{"paper_id":"d949d935-9df2-4460-8e0f-7a397ce67984","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nEndometriosis is a benign disease defined by the presence of \nendometrial glands and stroma outside the uterus. Examination \nof the ovaries at caesarean section is a normal practice as ovarian \npathology may be found. The incidence of an adnexal mass found \nat caesarean section ranges from 1 in 1231 to 3292. About 20-25% \nof women have asymptomatic endometriosis. 1 Endometriosis affects \n6% to 10% of reproductive age women6. Approximately 1% to 4% \nof pregnant women are diagnosed with an ovarian mass. Of all the \nadnexal masses reported during pregnancy the incidence of ovarian \nendometriosis varies widely from 5% to 30%. 2,3 We are reporting \na case of incidentally found atypical endometriosis at emergency \ncaesarean section.\nCase report\nA 32-year-old primigravida, married for one year, conceived \nspontaneously without any history of infertility was registered with us \nfor antenatal care. At 39+2 weeks of gestation she came with h/o pain \nabdomen and headache and was admitted in labor room. BP at admission \nwas 140/90 and headache was persistent even after analgesics and \nantihypertensives. She was taken up for emergency lower segment \ncesarean section (LSCS) in view of imminent eclampsia and bad \nbishop score after giving a loading dose of MgSO4. After the delivery \nof fetus, intraoperatively left ovary was adherent to posterior uterine \nwall and a highly vascular cauliflower like growth was seen extending \nfrom posterior part of left mesosalphinx, left ovary, posterior uterine \nwall upto pouch of douglas (Figure 1). Left fallopian tube was free \nand right side ovary and tube were normal. Biopsy was taken from the \ngrowth and its histopathological examination was reported as atypical \nendometriosis (Figure 2). Markers for ovarian carcinoma (Beta HCG, \nLDH,CA-125, CEA, AFP) were within normal limits. Ultrasonogram \ndone on post operative day 7, reported it as an echogenic lesion, \ncould be endometriosis. Her course in the ward postoperatively was \nuneventful. Patient was discharged on postoperative day 8.\nFigure 1 Incidental detection of left ovarian atypical endometriosis during \nLSCS extending over posterior uterine wall upto the pouch of Douglas\nFigure 2 Left tube is free from the polypoid atypical endometriosis\nDiscussion\nEndometriosis is a benign disease defined by the presence of \nendometrial glands and stroma outside the uterus and is associated \nwith both pelvic pain and infertility. The prevalence of endometriosis \nEndocrinol Metab Int J. 2018;6(5):324‒326. 324\n© 2018 Tejaswini et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nIncidental detection of atypical endometriosis during \ncaesarean section suspicious of malignancy-a case \nreport\nVolume 6 Issue 5 - 2018\nT ejaswini B, Chandushree, Ashok Kumar, \nBharathi, Sumayya, Shruthi K, Sreelatha S\nDepartment of Obstetrics & Gynaecology, ESIC-MC & PGIMSR, \nIndia\nCorrespondence: Sreelatha S, Professor, Department of \nObstetrics & Gynaecology, ESIC-MC & PGIMSR, Bangalore, \nIndia, T el 9448915477, Email drsreeletha2011@gmail.com \n \nReceived: August 23, 2018 | Published: October 30, 2018\nAbstract\nEndometriosis is defined as presence of endometrium including glands and stroma at \nlocations other than the uterine cavity. Atypical endometriosis is rarely seen, accounting \nfor 4.38% amongst endometriosis cases and is reported to possess a precancerous \npotential. We are reporting a case of primigravida with term gestation, taken up for \nemergency caesarean section in view of severe preeclampsia with imminent signs of \neclampsia. Intraoperatively left ovary was adherent to posterior uterine wall and a \ncauliflower like growth was seen extending from posterior part of left mesosalphinx, \nleft ovary, posterior uterine wall upto pouch of douglas. Biopsy was taken from the \ngrowth and its histopathological examination was reported as atypical endometriosis. \nPostoperatively patient was stable and was discharged on postoperative day 8.\nKeywords: atypical endometriosis, pregnancy, ceasaeean section, imminent \neclampsia, malignant potential\nEndocrinology & Metabolism International Journal\nCase Report\n Open Access\n\n\nIncidental detection of atypical endometriosis during caesarean section suspicious of malignancy-a case \nreport\n325\nCopyright:\n©2018 T ejaswini et al.\nCitation: T ejaswini B, Chandushree, Kumar A, et al. Incidental detection of atypical endometriosis during caesarean section suspicious of malignancy-a case \nreport. Endocrinol Metab Int J. 2018;6(5):324‒326. DOI: 10.15406/emij.2018.06.00206\nis 6-10% in women of reproductive age group. 4,5 Nearly 20-25% of \npatients are asymptomatic.1 \nRisk factors are early menarche, short menstrual cycles, 6,7 \nnulliparity, 1st degree relative, drug exposure to DES, Dioxin \nand in younger age group it is usually associated with müllerian \nanomalies and cervical or vaginal obstruction. 8 In the recent years \nthe etiopathogenesis is also attributed to autoimmune disorder. 5 \nProlonged lactation and multiparity are protective. 4 The clinical \nfeatures of endometriosis are varied, and the presentation depends \non the site of growth and severity of disease. Although usual \npresentation being six D’s: dysmenorrheal (most common symptom), \ndisorders of menstruation, dyspareunia, dyschezia, dysuria and \ndull aching chronic pain abdomen. Three types of endometriosis \nhave been described: peritoneal superficial endometriosis, ovarian \nendometriomas, and deep infiltrating endometriosis (DIE). DIE \nusually involves the uterosacral ligaments, the rectovaginal space, \nand the upper third of the posterior vaginal wall, the bowel, and \nthe urinary tract. 6 Endometriosis is primarily found in the pelvis: \non the ovaries most commonly, uterus, fallopian tubes, uterosacral \nligaments, broad ligaments, round ligaments, cul-de-sac or ovarian \nfossa, as well as on the appendix, large bowel, ureters, bladder, or \nrectovaginal septum. Extra-pelvic locations of endometriosis are rare, \nbut can include the upper abdomen, diaphragm, abdominal wall or \nabdominal scar tissue. Peritoneal implants of endometriosis and the \npresence of endometriomas are more common on the left side of \nthe pelvis than the right. The position of the sigmoid colon creates \na sequestered microenvironment around the left adnexa, which \nfacilitates implantation of endometrial cells regurgitated through the \nleft tube.4 \nLaparoscopy with histologic examination of excised lesions is \nthe gold standard for the diagnosis of endometriosis. The classic \nperitoneal implant is a blue-black “powder burn” lesion with varying \namounts of surrounding fibrosis, typically observed on the ovaries \nand on peritoneal surfaces in the cul-de-sac, uterosacral ligaments, \nand ovarian fossa.11 Less commonly, disease may be found in ovarian \nadhesions, yellow- brown patches, in peritoneal defects, or involving \nthe appendix. 11 Red lesions are highly vascular, proliferative, and \nrepresent an early stage of disease. Pigmented lesions represent more \nestablished or advanced disease.\nEndometriosis is biologically the same as basal endometrial tissue. \nMicroscopically foci of endometriosis consist of glands, stroma cells, \nand smooth muscle; they are supplied by nerves, lymphatic vessels, \nand blood vessels.12,13 Endometriosis cells express estrogen receptors \n(ER α/β) and progesterone receptors (PR A/B) and therefore respond \nto endocrine treatment.14–17\n Treatment can be medical or surgical depending on the symptoms \nand time of presentation. In a young woman with minimal symptoms \nmedical line of management can be tried, similarly a patient who \nhas presented in the perimenopausal age group, we can wait till \nmenopause because the symptoms regress after menopause due to \nwithdrawal of estrogen and progesterone. Surgical line of treatment \nwill suffice for such patients who are infertile or young and \nsymptomatic. The hormonal therapy counteracts only the stimulus \nof endometriotic tissue proliferation. The overall recurrence rate is \nabout 30% for combined therapies and about 35% for the hormonal \ntreatment alone 19.Medical treatment for pelvic pain and suspected \nendometriosis involve trial of NSAIDS or oral contraceptive, if failed \nempirical GnRH agonist therapy plus estrogen-progestin add-back \ntherapy or danazol is used. In case of above medical management \nfailure and associated infertility, operative laparoscopy is done for \nremoval of endometriosis and restoration of pelvic anatomy. In our \ncase, the patient who was neither symptomatic nor infertile, it was an \naccidental diagnosis.\nApproximately 0.7% to 1.0% of patients with endometriosis \nhave lesions that undergo malignant transformation. 4 Atypical \nglandular changes have been found in 3% to 6% of cases of ovarian \nendometriosis. Endometroid adenocarcinomas account for 69% of \nreported lesions, with the ovary being the primary site in most cases.4 \nSo the further plan of management for the patient is to follow up with \nserial ultrasonography scans and markers for ovarian carcinoma for \nearly detection and management for malignant transformation of \nendometriosis.\nConclusion\nAtypical endometriosis was incidentally found during the \ncaesarean section in a patient with no previous clear symptoms, which \nadds this case to the small number of similar cases described. In our \ncase we decided to take biopsy of the tissue as it was highly vascular \nand malignancy had to be ruled out.\nAcknowledgments\nNone.\nConflict of interest\nThe author declares there is no conflict of interest.\nReferences\n1. Bulletti C, Elisabetta M, Battistoni CS, et al. Endometriosis and \nInfertility. J Assist Reprod Genet. 2010;27(8):441–447.\n2. White KC. Ovarian tumors in pregnancy: a private hospital ten \nyear survey. American Journal of Obstetrics and Gynecology. \n1973;116(4):544–550. \n3. Raffi F, Amer S. Endometriosis. Obstetrics, Gynaecology and \nReproductive Medicine. 2011;21(4):112–117.\n4. Ueda Y , Enomoto T, Miyatake T, et al. A retrospective analysis of ovarian \nendometriosis during pregnancy. Fertil Steril. 201094(1):78–84.\n5. Cramer DW, Missmer SA. The epidemiology of endometriosis. Ann NY \nAcad Sci. 2002;955:34–36. \n6. Missmer SA, Hankinson SE, Spiegelman D, et al. Incidence \nof laparoscopically confirmed endometriosis by demographic, \nanthropometric, and lifestyle factors. Am J Epidemiol. 2004;160(8):784–\n796. \n7. Troncon JK, Zani AC, Vieira AD, et al. Endometriosis in a patient with \nmayer-rokitansky-küster-hauser syndrome. Case Rep Obstet Gynecol . \n2014;164:218–219.\n8. Barrier BF. Immunology of endometriosis. Clin Obstet Gynecol . \n2010;57(3):397–402.\n9. Stegmann BJ, Sinaii N, Liu S, et al. Using location, color, size, and depth \nto characterize and identify endometriosis lesions in a cohort of 133 \nwomen. Fertil Steril. 2008;89(6):1632–1636.\n10. Gylfason JT, Kristjansson KA, Sverrisdottir G, et al. Pelvic endometriosis \ndiagnosed in an entire nation over 20 years. Am J Epidemiol.  \n2010;172(3):237–243.\n11. Meyer R, Stoeckel W. Die Pathologie der Bindegewebe . Geschwülste \nund der Mischgeschwülste. Handbuch der Gynäkologie, München JF, \neditors, Bergmann. 1930;211–853. \n\nIncidental detection of atypical endometriosis during caesarean section suspicious of malignancy-a case \nreport\n326\nCopyright:\n©2018 T ejaswini et al.\nCitation: T ejaswini B, Chandushree, Kumar A, et al. Incidental detection of atypical endometriosis during caesarean section suspicious of malignancy-a case \nreport. Endocrinol Metab Int J. 2018;6(5):324‒326. DOI: 10.15406/emij.2018.06.00206\n12. Mechsner S, Schwarz J, Thode J, et al. Growth-associated protein \n43-positive sensory nerve fibers accompanied by immature vessels \nare located in or near peritoneal endometriotic lesions. Fertil Steril . \n2007;88(3):581–587.\n13. Leyendecker G, Wildt L, Mall G. The pathophysiology of endometriosis \nand adenomyosis: tissue injury and repair. Arch Gynecol  Obstet. \n2009;280(4):529–538.\n14. Roman H, Vassilieff M, Gourcerol G, et al. Surgical management of deep \ninfiltrating endometriosis of the rectum: pleading for a symptom-guided \napproach. Hum Reprod. 2011;26(2):274–281.\n15. Dede M, Yenen MC, Yilmaz A, et al. Treatment of incidental adnexal \nmasses at caesarean section: a retrospective study. Int J Gynecol Cancer. \n2007;17(2):339–341.\n16. Ulker V , Gedikbasi A, Numanoglu C, et al. Incidental adnexal masses \nat caesarean section and review of the literature. J Obstet  Gynecol \nResearch. 2010;36(3):502–505.\n17. Howard W, Jones, John A Rock. Ti Linde’ s operative gynecology. 11th \nedn. Endometriosis: 402–444.","source_license":"CC0","license_restricted":false}