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بسم الله الرحمن الرحیم

بسم الله الرحمن الرحیم. Severe Endometriosis. Dr.Zarean Dr.Naderi. CASE 47 years old/ G 2 L 2 (2×C/S) C.C: Abdominal Pain Admission Date: 26/12/1385 P.I : LLQ and Hypogastric Pain from 1 month ago that increasing 2 days before.

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بسم الله الرحمن الرحیم

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  1. بسم الله الرحمن الرحیم

  2. Severe Endometriosis Dr.Zarean Dr.Naderi

  3. CASE 47 years old/ G2L2 (2×C/S) • C.C: Abdominal Pain Admission Date: 26/12/1385 • P.I : LLQ and Hypogastric Pain from 1 month ago that increasing 2 days before. AUB: Menometrorhagia from 85’s Mordad. LMP:15/12/1385.Irregular Mense Nausea -) Vomiting -) Shoulder Pain -) Rectal Pressure -) PCB -) Dysmenorrhea +) Occasionally Dys paronia +) • PMH : Primary and Secondary Infertility Laparascopy . 3x IVF. 2xc/s. Married Date:24 Y/O • DH : HD  2 cycle • Ph.E : BP: 90/60 PR: 80 RR: 20 T : 37 Abd : Guarding +) LLQ and Hypogastric Tenderness +) VE : Cervical motion tenderness CX : NL Adnexes : Fullness and Tenderness specially left side • Lab Data : BG:A+ Hb :12.7  10.6  12.1PLt :188000 Cr : 0.7 ßHCG : Negative • Sonography : 23/5/1385 : L.t.Ovary  2 Simple Cyst : 3cm , 2cm FF -) :30/10/1385 : L.t.Ovary  2 Simple Cyst : 45mm , 33mm and R.t.Ovary  1 Simple Cyst : 35mm :23/12/1385:Uteruse: NL ET : 10mm R.t.Ovary  1 Simple Cyst : 43mm L.t.Ovary  1 Simple Cyst : 53mm

  4. Pre Operative Diagnosis : Acute Abdomen Complicated Bilateral Ovarian Cyst Probably Torsion. • Plan : Laparatomy Under General Anesthesia. • Findings :300 cc Blood in peritoneal Cavity. • Abundant and severe adhesion band . • Left Ovary : 7cmx6cm fixed to posterior of uterus ,pelvic floor and bowels. • The size of Right Ovary wasn’t cleared because of adhesion. • Enterolysis and disection of Ovaries ,uterus and inflammatory Tubes was performed to some extent. • There was bilateral Endometrioma and masive and severe Endometriosis that caused adhesion. • The uterus was fixed to pelvic floor in lateral and posterior. • Bilateral Adnexectomy and endometrial biopsy was performed.

  5. Pathology Left ovary endometrium Right ovary 7 cm Endometriosis Semitorsion Hemorrhagic fibrin deposition Inflamation Endometriosis Early secretory

  6. Severe Endometriosis: multiple superficial and deep implants including large ovarian endometrioma ,filmy and dense adhesions are usually present. • Symptoms: chronic pelvic pain (may be) but is often more severe during mense or at ovulation. • Dysmenorrhea infertility Deep Dysparomia AUB chronic fatigue cyclical bowel or bladder symptom • Endometriosis is the most common diagnosis made at the time of Gynecological Laparascopy for evaluate of CPP(1/3). 40% with CPP due to endometriosis have physical findings on pelvic examination: • Uterosacral ligament abnormalities (nodularity ,thickening focal tenderness) • lat. displacement of cervix • Cervical stenosis • Adnexal enlargement maybe palpable if an endometrioma is present. • Non Gynecological findings  red hair color  scoliosis  dysplastic nevi

  7. Pelvic ulterasound is highly sensitive for identifying pelvic masses , including ovarrian mass but is less reliable for distinguish. • sonography is useful for detecting small pelvicmasses (<4cm) which often can’t be palpated on pelvic examination • Endometrioma usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tarlike fluid(chocolate cyst) and are often densely adherent to surronding structures ,such as the peritoneum ,fallopian tubes and bowel. • An endometricma may be associatedwith symtoms of endometriosis or identified at the time of evaluation for a pelvic mass or infertility .

  8. Pseudo cyst (progressive invagination of the ovarian cortex over the implant. The cyst content has high concentration of iron • diagnosis: Histopathology is required to make a definitive diagnosis of endometrioma. However, a cilinical diagnosis can often be made with a high degree of certainty in a woman with histologically confirmed endometriosis and on adnexal mass , since 50% of women with endometriosis develop endometrioma, which are often bilateral.

  9. Ultrasound supports the diagnosis ,but of limited value for determining extent of disease since it lacks adequate resolution for visualizing adhesions and superficial implants. • However when there are sonographic signs suggestive of endometrioma ,it is likely that moderate to severe endometriosis is present. • Therefore ,extensive surgery may be required for relief of pain. • CA125: stage III or IV . levels > 100 IU/mL :adhesions or ruptured endometrioma. • DDx : hemorrhagic cyst/neoplasm.

  10. medical Management surgery: Cystectomy- oophorectomy the prefered therapeutic approach pain indications asymptomatic

  11. پایان

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