Intestinal Perforation due to Deep Infiltrating Endometriosis during Pregnancy: Case Report

Abstract

We report the case of a 33 year-old woman who complained of severe dysmenorrhea since menarche. From 2003 to 2009, she underwent 4 laparoscopies for the treatment of pain associated with endometriosis. After all four interventions, the pain recurred despite the use of gonadotropin-releasing hormone (GnRH) analogues and the insertion of a levonorgestrel intrauterine system (LNG-IUS). Finally, a colonoscopy performed in 2010 revealed rectosigmoid stenosis probably due to extrinsic compression. The patient was advised to get pregnant before treating the intestinal lesion. Spontaneous pregnancy occurred soon after LNG-IUS removal in 2011. In the 33rd week of pregnancy, the patient started to feel severe abdominal pain. No fever or sings of pelviperitonitis were present, but as the pain worsened, a cesarean section was performed, with the delivery of a premature healthy male, and an intestinal rupture was identified. Severe peritoneal infection and sepsis ensued. A colostomy was performed, and the patient recovered after eight days in intensive care. Three months later, the colostomy was closed, and a new LNG-IUS was inserted. The patient then came to be treated by our multidisciplinary endometriosis team. The diagnostic evaluation revealed the presence of intestinal lesions with extrinsic compression of the rectum. She then underwent a laparoscopic excision of the endometriotic lesions, including an ovarian endometrioma, adhesiolysis and segmental colectomy in 2014. She is now fully recovered and planning a new pregnancy. A transvaginal ultrasound (TVUS) performed six months after surgery showed signs of pelvic adhesions, but no endometriotic lesions.

Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

“…Setúbal et al reported on three cases of bowel perforation due to endometriosis, at their own center, as well as 12 cases through a search of the literature until 2013 [79]. A further three cases of spontaneous bowel perforation during pregnancy in endometriosis patients were reported in 2014 [80], 2016 [81], and 2018 [82]. All cases had the diagnosis proven either prior to pregnancy or through biopsies taken during surgery.…”

Novas perspectivas para o tratamento da endometriose

“…Por isso, na maioria dos casos só é possível diagnosticar através de exames de imagem, como ultrassonografia transvaginal (USTV), ultrassonografia No que se refere a EIP, é de suma importância a avaliação intestinal, uma vez que o envolvimento nessa área pode ser multifocal, podendo comprometer cólon, retossigmoide, o apêndice, o ceco e o íleo distal. O número de lesões e a profundidade delas estão relacionados no que tange a avaliação e o prognóstico do tratamento cirúrgico (CARNEIRO MM, et al, 2018). Em presença de indícios e sintomas de Endometriose Infiltrativa Profunda ou quando os testes revelam a presença de um endometrioma, é aconselhável procurar uma consulta com um ginecologista para realização de exames de imagens mais minuciosos, como Ressonância Magnética Pélvica ou Ecografia Transvaginal dinâmica.…”

“…A endometriose pode ser caracterizada como uma condição de crescimento celular progressivo, benigna, de dependência estrogênica e crescimento endotelial (CARNEIRO MM, et al, 2018). Tendo uma prevalência estimada em todo o mundo de 176 milhões de mulheres acometidas (ZONDERVAN KT, et al, 2018).…”

Obstetric and perinatal outcomes in women with endometriosis

“…Affecting the appendix***, 26 terminal ileum***, 27 and colon***, 28 causing tissue perforation with severe gastrointestinal bleeding 29 or urohaemoperitoneum*** with urinary tract endometriosis 30 Involution of decidualised (progesterone mediated*) endometriotic implants associated with parametrial veins causing vascular fragility and spontaneous peritoneal bleeding*** 31 Uterine rupture*** 32,33 in nulliparous women both before and during labour or uterine scar weakness following excision of rectovaginal nodule 34 or electrosurgical treatment 23 such cases, 61% occur antenatally in the third trimester, 18% intrapartum, and 21% up to 42 days postpartum. 38 A review of 21 studies 31 showed that 72% were nulliparous presenting with sudden onset of nonspecific abdominal pain (95%) and signs of hypovolemic shock (70%).…”