You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

CME / CE

Is There a Link Between Preterm Birth and Endometriosis?

  • Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MD
  • CME / CE Released: 3/18/2022
  • Valid for credit through: 3/18/2023
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion

Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists/women’s health clinicians, family medicine/primary care practitioners, nurses, and other members of the healthcare team for women with history of preterm birth and/or endometriosis.

The goal of this activity is to describe the association between the presence of endometriosis and preterm birth and effect of disease phenotype on risk, according to a cohort study of women with singleton pregnancies with and without endometriosis enrolled from 7 maternity units in France from February 4, 2016 to June 28, 2018.

Upon completion of this activity, participants will:

  • Describe the association between the presence of endometriosis and preterm birth and effect of disease phenotype on risk, according to a cohort study of women with singleton pregnancies with and without endometriosis
  • Identify clinical implications of the association between the presence of endometriosis and preterm birth and effect of disease phenotype on risk, according to a cohort study of women with singleton pregnancies with and without endometriosis
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Disclosure: Marcia Frellick has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stock, stock options, or bonds from: AbbVie Inc. (former)

Editor/CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CME/CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / CE

Is There a Link Between Preterm Birth and Endometriosis?

Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / CE Released: 3/18/2022

Valid for credit through: 3/18/2023

processing....

Clinical Context

Endometriosis is an inflammatory disease with heterogeneous presentations affecting 10% to 15% of women of reproductive age. Findings of previous studies are conflicting regarding implications of endometriosis for pregnancy outcomes. A recent multicenter cohort study by Marcellin and colleagues evaluated over 1300 women with singleton pregnancies in France from February 4, 2016 to June 28, 2018, with final follow-up in July 2019. This study was published in the February 1, 2021 issue of JAMA Network Open.[1]

Using non-modifiable risk factors, researchers found that modifying pregnancy monitoring strategies beyond the normal protocols or may not be warranted in cases of endometriosis. Additionally, there was no correlation discovered between a mother's endometriosis phenotype and preterm birth rate.

These novel results by Marcellin and colleagues have incited a potential interest in further studies related to pregnancy risk and endometriosis that would be valuable to the healthcare team.

Study Synopsis and Perspective

Researchers evaluating whether endometriosis is linked with preterm birth found no such association in a multicenter cohort study of more than 1300 women.

These new findings, which were published February 1 in JAMA Network Open,[1] suggest that changing monitoring strategies to prevent preterm birth for women with the disease may not be necessary.

The research team, led by Louis Marcellin, MD, PhD, with the department of obstetrics and gynecology at Université de Paris, in Paris, France, also found that disease phenotype or whether the preterm birth was induced or spontaneous did not appear to alter the result.

Those results differ from previous research. Data on the phenotypes and their link with preterm birth have been scarce, but previous studies have shown the risk for preterm birth is more pronounced in women who have deep endometriosis than in women with ovarian endometriosis.

Marcellin told Medscape Medical News, "Little is known about the impact of endometriosis on obstetric outcomes. In contrast to previous studies, we reported no differences in the risk for preterm delivery between women with endometriosis (34 of 470 [7.2%]) and those without endometriosis (53 of 881 [6.0%]), even when adjusted for multiple factors."

The authors accounted for mother's age, body mass index (BMI) before pregnancy, birth country, number of times the woman had given birth, previous cesarean delivery, and history of preterm birth. After adjusting for potential confounders, endometriosis was not associated with preterm birth (adjusted odds ratio [aOR] 1.07 [95% CI: 0.64, 1.77]).

The researchers found no differences among preterm births based on a mother's endometriosis phenotype. Those phenotypes include isolated superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA), and deep endometriosis (DE).

"Monitoring pregnancy beyond the normal protocols or changing management strategies may not be warranted in cases of endometriosis," Marcellin said.

More research on endometriosis' potential link to birth outcomes is needed.

An expert not involved with the study said the new paper highlights important new avenues of research but should not be seen as the final word on the connection between endometriosis and preterm birth.

Of the 1351 study participants (mean age, 32.9 ± 5 years) who had a singleton delivery after 22 weeks of gestation, 470 were assigned to the endometriosis group, and 881 were assigned to the control group.

The authors concluded, "Pregnant women with endometriosis should not be considered to have an exceptionally high risk for preterm birth. However, further studies are needed to examine the potential for other adverse perinatal outcomes or specific but rare complications."

Daniela Carusi, MD, said the difficulty with the study's design is that "premature birth is not one problem or one disease."

Many very different problems can all end with premature birth. Sometimes it's an infection or inflammation or bleeding in the uterus or hypertension in the mother, for example, and all those things can lead to a preterm birth, she explained.

"This study inherently lumps all those things together," said Carusi, who is director of surgical obstetrics and placental abnormalities in the department of obstetrics and gynecology at Brigham and Women's Hospital in Boston, Massachusetts. "It's quite possible endometriosis can have a big impact in one of those areas and no impact in the other areas, but the study design wouldn't be able to pick that up."

Editorialists: Results Challenge Findings of Previous Studies

In an accompanying commentary,[2] Liisu Saavalainen, MD, PhD, and Oskari Heikinheimo, MD, PhD, both with the department of obstetrics and gynecology, and Helsinki University Hospital, in Helsinki, Finland, wrote that several previous studies have suggested that women with endometriosis have a slightly higher risk for preterm birth.

Those studies were mostly retrospective and differed in the way they classified endometriosis and the way they selected patients, the editorialists wrote. Also, most women in these studies typically had subfertility, they added.

The study by Marcellin and colleagues differs from previous related research in that it was prospective and assessed the risk for preterm delivery in women with endometriosis and women without endometriosis from several maternity centers in France. The women with endometriosis were classified according to the severity of their disease.

The editorialists wrote, "[T]he novel results by Marcellin et al challenge the findings of most previous studies on this topic. These results are valuable and comforting. However, they are also likely to trigger new studies on the pregnancy risks associated with different types of endometriosis That is good news."

Carusi said the study was well done and included a notably large size. Further complimenting the research, she said it is important to talk about this little-discussed pregnancy complication.

There has been much more focus for women with endometriosis and their physicians on getting pregnant and on talking about the length of their term, she said.

The study leaves some things unanswered.

The study was funded by research grants from the French Ministry of Health and was sponsored by the Département de la Recherche Clinique et du Développement de l'Assistance Publique–Hôpitaux de Paris. Carusi reports no relevant financial relationships. A coauthor of the study reports personal fees from Bioserinity and Ferring outside the submitted work. No other disclosures were reported.

Study Highlights

  • This cohort study took place in 7 maternity units in France from February 4, 2016 to June 28, 2018, with final follow-up in July 2019.
  • Participants were 1351 women (mean age, 32.9 ± 5 years) with singleton pregnancies followed up before 22 weeks’ gestation and their newborns delivered at ≥ 22 weeks’ gestation.
  • There were 470 with documented history of endometriosis (48 [10.2%] SUP, 83 [17.7%] OMA, 339 [72.1%] DE), and 881 control participants without clinical symptoms of endometriosis.
  • Primary outcome was preterm birth between 22 weeks’ and 36 weeks 6 days’ gestation.
  • Researchers assessed association between endometriosis and primary outcome through univariate and multivariate logistic regression analyses.
  • Endometriosis and control groups did not differ in preterm delivery rate before 37 weeks’ gestation (7.2% vs 6%; P = .38).
  • After adjustment for risk factors for preterm birth (maternal age, BMI before pregnancy, birth country, parity, previous cesarean delivery, history of myomectomy and hysteroscopy, and preterm birth), endometriosis was not associated with preterm birth before 37 weeks’ gestation (aOR 1.07 [95% CI: 0.64, 1.77).
  • Results were similar for SUP (6.2%), OMA (7.2%), and DE (7.4%); P = .84).
  • Whether preterm birth was induced or spontaneous did not appear to affect the findings.
  • Nonetheless, the endometriosis group had higher rates of threatened preterm labor, labor induction, instrumental delivery, and cesarean delivery.
  • The investigators concluded that after adjusting for risk factors for preterm delivery, there was no association between endometriosis and preterm birth and that disease phenotype did not affect the result.
  • Given the higher rate of threatened preterm labor in the endometriosis group, the present study cannot rule out an association among endometriosis, uterine contractions, and cervical changes.
  • Higher rates of labor induction, instrumental delivery, and cesarean delivery may reflect overestimation of high-risk pregnancies in women with endometriosis.
  • As pregnant women with endometriosis should not be considered to have an exceptionally high risk for preterm birth, monitoring pregnancy beyond normal protocols or changing management strategies may not be warranted.
  • Still, further studies are needed to examine the potential for other adverse perinatal outcomes or specific but rare complications.
  • The findings differ from those in studies on the increased risk for preterm delivery in women with endometriosis, including 3 meta-analyses showing an association between endometriosis and adverse pregnancy outcomes, especially preterm birth before 37 weeks’ gestation (ORs ranging from 1.38 to 1.7).
  • Note: The included studies were mostly small and retrospective.
  • Practitioners also often mistakenly consider pregnancies of women with endometriosis as high-risk because of available retrospective data on adverse pregnancy outcomes, known rare but potentially catastrophic acute surgical complications during pregnancy that were related to DE, extensive surgical history, or lengthy infertility.
  • Despite the absence of an association with increased risk for preterm birth, this anxiety-provoking setting may explain the association between endometriosis and hospitalization for threatened preterm labor.
  • The results may reassure patients and encourage practitioners to monitor such pregnancies according to normal pregnancy protocols to prevent preterm birth while considering exceptional gestational acute surgical complications.
  • Endometriosis may adversely affect uterine functions, especially by compromising properties of the ectopic endometrium.
  • Such changes could interfere with the normal process of decidualization that helps control trophoblast invasion at the maternal-fetal interface, potentially causing t placentation defects and obstetric complications.
  • Study limitations include observational design with uncontrolled confounders and recruitment difficulties limiting sample size.

Clinical Implications

  • After adjusting for risk factors, endometriosis was not associated with preterm birth, overall or based on disease phenotype.
  • For women with endometriosis, monitoring pregnancy beyond normal protocols or changing management strategies may not be warranted.
  • Implications for the Healthcare Team: Further studies are needed to examine the potential for other adverse perinatal outcomes or specific but rare complications.

 

Earn Credit

  • Print