Endometriosis - beheshti.ircme.ir
Transcript of Endometriosis - beheshti.ircme.ir
Endometriosis during pregnancy
Dr. T. ArbabzadehOb & Gyn. PerinatalogistSBMU
References:
• UpToDate
• Petresin J, et al. Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review. Geburtshilfe Frauenheilkd. 2016;76(8):902-905.
• Umberto L.et al. A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes, Human Reproduction Update, Volume 22, Issue 1, January/February 2016, Pages 70–103.
• ESHRE GUIDELINE,ENDOMETRIOSIS 2021
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Course During
Pregnancy
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• Improvement
“Pseudopregnancy” induced through hormonal therapies has a positive effect on symptoms.
Course During
Pregnancy
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• Complications:
• Adhesion formation: Intestinal obstruction and perforation
• Hemoperitoneum
• Uroperitoneum
• Acute appendicitis
• Ruptured or infected ovarian endometrioma
Mechanisms of complications ?
Course During
Pregnancy
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• Complications:
• Intestinal perforation
• Hemoperitoneum
• Uroperitoneum
• Acute appendicitis
• Ruptured or infected ovarian
endometrioma
• Mechanisms of complications ?
Obstetric Outcomes
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• Preterm birth
• Preeclampsia ?
• Gestational DM
• Cesarean delivery
• Miscarriage
• Ectopic pregnancy
• Placenta previa
• Unexplained antepartum hemorrhage
• Postpartum hemorrhage
• Stillbirth
• Low birth weight, admission to NICU, neonatal death
• Ovarian torsion
• High in the second
half of pregnancy
and during labor.
• Bowel perforation:
2× small bowel, 1× cecum, 3× appendix and 6×
rectum and sigmoid colon
• Uterine rupture:
Spontaneous
Intrapartum uterine rupture following previous
surgery
• Endometrioma:
infected, enlarged, and ruptured
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Complications in
Pregnancy
Deciduosis from
decidualized endometriosis
• Ectopic decidua is most commonly localized in the ovary, cervix, uterine serosa and the lamina propria of the salpinx.
• The peritoneal localization is uncommon.
Term ‘deciduosis’ is used to indicate two different entities:
(i) metaplasia of the sub-coelomic pluripotent mesenchymal cells under the effect of progesterone: very frequently in the ovary of term pregnancies and regressing post-partum within 4–6 weeks
(ii) The pregnancy-associated stromal decidualization of ectopic endometrium (endometriosis) that under progesterone action increases glandular epithelial secretion, stromal vascularity and edema
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• Ovarian endometriosis in
pregnancy is a rare condition
with an estimated frequency of
about 0.05–0.5%.
• Transvaginal sonography : Gold
standard imaging method.
Ovarian Endometrioma
• During pregnancy, changes in the dimension and in
the appearance of the endometriotic cyst:
52%
unchangedin 28%
20%
Ovarian Endometrioma
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• The sonographic pattern of decidualized ovarian
endometrioma:
1. ground-glass or low level echogenicity of the cyst
2. papillary projections with smooth rounded contour
3. multiple vascularization signals within the solid part with low resistance index
✿ Differentiating malignant papillations from decidualized endometriomas would be crucial to avoid unnecessary surgery during pregnancy:
Round-shaped appearance benign papillations →decidualized endometriomas
Irregular surface papillary projections → borderline malignancies.
✿ The absence of septations & growth could be a reassuring sign
Treatment
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Decidualized
ovarian
endometriosis
Expectant management vs. Surgical intervention
✿ Surgery• Cystectomy• Salpingo-oophorectomy• Laparoscopy is safe • Increased risk after 23 weeks’ gestation• Surgical approach in the late 3rd trimester shouldbe postponed until after or at the time of delivery.
Decidualized endometriomas
mimicking ovarianmalignancies
ESHRE2021
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Endometrioma in
pregnancy
• The decidualization of an endometrioma in pregnancy may in some cases resemble malignant
ovarian tumors posing a clinical diagnostic dilemma,
although the true incidence of this phenomenon is
uncertain (prevalence 0-12%).
• First-line management: serial monitoring
(with ultrasound, or MRI if necessary) and expectant
management.
• When a malignancy is suspected and surgery is
considered necessary, a minimally invasive
laparoscopic approach is recommended not later
than 23 weeks.
ESHRE2021
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Recommendation
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Decidualized
endometriosis in
extra-ovarian
sites
• Sites:PeritoneumBladderBowelDiaphragmpleura, lungs, breastskin, either intact or following surgery (scars, episiotomy)
• Becoming hypertrophic or gaining features of decidualization or mimicking carcinomatosis.
• No case of peritoneal decidualized endometriosis in pregnancy has been described.
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Cutaneous
decidualized
endometriosis
• DDX: Malignancy • Cyclical pain• Typical lesion enlargement occurring during pregnancy• Shape of the nodules with smooth rounded borders
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Decidualized
endometriosis of
the bladder
✿ Clinical Assessment:• Ultrasound:malignancy → high vascularization on color DopplerAnalysis, feeding arterial vessels seen on MRI scans and the location most commonly found at the bladder dome. benign endometriosis → vesicouterine pouch• Cystoscopy• MRI
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Thank you