{"paper_id":"8a663107-cbe6-4ec7-9188-5509e3eaf60c","body_text":"~ 20 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2023; 7(5): 20-22 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2023; 7(5): 20-22 \nReceived: 16-06-2023 \nAccepted: 24-07-2023 \n \nDr. Indrani Roy \nMD, Senior Consultant and Head \nof the Department, Department of \nObstetrics and Gynecology, \nNazareth Hospital, Meghalaya, \nIndia \n \nDr. Angelin Shalom J \nDNB OBG Trainee, Department of \nObstetrics and Gynecology, \nNazareth Hospital, Meghalaya, \nIndia \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 \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Indrani Roy \nMD, Senior Consultant and Head \nof the Department, Department of \nObstetrics and Gynecology, \nNazareth Hospital, Meghalaya, \nIndia \n \nScar Endometriosis: A rare scenario \n \nDr. Indrani Roy and Dr. Angelin Shalom J \n \nDOI: https://doi.org/10.33545/gynae.2023.v7.i5a.1374 \n \nAbstract \nScar endometriosis is a rare entity most commonly seen after surgical treatment of the uterus or fallopian \ntubes. Caesarean scar endometriosis is the most common type of abdominal wall endometriosis. It is \nusually confused with other dermatological and surgical conditions which delays the diagnosis. We report a \ncase of a 34 -year-old patient with scar endometriosis, six years after her lower segment caesarean section. \nTreatment is surgical and diagnosis is confirmed by histopathological examination. \n \nKeywords: Endometriosis, caesarean scar endometriosis, lower segment caesarean section \n \nIntroduction  \nEndometriosis is a condition in which the endometrial glands and stroma -like lesions are present \noutside the uterus cavity [1]. The ectopic endometrial tissue responds to the ovarian hormones  [2]. \nIt generally occurs in pelvic sites like the ovary, posterior cul -de-sac, uterine ligaments, pelvic \nperitoneum, bowel and rectovaginal septum. Extra pelvic endometriosis can be found in unusual \nsites like th e nervous system, thorax, urinary tract, gastrointestinal tract and cutaneous tissues, \nmost frequent being the abdominal wall  [3]. Although benign in structure, endometriosis has the \nfeatures of malignancy like spread, invasiveness and transmission. One of  the most accepted \ntheories is mechanical iatrogenic implantation  [4]. Wide en bloc excision is both diagnostic and \ntherapeutic. Histopathological examination is confirmatory. Given that it is prone to recurrence, \nfollow-up is crucial. \n \nCase Report \n34-year-old female, P5L4, once post caesarean delivery came with complaints of pain and \nswelling in the left angle of the caesarean scar for 4 months. She noticed that the pain and \nswelling increased typically with menses with a sense of relief between menses. Her lower \nsegment caesarean section (LSCS) was done 6 years back in emergency in view of non -progress \nof labour. Her medical and family history were not significant. On examination, a small 3*3 cms \nfirm, irregular, cystic and no tender swelling was noted in the left angle of the LSCS scar with \nrestricted mobility. There was no rise in local temperature or any signs of inflammation. \nUltrasonography revealed small incisional hernia. CT scan suggested differential diagnosis of \nDesmoid tumour and Scar Endometriosis. \n \n \n \nFig 1: Intraoperative picture - Fibrosed and necrotic areas at the left angle of around 3*3 cm \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 21 ~ \n \n \nFig 2: Excised mass \n \nWide excision was done and histopathological examination \nrevealed Scar Endometriosis.  No recurrence was found in the \nfollow-up period of 1 year. \n \nDiscussion \nEndometriosis is a ubiquitous and enigmatic disease that \ncontinues to challenge both clinicians and researchers  [5]. \nEndometrium is a well circumscribed mass of endometriosis. \nGenerally, few publications have focused on caesarean scar \nendometriosis and a majority of them are either case series or  \ncase reports. \n \nThe definitive pathophysiology remains unknown. But few \ntheories are postulated to explain endometriosis \n[6]. \n1. Implantation theory:  Reflux of menstrual blood and its \nimplantation and growth \n2. Coelomic metaplasia theory: Metaplastic changes in the \nembryonic cell rests  \n3. Metastatic theory: Embolisation of menstrual fragments \nthrough vascular or lymphatic channels.  \n \nDirect implantation of endometriosis  tissue which is the most \nwidely accepted theory in scar endometriosis. The wound is \nseeded with the endometrial tissue during caesarean delivery. \nThese endometrial cells survive and multiply when given the \nright amount of nutrition and hormonal stimulation which \nultimately results in caesarean scar endometriosis. \nClinical features range from a painful nodule that has cyclical \npain associated with menses to being completely asymptomatic. \nWomen may experience chronic and cyclical lower abdominal \ndiscomfort. It typically presents as a hard, palpable mass or lump \naccompanied by cyclic pain. However, it could be difficult to \nidentify, particularly if it is confined to deeper places or is \nasymptomatic. It may even take up to 10 years from the onset of \nsymptoms to a certain diagnosis. \nEsquivel-Estrada et al. (2004) described the triad that is present \nin cases of scar endometriosis which includes a history of \ncaesarean section or any other gynaecological surgery, cyclical \nwaxing and waning pain accompanied by the patient's menstrual \ncycle with  a tumour inside or near the scar site serving as the \nclinical diagnostic sign for scar endometriosis \n[7]. \nThe two non -invasive imaging modalities that are most \nfrequently used for endometriosis are Ultrasonography (USG) \nand Magnetic Resonance Imaging (MRI ). When used to \ndiagnose endometrioses, USG has a sensitivity and specificity of \n65% and 95% respectively. MRI has a 90 -92% sensitivity and \n91-98% specificity for the diagnosis of endometrioses  \nrespectively [8]. \nTypically, the diagnosis is made after surgery based on the \nhistological report [9]. Medical treatment is not helpful. Wide \nexcision is  the treatment of choice. The patient should be \nfollowed up for recurrence [10]. \nUsing abdominal compresses on the skin and subcutaneous \ntissue, using separate tools  to close the uterus and abdominal \nlayers and irrigating with saline solution could lower the risk of \nendometrial tissue growing on incisions. However, pathogenesis \nalso involves endocrine, immune, inflammatory and genetic \nfactors that facilitate the growt h of the ectopic implanted cells  \n[11]. \n \nConclusion \nWomen of reproductive age who experience lower abdomen \npain or a mass at the scar site following obstetric -gynaecologic \nsurgery should be evaluated for caesarean scar endometriosis. \nThe likelihood of disco vering cutaneous endometriosis has \nincreased due to the rising caesarean section rate. Therefore, \npreventing cutaneous endometriosis requires education to \nincrease awareness among obstetricians. \n \nConflict of Interest \nNot available \n \nFinancial Support \nNot available \n \nReferences \n1. Parasar P, Ozcan P, Terry KL. Endometriosis: \nEpidemiology, Diagnosis and Clinical Management. Curr \nObstet Gynecol Rep. 2017;6(1):34-41.  \nDOI: 10.1007/s13669-017-0187-1 \n2. Textbook of operati ve gynaecology by Wilfred Shaw.  \nChurchill Livingstone, distributed in the U.S. of America by \nLongman edition, in English - 4\nth Edition. / Revised by John \nHowkins and Christopher N Hudson; c1977. \n3. Uzunçakmak C, Güldaş A, Ozçam H, Dinç K. Scar \nendometriosis: A case report of this uncommon entity and \nreview of the literature. Case Rep Obstet Gynecol. \n2013;2013:386783. DOI: 10.1155/2013/386783. EPUB \n2013 May 12. PMID: 23762683; PMCID: PMC3665185. \n4. Surgical Treatment of Scar Endometriosis Following \nCesarean Section, a Series of 12 Cases. Indian J Surg. 2015 \nDec;77(2):682-6. DOI: 10.1007/s12262- 013-0978-1. EPUB \n2013 Sep 26. PMID: 26730088; PMCID: PMC4692860. \n5. Wolf GC, Singh KB. Cesarean Scar Endometriosis : A \nreview. 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Scar Endometriosis: A Case Report with \nLiterature Review. Acta Med Iran. 2015 Dec;53(12):793 -5. \nPMID: 26749239. \n11. Ananias P, Luenam K, Melo JP, Jose AM, Yaqub S, \nTurkistani A, et al. Cesarean Section: A Pot ential and \nForgotten Risk for Abdominal Wall Endometriosis. Cureus. \n2021 Aug 24;13(8):e17410. DOI: 10.7759/cureus.17410. \nPMID: 34589321; PMCID: PMC8459811. \n \n \nHow to Cite This Article \nRoy I, Shalom J A. Scar Endometriosis : A rare scenario . International \nJournal of Clinical Obstetrics and Gynaecology. 2023;7(5):20-22. \n \n \nCreative Commons (CC) License \nThis is an open -access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -Non Commercial-Share Alike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}