{"paper_id":"20be7e2f-8827-4fb8-afc3-ab935bdae92d","body_text":"~ 210 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(4): 210-212 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(4): 210-212 \nReceived: 04-05-2021 \nAccepted: 06-06-2021 \n \nNeelotparna Saikia \nConsultant, Department of \nObstetrics and Gynecology, \nNazareth Hospital, Shillong, \nMeghalaya, India \n \nDarilin M Shangpliang \nConsultant, Department of \nPathology, Nazareth Hospital, \nShillong, Meghalaya, India \n \nNeha Choubey \nDNB (T), Department of \nObstetrics and Gynecology, \nNazareth Hospital, Shillong, \nMeghalaya, India \n \nGunti Navyasri \nDNB (T), Department of \nObstetrics and Gynecology, \nNazareth Hospital, Shillong, \nMeghalaya, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nNeelotparna Saikia \nConsultant, Department of \nObstetrics and Gynecology, \nNazareth Hospital, Shillong, \nMeghalaya, India \n \nScar endometriosis-rare sequel of caesarean section: A \ncase report \n \nNeelotparna Saikia,  Darilin M Shangpliang, Neha Choubey  and Gunti \nNavyasri \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i4d.985 \n \nAbstract \nScar endometriosis is the implantation of endometrial glands and stromal cells at the incision site following \nobstetrics and gynaecological surgery. Although incidence is very rare, women in the reproductive age with \nno history of endometriosis, presents with complaints of cyclical pain a t the scar due to any previous \nsurgeries is highly suspicious of scar endometriosis. Treatment of choice is excision. Diagnosis is by \nhistopathological examination of the excised tissue. We report a case of scar endometriosis presenting 5 \nyears after caesarean section and emphasised on diagnosis and treatment. \n \nKeywords: scar endometriosis, caesarean section, painful scar, pfannenstiel incision \n \nIntroduction  \nEndometriosis is defined as the presence of endometrial glands and stroma outside the uterus. \nEndometriosis affects 10-15% of women of reproductive age group that is 18 -45 years and 70% \nof women with chronic pelvic pain  [1]. Although benign in structure, endometriosis has all the \nfeatures of malignancy like local spread, invasiveness, and an outstandin g ability to \ndisseminatec [2]. The most common site is the ovary and less frequent sites include peritoneum, \nintestine, bladder, inguinal region, lungs, pleura, pancreas, central nervous system and vertebrae. \nFurthermore, endometriosis can be seen in the a bdominal wall after surgery, in particular, in \nwomen with a history of caesarean section [3]. \nScar endometriosis a rare disease and is difficult to diagnose, the symptoms are nonspecific \ntypically involving abdominal wall pain at the incision site during t he time of menstruation  [8]. \nEndometriosis at a scar site can be found after caesarean section, hysterectomies, amniocentesis, \nlaparoscopic trocar tracts, or perineal episiotomy. The most frequent localization of \nendometriosis in surgical scars is in the abdominal skin and subcutaneous tissue [4]. Furthermore, \nthis disease is also related to surgery performed by general surgeons, such as appendectomy, \ngroin and umbilical hernia corrections. However, most of the cases reported have occurred \nfollowing obstetric  procedures that exposed the endometrial tissue, especially in cases of \ncaesarean section  [5]. Endometrial cells are inoculated directly into the surgical area and can \nprogress to endometriosis in optimal conditions. This causes various clinical symptoms d ue to \nproliferation of these cells under the influence of female hormones [2]. \n \nCase Report \nA 34 year old female presented with complaints of pain and swelling over the left side of \ncaesarean section scar since 6-7 months, which aggravates during menstruation . She has regular \nmenstrual cycles, normal in flow and duration and no history of endometriosis in the past. \nPatient underwent Emergency caesarean section and bilateral tubal ligation 5 year ago in view of \nfailed induction. On inspection, a transverse scar  of 10cm seen, no obvious swelling noted. On \ndeep palpation small irregular mass of size 1.5 cm felt near left angle of LSCS scar. On per \nvaginal examination uterus was anteverted and normal in size and fornices were free and \nnontender. Ultrasonography was  done which showed a hypoechoic lesion in soft tissue at \ncaesarean scar site (left side) which was 1.2 x0.7 cm above the left rectus abdominis muscle at \nlevel of caesarean scar mostly suggestive of scar endometriosis. Patient was posted for excision \nof scar endometriosis. Intraoperatively sharp dissection was done with a scalpel within the area \nof incision from previous caesarean section. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 211 ~ \nThe cystic mass which was surrounded by fibrosis of 2cm was \nremoved carefully with a wide margin of rectus sheath as s hown \nin figure 1 and 2 followed by reconstruction of abdominal wall \nin layers. Definitive diagnosis was confirmed by histo \npathological examination. \n \n \n \nFig 1: Intraoperative picture \n \n \n \nFig 2: Excised specimen \n \n \n \nFig 3: H&E sections showing fibrocollagenous tissue with occasional \nendometrial-type glands and surrounded by scant endometrial stroma \nS/O Scar endometriosis \nDiscussion \nAbdominal wall endometriosis was first documented by Meyer \nin 1903  [4]. It is a rare complication of a caesarean section. \nIncidence is 0.03% -1.73% with an average rate of 0.5%  [3]. To \nimprove the detection rate of scar endometriosis more attention \nto medical history and physical examination is mandatory. Other \nabnormalities should be excluded, and differential diagnosis \nincludes lipoma, haematoma, umbilical hernia, soft tissue \nsarcoma, abscess, carcinoma (primary), and metastasis. \nRemoving decidual tissue from the wound before closing and \ncleansing with normal saline solution has been described as a \npreventive measure [3].   \nCurrently, pregnancy is believed to provide immune tolerance to \nfetal antigens, and this inherent survival mechanism seems to be \ninvolved in the development of the endometrioma, consequently \ndecreasing the cell immunity at locations where decidual cells \nare present. Thus, labor onset with cervical ripening and regular \ncontractions would be a marker for the end of immune tolerance, \nbecause in the absence of this condition (elective caesarean \nsection), labor seems to be a factor related to the disease. \nHowever, the ability of ectopic endometrial cells to resist cell \napoptosis allows them to survive in the surgical scar  [5]. The \npathogenesis of endometriosis is complex and caesarean scar \nendometriosis is believed to be the result of a mechanical \niatrogenic implan tation, through the direct inoculation in the \nabdominal fascia and/or subcutaneous tissue with endometrial \ncells during the surgical intervention, which, stimulated by \nestrogen, become active and expand  [6]. The Pfannenstiel \nincision is the most commonly r eported type for the occurrence \nof caesarean scar endometriosis  [7]. Early hysterotomy in \npregnancy especially before 22nd week of gestation is the main \nrisk factor. Additionally, increased menstrual flow and alcohol \nconsumption are also concluded as risk factors, while high parity \nmay be a protecting factor. The most evident risk factor for the \npresence of endometriosis in scar tissue is a previous history of \nobstetric surgical procedures  [2]. Positive histology confirms the \ndiagnosis of endometriosis; neg ative histology does not exclude \nit, whether histology should be obtained if peritoneal disease \nalone is controversial. Visual inspection is usually adequate but \nhistological confirmation of at least one lesion is ideal. MRI \nremains the most useful imaging  modality to exclude other \npathology [1]. Management includes both surgical excision and \nhormonal suppression. Oral contraceptives, progestational and \nandrogenic agents have been tried. It is believed that hormonal \nsuppression is only partially effective a nd surgical excision of \nthe scar is the definitive treatment [8]. \n \nConclusion \nEndometriosis is a debilitating disease that impacts the quality of \nlife of adolescent and adult patients. Preventive rules in all \ngynaecological and obstetric surgeries is the most important way \nto eradicate this disease. We noticed that caesarean section is an \napparent risk factor for the presence of endometriosis. To \nprevent iatrogenic transplantation, additional attention is needed \nduring surgery that exposes endometrial tissu e. Complete wide \nexcision with clear margins is both diagnostic and therapeutic. \nLiterature recommends that thorough cleaning, irrigation with \nsaline and closure of abdominal wound will prevent scar \nendometriosis. \n \nReferences \n1. Tabassum K, Ambar S, Habiba S. Case report of atypical \nscar endometriosis. Endocrinology  & Metabolism \nInternational Journal 2019, 7(5). \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 212 ~ \n2. Ucar M, Sanlıkan F, Gocmen A. Surgical Treatment of Scar \nEndometriosis Following Cesarean Section, a Series of 12 \nCases. Indian Journal of Surgery 2013;77(S2):682-686. \n3. Adriaanse B, Natté R, Hellebrekers B. Scar endometriosis \nafter a caesarean section: A perhaps un derestimated \ncomplication. Gynecological Surgery 2013;10(4):279-284. \n4. Ramdani A, Rais K, Rockson O, Serji B, El Harroudi T. \nParietal Mass: Two Case Reports of Rare Cesarean Sc ar \nEndometriosis. Cureus 2020. \n5. Leite G, Carvalho L, Korkes H, Guazzelli T, Kenj G,  Viana \nA. Scar endometrioma following obstetric surgical \nincisions: retrospective study on 33 cases and review of the \nliterature. Sao Paulo Medical Journal 2009;127(5):270-277. \n6. Khachani I, Filali Adib A, Bezad R. Cesarean Scar \nEndometriosis: An Uncommon Su rgical Complication on \nthe Rise? Case Report and Literature Review. Case Report s \nin Obstetrics and Gynecology 2017;2017:1-4. \n7. Zhang P, Sun Y, Zhang C, Yang Y, Zhang L, Wang N , et \nal. Cesarean scar endometriosis: presentation of 198 cases \nand literature review. BMC Women's Health. 2019;19(1). \n8. Danielpour P, Layke J, Durie N. Scar endometriosis - a rare \ncause for a painful scar: A case report and review of the \nliterature. Plastic Surgery 2010;18(1).","source_license":"CC0","license_restricted":false}