DOI: 10.1111/1471-0528.14221 www.bjog.org
Maternal and neonatal outcomes in women with colorectal endometriosis A Thomin,a,b,* J Belghiti,a,b,* C David,c O Marty,a,b M Bornes,a,b M Ballester,a,b,d H Roman,e,f E Dara€ıa,b,d a
Department of Gynaecology and Obstetrics, Hoˆpital Tenon, Assistance Publique des Hoˆpitaux de Paris, Universite´ Pierre et Marie Curie, Paris, France b GRC 6 UPMC (C3E) Centre Expert en Endome´triose, Paris, France c Department of Gynaecology and Obstetrics, Rouen University Hospital, Hospital-Charles Nicolle, Rouen, France d UMRS938, Universite´ Pierre et Marie Curie, Paris, France e Department of Gynaecology and Obstetrics, Rouen University Hospital, Rouen, France f Research Group 4308, Spermatogenesis and Gamete Quality, IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory, Rouen University Hospital, Rouen, France Correspondence: Professor E Daraı¨, Service de Gynecologie-Obste´trique, Hoˆpital Tenon, 4 rue de la Chine, 75020 Paris, France. Email
[email protected] Accepted 9 June 2016. Published online 18 July 2016.
Objective To evaluate delivery and neonatal outcomes in women
with resected or in situ bowel endometriosis. Design Retrospective cohort study. Setting France. Population and sample Analysis of 72 pregnancies from 67 women followed for colorectal endometriosis from 2001 to 2014 in six centres including two university expert centres for endometriosis. Methods Univariate analysis of maternal and neonatal outcomes. Main outcome measures Routes for delivery and rate of
complications. Results The colorectal surgery group comprised 41 women and
the in situ colorectal group, 26 women. Overall, half of the women underwent caesarean section. A high incidence of postoperative complications (39%) was observed after caesarean section with no difference between the groups. Surgical difficulties at newborn extraction (22%) and postoperative
complications (39%) occurred more often in women with anterior deep infiltrating endometriosis (respectively 63 versus 11%, P = 0.007 and 67% versus 26%, P = 0.046) independently of prior surgery for endometriosis. In the remaining half, vaginal delivery required an operative procedure in 28% of the women with a significant increase in postpartum complications compared with those who did not require a procedure (P = 0.001). Overall, the incidence of postpartum complications was lower after vaginal delivery (14%) than after caesarean section (39%) (P = 0.03). Conclusion Pregnant women with colorectal endometriosis,
irrespective of prior surgery, should be informed of the high risk of delivery by caesarean section. Vaginal delivery is preferrable in this setting because of the lower incidence of postpartum complications. Keywords Caesarean section, colorectal endometriosis, delivery complications, maternal outcomes, neonatal outcomes, postpartum complications. Tweetable abstract Due to the incidence of postpartum
complications whatever the route of delivery, women should receive level III maternal care.
Please cite this paper as: Thomin A, Belghiti J, David C, Marty O, Bornes M, Ballester M, Roman H, Dara€ı E. Maternal and neonatal outcomes in women with colorectal endometriosis. BJOG 2016; DOI: 10.1111/1471-0528.14221.
Introduction Endometriosis, defined by the presence of endometrial glands and stroma outside the uterus, is thought to affect *These authors contributed equally to this work. Institutions in which the study was performed: Country: France University Hospitals of Tenon (Paris) and Rouen; Hospitals of Lisieux, Evreux and Fecamps, Clinic Mathilde (Rouen)
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10–15% of women in the reproductive period.1 Deep infiltrating endometriosis (DIE) with bowel involvement is estimated to affect 3–12% of women with endometriosis.1 Endometriosis is a well-known cause of pain and infertility. Numerous studies have suggested that bowel involvement negatively impacts reproductive outcomes and that complete removal of endometriosis enhances fertility.2–4 However, the recent ESHRE guidelines state that there are insufficient data to recommend the removal of DIE prior
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to IVF with the sole goal of improving IVF outcomes. In a previous review,5 the overall postoperative pregnancy rate averaged 46.9%, following either postoperative spontaneous conception (28.6%) or postoperative medically assisted reproduction (MAR) (29%) and supporting the potential benefit of combining surgery and MAR. A recent series has reported a rate of postoperative pregnancy as high as 65%,6 with a majority of spontaneous conceptions, providing support for a strategy of primary surgery instead of systematic IVF.7 Previous studies have shown that endometriosis is associated with an increased incidence of preterm birth,8 placenta praevia,9,10 potential pre-eclampsia,8,11,12 spontaneous haemoperitoneum and intestinal perforation.13–17 However, in contrast to data on infertility and pathologies associated with pregnancy, there is a lack of data on delivery and neonatal outcomes in women with colorectal endometriosis. Therefore, the aim of this retrospective study was to evaluate delivery risks and neotnatal outcome in women with colorectal endometriosis, the impact of prior resection and whether bladder involvement could have an additional impact.
Methods From 2001 to 2014, all pregnant women with DIE and colorectal endometriosis either resected or in situ before the pregnancy and who delivered in one of two expert centres in endometriosis [Tenon (Paris) and Rouen University Hospitals] or four departments of Gynaecology and Obstetrics (Lisieux, Evreux and Fecamps Hospitals, Clinic Mathilde in Rouen) were included. All the women gave their informed consent to participate in the study. The study was approved by the Ethics Committee of the College National des Gynecologues et Obstetriciens Francßais (CNGOF; number: CEROG 2012-GYN-10-03).
Diagnosis of DIE with colorectal involvement All the women had symptoms suggesting bowel endometriosis: dyschezia, constipation, diarrhoea, pain on defecation, or cyclic rectal bleeding. DIE with colorectal involvement was diagnosed clinically by three experienced surgeons (E.D., M.B., H.R.) based on the following criteria: visible dark blue nodules on the posterior vaginal fornix on speculum examination or infiltration associated with palpable induration on vaginal and rectal digital examinations involving the rectum, rectosigmoid junction associated with vaginal, uterosacral ligaments or torus uterinum infiltration. Diagnosis was confirmed by the following imaging techniques: transvaginal sonography (TVS), magnetic resonance imaging (MRI), endorectal ultrasound (ERUS), rectal echoendoscopy (RES) or computed-tomography-based
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virtual colonoscopy (CTC), depending on the expert centre. Criteria to diagnose DIE with colorectal endometriosis were those previously reported by Bazot et al.18,19 and by Roman et al. for ERUS and CTC.20,21 All the women with prior surgery for colorectal lesions had histologically confirmed colorectal endometriosis. Two groups of women were defined: the colorectal surgery group consisting of women who had had surgery with removal of colorectal endometriosis; and the in situ colorectal group consisting of women with unresected colorectal endometriosis. For the colorectal surgery group, all laparoscopically assisted and open colorectal resections were performed with an objective of complete resection as previously described.22–24 Treatment of the colorectal lesion consisted of rectal shaving, discoid resection or segmental resection depending on lesion size, infiltration in bowel muscularis or multifocality of colorectal lesions, and on the department’s protocol.25,26 In addition to colorectal resection, the surgery included ovarian cystectomy or salpingooophorectomy, ovarian endometrioma ablation using plasma energy, uterosacral ligament resection, colpectomy, and treatment of anterior DIE (with or without partial bladder resection) when required.
Delivery management Labour and delivery was managed in accordance with French recommendations.27 Presence or prior surgery for DIE with colorectal endometriosis was not an indication for systematic caesarean section.
Main outcome measures The primary outcome was the rate of caesarean section. The secondary outcomes were the incidence of complications according to the route of delivery and the neonatal outcome.
Study variables Data were retrospectively recorded from the patients’ charts: epidemiological characteristics, pregnancy, and maternal and neonatal delivery outcomes. The pregnancy outcomes recorded were the need for MAR and time to conception for infertile patients. For vaginal delivery, complications included postpartum hemorrhage (defined by the loss of more than 500 ml of blood), III–IV degree perineal tear and requirement for surgery. For caesarean section, intraoperative complications included bladder, bowel, vascular or ureteral injury. Difficulties to extract the newborn were semi-quantitatively evaluated in accordance with Rossouw et al.28 as follows: very easy, easy, slightly difficult, moderately difficult and very difficult. Postoperative surgical complications after caesarean section were classified according to the revised Clavien–Dindo
ª 2016 Royal College of Obstetricians and Gynaecologists
Delivery outcomes and colorectal endometriosis
classification.29 A grade I complication is defined as any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, or radiologic interventions. This grade also includes any wound infection treated at the bedside. A grade II complication is defined by the requirement of pharmacological treatment and includes blood transfusion and total parenteral nutrition. A grade III complication is defined by the requirement of surgical, endoscopic or radiologic intervention. A grade IV complication is defined by a life-threatening complication including central nervous system complications requiring intermediate care or transfer to the intensive care unit. Grade V is defined by death. For the purpose of this analysis, we grouped non-severe complications (grade I and II) together. Postoperative endometritis was defined as fever with abnormal uterine tenderness in the absence of other findings suggesting another source of infection. Wound complications included seroma, haematoma or infection. The diagnosis of wound infection required erythema of the incision accompanied by purulent drainage. Neonatal outcomes recorded were fetal weight, a 5-minute Apgar score under 7, arterial pH under 7.20, admission to the neonatal intensive care unit (ICU) and neonatal death. Indications for ICU admission were seizures or cardiopulmonary resuscitation during the first 24 hours of life, arterial or venous cord pH
