LAUSR

In this issue, Nirgianakis et al. (1) present a retrospective analysis of the complications of pregnancy after laparoscopic excision of deep infiltrating endometriosis (DIE). Most important is that excision of DIE does not affect the increased risk of placenta previa, gestational hypertension, and intrauterine growth retardation (IUGR) associated with endometriosis. In addition, the risk of a vaginal delivery was not increased in the entire group or in the 26 women with a vaginal excision of endometriosis. In the Nirgianakis et al. (1) study previous deep endometriosis surgery seems not to significantly affect the probability of cesarean section or the risk of vaginal delivery. The observation that segmental bowel resection was associated with an increased cesarean section rate might be the consequence of a decision by the obstetrician rather than a clinical necessity. It is reassuring to know that it is unlikely that surgery of the bowel, the pouch of Douglas, or the vaginal cuff without affecting the cervix, would complicate a vaginal delivery. The risk of postpartum bleeding and placental retention is intriguing and has not been reported before. Although not significant in this small series, it could be caused by pelvic nerve damage during deep endometriosis surgery as occurs for bladder and bowel motility. Much larger series will be necessary to confirm this potentially important observation. This Nirgianakis et al. (1) article confirms the increased incidence of placenta previa, pregnancy hypertension, and intrauterine growth retardation in women with deep endometriosis. The mechanism of this association has been explained as follows. The human pregnancy is characterized by deep placentation, which is an invasive process with the intravascular presence of endometrial cells and physiological changes of the spiral arteries in the junctional zone (JZ). If this mechanism of vascular transformation fails, there is a risk of women becoming hypertensive with small for gestational age (SGA) babies and preeclampsia. A changed uterine contractility and a JZ dysfunction could be the link between endometriosis and adenomyosis which are believed to be associated (2). Focal adenomyotic nodules are more frequent in women with deep endometriosis. Imaging studies found a strong association of cystic ovarian or deep endometriosis with adenomyosis defined as JZ thickening, diffuse adenomyosis, or focal adenomyotic nodules with a prevalence of 80.6 % endometriosis in adenomyosis and 91.1 % of adenomyosis in endometriosis. We do not know whether some phenotypes of endometriosis specifically correlate with the JZ thickening. Also, hereditary, biochemical, and genetic aspects as clonality of adenomyosis are poorly investigated. The association of endometriosis and adenomyosis with placenta previa, pregnancy hypertension and SGA babies has been discussed in a recent systematic review (3) and meta-analysis (4). The odds ratios (OR) of large cohort studies evaluating the association of endometriosis with preeclampsia (3) were either slightly increased or not significantly different from a control group. The meta-analysis (4) did