The ominous association between severe endometriosis, in vitro fertilisation, and placenta previa: raising awareness, limiting risks, informing women

Abstract

Please cite this paper as: Vercellini P, Frattaruolo MP, Barbara G, Buggio L, Somigliana E. The ominous association between severe endometriosis, in vitro fertilisation, and placenta previa: raising awareness, limiting risks, informing women. BJOG 2018;125:12-15. Endometriosis is associated with several adverse pregnancy outcomes.1 The most severe maternal complications are spontaneous haemoperitoneum in the second half of pregnancy and placenta praevia.1 Spontaneous haemoperitoneum, mostly associated with endometriosis infiltrating the broad and uterosacral ligaments and the Douglas pouch, is a potentially fatal but rare event. Placenta praevia is more common, 1-3 and it is important to define its incidence, the association with different lesion types, the impact of additional risk factors, the potential obstetrical consequences, and the information that women should receive.The association between endometriosis and placenta praevia Reliable estimates of the risk of placenta praevia in women with endometriosis could be obtained by investigating large population-based national cohorts. Harada et al.2 used data of the Japan Environment and Children's Study to evaluate obstetrical outcomes in 9186 pregnant women with (n = 330) or without (n = 8856) a self-reported history of endometriosis. Placenta praevia was observed in 3.6% of women with endometriosis and 0.6% of those without the disease (adjusted OR, 6.4; 95% CI, 3.2-12.6).2 Saraswat et al., using Scottish Record Linkage System data, compared late pregnancy outcomes in 4232 women with and 6707 without a diagnosis of endometriosis. The rate of placenta praevia was 1.7% in the former group and 0.8% in the latter (adjusted OR, 2.2; 95% CI, 1.5-3.3).3 Berlac et al., extracting data from the Danish Health Register and the Medical Birth Register, observed a higher risk of several obstetrical and neonatal complications in the 11 739 patients with endometriosis compared with the 615 533 women without a diagnosis of endometriosis. The highest risk was observed for pregnancies complicated by placenta praevia (2.1% versus 0.5%, respectively; OR, 3.9; 95% CI, 3.5-4.3).1

Horizontal Cervix as a Novel Sign for Predicting Adhesions on the Posterior Extrauterine Wall in Cases of Placenta Previa

“…Saraswat et al compared late pregnancy outcomes in 4232 women with endometriosis and 6707 without endometriosis and reported that the rate of placenta previa was 1.7% in the former group and 0.8% in the latter (adjusted odds ratio, 2.2; 95% CI, 1.5-3.3) [16,17]. Other studies have also reported that the incidence of placenta previa is high in patients with endometriosis [4,5,18]; thus, the frequency at which obstetricians encounter placenta previa or PAS may increase with an increase in the incidence of endometriosis.…”

Medical treatment in the management of deep endometriosis infiltrating the proximal rectum and sigmoid colon: a comprehensive literature review

“…In fact, some cases of large bowel occlusion or perforation as well as hydroureteronephrosis have been reported during pregnancy (53)(54)(55). Abdominal procedures for complicated colorectal endometriosis in the presence of a gravid uterus may reveal technically demanding and risky for both the mother and the fetus (58,59). Surgery should be also discussed before undertaking in vitro fertilization, as similar complications have been observed during ovarian stimulation (56,57).…”

“…Surgery should be also discussed before undertaking in vitro fertilization, as similar complications have been observed during ovarian stimulation (56,57). Abdominal procedures for complicated colorectal endometriosis in the presence of a gravid uterus may reveal technically demanding and risky for both the mother and the fetus (58,59). Thus, women with sub-occlusive forms seeking pregnancy in the future should be thoroughly informed about the risks of not undergoing prior bowel surgery and should be referred to tertiary care endometriosis centers where expert abdominal surgeons are available for pre-conception evaluation and advice.…”

Ovarian stimulation and endometriosis progression or recurrence: a systematic review

“…In a systematic review of the literature on this serious complication, Brosens et al (2016) showed that 24 out of the 64 described cases (38%) occurred in women with endometriosis undergoing ovarian stimulation. It remains to be clarified whether this observation reflects a real detrimental effect of IVF or, conversely, whether it is just consequent to the fact that women with worse endometriosis require IVF treatment more frequently (Vercellini et al, 2018).…”