33 Adenomyosis and pre-term birth and miscarriage One of the most commonly reported adverse obstetric outcomes that has been associated with adenomyosis is pre-term birth (PTB, delivery prior to 37 weeks gestation). A recently published systematic review and meta-analysis based on 4 studies investigating pregnancies in women with adenomyosis calculated an odds ratio (OR) of 2.74 for PTB. The calculated OR for miscarriage was even higher at 3.40 (81). Taken individually, the reported OR’s for PTB in women with adenomyosis have ranged from 1.96 (102) to as high as 24.53 (103). While most studies were conducted in women with and without adenomyosis, several investigated obstetric outcomes in women with endometriosis, stratified by the presence or absence of adenomyosis. These studies showed mixed results (86,104–106). A meta-analysis did however report higher OR’s for PTB in adenomyosis compared to only endometriosis patients (1.47 vs. 3.09) (107). Due to infertility often accompanying adenomyosis, a large proportion of women with adenomyosis end up going on to have pregnancies facilities with assisted reproductive technologies (ART). This is a potentially confounding factor in adverse obstetric outcomes as there is a higher risk of preterm birth in IVF pregnancies. Several studies did however correct for mode of conception, and still reported a statistically significant higher odds ratio for preterm birth in women with adenomyosis (101,103,104,108,109). Adenomyosis and placental function In addition to impacting fertility, recent studies also suggest that adenomyosis gives an increased risk for adverse obstetric outcomes (50,107,110). This is possibly due to altered trophoblast invasion and spiral artery remodelling (111,112), linking it to conditions such as placental disorders, hypertensive disorders of pregnancy (HDPs) and foetal growth restriction (FGR) and smallfor-gestational age (SGA) infants. In accordance with this theory, significantly higher OR’s have been reported by the majority of studies investigating obstetric outcomes in adenomyosis. A meta-analysis of eleven studies calculated a composite OR of 3.90 for SGA (81). The studies that did not report significant outcomes did still report a trend of a higher risk of SGA in adenomyosis (86,106). A few studies have also been published linking adenomyosis and hypertensive disorders such as preeclampsia (PE), with an OR of 7.87 being suggested in one meta-analysis (81). One study also
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