Endometriosis and pregnancy

Among the medical problems of women's reproductive health, endometriosis and pregnancy take a special place. That is, the probability of pregnancy with endometriosis - a gynecological pathology that appears in the abnormal proliferation of cells of the glandular inner layer of the uterus (endometrium) beyond its cavity.

This problem is topical, since endometriosis is considered not only one of the main reasons for gynecological operations, but also the leading cause of female infertility and chronic pelvic pain.

But, despite the fact that up to 30-35% of women with endometriosis have problems with conception, the question is - is pregnancy possible with endometriosis? - gynecologists give an affirmative answer.

Why does not pregnancy occur during endometriosis?

Experts do not recommend identifying endometriosis with infertility: in women with this disease, the pregnancy test for endometriosis can be positive, because the possibility of becoming pregnant depends on the type and localization of dyshormonal endometroid heterosis, and also on the degree of cicatricial-adhesive process characteristic of endometriosis. However, the negative impact of this disease on fertility is also not to be ignored.

It should be noted that the types of pathology in the form of genital and extragenital endometriosis differ localization: either on the organs of the reproductive system, or on the structures and organs of the small pelvis and abdominal cavity. But in any case, their displacement relative to the normal position with various functional disorders occurs. Clinical varieties of genital endometriosis is the defeat of the ovaries, fallopian tubes, uterine ligaments, and then there is a problem - external endometriosis and pregnancy, with the level of secondary infertility to 25% of cases.

With endometrial heterosis of the cervix, cervical canal and myometrium (muscle shell), the problem is formulated as internal endometriosis of the uterus and pregnancy. Since endometriosis of the myometrium - adenomyosis of the uterus - can occur in parallel with the uterine myoma, women face such a dual problem as pregnancy with myoma and endometriosis, when the chances of motherhood are minimal. In addition, if pregnancy does occur, the nodes of myoma begin to grow, which increases the risk of interruption.

In the extragenital proliferation of tissues, similar to the inner lining of the uterine cavity, the bladder and urethra, the navel and the anterior abdominal wall are mostly affected, especially in the presence of postoperative scars.

But why does not pregnancy occur during endometriosis? Here are a few examples.

Endometriosis of the cervix and pregnancy: problems with conception arise due to the formation of a cyst (one or several) in the cervical canal, which leads to its deformation and narrowing.

Retrocervical endometriosis and pregnancy: in this rather rare type of pathology, endometrial tissue is found on the back of the cervix with extension to the posterior vaginal vault, septum between the vagina and rectum, intestines, urinary tracts, and also to the muscular walls of the uterus. And, according to experts, this complicates the conception, and the treatment of this clinical problem can be solved in isolated cases.

Endometriosis of the ovary and pregnancy: due to the proximity of the ovaries to the uterus, this is one of the most common places of development of endometriosis. Due to the appearance of endometrioid cysts of the ovaries, the functions of their follicular apparatus, that is, the ability to form eggs and synthesize hormones, are noted. See more details - Endometrioid cyst. Endometriosis of the ovaries is the most likely cause of infertility.

Endometriosis of fallopian tubes and pregnancy: the formation of external (peritubar) adhesions can lead to stenosis or complete obstruction of the fallopian tubes. In such cases, a fertilized egg simply can not enter the uterine cavity, and with this localization of pathology, there is often an ectopic (extrauterine) pregnancy.

Epidemiology

The number of women with this pathology is estimated by American Journal of Obstetrics & Gynecology experts at 6-10% (that is, up to 145-180 million) - regardless of the age and presence of children. First of all, it is a disease of reproductive age: the typical age at the time of diagnosis is 25 to 29 years. Endometriosis is more common in women with infertility and chronic pelvic pain (35-50%). The racial tendency is a higher level of endometriosis in white women.

According to some studies, endometriosis is the cause of 27-45% of cases of infertility in women of childbearing age. In the species ratio, patients with genital endometriosis account for slightly more than 90% of clinical diagnoses, and for diagnosed extragenial endometriosis no more than 7-8%.

And the probability of restoring the ability to conceive and bear a child after a comprehensive treatment of endometriosis depends on the characteristics of the body of women and the severity of the disease and can be up to 50% in mild cases, and in severe cases - within 10%.

[1], [2], [3], [4], [5]

Risk factors

Endometriosis develops in women of different ages, and the factors contributing to the emergence of pathology, gynecologists and endocrinologists include:

• acute and chronic forms of gynecological inflammatory diseases;
• presence in the anamnesis of abortions, complicated sorts, delivery by caesarean section;
• gynecological operations (laparoscopic and laparotomic), cauterization of the cervix, cavitary operations on the abdominal organs;
• violation of the balance of endogenous sex hormones with an increase in the level of estriol and estradiol ( hyperestrogenia ), which is associated with changes in the regulation of the hypothalamic-pituitary-ovary system;
• immune disorders;
• genetic predisposition;
• congenital or acquired lesions of the hypothalamus, pituitary gland, adrenal cortex (leading to a violation of the synthesis of a number of hormones).

[6]

Symptoms of the endometriosis in pregnancy

Endometriosis is a chronic disease, accompanied by intense menstrual discharge and severe pain, as well as certain anatomical changes in the pelvic area, although in 20-25% of women this pathology is not manifested.

Pregnancy does not relieve the disease, and the symptoms of endometriosis in pregnancy can range from mild to severe. For most patients with endometriosis, pregnancy - especially after the first weeks - is a period of relief from symptoms. This is mainly due to the increased level of progesterone associated with pregnancy: if a healthy woman produces up to 20 mg of progesterone per day during the next menstrual cycle, the pregnant daily amount of progesterone can reach 400 mg (due to the synthesis of this hormone by the placenta).

The first signs of pregnancy in endometriosis are the absence of menstruation, since progesterone prevents ovulation. In addition, this hormone prevents detachment of the uterine lining of the uterus, slowing the growth of its cells, so the lack of menstruation during pregnancy can also reduce the symptoms observed in endometriosis, as abnormally located areas of the endometrium cease to bleed.

However, studies have shown that in some women with endometriosis the reaction to progesterone is reduced or absent, which can be explained by the overall low sensitivity of the receptors that interact with this hormone. It is in such cases that there may be endometriosis during pregnancy and discharge (smearing, brown color).

Symptoms of endometriosis during gestation may increase. Mainly, these are the pains associated with the fact that the rapidly growing uterus stretches cystic formations and adhesions. And in the late stages of pregnancy, the synthesis of estrogen again increases (also due to its production by the placenta), which provokes an increased growth of endometrial cells and more pronounced symptoms of pathology.

How is pregnancy with endometriosis?

So, first, how does endometriosis affect pregnancy? And, secondly, does the pregnancy treat endometriosis?

Let's start with the second one. Previously, pregnancy was considered a "cure for endometriosis," but numerous studies have shown that this is not the case. Even if the symptoms of the disease subsided during pregnancy (and the reasons for this were mentioned in the previous section), then in most women after the birth or after the cessation of lactation they resume, sometimes with redoubled force.

Pregnancy in endometriosis can proceed in different ways. Obstetricians-gynecologists call the most difficult period the first two months (8 weeks): according to statistics, it is on these terms - while the formation of the placenta occurs - there is a spontaneous termination of pregnancy.

[7], [8], [9], [10]

Forms

Also in gynecology, there are four degrees of endometriosis, which largely determines the possibility of pregnancy.

Enough "peacefully get along" endometriosis 1 degree and pregnancy: foci of pathology are small and single, are not deep; affect, as it is commonly believed, only the vaginal part of the cervix and the anatomical structures of the small pelvis. Experts estimate the chances of pregnancy at 75-80%.

Endometriosis of 2 degrees and pregnancy: foci of growth of the endometrium are larger, and they are located deeper in the tissues of the small pelvis surrounding the bladder; in the deepening of the parietal peritoneum there is a congestion of bloody character; there is an adhesive process in the area of the fallopian tubes (with their constriction) and ovaries. Probability of pregnancy is about 50%.

Endometriosis of 3 degrees and pregnancy: foci of heterotopia in the uterus and fallopian tubes are multiple, their bedding is deep; presence of adhesions of the peritoneum and small one or bilateral endometrioid cysts of the ovaries. The probability of pregnancy is not more than 30-40%.

Endometriosis of 4 degrees and pregnancy: multiple and deep foci of endometrial overgrowth in the bladder and peritoneum of the small pelvis; multiple dense adhesions of the abdominal cavity; bilateral endometrioid cysts of ovaries of considerable size. The chances of becoming pregnant do not exceed 15%, since changes in the pelvic and uterine regions affect the implantation of the ovum and the development of the placenta.

[11], [12], [13], [14]

Complications and consequences

In addition, the most likely consequences and complications include:

• bleeding after the 24th week of pregnancy, which, as a rule, arise due to the presentation or detachment of the placenta;
• fetal fading at a period of about 20 weeks;
• pre-eclampsia in the second and third trimester of pregnancy;
• premature delivery;
• small weight of the newborn;
• weakness of labor and delivery through cesarean section.

Complications of pregnancy in the presence of internal endometriosis, in particular, myometrium endometriosis, are associated with increased loads on the muscular membrane of the uterus as the period increases, which is fraught with uterine rupture in the second half of gestation.

A rare but serious and life-threatening complication of endometriosis in pregnancy is intraperitoneal bleeding (hemoperitoneum), associated with either rupture of the vessels of the uterus or ovaries, or with the bleeding of endometrial heteropia.

[15],

Diagnostics of the endometriosis in pregnancy

The causes of endometriosis in pregnancy will not be established by doctors, since there are several versions of the etiology of the disease, including: an embryonic theory of pathology development from glandular elements of Mullerian ducts and volphic bodies; retrograde menstruation; mutations of genes that regulate estrogen-induced cellular endometrial cycle in the proliferative and menstrual phases, etc. More information in the article - Endometriosis

Endometriosis is difficult to diagnose. The only definitive way to make an accurate diagnosis is to hold a laparoscopy and examine a tissue sample (biopsy) that is obtained with this examination. But the diagnosis of endometriosis in pregnancy in this way is not due to the potential risks associated with uterine perforation, decreased uterine-placental blood flow and the development of fetal hypoxia, as well as the threat of intrauterine fetal injury.

Instrumental diagnostics in the form of hysteroscopy is also impossible. Therefore, a routine examination, ultrasound (which, according to the Uzi-diagnostician, does not give a picture of endometrial heterosis), all necessary blood tests, including hormones, are submitted.

A special diagnostic role is played by the collection of the anamnesis (with the mandatory account of the family history of the female line). Based on the complaints of the patient - on the pains during menstruation (their duration and intensity), pain during or after sex, on spotting outside the menstrual period, for unrelated to chronic pain in the lower abdomen and in the pelvic and lumbar region, for problems with the intestines - An experienced doctor may presume the presence of endometriosis.

[16], [17], [18]

Treatment of the endometriosis in pregnancy

Do not perform endometriosis treatment in pregnancy, but future mothers with endometriosis are on special account in women's consultations - with increased attention to their condition, development of the fetus and additional monitoring of the course of pregnancy. In this case, pregnant women with this pathology should be warned about the full risks of such a pregnancy.

In non-pregnant women, a key component of conservative treatment of endometriosis is hormonal drugs. Applied outside the gestation period, the hormonal preparation of Byzantine in endometriosis is contraindicated in pregnancy.

A hormonal drug containing goserelin (an analog of GnRH-gonadotropin-releasing hormone), Zoladex in endometriosis in pregnancy is also contraindicated due to embryotoxic effects and increased threat of abortion. For the same reason, similar drugs are forbidden during pregnancy: Triptorelin, Diferelin (Decapeptil), Buselerin, Leiprorelin.

Pregnant women with endometriosis should not use the drug Danazol (Danol, Danoval, etc.), an inhibitory synthesis of pituitary hormones.

But the analogue of natural progesterone DUFASTON from endometriosis during pregnancy (before 12-20 weeks) can be appointed by a gynecologist only in cases of habitual miscarriages or threatening abortion and only if the analyzes confirm the deficiency of progesterone. More in this article - Dufaston in pregnancy

In endometriosis, pregnancy is associated with certain problems, for example, the risk of miscarriage in this disease rises by 76% (compared with healthy women), so no alternative treatment, no herbal treatment and, especially, homeopathy can not be used!

Planning pregnancy in endometriosis

Women in general are much more likely to get pregnant when they are in the third decade of life (that is, at the age of 20-30 years) than when they are "over thirty". So, if endometriosis is diagnosed, plan pregnancy in endometriosis beforehand.

There are no medications for this disease, but there is a treatment that can help women fight her symptoms, and in the case of pregnancy problems, create the most favorable conditions for the dream of becoming a mother.

Today gynecologists use hormonal therapy, including oral contraceptives, progesterone preparations and GnRH analogues. But most of these drugs can only be used for a limited period of time, and side effects can cause problems for some women.

The best way to plan pregnancy in endometriosis is to call a full examination and, if necessary, surgical treatment - removal of the foci of endometriosis and excision of cysts, nodules and adhesions by laparoscopic or any other intervention.

If treatment fails, reproductive specialists offer in vitro fertilization (IVF). However, before resorting to this method, it is necessary to properly treat endometriosis, since the preparation for IVF involves an increase in the level of estrogen, which will stimulate the development of this pathology.

Prevention

Prophylaxis of endometriosis is not developed. Nevertheless, timely treatment for medical care in case of women's health problems can contribute to the identification of the developing pathology and its treatment.

[19], [20], [21], [22]

Forecast

The prognosis of the course of pregnancy and its outcome in diagnosed endometriosis largely depends on the phenotypic features of the endometrium, the type, location and extent of development of this pathology.

[23], [24]