Endometriosis in Caesarean section scar. A Case series.

1. Mohamed Hosni, Samantha Harrison, Amal Mighell, Fatima Nathani Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK. Case 2 A thirty eight years old lady, Para 4, was referred with right sided iliac fossa pain underneath the caesarean scar, together with heavy painful periods. The patient had a history of 4 caesarean deliveries; last one was 7 years ago. Different treatment options were discussed, and surgical excision under GA was decided. She made a good recovery and was prescribed 3 months course of GnRH analogues postoperatively to reduce the risk of resealing from any residual tissue. Her histopathology confirmed the diagnosis of endometriosis. Case 3 A thirty years old lady, Para 2, was referred with a painful lump at the right side of her caesarean scar, that became worse during her periods. The patient had a history of 2 caesarean deliveries; last one was 9 years ago and was on warfarin therapy for a history of pulmonary embolism. The patient decided to have surgical excision of the lesion after covering her perioperative period with LMWH. She recovered well and was prescribed 3 month course of GnRH analogues to treat any residual endometriosis. Her histopathology confirmed the diagnosis of endometriosis. Case 4 A thirty four years old lady, Para 1 caesarean delivery 3 years ago, was referred with a painful lump on the right side of her caesarean section scar. Pain killers did not help with the pains, however, the oral contraceptive pills helped to ease it off. As she was planning to get pregnant and wanted to come off the pills, surgical excision of the lesion was decided. Her histopathology confirmed the diagnosis of endometriosis. Discussion Scar endometriosis is not a very common condition and there is relatively very few case series reported in the literature. Typically it occurs after caesarean section or hysterectomy. Patients usually complain of pain and swelling which is worse at the time of periods. It is important that clinicians should have a high index of suspicion of such diagnosis. Further studies are required to determine the best way of management of such cases. References 1. A. Khalifa. Endometriosis at caesarean section scar. OMJ. 2009;24:294-295. 2. Iria Neri, Michela Tabanelli, Emi Dika, Gaspari Valeria and Annalisa Patrizi. Diagnosis and Treatment of Post-caesarean Scar Endometriosis .Acta Derm Venereol 2007:87 (5) 428-429. 3. Picod G., Boulanger L., Bounoua F., Leduc F., Duval G Abdominal wall endometriosis after caesarean section:Report of fifteen cases. Gynecologie Obstetrique Fertilite, January 2006, vol./is. 34/1(8-13). 4. K.K.singhet al: presentation of endometriosis to general surgeons: A 10 year experience. British journal of surgery vol 82 issue 10 pages 1349-1351 Oct 1995. Introduction Scar endometriosis is a relatively rare gynaecological condition that is usually associated with recent pelvic surgery. Direct inoculation is the most common cause (1), though cases have been reported in women with no previous surgery. Its incidence is 0.03-0.4%(2). It usually presents six months to two years following surgery; however, it has been reported up to 13 years postoperative. The diagnosis is usually based on history and clinical examination. Typical ultrasound features includes tender mass with an irregular shape of non-homogenous, hypo echogenic density, together with alterations in peripheral vasculature(2) Scar endometriosis is not often associated with pelvic endometriosis and diagnostic laparoscopy is not usually indicated unless there are associated pelvic symptoms(2,3). Management is usually via the surgical route. This carries a very low recurrence rate and allows histological confirmation of the lesion(4). Medical treatment is generally less successful and only helps control of symptoms. Case 1 Thirty four years old lady, Para 3, with secondary infertility for one and half years, was referred with a lump on the left side of her caesarean section scar that feels tender on the first day of her period. Prior to her caesarean section, she had 2 normal deliveries and open left salpingectomy for ectopic pregnancy. Different treatment options were discussed. The patient opted for surgical excision under GA. She made an uneventful recovery and fell pregnant two months afterwards. Her histopathology confirmed the diagnosis of endometriosis. • Endometriosis in Caesarean section scar.A Case series.