This document summarizes key information about endometriosis and its implications during pregnancy. It notes that deeply infiltrating endometriosis can cause unexpected complications during pregnancy like tissue perforation. Pregnancy outcomes may be negatively impacted by endometriosis through mechanisms like chronic inflammation and abnormal placentation. Complications of endometriosis during pregnancy can include hemorrhage, intestinal perforation, appendicitis, and spontaneous hemoperitoneum. Careful mapping of deeply infiltrating endometriosis is important before pregnancy. The document discusses various sonographic findings and management approaches for conditions like infected ovarian endometriomas.

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn ), F.I.A.O.G.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Let’s Start…
• Endometriosis is defined as the presence of
endometrium like tissue outside of the uterine
cavity.
• Deeply infiltrating endometriosis (DIE) is
defined as endometriotic lesions in the
rectovaginal septum, the vaginal fornix & the
peritoneum or if the bowel, the ureter, or the
bladder is infiltrated by the disease.
• It is estimated that 10 - 15 % of women in the
reproductive age are affected by the disease.
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3. • The incidence of bowel implants among
women with endometriosis is between 6 & 12 %.
• The most affected sites are the rectum and
recto-sigmoid junction, which account for up to
93 % of all intestinal endometriosis lesions.
• The incidence of Bladder and Ureter involvement
is between 8 – 15 % .
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4. Neglected Topic . . .
Many studies have been conducted on the
treatment of endometriosis-associated infertility
and pelvic pain;
But…
Very limited studies & Guidelines are available
on the obstetric outcomes in pregnant women
who have endometriosis.
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6. • For over a century, pregnancy has been considered to
have beneficial effects on endometriosis, and
‘pseudopregnancy’ induced through hormonal therapies has
been recommended as a way to manage symptoms.
• The coexistence of endometriosis and pregnancy was
first described in 1904–1905 .
(Olshausen, 1904; Amos, 1905).
• In the early 1920s, regression of endometriosis cysts
during pregnancy (Sampson, 1922, 1924) or during lactation
(Meigs, 1922) was observed in small case series.
• Beecham (1949) declared pregnancy as an efficient
prophylactic and curative measure against endometriosis.
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It’s Known that…

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8. Note that …
The very high concentrations of estrogens
and progestogens in pregnancy will stop growth of
most endometriosis lesions and most women with
endometriosis associated pain become pain free.
Decidualization and modified vascularization
of endometriotic implants and endometriomas has
been found during pregnancy .
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9. Effect Of Endometriosis On Pregnancy
It may negatively affect pregnancy in terms of an
 Increased Risk Of Spontaneous Miscarriage,
 Intrauterine Growth Restriction,
 Preeclampsia,
 Antepartum Hemorrhage,
Spontaneous Hemoperitoneum in Pregnancy
 Cesarean Delivery.
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10. Let’s See How…
Endometriosis is frequently associated with
abnormalities in the inner myometrium, a highly
specialized and functionally distinct uterine
structure, also known as the ‘‘ Junctional Zone.’’
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11. Pregnancy complications accompanying
preexisting endometriosis may be explained by
some pathogenic mechanisms, such as …
 Endometriosis-related chronic inflammation,
 Presence of adhesions and their mechanical
implications,
 Invasion of decidualized ectopic endometrium in
to the vessels wall.
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12. Endometriosis in Pregnancy
• A complex disease with multiple
pathophysiological mechanisms.
• The Eutopic endometrium of women with
endometriosis has been shown to be functionally
abnormal, exhibiting subtle but biologically
important molecular abnormalities, including …
1 ) An increased production of estrogen,
cytokines, prostaglandins, and metalloproteinases.
2 ) The increased expression of COX-2 causes
augmented secretion of PGE2 & PGF2α in the uterine
and endometriotic tissues.
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13. 3 ) Aromatase, a local enzyme, is hyper
expressed in endometriosis, leading to abnormal
biosynthesis of Estradiol (E2), which in turn,
increases PGE2 formation by stimulating COX-2
expression, resulting in a positive feed-forward
loop between estrogens and PGs that favors the
proliferative and inflammatory characteristics of
endometriosis.
4 ) Pro-inflammatory mediators, such as PGE2,
COX-2, and interleukin-8, reportedly cause uterine
muscle contractions and cervical ripening and are
linked to Preterm Birth.
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15. In DIE Specifically…
• Pregnancy complications may differ on the basis of the
type of endometriotic lesion .
• In fact, the presence of DIE lesions in pregnant women
has been underestimated, but and such lesions can cause
unexpected, severe complications during pregnancy and at
delivery .
• The risk of tissue perforation when endometriosis
involves the bowel and the bleeding during pregnancy
caused by decidualized ectopic implants on the terminal
ileum or colon have been described.
• Adequate mapping of DIE lesions before pregnancy is
mandatory for better counseling of the patient about the
potential risks related to the disease.
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17. Treatment of endometriosis and
spontaneous conception also avoids the use of
ART.
The high hormonal milieu associated with
ART may stimulate growth of endometriotic
implants and endometriomas.
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18. Abnormal Placentation in DIE
NORMAL PLACENTATION :
Characterized by a full conversion of the spiral
arteries into large utero-placental vessels at the
level of the JZ.
DEFECTIVE PLACENTATION :
Characterized by an absent or incomplete
remodeling of these arteries and the primary site of
the vascular abnormalities responsible for defective
placentation has been suggested to lie in the JZ.
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19. Very high incidence of placenta
previa in women with DIE—more than
10 times that of the general population.
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20. This Increase In Incidence Of Placenta Previa In
Women With Posterior DIE May Be Explained By …
• Anomalous blastocyst implantation, which could
be caused by uterine dysperistalsis.
• A fixed abnormal uterine position owing to dense
pelvic adhesions may theoretically reduce the
efficacy of myometrium contractility, particularly in
women with rectosigmoid lesions.
• The coexistence of adenomyosis and
endometriosis, and in particular the high prevalence
of adenomyosis in patients with DIE, could act as a
confounder in the placentation anomalies.
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21. Dysfunctional critical uterine changes during
the implantation process due to a defective
process of decidualization and placentation may
result in defective remodeling of the spiral arteries.
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22. Endometriosis Related Complications
 Rupture Of Endometriomas
 Intestinal Perforation (Colon, Appendix, Sigmoid)
 Spontaneous Hemoperitoneum/Rupture Of Uterine
And Non-uterine Blood Vessels
 Infection Of Endometrioma / Development Of
(Ovarian) Abscess / Appendicitis.
 Uterine Haemorrhage
 Spontaneous Pneumothorax
 Uroperitoneum
 Rupture Of Fallopian Tubes.
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23. Ovarian Endometriosis
A recent retrospective Japanese study
examined the incidence of ovarian endometriosis
in pregnancy and found that it has almost
quadrupled over the last 12 years, rendering it the
most common adnexal mass now detected during
pregnancy.
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24. Ovarian Endometriosis
• It can be explained by decidualization or
hemorrhage of the ectopic endometrium.
• An expanding endometrioma in pregnancy
constituted a risk factor for subsequent abscess
formation or rupture.
• Pregnancy may also increase the risk of tissue
perforation when endometriosis involves the
appendix and cases have been described of massive
gastrointestinal bleeding during pregnancy caused
by decidualizing ectopic implants on the terminal
ileum or colon .
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25. Sonographic Findings Of Endometrioma
During Pregnancy
95%
• A typical sonographicappearance:around shapedcystic
aspect,regular margins,homogeneous low echogenic fluid
content, scattered internal echoes and absence of papillae.
5%
• An atypical aspect: anechoiccontent, solid appearance,
and presenceof punctuate echogenic foci within thecystic
wall.
(PatelMD,et al. Radiology. 210:739-745.1999; Barbieri M, et al. HumReprod. 24:1818-1824.2009)

26. • Complications deriving from ovarian endometriotic
cysts, such as infected, enlarged and ruptured
endometrioma, represent rare events but they should
be considered in the differential diagnosis of pelvic pain
during pregnancy.
• Conservative treatment with antibiotic
therapy should represent the first-line management for
infected endometrioma,
although in case of
severe abdominal pain and systemic involvement,
drainage or surgery may be required.
• Changes in the size of endometrioma during
pregnancy, may increase, decrease or remains same.
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27. Spontaneous Hemoperitoneum in
Pregnancy ( SHiP )
• Rare but potentially catastrophic complication
of pelvic endometriosis
• SHiP in advanced pregnancy or during the
postpartum Period.
• Fetal mortality remains high at 31%.
• Noteworthy that in approximately 50% of
cases, endometriosis had not been diagnosed
before pregnancy.
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28. SHiP
• Recommended that selective biopsies be taken
from the site of bleeding for histology in all cases of
SHiP.
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29. Spontaneous Hemoperitoneum in
Pregnancy(SHiP)
- Prevalence -
0.38% (3/800)
in the endometriosis clinic at the University of TelAviv
KatorzaE,et al.AmJObstet Gynecol. 197:501.e501-504.2007
0.35% (2/573)
ZhangY,et al. Fertil Steril. 92:395.e313-396.2009

30. • 20casesof endometriosis - related SHiP
(in 16publications)
• Most casesin the third trimester (28.7 ± 4.3 wks,mean± SD)
and4cases(20%)in the post-partum period.
•Symptom: SuddenOnset Of Abdominal Pain With
Different Localizations(95%)
•Sign: Hypovolemic Shock(70%)
LeoneRoberti Maggiore U,et al. Hum ReprodUpdate. 22: 70-103.2016
SHiP

31. • In 40%of the cases,the presumed preoperative
diagnosis wasplacenta abruption with concealed
hemorrhage(75%) andauterine rupture (25%).
•In most cases,the diagnosisof ruptured utero-ovarian vessel
wasestablished at explorative laparotomy thatwas carried
out in the90%. LeoneRoberti Maggiore U,et al. Hum ReprodUpdate. 22: 70-103.2016
SHiP

32. •Bleeding site : 70% at the uterus, 15% at the
parametrium with its arteries and veins, and 5% at
the uterosacral ligament.
•Nomaternal death
•Perinatal mortality rate: 36%(7 casesof intrauterine
death and 1 neonataldeath)
•Histological examination wasperformed in 45%of cases,
in which decidualization wasdiagnosedin 67%.
LeoneRoberti Maggiore U,et al. Hum ReprodUpdate. 22: 70-103.2016
SHiP

33. Uterine Rupture
• 32 cases
• Previous endometriosis surgery in all cases.
(excision of a rectovaginal nodule, bilateral
ovarian cystectomy, and excision of cervical endometriosis)
• The rupture was localized on the posterior wall of the uterus at the
lower segment level in all cases.
• In all cases healthy babies were born, and no maternal death
was reported.
VanDePutte I, et al. Br JObstet Gynaecol.106:608-
609. 1999 SholapurkarSL,et al.Aust NZJObstet
Gynaecol.45:256-258. 2005 ChenZH,et al. TaiwanJ
Obstet Gynecol. 50:95-97.2011

34. Intestinal Perforation
•16casesof bowel perforation
(13 during pregnancy, 3inthe post-partum period)
•Ileum (N =1), Appendix (4), Cecum(1), SigmoidColon (8)And
Rectum (2).
•Mostly in the third trimester (30 ± 6.3 weeks).
•Clinical AndLaboratory SignsOf Peritonitis In13Patients
(81%).
•Decidualized Endometriosis Involving The Entire Intestinal
Wall In 14 Cases(88%).
•100% Live Births
LeoneRoberti Maggiore U,et al. Hum ReprodUpdate. 22: 70-103.2016

35. Appendicitis
 7 casesof appendiceal endometriosis
presenting asacute appendicitis during
pregnancy
 Gestational age at diagnosis: 20 ± 9.8 weeks
 The most frequent presenting symptoms:
nausea(29%), vomiting (43%) and abdominal
pain (86%).
 In all cases reported in the literature, the
patients underwent appendectomy
during pregnancy.
LeoneRoberti Maggiore U,et al. Hum ReprodUpdate. 22: 70-103.2016

36. Mode of Delivery in DIE.
 There are no guidelines concerning the mode of
delivery in pregnant women after surgery for deeply
infiltrating endometriosis.
 Even the “Guideline on the Management of Women
with Endometriosis” does not address this issue.
 The “Guideline for Diagnosis and Therapy of
Endometriosis” only suggests that the mode of delivery
should be discussed with each patient individually.
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U. Ulrich, O. Buchweitz, R. Greb et al., “Interdisciplinary S2k
guidelines for the diagnosis and treatment of endometriosis,”
Geburtshilfe Frauenheilkd, vol. 73, no. 9, pp. 890–898, 2013.

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38. Mode of Delivery
Women with endometriosis of the
compartment ENZIAN A or ENZIAN C had
statistically higher risk for delivery through
caesarean section than women without
endometriosis in these compartments.
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39. Several investigators have suggested a
possible positive role for complete surgical
resection of the DIE surgery before pregnancy,
not simply to improve conception rates but also
to reduce obstetric complications.
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Post Surgical Pregnancy

40. Post Surgical Pregnancy
• Literature describes that rectum resection due to
endometriosis may lead to several complications,
including rectovaginal fistula or anastomotic
insufficiency .
• A survey conducted by Remzi et al. described a
significantly higher risk of sphincter injury in women
who underwent an ileal pouch anal anastomosis and
afterwards delivered spontaneously compared to
women who delivered via caesarean section.
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41. • High cesarean delivery rate is probably due to
the complications that occurred during
pregnancy.
• Obstetric problems may be the result of a
double ‘‘Pathogenetic’’ mechanism:
- Both the presence of the disease and
- Lack of knowledge about the potential for
obstetric complications in women with DIE.
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Mode of Delivery

42. Counseling
 The presence of abdominal pain in pregnant
women with endometriosis and concomitant
posterior DIE should suggest the potential role of the
disease in generating pain, intimating a more careful
supervision of such pregnancies.
 Greater knowledge of this disease should help
avoid hasty obstetric decisions that could result in
iatrogenic neonatal disease, and patients also could
be fully informed about the potential for
complications during their pregnancy.
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43.  Providing women with DIE with the
correct information about obstetric
complications is crucial for patient counseling,
especially for promoting greater psychological
well-being during the development of the
pregnancy.
 This is especially true in cases of posterior
DIE, a disease that could lead severe
complications such as bowel perforation.
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44.  Pregnancyhasvarious impacts in women
with endometriosis.
 Although the incidence is low,
endometriosis related emergent events
during pregnancy would be serious but can
be managed well with knowledge about the
impact of pregnancy on endometriosis.
To Conclude. . .