{"paper_id":"bbe387e1-f859-4815-959a-43c074965f48","body_text":"IBIMA Publishing  \nInternational Journal of Case Reports in Medicine  \nhttp://www.ibimapublishing.com/journals/IJCRM/ijcrm.html  \nVol. 2016 (2016), Article ID 620369, 4 pages  \nDOI: 10.5171/2016.620369 \n \n______________ \n \nCite this Article as:  A. Louise D. Zierau, Jens Langhoff-Roos, Tórur Dalsgaard and Janne Foss Berlac \n(2016), \"Severe Complications Related to Caesarean Delivery in Patients with Endometriosis,\" \nInternational Journal of Case Reports in Medicine, Vol. 2016 (2016), Article ID 620369,  \nDOI: 10.5171/2016. 620369  \n \nA Case Report \n \nSevere Complications Related to Caesarean \nDelivery in Patients with Endometriosis \n \nA. Louise D. Zierau 1, Jens Langhoff-Roos 2, Tórur Dalsgaard 3 and Janne Foss Berlac 4 \n \n1Lungemedicinsk Forskningsenhed, Bispebjerg Hospital, Bispebjerg Bakke, Copenhagen Denmark \n \n2,3,4 Department of Gynaecology, Juliane Marie Centeret Rigshospitalet, Copenhagen University \nHospital Blegdamsvej, Copenhagen, Denmark \n \nCorrespondence should be addressed to: Dorthe Hartwell; dorthe.hartwell@regionh.dk \n \nReceived date: 27 March 2014; Accepted date: 12 May 2015; Published date: 11 February 2016 \n \nAcademic Editor: Yutaka Osuga     \n \nCopyright © 2016. A. Louise D. Zierau, Jens Langhoff-Roos, Tórur Dalsgaard and Janne Foss Berlac. \nDistributed under Creative Commons CC-BY 4.0  \n \n \nIntroduction  \n \nEndometriosis is a chronic inflammatory \ndisease characterized by the presence of \nendometrial-like tissue outside the uterine \ncavity. The advanced stages of \nendometriosis result in severe fibrosis and \nadhesions in the pelvic cavity. The \nprevalence of endometriosis in women of \nreproductive age is around 6-10%, but \namong women suffering from infertility, \nthe frequency is 35% - 50%.  \nWith the increasing use of assisted \nreproduction technology, more women \nwith endometriosis become pregnant. \n \nSeveral case reports have described severe \ncomplications during pregnancy such as \nspontaneous haemoperitoneum,  \nAbstract  \n \nIntroduction:  Endometriosis is a chronic inflammatory disease with endometrial-like tissue \noutside the uterine cavity, which leads to adhesions in the surrounding tissue. In pregnancy, \nendometriosis-derived ectopic decidua may be induced, and at delivery, the tissues are \nstretched and complications may occur. We report two cases where caesarean section in \nwomen with endometriosis led to severe complications.  Case presentations:  A 33-year old \nnullipara had an emergency caesarean section at 37+2 weeks of gestation. Extraction of the \ninfant was complicated due to endometriotic and fibrotic tissue. The postoperative course \nwas complicated by an infected haematoma.A 30-year old nullipara had an emergency \ncaesarean section at 38+3 weeks of gestation. Excessive bleeding and a large retroperitoneal \nhaematoma complicated the surgery.Conclusion:  These two cases emphasize that \ncaesarean delivery in patients with severe endometriosis may be associated with an \nelevated risk of complications such as intestinal perforation and excessive bleeding due to \nendometriotic lesions.  \n \nKey words:  Endometriosis, caesarean delivery, haematoma, postoperative complications  \n\nInternational Journal of Case Reports in Medicine                                                                                       2 \n______________________________________________________________________________________________________________  \n______________ \n \nA. Louise D. Zierau, Jens Langhoff-Roos, Tórur Dalsgaard and Janne Foss Berlac (2016), International \nJournal of Case Reports in Medicine, DOI: 10.5171/2016. 620369 \nspontaneous rupture of subserous uterine \nveins, and intestinal perforation in women \nwith endometriosis. Epidemiological \nstudies have suggested that endometriosis \nis associated with preterm birth, antepartal \nhaemorrhage, and an increase in cesarean \ndelivery. \n \nExcept for implantation of endometriosis in \nthe surgical scars, there are to our \nknowledge no reports of complications \nrelated to caesarean delivery in patients \nwith endometriosis. \n \nWe present two cases of severe \ncomplications to caesarean delivery in \npatients with endometriosis and discuss \nwhether changes in clinical practice may \navoid such complications.  \n \nCase I  \n \nA 33-year old nullipara pregnant after IVF \nhad an emergency caesarean section due to \nthe slow progress of labour at 37+2 weeks \nof gestation.  \n \nOne year earlier she had a laparotomy at a \nlocal hospital. Bilateral endometriomas, \nendometriotic lesions, and adhesions on \nthe posterior wall of the uterus involving \nthe recto-sigmoid wall were found. The \nendometriomas were excised but no \nextensive surgery was performed. A 13+4 \nweeks an ultrasound scan showed a mass \n(27 x 48 x 29 mm) in the bladder wall. \nCystoscopy showed typical deep infiltrating \nendometriosis in the bladder wall but no \nbiopsy was performed. At 19+3 weeks of \ngestation, she was admitted to the hospital \nwith lower abdominal pain and fever. \nMagnetic resonance imaging (MRI) showed \na slightly dilated small intestine and \nappendicitis was suspected. At laparotomy, \nthere were signs of diffuse peritonitis and \nthe appendix was removed. Microscopy of \nthe appendix showed acute subserous \ninflammation and oedema but no signs of \nprimary appendicitis or endometriosis. Her \ncondition improved and she was \ndischarged after seven days. The focus of \ninfection was never identified.  \n \nThe caesarean delivery was complicated by \ndense adhesions and difficult access to the \nuterus. Extraction of the infant was \ncomplicated due to the low anterior \nlocation of the placenta as well the \nendometriotic and fibrotic tissue. It was \nnecessary to induce general anesthesia and \nafter 5 minutes the infant was delivered \nwith low Apgar score and admitted to the \nneonatal intensive care unit. Haemostasis \nwas difficult and the total bleeding volume \nwas 1400 ml. The postoperative course \nwas complicated by an infected haematoma \nsized 4 x 6 x 3 cm, above the bladder. She \nhad elevated leucocytes (26 x109/l) and \nCRP (273 mg/l). The infection was treated \nconservatively with antibiotics, and the \npatient was discharged seven days after the \ncaesarean section. The follow-up showed \nfull remission of the haematoma and a \npersisting asymptomatic endometriotic \nnodule of 0,6 x 1,0 x 2,0 cm in the bladder \nwall. She was treated with oral \ncontraceptives.  \n \nCase II \n \nA 30-year old nulliparous pregnant after \nintrauterine insemination had an \nemergency caesarean section at 38+3 \nweeks of gestation due to the slow \nprogress of labour.  \n \nShe had a history of endometriosis verified \nby biopsy from the posterior fornix. At the \ncaesarean section, the posterior wall of the \nuterus was attached to the left ovary, \nintestine, and peritoneum.  \n \nMobilization of the uterus resulted in \ndiffuse bleeding from endometriotic lesions \non the uterus and the left ovary. \nHaemostasis was achieved by several \nsutures and application of TachoSil®. The \ntotal bleeding volume was 1500 ml and \npostoperative hemoglobin was 4.3 mmol/l. \nThe first postoperative day she complained \nof abdominal pain and a CT-scan showed a \nretroperitoneal haematoma stretching \nfrom the lower part of the left kidney to the \nbladder, and dilation of both ureters with \nbilateral hydronephrosis. She developed \noedema in the lower extremities and vulva. \nThe hemoglobin fell to 3.6 mmol/l and an \nultrasound scan showed that the \nhaematoma displaced the uterus to the \nright side and compressed the iliac vessels. \nAntithrombotic treatment was initiated. On \nthe sixth postoperative day, the patient had \nincreasing pain and fever (38.1°C). She was \ntreated with antibiotics (Cephalosporin), \nand received three units of red blood cells. \n\n3                                                                                       International Journal of Case Reports in Medicine  \n______________________________________________________________________________________________________________ \n______________ \n \nA. Louise D. Zierau, Jens Langhoff-Roos, Tórur Dalsgaard and Janne Foss Berlac (2016), International \nJournal of Case Reports in Medicine, DOI: 10.5171/2016. 620369 \n \nOn the sixteenth postoperative day she was \ndischarged, and one month later the \nhaematoma had decreased from 20 x 8 x 11 \ncm to 11 x 6 x 5 cm. At follow up six \nmonths later, the symptoms from the \nhaematoma had disappeared.  \n \nDiscussion  \n \nIn general, pregnancy has an alleviating \neffect on endometriosis related symptoms. \nHowever, endometriosis-derived ectopic \ndecidua and dense adhesions due to the \nendometriosis may cause severe \nobstetrical complications during pregnancy \nand in caesarean section as described in \nthe present two cases.  \n \nIn case I, the delivery of the infant and \nhaemostasis was difficult and resulted in a \npostoperative infected haematoma. In case \nII, a large retroperitoneal haematoma \naggravated the postoperative course.  \n \nEndometriosis is known to be associated \nwith fibrous adhesions as a response to \nchronic inflammation. During pregnancy, \ndecidualization of the endometriotic \nlesions changes the structure of the tissue \nand it becomes highly vascularized and \nmore sensitive. Mobilization of the uterus \nduring caesarean section may therefore be \nassociated with an increased risk of \ncomplications including perforation of the \nintestine and bleeding. Veins imbedded in \nthe adhesions covering the endometriotic \nlesions may be more likely to rupture - a \ncomplication similar to the spontaneous \nrupture of veins reported during \npregnancy \n and at vaginal delivery Error! \nBookmark not defined.  in women with \nendometriosis. \n \nSpontaneous intestinal perforation from \ndecidualized endometriosis in pregnancy \nhas been described. It is suggested that \nperforation is facilitated by the traction of \nthe enlarged uterus on the strictly adherent \nsigmoid colon. It seems that mobilization of \nthe uterus during caesarean section in \nwomen with severe endometriosis should \nbe managed carefully and preferably; the \nuterus should remain intra-abdominally \nduring surgery. Until now, only 21 cases of \nintestinal perforation due to endometriosis \nhave been reported, with our case being \nthe first report of perforation related to \ncaesarean section.  \nOur cases show that patients suffering from \nendometriosis and their infants may be at \nrisk of serious complications during \ncaesarean section. To the best of our \nknowledge, these two cases are the first to \nbe reported. However, with the increasing \nrate of caesarean sections in patients with \nendometriosis, these types of \ncomplications are likely to occur more \nfrequently in the future. Therefore, it is \nnecessary to raise awareness of the \nproblem and create guidelines on how to \nmanage caesarean delivery in patients with \nsevere endometriosis. We recommend that \nthe obstetrician leaves the uterus intra-\nabdominally during repair, thereby \nminimizing the stretch of the adhesions to \nreduce the risk of tissue rupture and \nbleeding. The risk of recurrence of \ncomplications during a second pregnancy \nin women with endometriosis is still \nunknown. However, detailed information \nand guidance is recommended to ensure a \nquick response to any symptoms. \n \nIn Denmark, the gynaecological treatment \nof severe endometriosis has been \ncentralized to optimize the treatment. We \npresume that also the obstetric patients \nwith known severe endometriosis would \nbenefit from centralized care. \n \nIn conclusion, caesarean delivery in \npatients with severe endometriosis may be \nassociated with excessive bleeding due to \nadhesions, dense fibrosis and \ndecidualization of the endometriotic tissue. \nThe rate of complications should be \ninvestigated in large population-based \nstudies.  \n \nAuthorization \n \nThe use of patient data in this project has \nbeen approved by The Danish Data \nProtection Agency [J.no. 2013-41-2150]. \nThe patients have both signed an informed \nconsent. \nFinancial disclosures \nNo financial disclosures have been received \nby the authors of this case report. \n\nInternational Journal of Case Reports in Medicine                                                                                       4 \n______________________________________________________________________________________________________________  \n______________ \n \nA. Louise D. Zierau, Jens Langhoff-Roos, Tórur Dalsgaard and Janne Foss Berlac (2016), International \nJournal of Case Reports in Medicine, DOI: 10.5171/2016. 620369 \nConflict of Interest \nThere is no conflict of interest regarding \nthis case report. \n \nReferences \n \n1.   Revised American Society for \nReproductive Medicine classification of \nendometriosis: 1996. Fertil Steril. 1997 \nMay;67(5):817-21. \n2.\n   Giudice LC, Kao LC. Endometriosis. \nLancet. 2004 Nov 13-19;364(9447):1789-\n99 \n3.\n   Stephansson O, Kieler H, Granath F, \nFalconer H. Endometriosis, assisted \nreproduction technology, and risk of \nadverse pregnancy outcome. Hum Reprod \n2009;24:2341-7 \n4.\n   Granese R. Acute abdomen in pregnancy \nwith endometriosis. Acta Obstet Gynecol \nScand 2010;89:844-5  \n5.\n   Wada S, Yoshiyuki F, Fujino T, Sato C. \nUterine vein rupture at delivery as a \ndelayed consequence of laparoscopic \nsurgery for endometriosis: a case report. J \nMinim Invasive Gynecol 2009;16:510-2  \n6.\n   Pisanu A, Deplano D, Angioni S, Ambu R, \nUccheddu A. Rectal perforation from \nendometriosis in pregnancy: case report \nand literature review. World J \nGastroenterol 2010;16:648-51  \n7.\n   Brosens I, Brosens JJ, Fusi L, Al-Sabbagh \nM, Kuroda K, Benagiano G. Risks of adverse \npregnancy outcome in endometriosis. \nLeuven Institute of Fertility and \nEmbryology, Leuven, Belgium. \nivo.brosens@med.kuleuven.be Fertil Steril. \n2012 Jul;98(1):30-5. doi: \n10.1016/j.fertnstert.2012.02.024. Epub \n2012 Mar 3. \n8.\n   Nishikawa A, Kondoh E, Hamanishi J, \nYamaguchi K, Ueda A, Sato Y, Konishi I. Ileal \nperforation and massive intestinal \nhaemorrhage from endometriosis in \npregnancy: case report and literature \nreview. ) Department of Gynaecology and \nObstetrics, Kyoto University, Kyoto, Japan \nEur J Obstet Gynecol Reprod Biol. 2013 \nSep;170(1):20-4. doi: \n10.1016/j.ejogrb.2013.04.018. Epub 2013 \nJun 10. \n9.\n   Andolf E, Thorsell M, Källén K. \nCaesarean section and risk for \nendometriosis: a prospective cohort study \nof Swedish registries. Division of Obstetrics \nand Gynaecology, Department of Clinical \nSciences, Karolinska Institutet, Danderyd \nHospital, Stockholm, Sweden. \nellika.andolf@ds.se BJOG. 2013 \nAug;120(9):1061-5. \n10.\n   Vercellini P, Parazzini F, Pietropaolo G, \nCipriani S, Frattaruolo MP, Fedele L. \nPregnancy outcome in women with \nperitoneal, ovarian and rectovaginal \nendometriosis: a retrospective cohort \nstudy. Clinica Ostetrica e Ginecologica, \nIstituto Luigi Mangiagalli, Università \nStatale di Milano, and Fondazione IRCCS Ca \nGranda - Ospedale Maggiore Policlinico, \nMilan, Italy BJOG. 2012 Nov;119(12):1538-\n43. \n11.\n   D'Hooghe T, Forman A. European \naccreditation of endometriosis centers of \nexpertise. Gynecol Obstet Invest. \n2013;76(1):1-3. doi: 10.1159/000354330. \nEpub 2013 Aug 7.","source_license":"CC0","license_restricted":false}