{"paper_id":"5514757c-2a85-4e77-9647-4eb5ef34550d","body_text":"Case Report \nIncisional Endometriosis following Caesarean Section - A Case Report  \n \nGomathy E1, Ashritha R2*,  Deepika N3, Anil Sakalecha4 \n1. Professor 2.  PG Resident 3. Assistant Professor, Department of Obstetrics and Gynaecology       \n4. Professor, Department of  Radiodiagnosis, Sri Devaraj Urs Medical College, SDUAHER, Kolar,            \nKarnataka, India.  \n*Corresponding Author \nDr. Ashritha  R,                                             \nPG Resident, Dept. of Obstetrics and Gynaecology, \nSri Devaraj Urs Medical College, SDUAHER, Kolar, \nKarnataka,  India.                                                                        \nE-mail: ashritharhms@gmail.com \nReceived  22th July  2016, Accepted 20th Aug 2016  \nAbstract  \n  \n Scar endometriosis can be located at the skin, subcutaneously in the uterine scar and intraperitone-\nally.  The incidence reported of abdominal scar endometriosis is 0.03 to 0.4%.  Cyclical pain in the scar asso-\nciated with the patients menstrual cycle is common. MRI is the most  sensitive imaging method. Histopatho-\nlogical  evaluation are confirmatory for the condition. Surgical excision of  the  scar is the treatment of \nchoice. We report a case of caesarean section scar endometriosis treated at a medical college hospital.  \nKeywords: caesarean section, pregnancy, scar endometriosis. \nCase Report \n \n A 30 year old Para 5, living 3, dead 2 \nunderwent lower section caesarean section 2 \nyears back presented to gynecology out patient \ndepartment with complaints of pain in caesare-\nan scar site from 1 year. The pain aggravated \nduring the menstrual periods. A firm and ten-\nder swelling of dark brown color measuring \n2×2 cm was found at the left edge of  the cae-\nsarean scar and was not fixed to the rectus \nsheath.  \nIntroduction \nEndometriosis was first defined by Rokitansky \nin 1860 as the presence and proliferation of the \nendometrium outside the uterine cavity.  It usu-\nally occurs in the pelvic sites such as ovaries, \nposterior cul -de-sac, uterine ligaments, pelvic \nperitoneum, bowel and rectovaginal septum. \nExtrapelvic endometriosis can be found in unu-\nsual places like nervous system, thorax, urinary \ntract, gastrointestinal tract and in cutaneous \ntissues.[1] Incisional endometriosis/ scar endo-\nmetriosis usually occurs in abdominal wall fol-\nlowing surgeries especially early hysterectomy \nand caesarean section (Fig 1). The incidence of \nscar endometriosis following hysterectomy is \n1.08-2.0% and after LSCS is 0.03 - 0.4%.[2] Its \noccurrence on the perineum, after episiotomy \nis still rare.  Patients present with symptoms of \npain and swelling at the incision site which be-\ncome more prominent during menstrual peri-\nods.[3,4] It is often misdiagnosed as stitch granu-\nloma, keloid, haematoma, or an abscess.  \n \nFig 1. Caesarean Section scar             \n100 \nJournal of Clinical and Biomedical Sciences  \n                                          \nJ Clin Biomed Sci 2016; 6(3):  100-102 \n\nIncisional Endometriosis following Caesarean Section \n Sonography revealed  a well defined \nhypo echoic lesion in the subcutaneous region \nbeneath the abdominal external scar. Mild vas-\ncularity was noted on color Doppler. MRI re-\nvealed an oval lesion mildly hyper intense to \nmuscle on T2 in the left lateral aspect of LSCS \nscar. Focal thinning of anterior myometrium  \nwas noted in mid segment of body of uterus \nwith a linear cleft extending from endometrial \ncavity into myometrium (Fig 2).  \n \n A wide excision of the abdominal scar \nwas performed under spinal anaesthesia. The \nexcised scar was hard in consistency, reddish \nbrown in colour and highly vascular.  Scar en-\ndometriosis was confirmed by  histopathologi-\ncal examination (Fig 3). There was no recur-\nrence of the symptoms up to six months of out \npatient follow-up. \n \nDiscussion \n \n Scar endometriosis on the abdominal \nwall is most commonly seen following surger-\nies on the uterus and the fallopian tubes. The \nendometrial tissue may be implanted in the \nscars during the surgical procedures and may \nproliferate on hormonal stimulation (cellular \ntransport theory). The other explanation is \nthat the neighborhood tissue may undergo \nmetaplasia which leads to scar endometriosis \n(coelomic metaplasia theory).[5]  \n \n The endometrial tissue may also reach \nthe surgical scar through lymphatic and vascu-\nlar routes. In a series of incisional endometrio-\nsis after caesarean section  studied over 30 \nyears, the incidence was found to be 0.08%. \nThe average time from surgery to the clinical \npresentation of endometriosis varied form 3 \nmonths to 12 years in different case series. [5] \nPresence of cyclic pain in an incisional mass is \npathognomonic of scar endometriosis. MRI is \nconsidered more sensitive and also  specific \nthan sonography  in the diagnosis of scar endo-\nmetriosis.[7]  \n \n The incidence of concomitant pelvic \nendometriosis with scar endometriosis has \nbeen reported to be from 14.3% to 26%. Ideal-\nly all patients must be examined for concomi-\ntant pelvic endometriosis. [8] Histopathology is  \nconfirmatory.  Wide local excision is the pre-\nferred treatment. Lesions extending deep to \nthe muscles and fascia may require a synthetic \nmesh replacement or a tissue transfer for clo-\nsure after resection. Recently usage of leupro-\nlide depot has been found to be beneficial.[6]    \n  \nFig 2. MRI image of the scar                                                              \nFig 3. Histopathology of the scar   showing           \nendometriosis  \n101 \n\nConclusion \n \n Scar endometriosis is a rare condition. \nIt should be considered in the differential diag-\nnosis in women presenting with painful symp-\ntoms with menstruation. The  treatment of \nchoice is  surgical resection  of the endometrio-\nsis with wide margins.  \n \nReferences \n \n1. Khalifa Al - Jabri. Endometriosis at caesarean \nsection scar. Oman Med J.2009;24:294-95. \n2. Goel P, Sood S. caesarean scar endometriosis . \nJIMA, 2013; 7: 56-58. \n3. Sudha. T, Anantha RP, Vani I, Subrahmanya SM. \nScar endometriosis - A clinical rarity. IAIM, \n2015; 2: 147-51. \n4. Zararia AN, Goverdhan NA, Patil RT. Post cae-\nsarean scar endometriosis. JCR. 2015; 5: 401 -\n05. Available from: http://\nwww.casereports.in/articles/5/2/Post-\nCaesarean-Scar-Endometr iosis. html  \n5. Minaglia S, Mishell DR Jr,  Ballard C A. Incisional \nendometriosis after Cesarean section: A case \nseries. J Reprod Med. 2007; 52: 630–34.   \n6. Rivilin ME, Das SK, Patel RB, Meeks GR. \nLeupride acetate in the management of cesare-\nan scar endometriosis. Obstet & gynecol. 1995; \n85: 838-39. \n7. Jubanyik KJ, Committee F. Extrapelvic endome-\ntriosis. Obstetrics and gynecology clinics of \nnorth America. 1997; 24: 411- 40. \n8. Gunes M, Kayikcioglu F, Ozturkoglu E, Haberal \nA. Incisional endometriosis after cesarean sec-\ntion, episiotomy and other gynecological proce-\ndures. Journal of obstetrics and gynecology \nresearch. 2005; 31: 471-75.  \nIncisional Endometriosis following Caesarean Section 102","source_license":"CC0","license_restricted":false}