Endometriosis in pregnancy – diagnostics and management

Česká verzia

Authors: F. Frühauf ¹; M. Fanta ¹; Andrea Burgetová ² ; D. Fischerová ¹
Authors place of work: Gynekologicko-porodnická klinika 1. LF UK a VFN, Praha, přednosta prof. MUDr. A. Martan, DrSc. ¹; Radiodiagnostická klinika 1. LF UK a VFN, Praha, přednostka doc. MUDr. A. Burgetová, Ph. D., MBA ²
Published in the journal: Ceska Gynekol 2019; 84(1): 61-67
Category:

Summary

Objective: Endometriosis in pregnancy predominantly tends to regress or to stay stable but small part of endometriomas and nodules of deep infiltrating endometriosis may undergo the process of decidualization. Therefore, the foci of endometriosis enlarge their volume and change their structure due to cellular hypertrophy and stromal edema associated with higher vascularization caused by the hormonal changes in pregnant women. Consequently, these totally benign lesions may resemble malignant tumors in ultrasound examination.

Design: Review article.

Setting: Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague.

Methods: A literature review of published data on decidualization of endometriosis.

Results: Majority of decidualized ovarian endometriomas is asymptomatic so it is mostly accidentally found during the routine ultrasound check-ups within the frame of perinatologic screening. The rounded, smooth, highly vascularized solid papillary projections in internal wall of endometroid cysts are the most specific characteristics of decidualization. If ultrasound simple rules are not applicable or show probable malignancy, the pregnant patient should be referred to a tertiary center for expert ultrasound assessment. Magnetic resonance is indicated in cases of uncertain ultrasound findings, because it can clarify the diagnostics due to its high accuracy in detection of products of blood degradation and ability of diffusion-weighted imaging to recognize lower tissue cellularity of benign decidualized endometriomas in comparison to malignant ovarian tumors.

Conclusion: If the imaging methods confirm supposed decidualized endometriosis, watch and wait management based on regular ultrasound examinations during the whole pregnancy and after childbed is recommended. The regression of the tumor size and disappearance of the solid portions within endometriomas is expected after delivery. Decidualized endometriosis is rarely a source of gestational or obstetrical complications demanding acute surgical intervention. Elective surgical procedures in pregnant women are indicated only if expert ultrasound or magnetic resonance imaging assess the masses as border-line or invasive tumors (carcinomas) and in cases of suspicious changes of the originally presumed benign cysts during the surveillance.

Keywords:

pregnancy – endometrioma – deep infiltrating endometriosis – decidualization

Zdroje

1. Aggarwal, P., Kehoe, S. Ovarian tumours in pregnancy: a literature review. Eur J Obstet Gynecol Reprod Biol, 2011, 155(2), p. 119–124.

2. Aslam, N., Ong, C., Woelfer, B., et al. Serum CA125 at 11–14 weeks of gestation in women with morphologically normal ovaries. BJOG, 2000, 107(5), p. 689–690.

3. Bailleux, M., Bernard, JP., Benachi, A., Deffieux, X. Ovarian endometriosis during pregnancy: a series of 53 endometriomas. Eur J Obstet Gynecol Reprod Biol, 2017, 209(2), p. 100–104.

4. Benaglia, L., Somigliana, E., Calzolari, L., et al. The vanishing endometrioma: the intriguing impact of pregnancy on small endometriotic ovarian cysts. Gynecol Endocrinol, 2013, 29(9), p. 863–866.

5. Clement, PB. The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol, 2007, 14 (4), p. 241–260.

6. Cohen, J., Naoura, I., Castela, M., et al. Pregnancy affects morphology of induced endometriotic lesions in a mouse model through alteration of proliferation and angiogenesis. Eur J Obstet Gynecol Reprod Biol, 2014, 183(12), p. 70–77.

7. Fischerová, D. Doporučený diagnostický postup u ženy s ovariální cystou nebo nádorem. Ces Gynek, 2014, 79(6), s. 477–486.

8. Fischerová, D., Zikán, M., Pinkavová, I., et al. Racionální předoperační diagnostika benigních a maligních ovariálních nádorů – zobrazovací metody, nádorové markery. Čes Gynek, 2012, 77 (4), s. 272–287.

9. Giudice, LC. Endometriosis. N Engl J Med, 2010, 362(25), p. 2389–2398.

10. Goh, W., Bohrer, J., Zalud, I. Management of the adnexal mass in pregnancy. Curr Opin Obstet Gynecol, 2014, 26(2), p. 49–53.

11. Guerriero, S., Condous, G., van den Bosch, T., et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol, 2016, 48(3), p. 318–332.

12. Huhtinen, K., Suvitie, P., Hiissa, J., et al. Serum HE4 concentration differentiates malignant ovarian tumours from ovarian endometriotic cysts. Br J Cancer, 2009, 100(8), p. 1315–1319.

13. Leiserowitz, GS., Xing, G., Cress, R., et al. Adnexal masses in pregnancy: how often are they malignant? Gynecol Oncol, 2006, 101(2), p. 315–321.

14. Maggiore, ULR., Ferrero, S., Mangili, G., et al. A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Hum Reprod Update, 2016, 22(1), p. 77–103.

15. Mascilini, F., Moruzzi, C., Giansiracusa, C., et al. Imaging in gynaecological disease (10): clinical and ultrasound characteristics of decidualized endometriomas surgically removed during pregnancy. Ultrasound Obstet Gynecol, 2014, 44(3), p. 354–360.

16. Pateman, K., Moro, F., Mavrelos, D., et al. Natural history of ovarian endometrioma in pregnancy. BMC Womens Health, 2014, 14(128), doi: 10.1186/1472-6874-14-128.

17. Sammet, S. Magnetic resonance safety. Abdom Radiol (NY), 2016, 41(3), p. 444–451.

18. Takeuchi, M., Matsuzaki, K., Nishitani, H. Magnetic resonance manifestations of decidualized endometriomas during pregnancy. J Comput Assist Tomogr, 2008, 32(3), p. 353–355.

19. Tanaka, YO., Okada, S., Yagi, T., et al. MRI of endometriotic cysts in association with ovarian carcinoma. AJR Am J Roentgenol, 2010, 194(2), p. 355–361.

20. Testa, AC., Timmerman, D., Van Holsbeke, C., et al. Ovarian cancer arising in endometrioid cysts: ultrasound findings. Ultrasound Obstet Gynecol, 2011, 38(1), p. 99–106.

21. Timmerman, D., Valentin, L., Bourne, TH., et al. International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol, 2000, 16(5), p. 500–505.

22. Ueda, Y., Enomoto, T., Miyatake, T., et al. A retrospective analysis of ovarian endometriosis during pregnancy. Fertil Steril, 2010, 94(1), p. 78–84.

23. Van Holsbeke, C., Van Calster, B., Guerriero, S., et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol, 2010, 35(6), p. 730–740.