Umbilical endometriosis along with peritoneal endometriosis: a case report

Incidence of endometriosis is around 10 to 15% in women of reproductive age group. Umbilical endometriosis is a very rare entity. Extra genital endometriosis accounts to 3% of endometriosis. Incidence of umbilical endometriosis is 0.5%-4% of extra genital endometriosis. 30 years old multi gravida was referred to our hospital with c/o periodic bleeding from the umbilicus for the past 3 months. She was also having dysmenorrhoea for about 3 months. On examination, patient had a small bluish nodule in the umbilicus around 1.5x1.2 cm in size. Clinically there was suspicion of pelvic endometriosis as the uterus was retroverted and fixed. CT abdomen showed a small hypo-echoeic area in the umbilicus and uterus was adenomyotic with normal ovaries. Patient was given the option of laparoscopy and excision of umbilicus, as there was suspicion of peritoneal endometriosis and the patient also insisted upon laparoscopic sterilization. Laparoscopy showed early peritoneal endometriosis with pelvic adhesions and the same adhesiolysis was done along with cauterization of endometriosis. Sterilization was also done as per the patient’s request. Umbilical excision and layer closure was done. Umbilical endometriosis is a rare entity. This patient had associated early pelvic endometriosis. Umbilical endometriosis could be secondary to the lympho vascular spread from the pelvic endometriosis or primary umbilical endometriosis. History, clinical and imaging were pointing towards umbilical endometriosis. Surgical excision of umbilical endometriosis and cauterisation of early pelvic endometriosis were done. Patient needs follow up. Umbilical endometriosis may be primary or secondary which needs total excision and follow up

Beliefs and Customs in Kunnam Region

Tamil poets have created, named, categorized, summarized and preserved dialects based on dialects in order to preserve the language they speak. Before exploring the importance of numbers in language it is necessary to know the design of grammatical literature. It is possible that the Sanskrit poets called the text grammar of the words when they recorded the language, they created in the journals so that it would be known to the world, and the textual literature of the world empirical biographies based on his quote characters. The words created for measurements such as size and mass are the primary letters of the words and the reasons for giving a special place to measurements in Tamil are explained. In order to give Tamil a lofty place in the world languages ​​in are the numbers to indicate the of an action, the time of action, and the number of soldiers involved in the war

Robert’s uterus: a rare mullerian anomaly mystery unfolded

Anomalies of female genital tract may not be detected until after menarche when they present a cyclical pain due to outlet obstruction. Mullerian anomalies represent a vast array of structural abnormalities resulting from improper development and fusion of embryological mullerian ducts. 19-year-old girl attained menarche at the age of 14, had progressive dysmenorrhoea and diagnosed as right haemotosalphinx and ovarian endometrioma which were removed in 2008. As pain progressed, she underwent laparoscopic adhesiolysis in 2013. Since, pain persisted, diagnosed as right haematometra, and drainage done by laparotomy. Left adnexa were normal. She was given depot provera till she completed schooling. She developed recurrent dysmenorrhoea after stopping depot provera. USG and MRI revealed recurrent haematometra on right side with normal left horn. The possibility of atypical septum was thought about and hystero laparoscopy was done. It showed right side haemetometra with absent right adnexa. Left adnexa normal. Hysteroscopy showed normal left horn with septum with a bulge towards the left side. Hence, proceeded with hysteroscopic septostomy and haemetometra was drained to the left horn. Later patient was free from dysmenorrhea and repeat hysteroscopy was found to be normal. This case highlighting mullerian anomalies have to be considered when young girls present with severe progressive dysmenorrhoea and diagnosis remains a challenge most of the clinicians. This rare entity has to be kept in mind while evaluating such patients. Prompt diagnosis and early surgical correction are essential to avoid future morbidity in the form of repeated unnecessary surgeries

Novel methods in diagnosis of endometriosis in future

Endometriosis causes severe pain and infertility affecting quality of life. According to ASRM it is a chronic inflammatory disease that requires life-long management plan and surgery has to be restricted only once in the life time of the patient. Earlier, the diagnosis of endometriosis was confirmed by surgical method and histo-pathological examination. There is often a diagnostic delay up to 7 years or even beyond, which will affect the patients getting earlier treatment. Recently, lot of non-invasive techniques for diagnosis of endometriosis have come into vogue so that, treatment can be planned without surgical diagnosis. Apart from imaging through USG, CT or MRI, earlier lesions can be picked up by biomarkers like IL-6, IL-8, CA 125, HE4, neutrophil-lymphocytic ratio, Hs-CRP, Tumour necrosis alpha and mi RNA, neural elements in endometrium, glyco-proteins like CA-125, CA-19.9, CA-15.3, CA-73, AFP and CEA. Urocortin, activin and follistatin are growth factors and VEGF, TNF-alpha, NK cells, i-SCAM-I, MCP-1 are immunologic markers for diagnosis of endometriosis. Circulating endometrial cells are also present in the peripheral blood of patients. miRNA in endometriosis is found to be a potential biomarker in the recent years and also associated with altered vaginal microbiome. There has been up-regulation and down-regulation of certain miRNAs in endometriosis patients. In patients with symptoms of endometriosis, miRNA study in peripheral blood can be used as a biomarker for confirmation of diagnosis. There is a strong association between mitochondrial DNA variation and endometriosis which is found to be rational biomarkers

Caesarean scar ectopic pregnancy

Ectopic pregnancy is a common cause of mortality and morbidity among the women of reproductive age group. Tubal pregnancy is the commonest.  It can occur in cervix, ovaries, previous caesarean scar, interstitial portion of the tube and abdominal cavity. Here we report a case of caesarean scar ectopic pregnancy which was managed conservatively. 31 yrs old gravid 3 previous 1 LSCS and 1 tubal ectopic come for antenatal consultation at 35 days of gestation. UPT was Positive. USG showed no evidence of intra uterine sac. Repeat scan after 10 days showed a gestational sac at the lower uterine segment scar. Hence it was decided for conservative management, injection methotrexate 50 mgm X 2 doses given. This was followed by misoprost vaginal insertion. Since patient did not expel the sac, injection PG F2 alpha 125 mg x 2 doses were given. Patient expelled the products of conception partially. This was followed by hysteroscopic guided evacuation.Caesarean scar ectopic was reported in 1978. Early diagnosis is by TV USG / MRI. Early ectopic can be treated medically. In delayed diagnosis, laparoscopic excision of the scar has to be done. In rupture of the scar site ectopic pregnancy laparotomy is indicated. In the event of heavy bleeding, hysterectomy has to be done. After conservative management and excision of the scar, fertility is not altered. Caesarean section scar pregnancy is a rare form of ectopic pregnancy which can lead to life threatening complications leading to mortality and morbidity. Treatment has to be individualized according to the gestational age, haemodynamic stability and desire for future fertility