{"paper_id":"5326fbc2-6a6c-46bc-a448-83249850cd17","body_text":"Review began\n 10/11/2026 \nReview ended\n 10/29/2026 \nPublished\n 11/04/2026\n© Copyright \n2026\nPrasad et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.119104\nPregnancy Outcomes in Women With\nEndometriosis: A Systematic Review and Meta-\nAnalysis of Maternal and Neonatal Complications\nAnima \nPrasad \n, \nMimansa \nBharti \n, \nMaignanamoorthy \nV \n, \nSieqa \nShah \n, \nJatin \nB. Goda \n, \nSinduja \nSomasekar \n,\nAshish Kumar Shukla \n1.\n Department of Obstetrics and Gynecology, T.S. Misra Medical College and Hospital, Lucknow, IND \n2.\n Department of\nPharmacology, The Tamil Nadu Dr. M.G.R. Medical University, Chennai, IND \n3.\n Department of Obstetrics and\nGynecology, Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Medical College and Hospital, Srinagar, IND \n4.\nDepartment of Anatomy, Dr. N. D. Desai Faculty of Medical Science and Research, Dharmsinh Desai University, Nadiad,\nIND \n5.\n Department of Clinical Embryology, Avinashilingam Institute for Home Science and Higher Education for\nWomen, Coimbatore, IND \n6.\n Department of Radiodiagnosis, Santosh Medical College, Santosh Deemed to be\nUniversity, Ghaziabad, IND\nCorresponding author: \nAnima \nPrasad, \nanimaprasad572@gmail.com\nAbstract\nEndometriosis may influence pregnancy beyond its established association with infertility by affecting\nplacentation, gestational duration, maternal health, and neonatal outcomes. This systematic review and\nmeta-analysis aimed to determine whether endometriosis is associated with adverse maternal, fetal, and\nneonatal complications. PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE),\nScopus, Web of Science, and Google Scholar were searched from inception to June 30, 2026, using controlled\nvocabulary and free-text terms related to endometriosis and pregnancy outcomes. Comparative\nobservational studies involving pregnant women with and without endometriosis were included. Two\nreviewers independently screened studies, extracted adjusted effect estimates, and assessed risk of bias\nusing Risk of Bias in Non-randomized Studies-of Exposures (ROBINS-E). Random-effects meta-analysis was\nperformed when at least three clinically comparable studies provided extractable data; the remaining\noutcomes were synthesized narratively. Ten studies were included. Women with endometriosis had\nsignificantly higher odds of placenta previa (pooled OR 2.98, 95% CI 2.00-4.45; I²=34.5%) and a higher risk of\npreterm birth (pooled adjusted OR/RR sensitivity estimate 1.24, 95% CI 1.14-1.36; I²=10.2%). Narrative\nfindings also suggested increased frequencies of hypertensive disorders, hemorrhage, cesarean delivery,\nfetal growth abnormalities, stillbirth, neonatal intensive care admission, and respiratory morbidity,\nalthough consistency varied. Endometriosis is associated with clinically important obstetric and neonatal\nrisks, particularly placenta previa and preterm birth, supporting individualized antenatal surveillance and\ndelivery planning.\nCategories:\n Obstetrics/Gynecology, Pediatrics, Epidemiology/Public Health\nKeywords:\n endometriosis, maternal outcomes, neonatal complications, placenta previa, preterm birth\nIntroduction And Background\nEndometriosis is a chronic inflammatory gynecological condition with estrogen dependency in which tissue\nresembling normal endometrial tissue is found outside of the uterine cavity \n[1]\n. Usually, the lesions are\nfound in the ovaries, pelvic peritoneum, uterosacral ligaments, rectovaginal septum, and adjacent pelvic\nstructures \n[2]\n. Clinical presentation and clinical severity are highly variable between women with the\ncondition, and it is often complicated by dysmenorrhea, chronic pelvic pain, dyspareunia, abnormal uterine\nbleeding, and infertility \n[3]\n. Endometriosis can present as superficial peritoneal disease, ovarian\nendometrioma, or deep infiltrating lesions and has various patient symptom patterns as well as different\nlocations and reproductive consequences \n[4]\n. Delay in diagnosis, and the fact that symptoms may vary or be\ndifficult to detect in most cases without invasive tests, may make clinical management and reproductive\ncounseling difficult \n[5]\n.\nIn the past, the impact of endometriosis on the reproductive system has been primarily discussed in terms of\ndiminished fertility. Distortion of pelvic anatomy, adhesion, altered tubo-ovarian relationships,\ninflammation of the pelvic environment, loss of follicular development, loss of oocyte competence, and\naltered endometrial receptivity may cause a reduction in spontaneous conception probability \n[6]\n. Assisted\nreproductive techniques have allowed many women with endometriosis-related infertility to conceive.\nAbsence of conception does not mean that the disease has no biological or anatomical effects \n[7]\n. Long-\nlasting inflammatory, endocrine, vascular, and structural changes may persist throughout pregnancy and\naffect embryo implantation, placental growth, uterine adaptation, fetal growth, and delivery (time and\nmode) \n[8]\n.\nThese steps of coordinated decidualization, trophoblast invasion, remodeling of spiral arteries, immune\n1\n1\n2\n3\n4\n5\n6\n \nOpen Access Review Article\nHow to cite this article\nPrasad A, Bharti M, V M, et al. (November 04, 2026) Pregnancy Outcomes in Women With Endometriosis: A Systematic Review and Meta-Analysis\nof Maternal and Neonatal Complications. Cureus 18(11): e119104. \nDOI 10.7759/cureus.119104\n\ntolerance, and vascular development in the placenta are important for successful pregnancy \n[9]\n.\nProgesterone resistance, dysregulation of cytokines, oxidative stress, angiogenic imbalance, abnormal\nuterine contractility, and decidual dysfunction have all been found to be related to endometriosis \n[2]\n. Such\nmechanisms may provide a biological explanation for the observed associations between endometriosis and\nadverse pregnancy outcomes. Altered decidualization, inflammatory signaling, and abnormal placentation\nhave been proposed as potential pathways linking endometriosis with complications such as placenta previa,\nplacental abruption, hypertensive disorders, fetal growth abnormalities, and preterm labor; however, a\ndirect causal relationship has not been established \n[10]\n. Other factors such as pelvic adhesions, past surgery,\ndeep infiltrating disease, and abnormal pelvic anatomy may contribute to operative delivery difficulties and\nmay be associated with increased rates of cesarean delivery, bleeding, or other complications during labor\n[11]\n.\nA wide variety of maternal and neonatal outcomes have been studied in women with endometriosis during\npregnancy. Maternal complications reported include placenta previa, placental abruption, and hypertensive\ndisorders, as well as gestational diabetes, antepartum hemorrhage, postpartum hemorrhage, and cesarean\ndelivery \n[12]\n. Endometriosis could be clinically relevant after conception due to the demands for coordinated\nimplantation, decidualization, placental development, vascular adaptation, and immune regulation during\npregnancy \n[3]\n. It has been suggested that these processes are the factors that may be implicated in the\ncorrelation of endometriosis and poor obstetric outcomes \n[9]\n. Pelvic deformities from disease or previous\nsurgery can also affect the positioning, function, and delivery of the placenta. These mechanisms offer a\njustification for considering pregnancy outcomes other than infertility \n[10]\n.\nSeveral maternal and neonatal complications, such as placenta previa, preterm birth, hypertension,\nbleeding, cesarean section, fetal growth abnormalities, stillbirth, and neonatal morbidity, have been\nevaluated in published evidence \n[8]\n. Associations have not been consistent, and evidence is different for\neach outcome. Existing observational evidence suggests that associations with placenta previa and preterm\nbirth are more consistently reported, whereas findings for hypertensive disorders, gestational diabetes, fetal\ngrowth abnormalities, and neonatal complications remain variable across studies. The uncertainty about the\nmost consistent complications of endometriosis has been caused by the fact that different study\npopulations, different definitions of endometriosis, different methods of reproduction, and different\nmethods of analysis have been used. Previous systematic reviews and meta-analyses have examined adverse\npregnancy outcomes associated with endometriosis; however, gaps remain due to inconsistent diagnostic\ncriteria, variability in outcome definitions, differences in confounder adjustment, and limited evaluation of\nindividual maternal and neonatal outcomes. These limitations have made it difficult to establish the\nconsistency of outcome-specific associations. The present review aims to address these gaps through an\nupdated synthesis of maternal, fetal, and neonatal outcomes, distinguishing findings suitable for\nquantitative analysis from those requiring narrative evaluation.\nObjectives of the review\nThis systematic review and meta-analysis aimed to determine whether endometriosis is associated with an\nincreased risk of adverse maternal, fetal, and neonatal outcomes during pregnancy. Particular emphasis was\nplaced on placenta previa, preterm birth, and other clinically relevant obstetric and perinatal complications,\nsuch as placental disorders, hypertensive and metabolic complications, hemorrhagic complications,\noperative delivery, fetal growth abnormalities, and fetal and neonatal morbidity.\nReview\nMethodology\nStudy Design and Reporting Framework\nThe purpose of this systematic review and meta-analysis was to examine maternal, fetal, and neonatal\noutcomes in women during pregnancy with endometriosis. The methodology was designed based on the\nPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement \n[13]\n.\nQuantitative synthesis was preceded by the development of the review question, eligibility criteria,\noutcomes, screening procedures, data-extraction framework, risk-of-bias assessment, and statistical\nanalyses. Non-randomized comparative studies were included in the review, as the association of maternal\nendometriosis and pregnancy outcomes is mainly studied in observational epidemiologic studies. During the\nreview, methodological changes were made, which were resolved by consensus and recorded for\ntransparency and reproducibility. PRISMA-2020 is the latest main reporting structure for systematic\nreviews.\nEligibility Criteria\nThe Population, Exposure, Comparator, and Outcomes (PICO) framework was used to define eligibility. The\npopulation consisted of pregnant women with singleton or mixed pregnancy populations for whom\nsingleton findings were separately extractable. Clinically diagnosed, surgically confirmed, imaging-detected,\nor administratively coded endometriosis was used as the diagnosis to define exposure. Comparators were\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n2\n of \n13\n\npregnant women without endometriosis. Eligible outcomes included placenta previa, placental abruption,\npreterm birth, hypertensive disorders, gestational diabetes, cesarean delivery, antepartum and postpartum\nhemorrhage, fetal growth restriction, low birth weight, small-for-gestational-age birth, stillbirth, admission\nto the neonatal intensive care unit, and neonatal respiratory morbidity. Comparative outcome data reports\nwere eligible if they were cohort, case-control, registry-linkage, or population-based studies. Reviews, case\nreports, conference abstracts, and non-English publications were not included.\nElectronic Databases and Information Sources\nUsing a comprehensive electronic literature search, literature was reviewed in PubMed/Medical Literature\nAnalysis and Retrieval System Online (MEDLINE), Scopus, Web of Science Core Collection, and Google\nScholar from the inception of the database to 2026. Eligible studies and relevant\nsystematic literature reviews (SLRs) were manually searched from reference lists to identify studies not\nidentified in the database searches. Grey literature and recently indexed literature were supplemented with\nGoogle Scholar to find these items, and the results were analyzed in the reverse order of relevance until no\nfurther potentially eligible studies were found. Only human research in English was included in the search.\nThere was no restriction on the country, healthcare context, number of samples, or published or\nunpublished status in the initial database search. All retrieved records were exported to a reference-\nmanagement file for deduplication and screening.\nSearch Strategy and Boolean Operators\nThe search strategy combined controlled vocabulary, including Medical Subject Headings where applicable,\nwith free-text terms related to endometriosis and pregnancy outcomes. The principal PubMed search syntax\nwas: (“Endometriosis” [MeSH] OR endometriosis OR endometriotic) AND (“Pregnancy” [MeSH] OR\npregnancy OR pregnant OR gestation OR obstetric) AND (“Pregnancy Outcome” [MeSH] OR “pregnancy\noutcome” OR maternal OR neonatal OR perinatal OR “placenta previa” OR preterm OR premature OR\npreeclampsia OR haemorrhage OR “gestational diabetes” OR cesarean OR “fetal growth restriction” OR “low\nbirth weight” OR stillbirth). Boolean operators OR and AND combined synonyms and conceptual groups,\nrespectively. Database-specific search syntax and truncation operators were adapted for Scopus and Web of\nScience, while keyword-based searches were used for Google Scholar. The complete database-specific search\nstrategies, search dates, and applied eligibility restrictions are provided in the Appendices. \nStudy Selection\nDuplicate citations were eliminated, and all records were retrieved from all sources and combined before\nscreening. Titles and abstracts were independently screened by two reviewers using the predetermined\ncriteria. Potentially relevant records were taken to full-text assessment. To ensure the eligible study design,\nexposure to endometriosis, a comparator group, and/or extractable maternal or neonatal outcome data were\nindependently examined through full-text articles. Comparisons were made between studies that shared a\ncommon population, recruitment period, sample size, and/or outcome definition, and the most complete or\nmethodologically most appropriate study was selected for each synthesis. If there was disagreement at either\nscreening stage, it was discussed and, when required, cross-referenced with a third reviewer. The reasons for\nexcluding full-text articles were documented, and the selection process was illustrated with a PRISMA 2020\nflow diagram.\nData Extraction and Outcome Classification\nData were abstracted by two reviewers independently using a standardized and pilot-tested data extraction\nform. The variables extracted were author, year of publication, country, type of study design, period of\nrecruitment, source of data, number of patients, definition of endometriosis, comparator characteristics,\nconception method, parity, maternal age, definitions of outcome, period of follow-up, covariates adjusted in\nmodels, effect measure, point estimate, and 95% confidence interval. Confounding was minimized by using\nadjusted estimates rather than unadjusted estimates. Maternal outcomes consisted of placental disorders,\nhypertensive disorders, gestational diabetes, hemorrhage, and cesarean delivery. Perinatal/neonatal\noutcomes included: preterm birth, fetal growth abnormalities, stillbirth, neonatal intensive care admission,\nand respiratory morbidity. The values that were extracted from the tables and figures were cross-checked\nwith the supplementary files and the study text before the analysis.\nRisk-of-Bias Assessment\nTwo reviewers independently evaluated the risk of bias in each study using the Risk of Bias in Non-\nrandomized Studies-of Exposures (ROBINS-E) tool, which is specifically designed for observational studies\nthat aim to estimate the effects of an exposure \n[14]\n. This tool was suitable given the evidence presented,\nwhich included cohort, case-control, registry-linkage, and other types of observational comparisons of\nmaternal exposure to endometriosis. All outcome-specific estimates were analyzed across seven areas:\nconfounding, exposure measurement, participant selection, post-exposure interventions, missing data,\noutcome measurement, and selection of the reported result. Judgments were made at the domain level and\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n3\n of \n13\n\noverall level and rated as low risk, some concerns, high risk, or very high risk. Clarifications were made by\nconsensus. The recommended tool for non-randomized epidemiological studies is ROBINS-E, a dedicated\nexposure-assessment tool.\nStatistical Analysis and Evidence Synthesis\nMeta-analysis was conducted if the study characteristics of three or more studies were sufficiently similar\nwith respect to populations, outcomes, and association measures adjusted for. Measure-specific synthesis\nwas done for adjusted odds ratios wherever possible. Reported 95% confidence intervals were converted into\nnatural log estimates of effects and standard errors. To account for clinical and methodological variability of\nstudies, random-effects models were adopted. The Cochrane's Q test, I², and between-study variance were\nused to assess statistical heterogeneity. For preterm birth, adjusted odds ratios (ORs) and risk ratios (RRs)\nwere combined in a random-effects sensitivity analysis using the rare-outcome approximation, rather than\ntreating the pooled estimate as a single measure-specific effect. This approximation was considered because\nORs and RRs may be similar when outcome frequencies are low. Estimates were pooled on the logarithmic\nscale, and differences in outcome frequency and study design were considered limitations of this approach.\nStudies that provided extractable and sufficiently similar statistical data were entered in the quantitative\nsynthesis, while studies that provided sufficient, but not extractable, statistical data and/or lacked\ncompatible effect estimates, variance measures, or consistent outcome definitions were retained in the\nnarrative synthesis. Syntheses with fewer than 10 studies were not analyzed with funnel plots or regression-\nbased tests because they would be underpowered for such analyses.\nRisk-of-Bias Visualization\nTraffic-light and summary plots were used to present domain-level ROBINS-E judgments. Each study was\nevaluated across the seven ROBINS-E domains, and judgments were categorized as low risk, some concerns,\nhigh risk, very high risk, or no information. The traffic-light plot was used to represent the domain-specific\njudgment for each study included; the summary plot was used to represent the distribution of the judgments\nacross all of the studies within a domain. Before manuscript inclusion, all figures have been checked against\nthe completed ROBINS-E assessment forms.\nResults\nStudy Selection\nThe literature search identified 337 records across PubMed/MEDLINE, Scopus, Web of Science, and Google\nScholar. After removing 39 duplicates, 298 records underwent title and abstract screening. Sixty-three full-\ntext articles were assessed for eligibility, and 53 were excluded because they did not satisfy the inclusion\ncriteria, lacked adequate pregnancy outcome data, or were published in non-English languages. Ten studies\nfulfilled the predefined criteria and were included in the final systematic review, with eligible outcome-\nspecific datasets subsequently incorporated into the quantitative meta-analysis. Figure \n1\n shows the PRISMA\n2020 flow diagram illustrating study identification, screening, eligibility assessment, and final inclusion in\nthe systematic review and meta-analysis.\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n4\n of \n13\n\nFIGURE\n 1: PRISMA 2020 flow diagram of the study-selection process\nPRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MEDLINE: Medical Literature\nAnalysis and Retrieval System Online\nCharacteristics of the Included Studies\nAll 10 studies were done in Japan, Germany, Australia, Italy, Iran, South Korea, France, and the U.S. Case-\ncontrol studies, prospective studies, retrospective studies, registry linkage, and population-based studies\nwere all included as study designs. Sample sizes ranged from 250 participants to over 1.25 million deliveries.\nExposed women included those who had been diagnosed with endometriosis by either a clinical or surgical\ndiagnosis or administrative data; the comparison groups included women without a diagnosis of\nendometriosis. Placenta previa, preterm birth, hypertensive disorders, hemorrhage, cesarean delivery,\ngestational diabetes, fetal growth, and neonatal morbidity were among the outcomes measured. Table \n1\nshows the detailed PICO-based characteristics of the included studies, including study design, population,\nendometriosis exposure, comparator groups, and reported maternal and fetal/neonatal outcomes.\nStudy\nCountry, setting,\nand design\nStudy period and\npopulation\nPopulation\nEndometriosis exposure\nComparator\nMaternal outcomes\nFetal/neonatal\noutcomes\nMiura et al.\n[15]\nJapan; single-\ncenter case-\ncontrol study at\nNagoya University\nHospital\nDeliveries from\n2010-2017; 2,769\nwomen, including\n80 with\nendometriosis and\n2,689 controls\nWomen who\ndelivered at a\ntertiary university\nhospital;\npregnancies with\nmaternal and\nneonatal outcome\ninformation\nEndometriosis diagnosed\nbefore pregnancy or ovarian\nendometriosis identified\nduring the first trimester.\nExposed women included\n49 with previous surgery,\nand 31 managed medically\nor without treatment\nWomen\nwithout\ndiagnosed\nendometriosis\nPlacenta previa, postpartum\nhemorrhage, hypertensive\ndisorders, gestational\ndiabetes, placental abruption,\nmode of delivery, and\noperative complications\nGestational age,\npreterm birth, birth\nweight, low birth\nweight, fetal growth,\nApgar scores,\numbilical artery pH,\nand neonatal\nintensive care unit\nadmission\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n5\n of \n13\n\nTéoule et al.\n[16]\nGermany;\nretrospective\ncohort study at\nUlm University\nHospital\n16,033\nprimiparous\nsingleton\npregnancies; 118\nexposed and\n15,915 controls\nPrimiparous\nwomen with\nsingleton\npregnancies\ndelivering at a\ntertiary-care\nuniversity hospital\nHistologically confirmed\nendometriosis diagnosed\nbefore conception following\nlaparoscopic surgery;\nadenomyosis was\ndocumented separately in a\nsubgroup\nPrimiparous\nwomen\nwithout\nendometriosis\nPrimary outcomes: cesarean\ndelivery and preterm birth; key\nsecondary outcome: placenta\nprevia. Additional delivery and\npregnancy characteristics\nwere assessed.\nGestational age,\npreterm birth before\n37 weeks, birth\nweight, neonatal\nsex, and other\navailable neonatal\noutcomes\nIbiebele et al.\n[17]\nAustralia;\npopulation-based\ncohort using\nlinked New South\nWales hospital,\nperinatal mortality,\nand assisted\nreproductive\ntechnology\nrecords\n578,221 index\nsingleton\npregnancies\nduring 2006-2015\nFemale residents\nof New South\nWales aged 15-45\nyears with a\nsingleton\npregnancy\nreaching at least 20\nweeks or a birth\nweight of at least\n400 g\nHospital-recorded\nendometriosis, examined\naccording to assisted\nreproductive technology\nuse: endometriosis without\nART and endometriosis\nwith ART\nWomen\nwithout\nendometriosis,\nseparated into\npregnancies\nconceived\nwithout ART\nand with ART\nAntepartum hemorrhage,\nplacenta previa, placental\nabruption, maternal morbidity,\ninduction of labor, cesarean\ndelivery, and planned birth\nPreterm birth, low\nbirth weight, small-\nfor-gestational-age\nbirth, large-for-\ngestational-age\nbirth, stillbirth, and\nneonatal morbidity\nHarada et al.\n[18]\nJapan;\nprospective\nnationwide cohort\nwithin the Japan\nEnvironment and\nChildren’s Study\nPregnancies\nenrolled during\n2011-2014;\nanalytical\npopulation of\n96,655 women,\nincluding 3,517\nwith endometriosis\nPregnant women\nenrolled in a large\nnational birth cohort\nwith information on\nmedical history,\nconception,\npregnancy, and\ndelivery\nSelf-reported or medically\ndocumented history of\nendometriosis before or\nduring pregnancy;\nadenomyosis was\nevaluated as a separate\nexposure\nPregnant\nwomen\nwithout a\nhistory of\nendometriosis\nComposite obstetric\ncomplications, placenta previa,\nplacental abruption,\nhypertensive disorders,\ngestational diabetes,\npremature rupture of\nmembranes, and mode of\ndelivery\nPreterm birth, very\npreterm birth, fetal\ngrowth outcomes,\nand other perinatal\ncomplications\nPorpora et al.\n[19]\nItaly; prospective\nobservational\ncohort at a single\ninstitution\n425\nspontaneously\nconceived\npregnancies; 145\nwomen with\nendometriosis and\n280 controls\nWomen with\nspontaneous\npregnancies\nfollowed for\nobstetric and\nneonatal outcomes\nClinically or surgically\ndiagnosed endometriosis;\ninformation collected on\ndisease type, location,\nadenomyosis, previous\nsurgery, and endometriotic\nlesions\nWomen with\nspontaneous\npregnancies\nand no\nendometriosis\nMiscarriage, threatened\nmiscarriage, threatened\npreterm labor, placental\nabruption, pregnancy-induced\nhypertension, preeclampsia,\nhemoperitoneum, and\ncesarean delivery\nPreterm delivery,\nneonatal condition,\nbirth weight, fetal\nwell-being, and\nother neonatal\ncomplications\nShahmoradi\net al. \n[20]\nIran; hospital-\nbased case-\ncontrol study at\nHazrat Rasoul\nAkram Hospital,\nTehran\nDeliveries from\nFebruary 2015 to\nDecember 2019;\n250 women,\nincluding 125\ncases and 125\ncontrols\nWomen delivering\nat the study\nhospital with\nretrievable\nmaternal, delivery,\nand neonatal data.\nEndometriosis documented\nin hospital records;\nadditional assessments\nconsidered deep\nendometriosis, rectal\ninvolvement, adenomyosis,\nand previous surgical\ntreatment\nWomen\nwithout\nendometriosis\nmatched or\nselected from\nthe same\nhospital\npopulation.\nPlacenta previa, placenta\naccreta, placental abruption,\npreeclampsia, gestational\ndiabetes, postpartum\nhemorrhage, cesarean\ndelivery, and other maternal\ncomplications\nPreterm birth, small-\nfor-gestational-age\nbirth, neonatal\nintensive care unit\nadmission, and\nother neonatal\noutcomes\nLim et al. \n[21]\nSouth Korea;\nnationwide\nretrospective\npopulation-based\ncohort using the\nKorean Health\nInsurance Review\nand Assessment\nService database\nSingleton\ndeliveries from\nJanuary 2014 to\nOctober 2019;\n1,251,597\npregnancies,\nincluding 32,951\nwith endometriosis\nand 1,218,646\ncontrols\nWomen with\nsingleton deliveries\nrecorded in the\nnational health\ninsurance\ndatabase.\nEndometriosis identified\nthrough healthcare\ndiagnostic records before or\nduring the defined exposure\nperiod.\nWomen\nwithout an\nendometriosis\ndiagnosis\nPreterm labor, preeclampsia,\ngestational diabetes, placenta\nprevia, placental abruption,\nantepartum hemorrhage,\npostpartum hemorrhage, blood\ntransfusion, uterine artery\nembolization, cesarean\ndelivery, and cesarean\nhysterectomy\nPreterm birth, fetal\ngrowth restriction,\nstillbirth, and other\nperinatal outcomes\navailable in the\nadministrative\ndatabase\nMarcellin et\nal. \n[22]\nFrance;\nprospective\nmulticenter\nexposed-\nunexposed cohort\n1,351 singleton\npregnancies\nfollowed before 22\nweeks; 470\nexposed and 881\ncontrols\nWomen with\nsingleton\npregnancies\ncontinuing beyond\n22 weeks of\ngestation\nSurgically and\nphenotypically\ncharacterized\nendometriosis: superficial\nperitoneal endometriosis,\novarian endometrioma, or\ndeep endometriosis\nPregnant\nwomen\nwithout\nendometriosis\nrecruited from\nthe same\nparticipating\ncenters\nPreeclampsia, placenta previa,\npostpartum hemorrhage,\nthreatened preterm labor,\npremature rupture of\nmembranes, cesarean\ndelivery, and other obstetric\ncomplications\nPrimary outcome:\npreterm birth\nbetween 22 weeks\nand 36 weeks plus\n6 days; small-for-\ngestational-age birth\nand other neonatal\noutcomes\nUnited States;\nDeliveries from\n2013-2017;\nWomen with\ndeliveries recorded\nEndometriosis identified\nthrough All-Payers Claims\nWomen\nPregnancy-induced\nhypertension, preeclampsia or\nPreterm birth, low\nbirth weight, small-\nfor-gestational-age\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n6\n of \n13\n\nFarland et al.\n[23]\nMassachusetts\nregistry-linkage\ncohort\n91,825 deliveries,\nincluding 1,560\nwomen with\nendometriosis\nin Massachusetts\nvital records linked\nto hospital, claims,\nand ART\ndatabases\nDatabase diagnoses before\nthe index delivery; infertility\nand ART use were\nexamined as potential\nmodifiers\nwithout\nendometriosis\nor uterine\nfibroids\neclampsia, gestational\ndiabetes, placental\nabnormalities, cesarean\ndelivery, and other pregnancy\ncomplications\nbirth, respiratory\nmorbidity, prolonged\nneonatal\nhospitalization, and\nother adverse\nneonatal outcomes\nGebremedhin\net al. \n[24]\nAustralia;\npopulation-based\nretrospective\ncohort using\nWestern\nAustralian linked\nperinatal and\nhospital data\n468,778 women\ncontributing\n912,747 singleton\nlive births during\n1980-2015;\n19,476 exposed\nlive births among\n8,874 women\nWomen with\nsingleton live births\nrecorded in the\nWestern Australian\nMidwives\nNotification System\nMaternal endometriosis\nidentified through linked\nhospital morbidity records\nusing diagnostic coding\nbefore the relevant\npregnancy\nSingleton live\nbirths among\nwomen\nwithout\nrecorded\nendometriosis\nPreeclampsia and placenta\nprevia; analyses also\nconsidered medically assisted\nreproduction as a potential\nexplanatory factor\nPreterm birth before\n37 weeks, with\nstratified analyses\naccording to\nmedically assisted\nreproduction\nTABLE\n 1: Characteristics of the included studies\nART: assisted reproductive technology; NIC: neonatal intensive care unit\nRisk-of-Bias Assessment\nThe included studies generally demonstrated acceptable methodological quality, although the strength of\nevidence varied across designs. The strengths of large population-based or registry-linked cohorts included\nrepresentative samples, objective ascertainment of outcomes, and multivariable adjustment, which led to\nlow risk of bias. Single-center case-control and observational studies were more likely to be subject to\nselection bias, residual confounding, and lack of generalizability. The main concerns were variation in the\nascertainment of endometriosis, exposure to assisted reproductive technology, parity, and coping strategies.\nNone of the studies was excluded due to methodological quality. Figure \n2\n shows the domain-level ROBINS-E\nrisk-of-bias judgments for the included studies across seven bias domains, with green indicating low risk and\nyellow indicating some concerns.\nFIGURE\n 2: Risk-of-bias assessment of the included studies\n[15-24]\nAssociation Between Endometriosis and Placenta Previa\nThe random-effects meta-analysis demonstrated a significant association between endometriosis and\nplacenta previa, with a pooled adjusted odds ratio of 2.98 (95% CI: 2.00-4.45). Statistical heterogeneity was\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n7\n of \n13\n\nlow to moderate (I²=34.5%). These findings indicate higher odds of placenta previa among women with\nendometriosis compared with pregnant women without endometriosis. Figure \n3\n presents the forest plot of\nthe pooled association between endometriosis and placenta previa.\nFIGURE\n 3: Forest plot of placenta previa risk in women with and without\nendometriosis\n[15,16,18,22]\nAssociation Between Endometriosis and Preterm Birth\nThe limited analysis of preterm birth was performed using five clinically similar cohorts. Study-level\nadjusted estimates varied between 0.75 and 1.32. For the random-effects model, there was a significant\nassociation between endometriosis and preterm birth with a pooled adjusted mixed-measure sensitivity\nestimate of 1.24 (95% CI: 1.14-1.36). Statistical heterogeneity was low (I²=10.2%, Q=4.45, p=0.348). Adjusted\nodds ratios and risk ratios were combined using the rare-outcome approximation; therefore, the pooled\nestimate was interpreted as a sensitivity analysis rather than a uniform measure-specific primary analysis.\nFigure \n4\n shows the random-effects sensitivity analysis of adjusted effect estimates for preterm birth among\nwomen with and without endometriosis.\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n8\n of \n13\n\nFIGURE\n 4: Forest plot of preterm birth risk in women with and without\nendometriosis\n[16-18,22,23]\nAdditional Maternal and Neonatal Outcomes\nThe remaining studies measured the incidence of hypertensive disorders, gestational diabetes, cesarean\ndelivery, antepartum and postpartum hemorrhage, placental abruption, fetal growth restriction, low birth\nweight, small-for-gestational-age birth, stillbirth, admission to the neonatal intensive care unit, and\nneonatal respiratory morbidity. For most outcomes, the direction of the difference was in favor of greater\nobstetric/neonatal risk in women with endometriosis, but the difference was not statistically significant.\nLimited numbers of studies, definition problems, effect measure problems, and significant heterogeneity\nprevented quantitative pooling. The findings from these were kept in the narrative synthesis to capture the\nbroader range of pregnancy complications.\nDiscussion\nThe results of this systematic review and meta-analysis suggest an increased risk of selected adverse\npregnancy outcomes in women with endometriosis, particularly placenta previa and preterm birth. The\npooled analysis revealed almost three times the odds of placenta previa among women with endometriosis,\nwith low to moderate heterogeneity. This finding is clinically relevant because placenta previa is associated\nwith antepartum bleeding, operative delivery, postpartum hemorrhage, the need for transfusion, and\nincreased maternal and neonatal morbidity. These findings suggest an association between endometriosis\nand placenta previa, although differences in study populations and clinical characteristics should be\nconsidered when interpreting the results \n[25]\n.\nThere is a biological association between endometriosis and placenta previa \n[26]\n. Endometriosis can change\nthe uterine and pelvic microenvironment by inducing chronic inflammation, resistance to progesterone,\nfailure of decidualization, and abnormal endometrial receptivity \n[19]\n. These modifications could affect the\nselection of the implantation site and the morphology of the placenta \n[21]\n. The localization of the placenta\nmay be abnormal due to previous pelvic surgery, adhesions, a change in uterine tone, and/or distortion of\nthe pelvic anatomy \n[24]\n. Although the pooled findings suggest an association across studies, differences in\nstudy design, exposure ascertainment, and covariate adjustment may influence the estimates. Low to\nmoderate statistical heterogeneity does not establish that the underlying risk is identical across clinically\ndiverse populations.\nThe pooled adjusted mixed-measure sensitivity estimate for the preterm birth analysis was 1.24 with low\nheterogeneity, suggesting an association between endometriosis and a higher likelihood of preterm delivery,\nalthough the estimate should not be interpreted as a conventional risk ratio. This smaller association\ncompared with placenta previa may reflect the involvement of maternal, placental, fetal, and treatment-\nrelated factors. Earlier delivery might be due to endometriosis-associated inflammation, changes in immune\nregulation, placentation, the rupture of membranes, and increased obstetric intervention \n[27]\n. Although the\nincluded studies reported odds ratios and risk ratios, the low degree of heterogeneity does not establish\nequivalence between these effect measures.\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n9\n of \n13\n\nThe preterm birth results are generally consistent with previous observational syntheses, which found\nincreased preterm birth rates in women with endometriosis \n[16]\n. Other evidence suggests that the\nassociation might remain after controlling for maternal age, parity, infertility, and assisted reproduction\ntechnology. The present analysis pooled adjusted estimates from clinically comparable groups, although\ndifferences in adjustment strategies may remain \n[19]\n. The sensitivity analysis combined adjusted odds ratios\nand risk ratios using the rare-outcome approximation, and the resulting estimate should be interpreted\ncautiously because these measures are not directly interchangeable.\nBeyond placenta previa and preterm birth, the narrative synthesis examined other maternal and neonatal\ncomplications \n[20]\n. The majority of these studies found higher rates of hypertensive disorders, gestational\ndiabetes, placental abruption, antepartum or postpartum hemorrhage, cesarean delivery, fetal growth\nrestriction, low birth weight, stillbirth, admission to the neonatal intensive care unit, and respiratory\nmorbidity \n[20,22]\n. However, the statistical significance and consistency of these associations varied across\nstudies because of differences in sample size, diagnostic criteria, outcome definitions, disease phenotype,\nand covariate adjustment.\nThe findings are consistent with earlier research indicating that women with endometriosis have an\nincreased likelihood of cesarean delivery \n[28]\n. This association may be related to placenta previa, previous\npelvic surgery, adhesions, deep disease, maternal preference, clinician caution, and increased obstetric\nintervention \n[13]\n. Previous evidence has also described associations with hemorrhagic and placental\ncomplications, although the underlying mechanisms remain uncertain \n[29]\n. Evidence regarding hypertensive\ndisorders, gestational diabetes, fetal growth abnormalities, and neonatal morbidity was less consistent,\nsuggesting that these outcomes may also be influenced by comorbidities, reproductive characteristics, and\ndifferences between study populations \n[30]\n.\nRecent evidence published after the predefined literature search cut-off of June 30, 2026, provides additional\ncontext for these findings. A subsequent systematic review and meta-analysis involving 24 cohort studies\nreported an association between endometriosis and preterm birth (RR 1.36, 95% CI 1.26-1.46), although\nsubstantial heterogeneity was observed \n[31]\n. Similarly, a population-based cohort study reported increased\nodds of preterm birth among women with histologically confirmed endometriosis (aOR 1.43, 95% CI 1.37-\n1.50), alongside other adverse obstetric and neonatal outcomes \n[32]\n. These findings are broadly consistent\nwith the present review; however, both studies were published after the original search period and were\ntherefore not included in the quantitative synthesis.\nThe results of this study have clinical implications. Endometriosis may be considered during preconception\nassessment and antenatal risk stratification, particularly regarding placental location and the possibility of\npreterm delivery \n[27]\n. Ultrasound evaluation of placentation, monitoring for bleeding, and awareness of the\nrisk for preterm labor may be considered as potential clinical measures in affected pregnancies. These are\nproposed clinical considerations, as the observational evidence does not establish whether intensified\nsurveillance improves maternal or neonatal outcomes. Additional factors relevant to delivery planning\ninclude placenta previa, previous pelvic surgery, and deep infiltrating disease. Individualized obstetric\nmanagement should therefore consider disease history, mode of conception, placental findings, and other\nrelevant clinical factors.\nLimitations and Future Recommendations\nThe interpretation of the findings is limited by the observational design of all included studies, as the pooled\nestimates may be affected by residual confounding and exposure misclassification. The definition and\nseverity of endometriosis varied according to the diagnostic methods used, including surgical confirmation,\nself-report, clinical diagnosis, and administrative coding. Differences in maternal age, parity, assisted\nreproductive technology, adenomyosis, previous surgery, outcome definitions, and covariate adjustment\nalso affected comparability across studies. The limited number of studies included in each meta-analysis\nrestricted the assessment of publication bias and additional subgroup analyses. Furthermore, the preterm\nbirth sensitivity analysis combined adjusted ORs and RRs, which are not directly interchangeable and may\nintroduce uncertainty in interpreting the pooled estimate.\nFuture studies should adopt prospective, multicenter designs with consistent diagnostic criteria and\nstandardized definitions of maternal and neonatal outcomes and endometriosis phenotypes. Analyses\nshould distinguish between spontaneous and assisted conceptions and consistently adjust for relevant\nfactors, including maternal age, parity, comorbidities, previous surgery, and adenomyosis. Individual\npatient data meta-analyses or sufficiently powered disease-specific studies may help clarify whether\nendometriosis location, severity, or treatment history influences pregnancy outcomes.\nConclusions\nThe systematic review and meta-analysis show that endometriosis is associated with an increased risk of\ncertain adverse pregnancy outcomes, including placenta previa and preterm birth. Overall, the combined\nresults indicated almost three times greater odds of placenta previa and a small but statistically significant\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n10\n of \n13\n\nassociation with preterm birth in women with endometriosis compared with those without. The wider\nnarrative synthesis also suggested possible associations with other maternal and neonatal complications,\nincluding hypertensive disorders, hemorrhagic complications, cesarean section, fetal growth abnormalities,\nstillbirth, admission to the neonatal intensive care unit, and respiratory morbidity. These findings suggest\nthat endometriosis may be considered during individualized antenatal risk assessment and delivery\nplanning, although the benefits of intensified surveillance have not been established by the included\nobservational studies. Due to the observational nature of the studies, the findings should be interpreted\ncautiously because of differences in exposure definitions, effect measures, and covariate adjustment across\nstudies. Overall, the results underscore the clinical importance of endometriosis beyond its impact on\nfertility and highlight its associations with placentation, gestational duration, maternal morbidity, and\nneonatal outcomes.\nAppendices\nDatabase-specific search strategies\nThe complete search strategies used for PubMed/MEDLINE, Scopus, Web of Science Core Collection, and\nGoogle Scholar, including search dates and eligibility restrictions.\nDatabase\nComplete search strategy\nSearch\ndate\nFilters and\nrestrictions\nPubMed/MEDLINE\n(\"Endometriosis\"[MeSH] OR endometriosis OR endometriotic) AND (\"Pregnancy\"\n[MeSH] OR pregnancy OR pregnant OR gestation OR obstetric) AND (\"Pregnancy\nOutcome\"[MeSH] OR \"pregnancy outcome\" OR maternal OR neonatal OR perinatal\nOR \"placenta previa\" OR preterm OR premature OR preeclampsia OR haemorrhage\nOR \"gestational diabetes\" OR cesarean OR \"fetal growth restriction\" OR \"low birth\nweight\" OR stillbirth)\nJune 30,\n2026\nHuman\npregnancy\nstudies;\ncomparative\nobservational\ndesigns\nScopus\nTITLE-ABS-KEY(endometriosis OR endometriotic) AND TITLE-ABS-KEY(pregnancy\nOR pregnant OR gestation OR obstetric) AND TITLE-ABS-KEY(\"pregnancy outcome\"\nOR maternal OR neonatal OR perinatal OR \"placenta previa\" OR preterm OR\npremature OR preeclampsia OR haemorrhage OR \"gestational diabetes\" OR\ncesarean OR \"fetal growth restriction\" OR \"low birth weight\" OR stillbirth)\nJune 30,\n2026\nHuman\npregnancy\nstudies;\ncomparative\ncohort, case-\ncontrol, registry-\nlinkage, and\npopulation-\nbased designs\nWeb of Science\nCore Collection\nTS=(endometriosis OR endometriotic) AND TS=(pregnancy OR pregnant OR\ngestation OR obstetric) AND TS=(\"pregnancy outcome\" OR maternal OR neonatal\nOR perinatal OR \"placenta previa\" OR preterm OR premature OR preeclampsia OR\nhaemorrhage OR \"gestational diabetes\" OR cesarean OR \"fetal growth restriction\" OR\n\"low birth weight\" OR stillbirth)\nJune 30,\n2026\nHuman\npregnancy\nstudies;\ncomparative\nobservational\ndesigns\nGoogle Scholar\n\"endometriosis\" \"pregnancy outcomes\"; \"endometriosis\" \"placenta previa\";\n\"endometriosis\" \"preterm birth\"; \"endometriosis\" \"maternal\" \"neonatal\";\n\"endometriosis\" \"gestational diabetes\"; \"endometriosis\" \"fetal growth restriction\";\n\"endometriosis\" \"stillbirth\"\nJune 30,\n2026\nHuman\npregnancy\nstudies;\ncomparative\nobservational\ndesigns\nTABLE\n 2: Database-specific search strategies, search dates, and eligibility restrictions\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nAnima \nPrasad, Mimansa \nBharti, Maignanamoorthy \nV, Sieqa \nShah, Jatin \nB. Goda,\nSinduja \nSomasekar, \nAshish Kumar Shukla\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n11\n of \n13\n\nAcquisition, analysis, or interpretation of data:\n  \nAnima \nPrasad, Mimansa \nBharti, Maignanamoorthy \nV,\nSieqa \nShah, Jatin \nB. Goda, Sinduja \nSomasekar, \nAshish Kumar Shukla\nDrafting of the manuscript:\n  \nAnima \nPrasad, Mimansa \nBharti, Maignanamoorthy \nV, Sieqa \nShah, Jatin \nB.\nGoda, Sinduja \nSomasekar, \nAshish Kumar Shukla\nCritical review of the manuscript for important intellectual content:\n  \nAnima \nPrasad, Mimansa \nBharti,\nMaignanamoorthy \nV, Sieqa \nShah, Jatin \nB. Goda, Sinduja \nSomasekar, \nAshish Kumar Shukla\nSupervision:\n  \nJatin \nB. Goda\nDisclosures\nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors declare the\nfollowing: \nPayment/services info:\n All authors have declared that no financial support was received from\nany organization for the submitted work. \nFinancial relationships:\n All authors have declared that they have\nno financial relationships at present or within the previous three years with any organizations that might\nhave an interest in the submitted work. \nOther relationships:\n All authors have declared that there are no\nother relationships or activities that could appear to have influenced the submitted work.\nAcknowledgements\nGrammarly (Grammarly, Inc., San Francisco, CA, USA) was used solely for grammar, punctuation, and\nlanguage refinement. 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Sci Rep. 2026, \n10.1038/s41598-026-65907-5\n32\n. \nRees C, Gabriels EM, Weyers S, Siebers AG, Westerhuis M, Schoot B, van Vliet H: \nHistological diagnosis of\nendometriosis and adenomyosis in relation to obstetric outcomes: a Dutch population-based cohort study\n.\nEur J Obstet Gynecol Reprod Biol. 2026, 327:115434. \n10.1016/j.ejogrb.2026.115434\n \n2026 Prasad et al. Cureus 18(11): e119104. DOI 10.7759/cureus.119104\n13\n of \n13","source_license":"CC0","license_restricted":false}