Obstetric Outcome After Surgical Treatment of Endometriosis: A Review of the Literature

A diagnosis of endometriosis is associated with increased risks of adverse pregnancy outcomes including placenta praevia and preterm birth. Some studies have also suggested associations with gestational hypertension, foetal growth restriction, gestational diabetes, perinatal death, and obstetric haemorrhage. This review aims to assess the impact of pre-pregnancy surgical treatment of endometriosis on future obstetric outcomes. A search of the Medline, Embase and PubMed electronic databases was performed to identify studies reporting pre-pregnancy surgery for endometriosis and subsequent pregnancy outcome compared to controls with unresected endometriosis. Three studies met the inclusion criteria. The studies were heterogenous in design, definition of study groups and outcome measures. All three studies were judged at critical risk of bias. Pre-pregnancy excision of endometriosis was associated with an increased risk of caesarean section in one of two studies, OR 1.72 (95% CI 1.59–1.86) and OR 1.79 (95% CI 0.69–4.64). Placenta praevia rates were also increased in one of two studies OR 2.83 (95% CI 0.56–12.31) and OR 2.04 (95% CI 1.66–2.52). One study found increased risks of preterm birth, small for gestational age, gestational hypertension, and antepartum and postpartum haemorrhage (all p < 0.05) with pre-pregnancy excision of endometriosis. There is insufficient evidence examining the role of pre-pregnancy endometriosis surgery in ameliorating adverse pregnancy outcomes, and thus reliable conclusions cannot be drawn. Prospectively designed studies are needed to assess the relationship between surgical treatments for endometriosis and obstetric outcome and examine potential confounders such as comorbid adenomyosis and infertility.

Pattern of Blood Transfusion among Women Undergoing Caesarean Section in a Tertiary Health Care Centre

Background: Cesarean section delivery causes major risk factors in terms of intraoperative performance and blood loss while blood transfusion is a promising factor in emergency care in case of blood unavailability. Women undergoing cesarean section routinely require blood cross-matching. Aim: The present study aimed to evaluate the pattern of blood transfusion among women who underwent c/section at the tertiary care center. Materials and Methods: This cross-sectional study was conducted on 745 pregnant women who underwent cesarean section at Obstetrics & Gynaecology department of Quaid-e-Azam International Hospital Islamabad and PAF hospital Masroor, Karachi for duration of six months from January 2021 to June 2021. The demographic details, incidence of cesarean section, blood transfusion indications and types were recorded. Antenatal intraoperative and pre-operative details were also noted. Complications regarding blood transfusion were analyzed using multivariable analysis and EPI-statistical software v 3.5.3. Results: Of the total 745 cesarean sections, the prevalence of blood transfusion was 10.1%. About 75 women transfused 216 units of blood with packed cells tailed by Fresh Frozen Plasma (FFP). The prevalence of emergency cesarean section was 61 (81.3%) while general anesthesia was utilized in 27 (44.3%) cases. Fetal distress and placenta praevia were the common indications of cesarean section. Placenta praevia Respiratory rate (RR) was 5.01 (p<0.001). Other obstetric complications and risk factors were anemia, antepartum hemorrhage, hypertension, and previous cesarean section. The cross-matched transfusion ratio was 9.93 while the transfusion index and probabilities were 0.078 and 10.1 respectively. Conclusion: Our study found a higher prevalence of blood transfusion risks among pregnant women who underwent cesarean section. It has been observed that the risk of blood transfusion increased with placenta previa, preoperative maternal anemia, placenta abruption, and second stage cesarean section. During the antenatal period, the need for blood transfusion might be reduced with an increased concentration of maternal hemoglobin. Keywords: Blood transfusion, Complications, Caesarean delivery, Transfusion index

1332Endometriosis, assisted reproductive technology and adverse pregnancy outcomes: a population based data linkage study

Background Endometriosis is a chronic inflammatory disease characterised by endometrial tissue outside the uterus – pain and infertility are common symptoms. There is a paucity of data on the association between endometriosis and adverse pregnancy outcomes where the contribution of assisted reproductive technology (ART) use is also considered. This study will examine the association between endometriosis, with and without ART use, on adverse pregnancy outcomes. Methods Population data linkage study of all female NSW residents aged 15-45 years with a singleton birth in 2006-2015. Pregnancies were classified into 4 groups based on endometriosis diagnosis (yes/no) and ART use (yes/no). Multinomial logistic regression was used to estimate the odds of adverse pregnancy outcomes with 99% confidence intervals, adjusting for maternal and pregnancy factors. Outcomes assessed included placenta praevia, antepartum haemorrhage, planned birth (induction of labour or caesarean section) and preterm birth. Results Of 889,101 eligible pregnancies, women with endometriosis were more likely to be older while women who used ART were more likely to be nulliparous, birth in a private hospital and less likely to smoke. Adjusted odds ratios for selected study outcomes are outlined below. Conclusions Endometriosis is associated with increased odds of preterm birth, placenta praevia, antepartum haemorrhage and planned birth. In general, the odds of adverse pregnancy outcomes associated with endometriosis were further increased with ART use. Key messages These findings suggest that women with endometriosis, especially those who achieved pregnancy via ART use, represent a high risk obstetric population requiring appropriate surveillance and management.

P–324 Pregnancy outcome after IVF for endometriosis or male infertility: What differs?

Study question Are endometriosis women pregnant after IVF at increased risk of preeclampsia or placenta praevia than patients monitored for male infertility? Summary answer Patients with endometriosis are at greater risk than patients monitored for male infertility of developing preeclampsia and placenta previa. What is known already Endometriosis is a chronic estrogen-dependent disease that affects women of childbearing age which represents 10% of the general population[.The main symptoms found are chronic pelvic pain, infertility, dyspareunia and dysmenorrhea. Numerous publications have highlighted the deleterious effect of endometriosis on pregnancy i.e miscarriage, placental abnormalities, preeclampsia, preterm birth, low gestational weight. This complication may be related to the molecular and cellular abnormalities present in the endometrium of these patients and to the inflammatory state that may lead to abnormal contractility of the uterus at the time of the implantation window and trophoblastic invasion. Study design, size, duration This study is a retrospective, non-interventional monocentric cohort study conducted between January 2011 and December 2017 in Institut de Medecine de la Reproduction - Clinique Bouchard in Marseilles, France. Participants/materials, setting, methods The outcome of pregnancies obtained after IVF and/or ICSI in patients with endometriosis (n = 270) was compared with patients,free of endometriosis,monitored for male infertility (n = 366) The statistical study was carried out using GraphPad Version 8 The Student T-test was used to compare means across them. Results were considered significant for p &lt; 0.05. Main results and the role of chance Patients with endometriosis and monitored during this period were older than those managed for male infertility. (33.59 vs 32.78) (p = 0.04). There was no difference between the two populations regarding BMI (p = 0.31) or smoking (p &gt; 0.9). The rate of miscarriage observed in the two populations was comparable (25.37 vs. 25.78%) (p &gt; 0.9), so was the rate of IUGR (5.81% vs. 2.29%) despite the observed percentages (p &gt; 0.9). The rate of premature deliveries did not differ between the two populations (18.37% vs. 14.29%) (p = 0.55) neither did the number of children born with a weight &lt;2500g at term (13.68% vs. 12.5%) (p = 0.83). Although the rate of gestational diabetes was comparable in both groups (4.11% vs 4.56%), the rate of preeclampsia was higher in the group of patients with endometriosis with a statistically significant difference (4.79% vs 0.79%) (p = 0.01). Similarly, the rate of placenta previa was higher in patients with endometriosis (4.11% vs 0.76%) (p = 0.02). All pregnancies complicated by placenta previa resulted from J2/J3 embryo transfer. Estradiol levels on the day of induction (2166 pg/ml vs 2452) (p = 0.67) and endometrial thickness was not different between patients with placenta praevia or no (10.45 vs 10.51) (p = 0.66). Limitations, reasons for caution Our study is retrospective which may introduce several biases despite the size of our sample i;e patients with endometriosis are older, adenomyosis was not included in the criteria. In our study we have not found any additional risk related to the type of embryo transferred. Wider implications of the findings: Patients with endometriosis are at greater risk than patients managed for male infertility of developing preeclampsia and placenta previa. It is advisable to warn patients of this possible complication, to promote e-SET and to set up early monitoring in order to place the appropriate management around these patients. Trial registration number Not applicable

A case of multiple fibroid uterus, complete placenta praevia, antepartum haemorrhage, myomectomy and obstetric hysterectomy: a near miss

An interesting case of young unbooked, unregistered, primigravida with multiple fibroid uterus, placenta praevia type IV, presented with APH in haemorrhagic Shock, impacted large fibroid in Lower Uterine Segment and Multiple fibroids on Anterior wall, fundus for which myomectomy was performed. Preterm Caesarean Section with extremely low birth weight infant delivered followed by life-saving Emergency Obstetric hysterectomy. She had uneventful recovery without any complications of massive transfusion or surgery. Case is being reported as an obstetric near miss.

Spontaneous rupture of vaginal varicose veins mimicking placenta praevia

Vaginal varicosities are often an asymptomatic venous disorder that rarely occur in pregnant women. There is little information in medical literature concerning diagnosis and management.1 We present an isolated incident of spontaneous rupture of vulvar varicosities mimicking the presentation of placenta previa. It was successfully managed with a simple surgical approach done under local anesthesia.

A prediction model for placenta accreta spectrum: A multicentre external validation study.

Objective: To validate the Weiniger model, a multivariable prediction model for placenta accreta spectrum (PAS). Design: Multicentre external validation study. Setting: Two tertiary care hospitals in the United States. Population: Cohort A included patients with risk factors (prior caesarean delivery, placenta praevia) and/or ultrasound features of PAS (variable risk) presenting to a tertiary care hospital. Cohort B patients were referred to a tertiary care hospital specifically for ultrasound features of PAS (higher risk). Methods: Weiniger model variables (prior caesarean deliveries, placenta praevia and ultrasound features of PAS) were retrospectively collected from both cohorts and predictive performance of the model was evaluated. Main Outcome Measures: Surgical and/or pathological diagnosis of PAS. Results: The model c-statistic in cohorts A and B was 0.728 (95% CI: 0.662, 0.794) and 0.866 (95% CI: 0.754, 0.977) signifying acceptable and excellent discrimination, respectively. Based on calibration curves, the model underestimated average PAS risk in both cohorts. In both cohorts, high risk was overestimated and low risk underestimated. Use of this model compared to a “treat all” strategy had greater net benefit at a threshold probability of > 0.25 in cohort A, but no net benefit in cohort B. Conclusions: This study provides multicentre external validation of the Weiniger model for PAS prediction, making it a useful triaging tool for management of this high-risk obstetric condition. Clinical usefulness of this model is influenced by the incidence of risk factors and PAS ultrasound features, with better performance in a variable-risk population at threshold probability >25%.