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Beyond infertility: obstetrical and postpartum complications associated with endometriosis and adenomyosis
Open accessAbstract
The risk of pregnancy and neonatal complications in women with endometriosis and adenomyosis is debatable. A literature review looking at rates, presentation, and management of spontaneous hemoperitoneum, enlargement, abscess, and rupture of an endometrioma, uterine rupture, and bowel perforation in pregnant women with endometriosis was conducted. Moreover, studies addressing differences in early pregnancy (miscarriage), late pregnancy (gestational diabetes mellitus, preeclampsia, prematurity, placenta previa, placental abruption, cesarean section, hemorrhages) and neonatal outcomes (weight at birth) between endometriosis and adenomyosis patients versus control subjects were reviewed. The overall prevalence of endometriosis-related spontaneous hemoperitoneum in pregnancy is estimated to be ∼0.4%. Only four cases of endometrioma rupture in pregnancy have been reported. Although during pregnancy there is no way to anticipate the onset of complications from preexisting endometriosis, it is important, when a specific abdominal pain occurs, to suspect rare but potentially life-threating events. Population-based studies suggest a possible association of endometriosis with preterm birth and placenta previa. Limits of the published studies are noted and discussed.
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“AM-associated disruption of the junctional zone and the inner myometrium may lead to placental implantation disorders [29,30,31,32].”
From Women with Endometriosis—Who Is at Risk for Complications Associated with Pregnancy and Childbirth? A Retrospective Case–Control Study (2024) · cites this paper as [31]
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“Instead of becoming at rest during a pregnancy, some deep lesions do progress and can cause bowel (65,66), uterus, or bladder perforations.”
From Pathogenesis of deep endometriosis (2017) · cites this paper as [66]
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“It has been suggested that both endometriosis and adenomyosis could be associated with obstetrical complications (8), and speculation on whether adenomyosis poses a larger threat to the pregnancy exist.”
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“3 Endometriose: Schwangerschaft und Geburt Bezüglich der Schwangerschaft existiert inzwischen eine größere Anzahl an Studien, die eine erhöhte Risikokonstellation wie folgt darstellt: ▪ Abortrate [28] ▪ Frühgeburtlichkeit [29] ▪ vorzeitiger Blasensprung [30] ▪ vorzeitige Plazentalösung [31] ▪ Placenta praevia [31] ▪ P…”
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Leone Roberti Maggiore, U., Inversetti, A., Schimberni, M., Viganò, P., Giorgione, V., & Candiani, M. (2017) · Fertility and Sterility · doi:10.1016/j.fertnstert.2017.10.035 · Cited by 60
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“Complications of preexisting endometriotic foci during pregnancy are rare [46]; in our study, we observed one case of hemoperitoneum due to probable rupture of an ovarian endometrioma in the third trimester of pregnancy.”
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“Two other systematic reviews failed to draw conclusions on obstetrical complications related to EM except for preterm delivery [34] and placenta previa [35].”
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Shmueli, A., Salman, L., Hiersch, L., Ashwal, E., Hadar, E., Wiznitzer, A., Yogev, Y., & Aviram, A. (2017) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2017.1393513 · Cited by 29
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“Recently, interest on this argument has re-flourished (8,9) but, to date, definite conclusions cannot be drawn because the designs of the available studies are generally weak and results inevitably exposed to confounders (Table 1) (10-16).”
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“…addition, some studies suggest that the presence of endometriosis per se may adversely affect pregnancy and neonatal outcomes (Brosens et al., 2012; Vigano et al., 2015; Jacques et al., 2016), while a recent systematic review stated that complications of endometriosis during pregnancy were rare…”
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Vercellini, P., Viganò, P., Frattaruolo, M. P., Borghi, A., & Somigliana, E. (2018) · Human Reproduction · doi:10.1093/humrep/dey104 · Cited by 20
“In any case, the association seems to be with deep endometriosis in general and not specifically with colorectal endometriosis (Vigano et al., 2015; Leone Roberti Maggiore et al., 2017; Zullo et al., 2017).”
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“The expansion of results from most previous studies is limited by the methodology, sample size and accurate diagnosis (28,29).”
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“MAR treatment itself has shown to be a risk factor for adverse pregnancy outcomes, with mixed results for women with endometriosis [47].”
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Frîncu, F., Carp-Velișcu, A., Petca, A., Badiu, D., Brătilă, E., Cîrstoiu, M., & Mehedințu, C. (2021) · Medicina · doi:10.3390/medicina57111258 · Cited by 17
Effects of adenomyosis on obstetric outcomes
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Adenomyosis: Disease, uterine aging process leading to symptoms, or both?
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“Previous studies have shown that deeply infiltrating endometriosis can be associated with a various number of complications during pregnancy and delivery [6].”
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Petresin, J., Wolf, J., EMİR, S. N., Müller, A., & Boosz, A. S. (2016) · Geburtshilfe und Frauenheilkunde · doi:10.1055/s-0042-101026 · Cited by 15
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“Similar to endometriosis, adenomyosis is closely associated with inflammation and angiogenesis (8,9), to which the prostaglandin cascade initiated by cyclooxygenases (COXs) may serve an important role.”
Uterine Artery Pseudoaneurysm in a Pregnant Patient with Retrocervical Endometriosis
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“These factors potentially interfere with folliculogenesis, sperm function, embryo transport, and endometrial receptivity (4, 5).”
Ribot, É., Berbis, J., Hamouda, I., Cohen, D. T., Agostini, A., & Courbière, B. (2021) · Journal of Gynecology Obstetrics and Human Reproduction · doi:10.1016/j.jogoh.2021.102274 · Cited by 12
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“Previous case reports and reviews have reported a favorable outcome when a close follow-up was maintained.(9,11,18,27,28) Repeated assessments of hemoglobin level, vital signs, and sonography are helpful in the early identification and prevention of deterioration.”
ResultYang, B., Wang, L., Wan, X., Li, Y., Yu, X., Qin, Y., Luo, Y., Wang, F., & Huang, O. (2017) · BMC Women s Health · doi:10.1186/s12905-017-0474-z · Cited by 12
“A series of hypotheses that attempt to explain the genesis of adenomyosis has been established [3].”
BackgroundDeep Infiltrating Endometriosis and Adenomyosis: Implications on Pregnancy and Outcome
Gruber, T. M., Ortlieb, L., Henrich, W., & Mechsner, S. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm11010157 · Cited by 11
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“Furthermore, adenomyosis is associated with higher rates of obstetric complications, such as preterm birth and preterm rupture of the amniotic membranes [19,20].”
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Park, B. Y., Yao, R., Rossi, J., & Lee, A. W. (2023) · Fertility and Sterility · doi:10.1016/j.fertnstert.2023.03.033 · Cited by 8
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Hemoperitoneum Following Sexual Intercourse in a Woman with Deep Infiltrating Endometriosis
Buggio, L., Aimi, G., & Vercellini, P. (2016) · Gynecologic and Obstetric Investigation · doi:10.1159/000447262 · Cited by 7
Li, Y., Ge, L., Yang, X., Cui, L., & Chen, Z. (2023) · Frontiers in Medicine · doi:10.3389/fmed.2023.1248274 · Cited by 6
Riemma, G., Cobellis, L., Laganà, A. S., Etrusco, A., Corte, L. D., Torella, M., Vastarella, M. G., Carotenuto, R. M., & FRANCISCIS, P. D. (2025) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.70134 · Cited by 7
“31 This network meta-analysis did not evaluate this issue as only one out of the nine included studies evaluated the co-presence of ade-nomyosis, without providing separate data.”
Adenomyosis and pregnant uterus: An alliance doomed to rupture?
Nohuz, E., Albaut, M., Bayeh, S., Tamburro, S., & Chene, G. (2019) · Journal of Gynecology Obstetrics and Human Reproduction · doi:10.1016/j.jogoh.2019.101632 · Cited by 5
Wang, Y., Hu, Z., Jiang, P., Kong, W., Gong, C., Chen, Y., Xu, L., Yang, Y., & Hu, Z. (2023) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-023-07136-z · Cited by 5
“…pregnancy-related complications (hypertensive disorder complicating pregnancy, PPROM, GDM, postpartum hemorrhage, etc.) was also much higher than that in the low-risk group, which undoubtedly increased the risk of adverse pregnancy outcomes on another level, thus entered a “vicious circle” [7, 27].”
Spontaneous hemoperitoneum in pregnancy due to endometriosis
Kim, T. G., Sudhof, L. S., Liu, F. W., & Shainker, S. A. (2020) · Journal of Endometriosis and Pelvic Pain Disorders · doi:10.1177/2284026520942432 · Cited by 5
Labor may mask a symptom of the rupture of ovarian endometrial cyst: a case report
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“The clinical symptom of rupture of endometrial cyst is often lower abdominal pain without signs of infection [8].”
BackgroundAgrawala, S., Patil, J., Campbell, S. B., & Woodard, T. L. (2021) · Fertility Research and Practice · doi:10.1186/s40738-021-00097-4 · Cited by 4
Endometriosis and risk factors in pregnancy, labor and delivery: a case-control study
Alboni, C., Cannoletta, M., MOSCA, S., PASINI, S., Farulla, A., & Chiossi, G. (2024) · Minerva Obstetrics and Gynecology · doi:10.23736/s2724-606x.24.05527-1 · Cited by 3
A bélendometriosis miatt végzett műtétek hatása a fertilitásra
Brubel, R., Dobó, N., Csibi, N., Kövesdi, A., Máté, S., Ács, N., Lukovich, P., Murber, Á., & Bokor, A. (2019) · Orvosi Hetilap · doi:10.1556/650.2019.31514 · Cited by 3
Nomograms for predicting adverse obstetric outcome in IVF pregnancy: A preliminary study
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A narrative review of endometriosis surgery and infertility
Çoban, U., Hatırnaz, Ş., & Kalkan, Ü. (2021) · Gynecology and Pelvic Medicine · doi:10.21037/gpm-20-55 · Cited by 2
“Endometriosis, and particularly DIE, is known risk factor for abnormal placental implantation (11).”
BackgroundFrom Endometriosis to Pregnancy: Which is the “Road-Map”?
Zupi, E., Felice, G. D., Conway, F., Martire, F. G., Exacoustós, C., Centini, G., Patrizi, L., Piccione, E., & Lazzeri, L. (2017) · Journal of Endometriosis and Pelvic Pain Disorders · doi:10.5301/jeppd.5000307 · Cited by 2
“In a review conducted by Viganò et al (90) the prevalence of spontaneous bowel perforations remained unknown.”
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Hemoperitoneu Espontâneo na Gravidez
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Rare and acute complications of endometriosis in pregnant women
Николаевна, В. Е., Артымук, Н. В., & Zotova, O. A. (2021) · Fundamental and Clinical Medicine · doi:10.23946/2500-0764-2021-6-1-69-76 · Cited by 2
“(2015), показал, что общая распространенность спонтанного гемоперитонеума, связанного с эндометриозом, у беременных составляет около 0,4%, риск его повышен у женщин с эндометриозом в случае зачатия с помощью ЭКО [34].”
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Impact of adenomyosis on fertility and obstetric outcomes among women in tertiary care center
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“Many recent reports have shown a relationship between endometriosis and perinatal complications 1 ― 5 .”
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Kinderwunsch und Schwangerschaft bei Endometriose
Shebl, O. J., Ebner, T., & Oppelt, P. (2016) · Gynäkologische Endokrinologie · doi:10.1007/s10304-015-0052-0
L’endométriose, une maladie encore méconnue
Linet, T. (2018) · Vocation Sage-femme · doi:10.1016/j.vsf.2018.05.003
Usefulness of plasma D-dimer levels in detecting ruptured ovarian endometrioma
Kajimura, I., Fujishita, A., Fukushima, A., Matsumoto, K., Yoshitake, T., & Hiraki, K. (2018) · JAPANESE JOURNAL OF GYNECOLOGIC AND OBSTETRIC ENDOSCOPY · doi:10.5180/jsgoe.34.1_86
Reproductive disorders and obstetric complications in gynecological diseases
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Hemoperitoneo postcoital secundario a desgarro mesentérico sin lesión vaginal asociada
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A case of spontaneous bowel perforation in labour secondary to endometriosis
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“It is likely that they are under-reported in the literature and the true prevalence of spontaneous bowel perforation in pregnancy is unknown (Vigano et al. 2015).”
BackgroundDie Uterusruptur – eine lauernde Gefahr
Küpker, W., Agic, A., Diedrich, K., & Felberbaum, R. E. (2022) · Der Gynäkologe · doi:10.1007/s00129-022-04923-8
“Als mögliche Schwangerschafts- und Geburtskomplikationen sind hier das spontane Hämatoperitoneum, Ruptur von Endometriosezysten, Ruptur des Ureters, spontaneDarmperforationenundebendieUterusruptur zu nennen [14].”
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Pregnancy and Obstetric Outcomes in Endometriosis
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Complicated Pelvic Inflammatory Disease
Augustin, G. (2023) · Springer eBooks · doi:10.1007/978-3-031-26021-6_13
Endometriosis-Related Complications in Women Undergoing In Vitro Fertilization
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“However, several studies have suggested an association between adhesions and ovarian endometrioma rupture [1,3,5].”
Uterine rupture during labor in a patient with endometriosis: A case report
Häusler, J., Studer, C., Bütikofer, K., & Stevanovic, N. (2026) · Case Reports in Women s Health · doi:10.1016/j.crwh.2026.e00789
Koroneos, Z., Cao, M., Mooney, S. S., Tyson, K., & Holdsworth‐Carson, S. J. (2026) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2026.115094 · Cited by 1
Metadata
- Authors
- Vigano, P., Corti, L., & Berlanda, N.
- Affiliations
- IRCCS Ospedale San Raffaele (IT)
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (IT)
- Venue
- Fertility and Sterility
- Publisher
- Elsevier BV
- Published
- 2015-10
- Volume
- 104
- Issue
- 4
- Pages
- 802-812
- ISSN
- 0015-0282 (ISSN-L)
- OpenAlex
- W2149590430
- Cited by
- 103
- References
- 85
- Citations by year
- 2026: 5 · 2025: 6 · 2024: 3 · 2023: 15 · 2022: 7 · 2021: 14 · 2020: 10 · 2019: 8 · 2018: 11 · 2017: 12 · 2016: 11 · 2015: 1
- FWCI
- 1.77
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Fertility and Sterility (publishedVersion)
- PubMed (publishedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- Zenodo (CERN European Organization for Nuclear Research) (other-oa)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Ectopic Pregnancy Diagnosis and Management
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Keywords
- endometriosis, adenomyosis, pregnancy complications, spontaneous hemoperitoneum, uterine rupture, intestinal perforation, miscarriage, gestational diabetes mellitus, preeclampsia, preterm birth, placenta previa, placental abruption, cesarean section, neonatal outcomes, postpartum complications
- MeSH terms
- Endometriosis, Female, Hemoperitoneum, Humans, Infant, Newborn, Infertility, Ovarian Diseases, Peritoneal Diseases, Pregnancy, Pregnancy Complications, Puerperal Disorders, Postpartum Period, Adenomyosis
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