In this essay I will be exploring endometriosis and looking at if endometriosis affects obstetrical and neonatal outcomes. I chose to explore this topic as I didn’t have much knowledge about the condition so not only did, I think it would be interesting to find out, but I thought it is also important as it affects women of a child bearing age so therefore may affect some of the women in my care. I am also interested in having the knowledge of the journey a patient might take to conceive prior to midwifery care.
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Endometriosis is a medical condition that occurs when the lining of the uterus grows in other places such as the fallopian tubes, ovaries and along the pelvis. The endometrial tissue may also grow in the vagina, cervix, bowel or bladder and in rare cases it may spread to other parts of the body, such as the lungs. (Endometriosis UK, 2018). 1-2% of women are diagnosed as having endometriosis, particularly between the ages of 30-45 years. It is more common in nulliparous women. (Impey and Child, 2015)
How does endometriosis have an impact on conception? Up to 30% to 50% of women with endometriosis may experience infertility. This can be caused due to several factors. Some of these factors include; scarred fallopian tubes, distorted anatomy of the pelvis, adhesions, inflammation of the pelvic structure, hormonal environment of the eggs, altered egg quality and impaired implantation of a pregnancy (ASRM, 2016). One in ten women of childbearing age in the UK suffer from endometriosis. 10% of women have this condition which is 186 million women worldwide. (Johnson et al, 2017). Endometriosis is the second most common gynaecological condition in the UK (UCHL, 2014). A study carried out in 2011 found that out of a total 2890 women with endometriosis were diagnosed from symptoms within 7.5 years, on average (Arruda and Petta et al, 2011).
The exact cause of endometriosis isn’t known, however, there are a few theories on how it develops. One of these is retrograde menstrual flow. This is when menstrual blood flows backwards down the fallopian tubes into the pelvis. Endometrial cells within this blood may implant onto the surface of structures in the pelvis and continue to grow there, this in turn explains why endometriosis can be found in the pelvis. An additional theory is lymphatic or vascular spread. This theory explains how distant site endometriosis develops as the endometrial cells may be carried to different parts of the body via the lymphatic drainage or blood vessels. Another cause may be due to surgical scar implantation. This is when endometrial cells attach to a surgical incision after surgery such as a hysterectomy or a C-section. Endometriosis is also genetic, so a causing factor can be due to the fact it is inherited in the genes. (Eisenberg, 2014)
Management options for endometriosis include drug treatment and surgery. The aim of treatment is to reduce the severity of symptoms and to improve quality of life. It is to also improve chances of fertility if this is affected. Most of drug treatments work by suppressing ovarian function and are a contraceptive. NSAIDS are often used to treat period pain, as well as endometriosis. These include ibuprofen, diclofenac and aspirin. If women suffer with more severe pain, drugs such as opioids are considered too. Opioids act in a similar way to pain-relieving substances, influencing pain perception to the brain (Davies and Kennedy, 2007)
Hormone-based drugs will suppress the production in a women’s ovaries which prevents ovulation and their monthly period. Hormone therapy isn’t suitable for women who would like to conceive. There are different hormone treatments that can be used to treat endometriosis, these include: the pill or contraceptive patch which prevents ovulation, progestins, GnRH analogues and androgenic substances. Hormone treatments are used to help prevent mucous membranes in endometrial tissue building up which relieves pain. Once hormone therapy is stopped by the women, endometriosis symptoms can often return (Al Kadri and Hassan et al, 2009). Hormonal treatment should be offered to women with suspected, confirmed or recurrent endometriosis. All women should be informed of the side effects and contraindications before having hormonal therapy. If this therapy is not effective, not tolerated or is contra-indicated, the women should be referred to a gynaecologist or specialist endometriosis service. (NICE, 2017).
Endometriosis is additionally treated with surgery, usually the procedure laparoscopy. The surgical removal of endometrial tissue appears to relieve pain in mild to moderate endometriosis. Research from a Cochrane review suggests that removing this tissue can improve fertility. During this review, randomised controlled trials were selected in which the effectiveness and safety of laparoscopy surgery used to treat pain or subfertility associated with endometriosis compared with holistic or medical treatment (Duffy and Arambage et al, 2014). There is moderate quality evidence that laparoscopic surgery reduces overall pain and increases live birth or ongoing pregnancy rates. This review also found there is low quality evidence that laparoscopic excision and ablation were similarly effective in relieving pain. More research is needed surrounding more severe endometriosis and the different types of pain associated with endometriosis.
A case study carried out by Shmueli and Salman et al (2017) looked at obstetrical and neonatal outcomes of pregnancies complicated by endometriosis. This study aimed to evaluate whether endometriosis is associated with a higher incidence of obstetrical and neonatal complications. This study was published in 2017 but carried out between 2007-2014. Overall, 61,535 deliveries were eligible for analysis, of which 135 had endometriosis. Women within the endometriosis group were characterised by higher maternal age, lower parity and higher nulliparity rate with an earlier gestational age at delivery. The results of this case study were that women with endometriosis had a higher rate of failure of induction of labour, caesarean section, postpartum haemorrhage and postpartum haemoglobin less than 10mg/dL. They found no significant differences in neonatal outcomes were observed (Shmueli and Salman, 2019). To conclude, I found that endometriosis is associated with higher risk of caesarean delivery and postpartum haemorrhage. This relates to midwifery practice because there are precautions that could be applied to encourage positive outcomes. As a midwife I would ensure that women in my care that have endometriosis were aware of the risk factors and ensure they were booked to deliver on a high-risk consultant unit. I would also discuss with the women about caesarean section as a precaution, so they were aware of the procedure in case they were in that situation. Additionally, appropriate preparations for delivery should be considered such as blood products an uterotonic agents such as oxytocin. A disadvantage of this study is that it only included singleton pregnancies and women previously diagnosed with endometriosis. This is a disadvantage as it doesn’t provide the reader with results for multiple pregnancies to compare the differences or to determine to the outcomes would be different. The author of this study has released publications since 1996 for the journal of maternal, fetal and neonatal medicine therefore this publication is reliable. It is additionally up to date after being reviewed and accepted in 2017.
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Another study I have looked at was carried out by Lalani and Choudhry et al (2018). This study looked at how endometriosis is associated with adverse maternal, fetal and neonatal outcomes of pregnancy. This was a systematic review and meta-analysis of observational studies that evaluated the effect of endometriosis. This included women greater than 20 weeks of gestational age with endometriosis and a control group of gravid women without endometriosis. The search strategy identified 33 studies for inclusion. This study found women with endometriosis compared with women without endometriosis had higher chances of pre-eclampsia, gestational hypertension, gestational diabetes, antepartum haemorrhage, malpresentation and caesarean sections. Fetuses and neonates were additionally more likely to have a preterm premature rupture of membranes or preterm birth. Also, this study found neonates were small for gestational age had higher odds of NICU admission and neonatal death. Limitations within this study is that it is a systematic review which means the comparison groups were not similar in participants. However, I know this study is reliable as it is up to date and wirrten for the department of Obstetrics and Gynecology.
Moore (2019) found that pregnancy does occur in the presence of endometriosis however there are risks to the mother and fetus including complications with bowel perforation, appendicitis, endometrioma infection or rupture and spontaneous hemoperitoneum (SHiP) (Rogers et al, 2017). Spontaneous hemoperitoneum is defined as the presence of blood within the peritoneal cavity that is unrelated to trauma. It may be idiopathic or related to spontaneous rupture of either a known or an unknown pathology. Lier et al (2017) found that SHiP occurred mostly in the second and third trimester. Signs and symptoms of SHiP are acute abdominal pain and low haemoglobin. Lier carried out at study to report pregnancy outcomes of SHiP and the association with endometriosis. The sample of this review was eleven women presenting with 15 events of SHiP resulting in 54.5% of women having preterm births, however, there was no mortality. To apply this to clinical practice, growing awareness of this serious complication should be addressed amongst the multidisciplinary team. Implications for clinical practice is that until the exact incidence of SHip is known and preventive procedures are available, appropriate counselling of pregnant women with endometriosis remains difficult. This study links to the results found in Lalani and Choudhry et als (2018) study as both studies found there was a higher increase of preterm births with women who have endometriosis.
To conclude, endometriosis is a common problem which millions of women suffer pain from alongside fertility challenges and decreased quality of life. As research of endometriosis is still on going, multidisciplinary teams can best serve patients by having awareness of this condition along with treatment options and potential complications in fertility and pregnancy.
- Endometriosis Facts and Figures | Endometriosis UK (2018). Available at: https://www.endometriosis-uk.org/endometriosis-facts-and-figures (Accessed: 24 October 2018).
- Rogers, D’Hooghe, et al. (2009) Priorities for endometriosis research: recommendations from an international consensus workshop. Reprod Sci 16: 335–46. – Open Access Library (2018). Available at: http://www.oalib.com/references/12532050 (Accessed: 24 October 2018).
- Endometriosis UK | the leading UK charity that supports women living with endometriosis (2018). Available at: https://www.endometriosis-uk.org/ (Accessed: 30 October 2018).
- University College London Hospitals. General information about Endometriosis (2014) Available at: https://www.uclh.nhs.uk/OURSERVICES/SERVICEA-Z/WH/GYNAE/ENDOM/Pages/Generalinformationabout.aspx. (Accessed: 30 October 2018).
- Esther Eisenberg, M.D., M.P.H., Medical Officer, Project Scientist, Reproductive Medicine Network, Fertility and Infertility Branch, National Institute of Child Health and Human Development. Available at: https://www.womenshealth.gov/a-z-topics/endometriosis. (Accessed: 09 November 2018)
- Duffy and Arambage et al(2014). Laparoscopic surgery for endometriosis. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24696265 [Accessed 6 Jan. 2019].
- Anat Shmueli, Lina Salman et al (2019) Obstetrical and neonatal outcomes of pregnancies complicated by endometriosis, The Journal of Maternal-Fetal & Neonatal Medicine, 32:5, 845-850, DOI: 10.1080/14767058.2017.1393513. [Accessed 20 Jan. 2019]
- Lier and Malik et al (2017). Spontaneous hemoperitoneum in pregnancy and endometriosis: a case series. BJOG: An international Journal of Obstetrics and Gynecology, 124(2), 306-312. https://doi.org/10.1111/1471-0528.14371 [Accessed 21 Jan. 2019]
- Davis L, Kennedy SS, Moore J, Prentice A. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2007; (3): CD001019. [PubMed] [Accessed 21 Jan 2019].
- Al Kadri H, Hassan S, Al-Fozan HM, Hajeer A. Hormone therapy for endometriosis and surgical menopause. Cochrane Database Syst Rev 2009; (1): CD005997. [PubMed] [Accessed 21 Jan 2019]
- Lalani, S., Choudhry, A., Firth, B., Bacal, V., Walker, M., Wen, S., Singh, S., Amath, A., Hodge, M. and Chen, I. (2018). Endometriosis and adverse maternal, fetal and neonatal outcomes, a systematic review and meta-analysis. [Accessed 21 Jan 2019]
- Impey, L. and Child, T. (2015). Obstetrics & Gynaecology. 4th ed. John Wiley & Sons, pp.67-71. [Accessed 21 Jan 2019]
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