Natural history of ovarian endometrioma in pregnancy

Abstract

BackgroundOvarian endometriomas are classified as benign ovarian lesions. During pregnancy endometriomas may undergo major morphological changes which are referred to as ‘decidualisation’. Decidualised ovarian endometrioma may resemble malignant ovarian tumours on ultrasound examination. The aim was to study variations in the morphology and size of ovarian endometriomas diagnosed on ultrasound during pregnancy.MethodsWe searched our database to identify pregnant women who were diagnosed with ovarian endometriomas on ultrasound in order to study the effect of pregnancy on their morphological characteristics. In women who underwent serial scans during pregnancy we examined the changes in the size of endometriomas with advancing gestation.ResultsTwenty four patients with a total of 34 endometriomas were included in the analysis. All women were managed expectantly during pregnancy. On the first ultrasound scan 29/34 (85.3%, 95% CI 73.4 - 97.2) endometriomas appeared unilocular with fine internal echoes (‘ground glass’ contents) and they were poorly vascularised on Doppler examination. 1/34 (2.9% 95% CI 0.0 - 8.5) endometrioma was multilocular, with regular margins, ‘ground glass’ contents and it was also poorly vascularised. 4/34 (11.8%, 95% CI 1.0 - 22.6) had sonographic features suggestive of decidualisation such as thick and irregular inner wall, papillary projections and highly vascular on Doppler examination. The endometriomas showed a tendency to decrease in size during pregnancy.ConclusionsPregnancy has a major effect on the size and morphological appearances of ovarian endometriomas. Rapid regression of decidualised endometriomas is a helpful feature which could be used to confirm their benign nature.

Severe spontaneous hemoperitoneum in pregnancy may be linked to in vitro fertilization in patients with endometriosis: a systematic review

“…Ovarian endometrioma was reported in seven cases, but extrapolation from literature reports suggests that it is likely that these were under-reported (69). Pateman et al (70) reported that the majority of endometriomas were observed to regress during pregnancy when followed up by serial ultrasound and that 12% of cases showed evidence suggestive of decidualization, such as a thick and irregular inner wall, papillary projections, and high vascularity on Doppler examination. These features can pose diagnostic challenges because they may mimic ovarian malignancy.…”

Benefits of pregnancy on endometriosis: can we dispel the myths?

“…The results of these reports are confusing with 15% to 50% of endometriotic lesions disappearing, 34% to 65% regressing and the remaining lesions either increasing (9% to 39%) or remaining unchaned (25%) during pregnancy. Anecdotal reports also describe reduction of non-ovarian lesions or regression of endometriotic lesions during the early puerperium period, however, the majority of lesions seem not to regress (3).…”

“…The few available studies support regression more often in the second or third than in the trimester or the lactation period. Imaging and histopathology studies of endometriotic lesions during pregnancy show that they may grow rapidly during pregnancy, making differentiation from malignant tumours challenging (3). The enlargement of endometriotic lesions and suspicious sono-morphological appearance is the most frequent reason for surgical interventions during pregnancy.…”

“…Such changes are most often a result from decidualization. Decidualization has been reported in up to 77% of endometriomas, and to comparable degree (0-77%) in peritoneal, cutaneous, vesical and pulmonary endometriotic lesions although this will be impacted by the difficulty of diagnosis and monitoring of the latter during pregnancy (1,3,4). Decidualization is considered to be the first step towards regression, and additionally, decidualized endometriotic lesions appear to have a decreased ability to transplant.…”

“…However, the conclusion that pregnancy supports resolution of disease symptoms has to be interpreted with caution as endometriosis-related subfertility likely biases such association. At the same time, endometriosis-related pain often leads to ultrasound evaluation of the ovaries which in turn may eventually lead to surgical intervention during pregnancy (3,4). In summary, currently available studies do not allow the conclusion that pregnancy may help against endometriosisassociated pain in the longer term.…”