Endometriosis and Pregnancy

Endometriosis is a condition where endometrial tissue grows outside of the uterus - commonly on the ovaries and rectum, but even as far as the lungs, brain, or sciatic nerve. This tissue often produces an inflammatory response resulting in symptoms like pain.

Back in the 20s, researchers believed that endometrial lesions regressed during pregnancy - and so doctors would sometimes tell their patients that pregnancy could be "curative" because the person was no longer ovulating or menstruating. However a decrease in symptoms isn't the case for everyone. Studies show that people with endometriosis can still be affected by this condition.

Pain and Lesions

Only a few studies have evaluated pregnancy and endometriosis-related pain. While some lesions can regress, others can remain stable or increase. The only beneficial effect of endometriosis in pregnancy is that amenorrhea (no periods) decreases the risk of new lesion formation.

One study by Alberico noted an improvement of endometriosis-related pain symptoms, where after 2 years about 63% of women experienced an improvement in pain symptoms and an improvement in quality of life. That said, in this same study, 84% of women still experienced pain-related symptoms after pregnancy.

Pregnancy Loss

People with endometriosis had a greater risk of pregnancy loss - specifically miscarriage before 20 weeks and ectopic pregnancy. The risk of miscarriage was highest in women younger than 35 and was their first pregnancy. The risk of ectopic pregnancy was stronger for pregnancies in women without a history of infertility.

Gestational Diabetes

In the review by Farland, women with endometriosis had a 35% greater risk of gestational diabetes in pregnancy. This risk was highest in women younger than 35, no history of infertility, and in second or later pregnancies.

Gestational diabetes is the onset of carbohydrate intolerance in pregnancy, which is typically diagnosed after the 24th week of pregnancy. It affects 3-25% of pregnancies.

If gestational diabetes was not controlled, it may put pregnant people at risk for abnormal fetal growth, hypertensive disorders of pregnancy, difficult labor and vaginal delivery, and increased risk of cesarean section. Risks for the baby include low blood sugar, increased bilirubin, and possibly delayed lung maturity. Moreover, they're also at risk for adult onset of metabolic disorders, diabetes, hypertension, obesity, cardiovascular disease, and shorter lifespan.

Hypertensive Disorders

The same review by Farland, women with endometriosis had a 30% greater risk of hypertensive disorders of pregnancy. The risk was highest in second or later pregnancies.

Hypertensive disorders of pregnancy are present in about 15% of pregnancies and include pre-existing high blood pressure, gestational hypertension, and preeclampsia.

Hypertension is defined as a diastolic rate above 90mmHg (based on 2 measurements), while severe hypertension is a blood pressure over 160/110 mmHg. Pre-existing high blood pressure occurs prior to pregnancy or before 20 weeks pregnant, while gestational hypertension is usually diagnosed at or after 20 weeks pregnant.

Preeclampsia is defined as the presence of one or more symptoms at or after 20 weeks of pregnancy with the involvement of other body systems. The main symptoms include: hypertension (greater than 140/90 mmHg taken at least twice, 4 hours apart) and protein in the urine. Other symptoms include visual complaints, headache, vomiting, and abdominal pain.

If left untreated, preeclampsia can lead to neurologic complications, such as seizures (eclampsia) and strokes, kidney injury, and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.

Preterm Birth

The review by Farland demonstrated that women with endometriosis had a 16% greater risk of preterm birth, specifically in second or later pregnancies. Preterm birth was defined as birth less than 37 weeks of gestation.

Low Birth Weight

Lastly, the review by Farland demonstrated that women with endometriosis had a 16% greater risk of low birth weight. Low birth weight was defined as birth weight less than 5.5 lbs (in a single pregnancy).

Final Thoughts

Overall, while new lesions are unlikely to develop during pregnancy, there's limited knowledge about the impact of existing lesions and related symptoms during pregnancy or in the postpartum.

Furthermore, because there are some adverse pregnancy outcomes in people with endometriosis, it may be warranted to think about conditions like gestational diabetes and hypertension prior to the second trimester. Perhaps thinking about prevention may be worthwhile in the first trimester. Also, since pregnancy loss has been shown to be an adverse event in the first trimester, it may be worthwhile to talk to your healthcare provider prior to pregnancy to see if there's anything that can be done to prevent this. However, miscarriage is more common than we think, and sometimes can be unavoidable.

At the end of the day, if you have endometriosis, don't buy into the hype that you should become pregnant to decrease symptoms, and this isn't the best advice. Choosing to expand your family should be done because you want to become a parent, not to improve your endometriosis symptoms.

If you have endometriosis and are looking to become pregnant or manage this condition during pregnancy, consider booking an appointment with a Naturopathic Doctor to complement obstetric or midwifery care.

References

Alberico, D., Somigliana, E., Bracco, B., Dhouha, D., Roberto, A., & Mosconi, P. et al. (2018). Potential benefits of pregnancy on endometriosis symptoms. European Journal Of Obstetrics & Gynecology And Reproductive Biology, 230, 182-187. https://doi.org/10.1016/j.ejogrb.2018.08.576

Denney, J., & Quinn, K. (2018). Gestational Diabetes. Obstetrics And Gynecology Clinics Of North America, 45(2), 299-314. https://doi.org/10.1016/j.ogc.2018.01.003

Farland, L., Prescott, J., Sasamoto, N., Tobias, D., Gaskins, A., & Stuart, J. et al. (2019). Endometriosis and Risk of Adverse Pregnancy Outcomes. Obstetrics & Gynecology, 134(3), 527-536. https://doi.org/10.1097/aog.0000000000003410

Leeners, B., & Farquhar, C. (2019). Benefits of pregnancy on endometriosis: can we dispel the myths?. Fertility And Sterility, 112(2), 226-227. https://doi.org/10.1016/j.fertnstert.2019.06.002

Leeners, B., Damaso, F., Ochsenbein-Kölble, N., & Farquhar, C. (2018). The effect of pregnancy on endometriosis—facts or fiction?. Human Reproduction Update, 24(3), 290-299. https://doi.org/10.1093/humupd/dmy004

Leone Roberti Maggiore, U., Ferrero, S., Mangili, G., Bergamini, A., Inversetti, A., & Giorgione, V. et al. (2015). A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Human Reproduction Update, 22(1), 70-103. https://doi.org/10.1093/humupd/dmv045

Shah, S., & Gupta, A. (2019). Hypertensive Disorders of Pregnancy. Cardiology Clinics, 37(3), 345-354. https://doi.org/10.1016/j.ccl.2019.04.008