{"paper_id":"650dec16-e535-4924-abde-58b61b78a18d","body_text":"Content uploaded by Hanan Jawad Kadhim\nAuthor content\nAll content in this area was uploaded by Hanan Jawad Kadhim on May 07, 2025\nContent may be subject to copyright.\nCase report\nAbdominal Wall Endometriosis Presenting\nas a Bloody Mass in a Patient with a\nHistory of Four Cesarean Sections\nby\nDr. Hanan Jawad Kadhim\nSenior specialist in obstetrics and gynecology\nsub-specialist in infertility, ART and bioengineering ,\nbiotechnology and human based research in IVF\nmember in the department of quality assurance at Kurdistan\nhigher council of medical spatiality\\ Kurdistan Iraq\nAbstract:\nI report the case of 39-year-old married female, gravida 7 para 4 ( all were\ndelivered by cesarean section ) last one 7 years ago and 3 miscarriages.\nShe presented to me at her 1st visit at 30th of November 2024 with sever chronic\nand cyclical abdominal pain with painful, bloody mass in the abdominal wall\nand menorrhagia\nThe lesion exhibited cyclical changes with menses and was associated with\nelevated serum estrogen levels. and CA125\nA thorough clinical evaluation, imaging studies including ultrasound and CT\nscan, as well as hormonal assays, led to the diagnosis of abdominal wall\nendometriosis.\nIntroduction:\nEndometriosis is defined as the presence of functional endometrial tissue\noutside the uterine cavity.\nCesarean scar endometriosis is a rare complication typically it affecting less\nthan 1% of women who have had a cesarean section\nIt occurs when endometrial tissue, grows in the scar tissue from the cesarean\nsection.\nThe exact cause of CSE is unknown, but it is thought to be related to the\nsurgical procedure itself.\nDuring a cesarean section, the uterus is opened and there is a risk of endometrial\ntissue being implanted in the abdominal wall. This tissue can then grow and\ncause this dramatic condition.\nHere, I describe a rare presentation of abdominal wall endometriosis forming a\nbloody, cyclically active mass in a cesarean section scar.\nCase Presentation:\nPatient Profile:\n-Age: 39 years\n-Gravida 7, Para 4, miscarriage 3\n-Past surgical history: 4 lower segment cesarean sections\nChief Complaint:\n39 y old women she presented to me at her 1st visit at 30th of November 2024\nwith sever chronic and cyclical abdominal pain and progressively enlarging,\npainful mass on the anterior abdominal wall with periodic bloody discharge\nfrom the overlying skin, exacerbated during menstruation with heavy menstrual\nperiod .\nClinical Examination:\n-Vital signs: BP : 100\\60 mm.hg\nPR: 110 b\\m\nTemp.: 36,4 c\n-Local exam:\nA firm, tender, palpable lower abdominal mass approximately 8 x 7 cm\nlocated near the previous cesarean scar with skin involvement showing a bloody\ndischarge. with cauliflower hyperpigmented skin lesion that is bleeding to\ntouch.\nShe complains of irregular menstrual cycle and menorrhagia. She was irritable,\nconfused and worried regarding her condition.\nInvestigations:\n1. Laboratory Findings:\nCBC: anemic , Hg 9.3 mg\\dl\nSerum Estradiol: Elevated 182.2.pg\\ml\nCA-125: at 30-11-2024 which is the date of her 1st visit,\nwas highly elevated, 137.3 u\\ml normal range was <35\nCA-125 at 31-12 -2024 which is the date of her 2nd visit was 21.8 u/ml ,\nnormal range was <35\nCA-125 at 30-1- 2025 which is the date of her 3rd visit was 11.9U/ml\nnormal range was <35\n2. Ultrasound (Abdominal Wall):\nBy 1st ultrasound at 8th of august 2023 the mass was (71 x 21)mm\nBy 2nd ultrasound at 20th of august 2023 the mass was (51 x 19)mm\nBy 3rd ultrasound at 27th of November 2023 the mas was (68 x 27)mm\nAt 27th of April 2024 a hypoechoic heterogenous mass ( 9.5 x3.3 x 6.7) cm\nwith irregular borders and internal vascularity located within the rectus sheath\nand anterior to the fascia, consistent with soft tissue lesion. All these readings\nwere before 30th of November 2024 before the patient visiting me\nAt 31 December 2024 while I treat the patient medically the US finding were\nshow big regression of the mass to (38 x 35)mm,\nAt March 15, 2025 the US report were show good response to treatment and\nthe mass become ( 21x 12 mm)\nAt in: 30 January 2025 the magic response was be report by the last US and the\nmass completely regressed to (14 x 13 mm ) and the skin lesion get complete\nhealing and the patient completely cured : she had no abdominal pain , no\nbleeding no skin lesion no abdominal mass\n3. Contrast-Enhanced CT Scan:\nAt 2nd of December and before I will start treating the patient A well-\ndemarcated soft tissue mass measuring ( 6.5 x 2.7 x 6 cm ) located within the\nanterior wall rectus abdominis muscle and rectus sheath. The mass enhanced\nheterogeneously post-contrast and was inseparable from the cesarean section\nscar.\nProvisional Diagnosis:\nAbdominal wall endometriosis (scar endometrioma)\nManagement:\nThe patient underwent full medical care inform of stabilization of her general\ncondition.\nI start with her medical treatment and she got very good response inform of\nclinical features, laboratory investigation and ultrasound finding.\nsurgical excisional biopsy was done to confirm he diagnosis\nHistopathology:\nConfirmed the presence of endometrial glands and stroma within fibrous tissue,\nconsistent with endometriosis.\nOutcome and Follow-up:\nAfter 3 months of medical treatment recovery was uneventful.\nThe mass was magically regressed, by late US was ( 11 x 12 mm ) and blood\ntest marker was\nAt 3-month and 5-month follow-ups, the patient reported complete resolution of\nthe symptoms, including cessation of cyclic pain, bleeding and discharge.\nFollowing several weeks of treatment, and follow up the cured laboratory test\nshowed magic improvement\nNo evidence of recurrence on follow-up ultrasound.\nDiscussion:\nAbdominal wall endometriosis is a rare but important differential in patients\nwith cyclical pain and masses near cesarean section scars.\nDiagnosis may be missed due to nonspecific symptoms. Imaging, hormonal\nassays, and surgical histopathology are key to diagnosis.\nThe medical management is the treatment of choice with excellent prognosis.\nConclusion:\nIn women with a history of cesarean section presenting with a painful, bloody\nabdominal wall mass, abdominal wall endometriosis should be considered.\nA multidisciplinary approach including imaging, hormonal studies, and medical\nand surgical intervention leads to effective management and recovery.\nDocumentation :","source_license":"CC0","license_restricted":false}