Endometriosis in Caesarean section scar.
A Case series.
Mohamed Hosni, Samantha Harrison, Amal Mighell, Fatima Nathani
radford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
B
Case 2
A thirty eight years old lady, Para 4, was referred with right sided
iliac fossa pain underneath the caesarean scar, together with
heavy painful periods. The patient had a history of 4 caesarean
deliveries; last one was 7 years ago. Different treatment options
were discussed, and surgical excision under GA was decided.
She made a good recovery and was prescribed 3 months course
of GnRH analogues postoperatively to reduce the risk of
resealing from any residual tissue. Her histopathology confirmed
the diagnosis of endometriosis.
Case 3
Introduction
Scar endometriosis is a relatively rare gynaecological
condition that is usually associated with recent pelvic
surgery. Direct inoculation is the most common cause (1),
though cases have been reported in women with no
previous surgery.
A thirty years old lady, Para 2, was referred with a painful lump at
the right side of her caesarean scar, that became worse during
her periods. The patient had a history of 2 caesarean deliveries;
last one was 9 years ago and was on warfarin therapy for a
history of pulmonary embolism. The patient decided to have
surgical excision of the lesion after covering her perioperative
period with LMWH. She recovered well and was prescribed 3
month course of GnRH analogues to treat any residual
endometriosis. Her histopathology confirmed the diagnosis of
endometriosis.
Case 4
Its incidence is 0.03-0.4%(2). It usually presents six months
to two years following surgery; however, it has been
reported up to 13 years postoperative. The diagnosis is
usually based on history and clinical examination. Typical
ultrasound features includes tender mass with an irregular
shape of non-homogenous, hypo echogenic density,
together with alterations in peripheral vasculature(2)
A thirty four years old lady, Para 1 caesarean delivery 3 years
ago, was referred with a painful lump on the right side of her
caesarean section scar. Pain killers did not help with the pains,
however, the oral contraceptive pills helped to ease it off. As she
was planning to get pregnant and wanted to come off the pills,
surgical excision of the lesion was decided. Her histopathology
confirmed the diagnosis of endometriosis.
Scar endometriosis is not often associated with pelvic
endometriosis and diagnostic laparoscopy is not usually
indicated unless there are associated pelvic symptoms(2,3).
Management is usually via the surgical route. This carries a
very low recurrence rate and allows histological
confirmation of the lesion(4). Medical treatment is generally
less successful and only helps control of symptoms.
Discussion
Case 1
Thirty four years old lady, Para 3, with secondary infertility
for one and half years, was referred with a lump on the left
side of her caesarean section scar that feels tender on the
first day of her period. Prior to her caesarean section, she
had 2 normal deliveries and open left salpingectomy for
ectopic pregnancy. Different treatment options were
discussed. The patient opted for surgical excision under
GA. She made an uneventful recovery and fell pregnant two
months afterwards. Her histopathology confirmed the
diagnosis of endometriosis.
Scar endometriosis is not a very common condition and there is
relatively very few case series reported in the literature. Typically
it occurs after caesarean section or hysterectomy. Patients
usually complain of pain and swelling which is worse at the time
of periods. It is important that clinicians should have a high index
of suspicion of such diagnosis. Further studies are required to
determine the best way of management of such cases.
References
1.
A. Khalifa. Endometriosis at caesarean section scar. OMJ. 2009;24:294-295.
2.
Iria Neri, Michela Tabanelli, Emi Dika, Gaspari Valeria and Annalisa Patrizi. Diagnosis and
Treatment of Post-caesarean Scar Endometriosis .Acta Derm Venereol 2007:87 (5) 428-429.
3.
Picod G., Boulanger L., Bounoua F., Leduc F., Duval G Abdominal wall endometriosis after
caesarean section:Report of fifteen cases. Gynecologie Obstetrique Fertilite, January 2006,
vol./is. 34/1(8-13).
4.
K.K.singhet al: presentation of endometriosis to general surgeons: A 10 year
experience. British journal of surgery vol 82 issue 10 pages 1349-1351 Oct 1995.