Endometriosis and adverse pregnancy outcome

INTRODUCTION

Endometriosis is a gynecologic disease affecting approximately 10% of reproductive age women, around 21-47% of women presenting subfertility and 71-87% of women with chronic pelvic pain. Main symptoms are chronic pelvic pain, dysmenorrhea, dyspareunia and infertility that seem to be well controlled by oral contraceptive pill, progestogens, GnRh antagonists. The aim of this review was to illustrate the modern diagnosis of endometriosis during pregnancy, to evaluate the evolution of endometriotic lesions during pregnancy and the incidence of adverse outcomes.

EVIDENCE ACQUISITION

Published literature was retrieved through searches of the database PubMed (National Center for Biotechnology Information, US National Library of Medicine, Bethesda, MD, USA). We searched for all original articles published in English through April 2020 and decided to extract every notable information for potential inclusion in this review. The search included the following MeSH search terms, alone or in combination: "endometriosis" combined with "endometrioma," "biomarkers," "complications," "bowel," "urinary tract," "uterine rupture," "spontaneous hemoperitoneum in pregnancy" and more "adverse pregnancy outcome," "preterm birth," "miscarriage," "abruption placentae," "placenta previa," "hypertensive disorder," "preeclampsia," "fetal grow restriction," "small for gestation age," "cesarean delivery."

EVIDENCE SYNTHESIS

Pregnancy in women with endometriosis does not always lead to disappearance of symptoms and decrease in the size of endometriotic lesions, but it may be possible to observe a malignant transformation of ovarian endometriotic lesions. Onset of complications may be caused by many factors: chronic inflammation, adhesions, progesterone resistance and a dysregulation of genes involved in the embryo implantation. As results, the pregnancy can be more difficult because of endometriosis related complications (spontaneous hemoperitoneum [SH], bowel complications, etc.) or adverse outcomes like preterm birth, FGR, hypertensive disorders, obstetrics hemorrhages (placenta previa, abruptio placenta), miscarriage or cesarean section. Due to insufficient knowledge about its pathogenesis, currently literature data are contradictory and do not show a strong correlation between endometriosis and these complications except for miscarriage and cesarean delivery.

CONCLUSIONS

Future research should focus on the potential biological pathways underlying these relationships in order to inform patients planning a birth about possible complications during pregnancy.

Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps

INTRODUCTION

Thanks to the progress of science, it is now understood that a successful implantation not only depends on the quality of the embryo, but also on having a receptive endometrium. During the years, several authors have reviewed the important role of the uterine factor, ranging from the congenital anomalies, such as uterine septa and subsepta, and acquired conditions such as endometrial polyps and submucous myomas. Currently, hysteroscopy has proved to be a powerful and accurate tool for visualizing the uterine cavity and treating intrauterine pathologies.

EVIDENCE ACQUISITION

This review of the literature aims to report the current available data on the effects of the two most common endouterine pathologies (i.e. endometrial polyps and submucous myomas) and the impact of hysteroscopic removal on fertility outcomes.

EVIDENCE SYNTHESIS

To date, the low number of randomized controlled trials available does not yet make it possible to give a definitive answer on what are the reproductive outcomes following treatment of endometrial polyps and leiomyomas. Nevertheless, existing evidence points to a benefit of removal of this two pathologies in infertile women, mostly when they have a history of recurrent pregnancy loss.

CONCLUSIONS

Further studies are needed to demonstrate that surgical treatments of endometrial polyps and myomas could improve not only the morphology but also the function of the uterine cavity before undergoing any assisted fertility treatment.

New development on hysteroscopy for endometrial cancer diagnosis: state of the art

Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.

Hysteroscopic approach to uterine cervical canal stenosis

Cervical stenosis is defined as an adhesion process of variable degree, producing narrowing, distortion, or complete obliteration of the cervix. Several techniques have been defined to access to the uterine cavity and nowadays hysteroscopy seems to be the best option. In this manuscript, we review all the hysteroscopic modalities to overcome a cervical stenosis and access to the uterine cavity.

Hysteroscopic approach to uterine cervical canal stenosis

Cervical stenosis is defined as an adhesion process of variable degree, producing narrowing, distortion, or complete obliteration of the cervix. Several techniques have been defined to access to the uterine cavity and nowadays hysteroscopy seems to be the best option. In this manuscript, we review all the hysteroscopic modalities to overcome a cervical stenosis and access to the uterine cavity.

Office myomectomy

Small myomas have a high potential to grow and either to become symptomatic or to cause complications in women of reproductive age. Furthermore, although the risk of malignancy is rare, even the most experienced operator cannot replace the histological analysis to exclude malignancy or premalignant lesions. Such small symptomatic and asymptomatic totally or partially intracavitary myomas may be treated effectively and safety in office setting. The aim of this paper is to describe the currently available hysteroscopic techniques to treat myomas <1.5 cm also with a minimal intramural component without anaesthesia or analgesia in ambulatory setting reducing patient's discomfort.

Resectoscopic myomectomy

Hysteroscopic myomectomy currently is the "gold standard" procedure for treating submucous myoma and represents an effective and safe solution to abnormal uterine bleeding and infertility myoma-related. Several studied have shown that, in the case of submucous myomas, resectoscopic myomectomy has several advantages compared with the traditional surgical treatment of myomectomy by laparotomy, in terms of reduced myometrial trauma, shorter hospitalization times and decreased risk of postoperative adhesion formation. The aim of this paper was to describe the alternative techniques, currently available, of resectoscopic myomectomy. The choice of the procedure mostly depends on the intramural extension of the myoma, as well as on personal experience and available equipment.

Hysteroscopic treatment of Müllerian duct anomalies

Müllerian duct anomalies are a broad and complex spectrum of abnormalities that are often associated with infertility, obstetric complications as well as gynecological disorders among women of reproductive age. Operative hysteroscopy is the gold standard in the treatment of most of those anomalies amenable to surgical correction. The evidence to date shows an ongoing increase in the release of recommendations in favour of operative hysteroscopic treatment, in concert with the progressive refinement of hysteroscopic technologies and techniques. The aim of this paper was to describe and critically evaluate the role of the currently available hysteroscopic techniques for treating Müllerian duct anomalies, taking into account their indications, feasibility and efficacy as well as their impact on the reproductive outcome. Special attention will be paid to the most recently developed minimally invasive treatments for uterine and vaginal anomalies.