{"paper_id":"c04651d1-b5bf-4cf3-9446-8bb83eb1199b","body_text":"*Correspondence to Author: \nNishat Fatema\nDepartment of Obstetrics & Gyne -\ncology, Imperial Hospital Limited, \nBangladeshHow to cite this article:\nNishat Fatema, Dil Anziz Begum,\nShirin Fatema, A.K.M Arif Uddin\nAhmed. An increasing trend of iat-\nrogenic scar endometriosis after\nlower segment cesarean section.\nInternational Journal of Case Re-\nports, 2020 4:117\neSciPub LLC, Houston, TX USA.\nWebsite: http://escipub.com/Ni\nshat Fatema et al., IJCR, 2020 4:11 7\n \nInternational Journal of Case Reports\n(ISSN:2572-8776)Case Repo\nrt                                                                                                        IJCR (2020) 4:117\nAn increasing trend of iatrogenic scar endometriosis after lower \nsegment cesarean section  \nCesarean scar endometriosis is an uncommon disorder devel -\noped due to iatrogenic implantation of endometrial tissues in the \ncesarean incision site. The frequency of the scar endometriosis \nis assumed to increase because of the increasing trend of lower \nsegment cesarean section in modern obstetric practice. Cesar -\nean section might be a great risk factor for the development of \nscar endometriosis due to higher exposure of endometrial cells \nto the subcutaneous tissue during the procedure. Prevention of \ndecidual cell contamination to the superficial abdominal layers \nmay reduce the occurrence of iatrogenic scar endometriosis. We \nreported a 21-year old para 2 woman with a history of cesarean \nsection 2.5 years back who presented with a small mass at the \nmiddle of the cesarean scar which was associated with pain and \nblood-stained discharge during menstruation. Based on clinical \nand USG findings the provisional diagnosis was made scar en-\ndometriosis and subsequently we managed her by wide local \nexcision of the lesion followed by adjuvant hormone therapy. No \nrecurrence of scar endometriosis was observed during her follow \nup period.\nKeywords: Endometriosis; Scar; Cesarean; Iatrogenic Disease \n(Mesh terms)\nNishat Fatema\n1*\n，Dil Anziz Begum\n1\n, Shirin Fatema\n1\n, A.K.M Arif Uddin Ahmed\n2\n1\nDepartment of Obstetrics & Gynecology, Imperial Hospital Limited, Chattogram Bangladesh \n2\nAcademic Coordinator Imperial Hospital Limited, Chattogram Bangladesh \nABSTRACTIJCR\n: https://escipub.com/international-journal-of-case-reports/                      1\n\n\nN\nishat Fatema et al., IJCR, 2020 4:117IJ\nCR: https://escipub.com/international-journal-of-case-reports/                       2\nIntroduction:  \nThe growth of functional endometrial tissues \noutside the uterine cavity is termed as \nendometriosis. It is a gynecological dis order \ndepended on the sex hormone1.  \nEndometriosis is categorized as intra-pelvic and \nextra-pelvic endometriosis.  Intra -pelvic \nendometriosis is developed in different pelvic \nstructures like ovaries, utero sacral ligaments, \npelvic peritoneum, recto -uterine pouch, cervix, \nvagina, and round lig ament. Although extra-\npelvic endometriosis is rare but may develop in \ngastrointestinal tract , respiratory tract, urinary \ntract, skin, brain, and abdominal wall2.  \nIn previous studies, the etiopathogenesis of scar \nendometriosis is described as, the direct \nimplantation of endometrial tissues to the uterine \nscar, abdominal musculature or  subcutaneous \ntissue during surgical procedures which \neventually become active and spread under the \ninfluence of Oestrogen3. \nAbdominal wall endometriosis is seen at the \nsurgical incision site following obstetric or \ngynecological surgeries, commonly observed in \ncesarean section scar4. \nDuring surgery, as the wall of the uterus is cut \nand opened, the endometrial cells may move to \nthe pelvic cavity by amniotic fluid and may be \ntransported to ectopic sites, such as on the skin, \nsubcutaneous tissues, muscles of the abdomen, \nnear the scar. Th en the implanted endometrial \ncells at the new site have the capability to \nproliferate due to a highly vascularized \nenvironment and then the hormonal effects \n(mainly for oestrogen) allowing the implanted \nendometrial tissues to grow and to form a mass \nwhich leads to clinical symptoms5. \nThe causes of iatrogenic scar endometriosis \n(ISE) are mainly due to the longitudinal pattern \nof the abdominal vessels and the large \ndissection. During a Pfannenstiel incision , more \ncapillaries are cut off than in a vertical incision, \ncausing more blood loss. So the Pfannenstiel \nincision that is commonly used in the lower \nsegment cesarean section (LSCS) is the most \ncommonly reported type for the occurrence of \nISE; The endometrial cells require an adequate \nblood supply to grow on the ectopic sites, thus \nthe angiogenesis plays an impor tant role in the \npathogenesis of endometriosis1. \nIn previous literature, the incidence of abdominal \nwall endometriosis following the cesarean \nsection is mentioned approximately 0.03% to \n0.4%. The incidence is increased by up to 1.08% \nafter hysterotomy2,4,6. Prevalence of  iatrogenic \nscar endometriosis is raised due t o the recent \nincreasing trend of cesarean section7. \nPatients with cesarean scar endometriosis may \npresent following the several months to years \nafter the surgical intervention. The provisional \ndiagnosis can be made if there is a tender \npalpable mass seen overlying the cesarean scar \nwhich may be associated with the secretion of \nblood during menstruation4. \nCase: A 21-year old para 2 woman had a history \nof cesarean section 2.5 years back, presented to \nus with a painful swelling on the overlying skin of \ncesarean wound scar. She noticed the swelling \naround 1 month back which became tender \nduring her last menstruation with blood stained \ndischarge. Her previous ob stetric course was \nuneventful, at term she had cesarean section \ndue to fetal distress. On local abdominal \nexamination, a healthy Pfannenstiel scar was \nseen with a small mass measuring around \n1.5x1.5 cm in the middle of the scar  (Figure 1). \nOn palpation , the mass was  found to be mild \ntender, firm feeling with restricted mobility. USG \nand doppler examinations of the abdominal wall \nsoft tissue  revealed a heterogeneous \nhypoechoic mass with  echogenic shadow and \nvascular signals inside the lesion (Figure 2). The \nlesions showed the involvement of some \nsuperficial fibers of the fascia. \nOn the basis of the history, clinical and USG \nfindings the provisional diagnosis was made \nscar endometriosis.  We performed surgical \nexcision of the suspected cesarean scar \nendometrioma with a 1 cm clear margin (Figure \n3A & 3B) . Histopathological analysis revealed \nendometrial glands and stroma associated with \n\nIJ\nCR: https://escipub.com/international-journal-of-case-reports/                       3N\nishat Fatema et al.,IJCR,2020 4:117\nevidence of hemorrhage in the fibrous scar\n(Figure 4A & 4B). Following surgery, we kept her\non the combined oral pill for 3 months as\nadjuvant therapy to avoid recurrence.  No \nrecurrence of scar endometriosis was observed \nduring her follow up period. \n \n \nFigure 1: Cesarean section scar with a small mass on overlying skin at the midpoint of the \nscar  \n \n \nFigure 2: Anterior abdominal wall showing an irregular hypoechoic lesion measuring \n1.8x1.5cm and color doppler demonstrates Doppler signal inside the lesion \n \nDiscussion: \nCesarean scar endometriosis is an uncommon \ndisorder developed due to iatrogenic \nimplantation of endometrial tissues in the \ncesarean incision site. The implantation theory is \nnot sufficient to explain the pathogenesis of ISE \ncompletely. The development of ISE may be \nrelated to the hereditary predisposition. Although \nThe occurrence of ISE is commonly reported in \nPfannenstiel type incision , the relationship \nbetween the CS incision type and the \npathogenesis of ISE is not well described in \nliterature1.  \n Surgical scar endometriosis is commonly seen \nin abdominal skin and subcutaneous tissues in \ncomparison to muscle and fascia.  In our case, \nwe found that the endometrial tissues spread up \nto some superficial fibers of the facia. Other than \nthe cesarean section, the scar endometriosis is \nobserved after the gynecological surgeries also \nwhich include hysterectomy, tubal ligation, \nlaparotomy for ectopic pregnancy, \nsalpingectomy and episiotomy3. \nThe patients with cesarean scar endometriosis \ntypically presented with a painful mass or lump \non the abdominal wall or at the cesarean scar \nsite. The mass is becoming more tender and \nsometime may associate with bleeding during \nmenstruation8. Our patient also reported to us \nwith the typical presentation. \n\n\nN\nishat Fatema et al., IJCR, 2020 4:117IJ\nCR: https://escipub.com/international-journal-of-case-reports/                       4\n \nFigure: 3 A & 3B Gross photograph showing wide excision of the mass  \n           \n        \nFigure 4: Histopathology  A: 10X view of endometriosis showing endometrial glands and \nstroma (surrounding purple area) ; B: 40x close up view of the endometri al glands with \nendometrial stroma associated blood \n3A 3B \nA \nB \n\nIJ\nCR: https://escipub.com/international-journal-of-case-reports/                      5N\nishat Fatema et al.,IJCR,2020 4:117\nThe diagnosis of scar endometriomas can be\nchallenging. These lesions need to be\ndistinguished from a number of other lesions 9.\nThe differential diagnosis of ISE may include\nother causes of abdominal wall mass like\ndesmoid tumor, hematoma, fibrosis, suture\ngranuloma, keloid scar, nodular fasciitis, and\nincisional hernia3,7.\nAfter the preliminary clinical diagnosis of ISE, the\nfurther evaluation of the mass should be done by\nvarious imaging techniques like USG, CT or\nMRI. Imaging techniques are nonspecific in\nterms of final diagnosis, which is only achieved\nin 20-50% of cases, probably due to low clinical\nsuspicion due to the non-specific nature of the\nsymptoms and their late development10.\nBut  by these investigation tools the location of\nthe mass, size, volume and local extension can\nbe  determined which may be helpful for further\nmanagement plan11,12.\nUSG and MRI are the most accepted methods\nfor the diagnosis of ISE. The typical USG\nfeatures of SE includes a hypoechoic echogenic\ntexture with internal scattered hyperechoic\nechoes8,11.\nMRI is considered the superior imaging modality\nfor differentiating the glandular and fibrous\ncomponents of the implanted endometrial tissue\nin an endometriotic lesion, and to exclude other\ndifferential diagnoses, as well as  helpful in\npreoperative management plan 7. We didn’t\nperform MRI for our patient because our clinical\nsuspicion and ultrasound finding was obvious for\nendometriosis.\nIn some studies authors suggested that FNAC\ncan be the option for the definitive diagnosis of\nscar endometriosis prior to surgical intervention.\nOn the contrary, in other studies the authors\ndidn’t encourage to use this technique  as a\ndiagnostic tool because with this procedure\nthere is an increased risk of de-novo\nendometriotic implants at the puncture site, as\nwell as organ injury if the diagnosis is\nuncertain6,8,11.\nWide local surgical excision with 1 cm negative\nmargin is the most recommended treatment \nmodality for the scar endometriosis . To repair \nthe large defect after the excision polypropylene \nmesh should be used to reinforce the defect for \nthe prevention of incisional hernia2,8.   \nIn previous studies authors have suggested that \npostoperative adjuvant therapy with GNRHa, \nOCP or aromata se inhibitor may be useful in \nsymptomatic relief and recurrence of \nendometriosis7.  \nFollowing surgery, we started combined oral pill \nfor our patient and continued till 3 months. \nHistopathological analysis of the excised \nspecimen is required for t he Final diagnosis of \nISE.  \nThe p resence of endometrial tissue can be \nconfirmed if two out of the three following \nhistopathological features are present , \nendometrial-like glands, spindled endometrial \nstroma or hemosiderin pigment either within \nmacrophages or in the stroma, Histopathological \nexamination reveals a mixture of different sized \nglandular structures that are capable of \nundergoing cyclical changes and. epithelial cells \nlining the glands can range from cuboidal to \ncolumnar with relatively normal cytomorphology \nand are surrounded by a mucinous and \nedematous stroma7.  \nRegarding the prevention of Iatrogenic Scar \nendometriosis, in some studies authors have \nproposed a variety of recommendations on the \nbasis of the implantation hypothesis. These \nrecommendations include  meticulous irrigation \nand pelvic lavage with saline before the closure \nof abdominal wall, to use separate sutures, \nneedles, gloves and sponges during uterine and \nthe abdominal wound closure and  closure of the \nparietal and visceral peritoneum13,14. \nConclusion: \nThe frequency of the ISE is raised because of \nthe increasing trend of lower segment cesarean \nsection in modern obstetric practice 1. CS might \nbe a great risk factor for the development of scar \nendometriosis due to higher exposure of \nendometrial cells to the subcutaneous tissue \n\nIJ\nCR: https://escipub.com/international-journal-of-case-reports/                      6N\nishat Fatema et al.,IJCR,2020 4:117\nduring the procedure 15. Prevention of decidual\ncell contamination to the superficial abdominal\nlayers may reduce the occurrence of ISE16. Early\ndiagnosis of ISE and timely surgical intervention\nand excision of endometrioma is crucial because\nfailure to perform the necessary treatment, or\nany delay in performing the treatment may have\na detrimental effect on the quality of life of the\npatient8.\nReferences:\n1. Zhang P, Sun Y, Zhang C, et al. Cesarean scar\nendometriosis: Presentation of 198 cases and\nliterature review. BMC Womens Health .\n2019;19(1). doi:10.1186/s12905-019-0711-8\n2. Tatli F, Gozeneli O, Uyanikoglu H, et al. The\nclinical characteristics and surgical approach of\nscar endometriosis: A case series of 14 women.\nBosn J Basic Med Sci . 2018;18(3):275-278.\ndoi:10.17305/bjbms.2018.2659\n3. Sedhain N, Dangal G, Karki A, et al. Caesarean\nScar Endometriosis. J Nepal Health Res Counc .\n2018;15(3):292-294.\ndoi:10.3126/jnhrc.v15i3.18859\n4. Khanani K. Scar Endometriosis: An Entity Not to\nBe Forgotten . Vol 67.; 2017.\nhttps://ecommons.aku.edu/pakistan_fhs_mc_radi\nol. Accessed November 14, 2019.\n5. Alnafisah F, Dawa SK, Alalfy S. Skin\nEndometriosis at the Caesarean Section Scar: A\nCase Report and Review of the Literature.\nCureus. January 2018. doi:10.7759/cureus.2063\n6. Khachani I, Filali Adib A, Bezad R. Cesarean Scar\nEndometriosis: An Uncommon Surgical\nComplication on the Rise? Case Report and\nLiterature Review. Case Rep Obstet Gynecol .\n2017;2017:1-4. doi:10.1155/2017/8062924\n7. Kocher M, Hardie A, Schaefer A, McLaren T,\nKovacs M. Cesarean-section scar endometrioma:\nA case report and review of the literature. J Radiol\nCase Rep . 2017;11(12):8-15.\ndoi:10.3941/jrcr.v11i12.3178\n8. Yıldırım D, Tatar C, Doğan O, et al. Post -\nCesarean scar endometriosis. Turk Jinekoloji ve \nObstet Dern Derg . 2018;15(1):33 -38. \ndoi:10.4274/tjod.90922 \n9. Francica G, Scarano F. Delayed diagnosis is \nassociated with changes in the cl inical and \nultrasound features of subcutaneous \nendometriosis near cesarean section scars. J \nUltrasound. 2009;12(3):101 -106. \ndoi:10.1016/j.jus.2009.05.004 \n10. Garcí a-Gavilá n M del C, Ferná ndez -Pé rez F, \nHinojosa-Guadix J, Gonzá lez -Bá rcenas ML. \nRectus abdominal e ndometriosis on cesarean \nscar. Gastroenterol y Hepatol (English Ed . \n2016;39(5):341-343. \ndoi:10.1016/j.gastre.2016.04.001 \n11. Goel P, Devi L, Tandon R, Saha PK, Dalal A. Scar \nendometriosis - A series of six patients. Int J Surg. \n2011;9(1):39-40. doi:10.1016/j.ijsu.2010.08.003 \n12. Nigam J, Omhare A, Sharma A. Fine -needle \naspiration cytology of a cesarean scar \nendometriosis. Tzu Chi Med J . 2017;29(4):232 -\n234. doi:10.4103/tcmj.tcmj_37_17 \n13. Akdemir A, Akman L, Yavuzsen HT, Zekioglu O. \nClinical features of patients with endometriosis on \nthe cesarean scar. Kaohsiung J Med Sci . \n2014;30(10):541-543. \ndoi:10.1016/j.kjms.2013.12.001 \n14. Ding DC, Hsu S. Scar endometriosis at the site of \ncesarean section. Taiwan J Obstet Gynecol . \n2006;45(3):247-249. doi:10.1016/S1028-\n4559(09)60234-5 \n15. Nominato NS, Prates LFVS, Lauar I, Morais J, \nMaia L, Geber S. Caesarean section greatly \nincreases risk of scar endometriosis. Eur J Obstet \nGynecol Reprod Biol . 2010;152(1):83 -85. \ndoi:10.1016/j.ejogrb.2010.05.001 \n16. Reddi Rani P, Soundararaghavan S, Rajaram P. \nEndometriosis in abdominal scars - review of 27 \ncases. Int J Gynecol Obstet. 1991;36(3):215-218. \ndoi:10.1016/0020-7292(91)90716-I","source_license":"CC0","license_restricted":false}