development in the second and third trimesters, postpartum uterine atony, need for blood transfusion and bladder injury in cesarean delivery are higher in women with endometriosis. Source of Finance During this study, no financial or spiritual support was received neither from any pharmaceutical company that has a direct con- nection with the research subject, nor from a company that pro- vides or produces medical instruments and materials which may negatively affect the evaluation process of this study. Conflict of Interest No conflicts of interest between the authors and / or family mem- bers of the scientific and medical committee members or mem- bers of the potential conflicts of interest, counseling, expertise, working conditions, share holding and similar situations in any firm. Authorship Contributions Idea/Concept: Aytaj Mahmudova, Elifnur Biçer; Design: Burçin Karakuş, Kutsiye Pelin Öçal; Control/Supervision: Aytaj Mah- mudova; Data Collection and/or Processing: Elifnur Biçer; Analysis and/or Interpretation: Burçin Karakuş; Literature Re- view: Aytaj Mahmudova; Writing the Article: Aytaj Mahmudova; Critical Review: Kutsiye Pelin Öçal; References and Fundings: Kutsiye Pelin Öçal; Materials: Elifnur Biçer. Aytaj MAHMUDOVA et al. JCOG. 2023;33(2):72-80 80 1. Yi KW, Cho GJ, Park K, Han SW, Shin JH, Kim T, et al. Endometriosis is as- sociated with adverse pregnancy outcomes: a national population-based study. Reprod Sci. 2020;27(5):1175-80. [Crossref] [PubMed] 2. Porpora MG, Tomao F, Ticino A, Piacenti I, Scaramuzzino S, Simonetti S, et al. Endometriosis and pregnancy: a single institution experience. Int J Environ Res Public Health. 2020;17(2):401. [Crossref] [PubMed] [PMC] 3. Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F, Crosignani PG. En- dometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril. 1996;65(2):299-304. [Crossref] [PubMed] 4. Hickey M, Ballard K, Farquhar C. Endometriosis. BMJ. 2014;348:g1752. [Crossref] [PubMed] 5. Duffy JM, Arambage K, Correa FJ, Olive D, Farquhar C, Garry R, et al. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev. 2014;(4):CD011031. Update in: Cochrane Database Syst Rev. 2020;10:CD011031. [Crossref] [PubMed] 6. Moen MH, Muus KM. Endometriosis in pregnant and non-pregnant women at tubal sterilization. Hum Reprod. 1991;6(5):699-702. [Crossref] [PubMed] 7. Glavind MT, Forman A, Arendt LH, Nielsen K, Henriksen TB. 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