The association of endometriosis with placenta previa and postpartum hemorrhage: a systematic review and meta-analysis


      This study aimed to review the effect of endometriosis on the prevalence of placenta previa and postpartum hemorrhage in pregnant patients and the surgical outcomes of pregnant patients with endometriosis developing placenta previa.


      In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the literature was conducted on December 31, 2020, using PubMed, Scopus, and the Cochrane Library.


      Comparative studies between pregnant women with and without endometriosis and studies that investigated the surgical outcomes of patients with and without endometriosis developing placenta previa were included.


      Here, 2 reviewers independently screened the titles and abstracts, completed data extraction, and assessed the reporting quality using the Risk of Bias in Nonrandomized Studies of Interventions tool.


      Overall, 19 studies (from 2010 to 2020) met the inclusion criteria (98,463 pregnancies with endometriosis and 7,184,313 pregnancies without endometriosis). In the adjusted pooled analysis, endometriosis was associated with a higher rate of placenta previa (adjusted odds ratio, 3.17; 95% confidence interval, 2.58–3.89), whereas the incidence of postpartum hemorrhage was similar between pregnant women with and without endometriosis (adjusted odds ratio, 1.15; 95% confidence interval, 0.99–1.34). When the analysis was restricted to histologically confirmed endometriosis cases, the relationship of endometriosis with placenta previa (adjusted odds ratio, 4.23; 95% confidence interval, 1.74–10.30) and postpartum hemorrhage (adjusted odds ratio, 1.29; 95% confidence interval, 0.50–3.34) was consistent with results from the nonrestricted analysis. There was no study that examined the surgical outcomes of patients with endometriosis developing placenta previa patients. However, there are 3 studies that examined the effect of endometriosis on surgical outcomes during cesarean delivery: 1 study showing that endometriosis was associated with increased intraoperative bleeding during emergent cesarean delivery; the other study showing that endometriosis was associated with an increased incidence of postpartum hemorrhage during cesarean delivery (adjusted odds ratio, 1.1; 95% confidence interval, 1.0–1.2), especially in primiparous women with singleton pregnancies (adjusted odds ratio, 1.7; 95% confidence interval, 1.5–2.0); and another study suggesting a significantly higher rate of hysterectomy (7.1%) and bladder injury (7.1%) in patients with endometriosis than in those without endometriosis.


      Endometriosis can potentially be associated with adverse surgical outcomes during cesarean delivery. Although there is a correlation between endometriosis and increased rate of placenta previa, the surgical outcomes of patients with endometriosis developing placenta previa remain understudied.

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        • Fuldeore MJ
        • Soliman AM.
        Prevalence and symptomatic burden of diagnosed endometriosis in the United States: national estimates from a cross-sectional survey of 59,411 women.
        Gynecol Obstet Invest. 2017; 82: 453-461
        • Macer ML
        • Taylor HS.
        Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility.
        Obstet Gynecol Clin North Am. 2012; 39: 535-549
        • Meuleman C
        • Vandenabeele B
        • Fieuws S
        • Spiessens C
        • Timmerman D
        • D'Hooghe T.
        High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners.
        Fertil Steril. 2009; 92: 68-74
        • Horton J
        • Sterrenburg M
        • Lane S
        • Maheshwari A
        • Li TC
        • Cheong Y.
        Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis.
        Hum Reprod Update. 2019; 25: 592-632
        • Senapati S
        • Sammel MD
        • Morse C
        • Barnhart KT.
        Impact of endometriosis on in vitro fertilization outcomes: an evaluation of the Society for Assisted Reproductive Technologies Database.
        Fertil Steril. 2016; 106 (164–171.e1)
        • Berlac JF
        • Hartwell D
        • Skovlund CW
        • Langhoff-Roos J
        • Lidegaard Ø.
        Endometriosis increases the risk of obstetrical and neonatal complications.
        Acta Obstet Gynecol Scand. 2017; 96: 751-760
        • Exacoustos C
        • Lauriola I
        • Lazzeri L
        • De Felice G
        • Zupi E.
        Complications during pregnancy and delivery in women with untreated rectovaginal deep infiltrating endometriosis.
        Fertil Steril. 2016; 106 (1129–1135.e1)
        • Kido A
        • Togashi K
        • Nishino M
        • et al.
        Cine MR imaging of uterine peristalsis in patients with endometriosis.
        Eur Radiol. 2007; 17: 1813-1819
        • Vercellini P
        • Parazzini F
        • Pietropaolo G
        • Cipriani S
        • Frattaruolo MP
        • Fedele L.
        Pregnancy outcome in women with peritoneal, ovarian and rectovaginal endometriosis: a retrospective cohort study.
        BJOG. 2012; 119: 1538-1543
        • Leone Roberti Maggiore U
        • Ferrero S
        • Mangili G
        • et al.
        A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes.
        Hum Reprod Update. 2016; 22: 70-103
        • Eisenberg VH
        • Weil C
        • Chodick G
        • Shalev V.
        Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members.
        BJOG. 2018; 125: 55-62
        • Nagase Y
        • Matsuzaki S
        • Mizuta-Odani C
        • et al.
        In-vitro fertilisation-embryo-transfer complicates the antenatal diagnosis of placenta accreta spectrum using MRI: a retrospective analysis.
        Clin Radiol. 2020; 75: 927-933
        • Lalani S
        • Choudhry AJ
        • Firth B
        • et al.
        Endometriosis and adverse maternal, fetal and neonatal outcomes, a systematic review and meta-analysis.
        Hum Reprod. 2018; 33: 1854-1865
        • Zullo F
        • Spagnolo E
        • Saccone G
        • et al.
        Endometriosis and obstetrics complications: a systematic review and meta-analysis.
        Fertil Steril. 2017; 108 (667–72.e5)
        • Uccella S
        • Manzoni P
        • Cromi A
        • et al.
        Pregnancy after endometriosis: maternal and neonatal outcomes according to the location of the disease.
        Am J Perinatol. 2019; 36: S91-S98
        • Miura M
        • Ushida T
        • Imai K
        • et al.
        Adverse effects of endometriosis on pregnancy: a case-control study.
        BMC Pregnancy Childbirth. 2019; 19: 373
        • Matsuzaki S
        • Okada A
        • Endo M
        • et al.
        Horizontal cervix as a novel sign for predicting adhesions on the posterior extrauterine wall in cases of placenta previa.
        J Clin Med. 2019; 8: 2141
        • Uccella S
        • Marconi N
        • Casarin J
        • et al.
        Impact of endometriosis on surgical outcomes and complications of total laparoscopic hysterectomy.
        Arch Gynecol Obstet. 2016; 294: 771-778
        • Hwang JH
        • Lim MC
        • Joung JY
        • et al.
        Urologic complications of laparoscopic radical hysterectomy and lymphadenectomy.
        Int Urogynecol J. 2012; 23: 1605-1611
        • Rosenberg T
        • Pariente G
        • Sergienko R
        • Wiznitzer A
        • Sheiner E.
        Critical analysis of risk factors and outcome of placenta previa.
        Arch Gynecol Obstet. 2011; 284: 47-51
        • Yi KW
        • Cho GJ
        • Park K
        • et al.
        Endometriosis is associated with adverse pregnancy outcomes: a national population-based study.
        Reprod Sci. 2020; 27: 1175-1180
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • Group PRISMA
        Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Sterne JA
        • Hernán MA
        • Reeves BC
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355: i4919
        • Danna SM
        • Graham E
        • Burns RJ
        • Deschênes SS
        • Schmitz N.
        Association between depressive symptoms and cognitive function in persons with diabetes mellitus: a systematic review.
        PLoS One. 2016; 11e0160809
      1. Sterne JAC Higgins JPT Elbers RG Reeves BC ROBINS-1 Group Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance. 2016 (Available at:) (Accessed September 20, 2020)
        • Egger M
        • Davey Smith G
        • Schneider M
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
      2. Deeks JJ, Higgins JPT, Altman DG (eds). Chapter 10: Analysing data and undertaking meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds). Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021). Cochrane, 2021. Available at: Accessed December 18, 2020.

        • Epelboin S
        • Labrosse J
        • Fauque P
        • et al.
        Endometriosis and assisted reproductive techniques independently related to mother-child morbidities: a French longitudinal national study.
        Reprod Biomed Online. 2021; 42: 627-633
        • Lin S
        • Xie X
        • Guo Y
        • et al.
        Clinical characteristics and pregnancy outcomes of infertile patients with endometriosis and endometrial polyps: a retrospective cohort study.
        Taiwan J Obstet Gynecol. 2020; 59: 916-921
        • Shmueli A
        • Salman L
        • Hiersch L
        • et al.
        Obstetrical and neonatal outcomes of pregnancies complicated by endometriosis.
        J Matern Fetal Neonatal Med. 2019; 32: 845-850
        • Chen I
        • Lalani S
        • Xie RH
        • Shen M
        • Singh SS
        • Wen SW.
        Association between surgically diagnosed endometriosis and adverse pregnancy outcomes.
        Fertil Steril. 2018; 109: 142-147
        • Nirgianakis K
        • Gasparri ML
        • Radan AP
        • et al.
        Obstetric complications after laparoscopic excision of posterior deep infiltrating endometriosis: a case-control study.
        Fertil Steril. 2018; 110: 459-466
        • Li H
        • Zhu HL
        • Chang XH
        • et al.
        Effects of previous laparoscopic surgical diagnosis of endometriosis on pregnancy outcomes.
        Chin Med J (Engl). 2017; 130: 428-433
        • Mannini L
        • Sorbi F
        • Noci I
        • et al.
        New adverse obstetrics outcomes associated with endometriosis: a retrospective cohort study.
        Arch Gynecol Obstet. 2017; 295: 141-151
        • Benaglia L
        • Candotti G
        • Papaleo E
        • et al.
        Pregnancy outcome in women with endometriosis achieving pregnancy with IVF.
        Hum Reprod. 2016; 31: 2730-2736
        • Fujii T
        • Wada-Hiraike O
        • Nagamatsu T
        • et al.
        Assisted reproductive technology pregnancy complications are significantly associated with endometriosis severity before conception: a retrospective cohort study.
        Reprod Biol Endocrinol. 2016; 14: 73
        • Harada T
        • Taniguchi F
        • Onishi K
        • et al.
        Obstetrical complications in women with endometriosis: a cohort study in Japan.
        PLoS One. 2016; 11e0168476
        • Baggio S
        • Pomini P
        • Zecchin A
        • et al.
        Delivery and pregnancy outcome in women with bowel resection for deep endometriosis: a retrospective cohort study.
        Gynecol Surg. 2015; 12: 279-285
        • Lin H
        • Leng JH
        • Liu JT
        • Lang JH.
        Obstetric outcomes in Chinese women with endometriosis: a retrospective cohort study.
        Chin Med J (Engl). 2015; 128: 455-458
        • Takemura Y
        • Osuga Y
        • Fujimoto A
        • et al.
        Increased risk of placenta previa is associated with endometriosis and tubal factor infertility in assisted reproductive technology pregnancy.
        Gynecol Endocrinol. 2013; 29: 113-115
        • Healy DL
        • Breheny S
        • Halliday J
        • et al.
        Prevalence and risk factors for obstetric haemorrhage in 6730 singleton births after assisted reproductive technology in Victoria Australia.
        Hum Reprod. 2010; 25: 265-274
        • Opøien HK
        • Fedorcsak P
        • Omland AK
        • et al.
        In vitro fertilization is a successful treatment in endometriosis-associated infertility.
        Fertil Steril. 2012; 97: 912-918
        • Matsuzaki S
        • Nagase Y
        • Takiuchi T
        • et al.
        Antenatal diagnosis of placenta accreta spectrum after in vitro fertilization-embryo transfer: a systematic review and meta-analysis.
        Sci Rep. 2021; 11: 9205
        • Romundstad LB
        • Romundstad PR
        • Sunde A
        • von Düring V
        • Skjaerven R
        • Vatten LJ.
        Increased risk of placenta previa in pregnancies following IVF/ICSI; a comparison of ART and non-art pregnancies in the same mother.
        Hum Reprod. 2006; 21: 2353-2358
        • Hayashi M
        • Nakai A
        • Satoh S
        • Matsuda Y.
        Adverse obstetric and perinatal outcomes of singleton pregnancies may be related to maternal factors associated with infertility rather than the type of assisted reproductive technology procedure used.
        Fertil Steril. 2012; 98: 922-928
        • Gasparri ML
        • Nirgianakis K
        • Taghavi K
        • Papadia A
        • Mueller MD.
        Placenta previa and placental abruption after assisted reproductive technology in patients with endometriosis: a systematic review and meta-analysis.
        Arch Gynecol Obstet. 2018; 298: 27-34
        • Getahun D
        • Oyelese Y
        • Salihu HM
        • Ananth CV.
        Previous cesarean delivery and risks of placenta previa and placental abruption.
        Obstet Gynecol. 2006; 107: 771-778
        • Roberts CL
        • Algert CS
        • Warrendorf J
        • Olive EC
        • Morris JM
        • Ford JB.
        Trends and recurrence of placenta praevia: a population-based study.
        Aust N Z J Obstet Gynaecol. 2012; 52: 483-486
        • Weis MA
        • Harper LM
        • Roehl KA
        • Odibo AO
        • Cahill AG.
        Natural history of placenta previa in twins.
        Obstet Gynecol. 2012; 120: 753-758