M, Dr. Poornima

Nagaraj, Dr. Punitha

English

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Digital Journal of Clinical Medicine Volume 3 Issue 2 Article 12 1-1-2021 A Case Of P2L2 With Scar Endometriosis With Previous Two LSCS Dr. Punitha Nagaraj JSS AHER Dr. Poornima M JSS AHER Follow this and additional works at: https://rescon.jssuni.edu.in/djcm  Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons Recommended Citation Nagaraj, Dr. Punitha and M, Dr. Poornima (2021) "A Case Of P2L2 With Scar Endometriosis With Previous Two LSCS," Digital Journal of Clinical Medicine: Vol. 3: Iss. 2, Article 12. This Case Report is brought to you for free and open access by Research Connect. It has been accepted for inclusion in Digital Journal of Clinical Medicine by an authorized editor of Research Connect. A Case of P2L2 With Scar Endometriosis With Previous Two LSCS  Dr. Punitha Nagaraj, Dr. Poornima (Associate Professor, Department Of Obstetrics And Gynaecology, JSS Hospital), JSS Medical College, JSS AHER,Mysuru   Clinical History  CHIEF COMPLAINTS: 27year old P2 L2 came with h/o pain abdomen on and off since 7years, increased since 2 months. HISTORY OF PRESENTING ILLNESS: 27year old para 2 living 2 came with pain abdomen since 7years, increased since 2months, sudden in onset, progressive in nature, pain over suprapubic region, pricking kind of pain, aggravates significantly during menstrual cycles and relives after taking medications. Pain associated with the mass. Mass present over the cesarean scar , tender in nature , protrudes during menstrual cycles. NEGATIVE HISTORY: No history of menorrhagia No history of intermittent bleeding No history of abdominal distension No history burning micturition No history of increased frequency of micturition No history of constipation No history of loss of appetite No history of loss of weight No history of twinning and congenital Anomalies MENSTRUAL HISTORY : LMP : 20/11/2020 Past cycles : 3-4 days/30days , 2-3 pads per day , pain ++, no clots 1Nagaraj and M: A Case Of P2L2 With Scar Endometriosis With Previous Two LSCSPublished by Research Connect, 2021OBSTETRIC HISTORY : PARA 2 LIVING 2 , 2FTLSCS 1st- conceived spontaneously , FTLSCS, male baby, at present 7years alive, healthy 2nd- conceived spontaneously, FTLSCS, male , at present 4years alive and healthy MEDICAL HISTORY : no history of Diabetes, Hypertension , Tuberculosis, seizures, bronchial asthma PAST SURGICAL HISTORY: Underwent open appendectomy 10years back Underwent open cholecystectomy 10years back Underwent 2 LSCS 7 and 4 years back with concurrent tubal sterilisation Family history : nothing significant Personal history : diet mixed , normal appetite, regular bowel and bladder , sleep not disturbed EXAMINATION AND INVESTIGATIONS General physical examination: Patient aged 27years , moderately built , moderately nourished , oriented to time, place, person. No pallor, Icterus , cyanosis, clubbing, lymphadenopathy, Edema VITALS: PULSE- 90/MIN Blood pressure – 130/80mmhg SYSTEMIC EXAMINATION: Per abdomen Inspection – Abdomen scaphoid shaped 2Digital Journal of Clinical Medicine, Vol. 3 [2021], Iss. 2, Art. 12https://rescon.jssuni.edu.in/djcm/vol3/iss2/12DOI: –All quadrants moves equally on respiration Multiple healed scars present 1. Right hypochondriac region 10cm healed scar,suggestive of cholecystectomy healed by primary intention. 2. Suprapubic transverse healed scar suggestive of cesarean section healed by primary intention. 3. 3*3cm circular scar with black pigmentation in subumblical region. No dilated veins, all hernial orifices normal Palpation : Soft No local rise of temperature Tenderness present 3*3cm circular hard mass with black pigmentation in subumbilical region, tender with restricted mobility and felt arising from skin to deep down. No fluctuant No organomegaly No Other mass palpable Percussion : tympanic notes in all 9 quadrants Auscultation: bowel sounds heard Local examination :External genitalia normal No excoriation No discharge Per speculum : Cervix and vagina normal No discharge Per vaginal examination: cervix firm , directed downwards backwards, Uterus normal size, anteverted. Fornices free and non tender 3Nagaraj and M: A Case Of P2L2 With Scar Endometriosis With Previous Two LSCSPublished by Research Connect, 2021Cvs: s1 s2 heard . No murmurs Rs: B/L normal vesicular breath sounds heard. No added sounds Cns: normal  *USG abdomen: well defined subcutaneous hypoechoic lesion 3*2.5cm in lower abdomen at incision site. Showing increased vascularity.  Subcutaneous scar endometriosis. DIAGNOSIS Final Diagnosis: P2L2 with scar endometriosis with previous 2 LSCS DISCUSSION Endometriosis is a benign disease, defined as presence of ectopic (outside the uterus ) endometrial gland and stroma. Risk factors: 4Digital Journal of Clinical Medicine, Vol. 3 [2021], Iss. 2, Art. 12https://rescon.jssuni.edu.in/djcm/vol3/iss2/12DOI: –Previous LSCS /late marriages/ late child birth / genital tract obstruction / frequent and prolonged menstrual cycles / nulliparity / early menarche Theories of sites of endometriosis: 1. Pelvic endometriosis- Retrograde metaplasia 2. Abdominal viscera – coelomic metaplasia 3.Pelvic peritoneum- coelomic metaplasia 4.Rectovaginal septum – coelomic metaplasia 5.umbilicus – coelomic metaplasia 6. Abdomen scar – direct implantation 7. Episiotomy scar – direct implantation 8. Vagina and cervix – direct implantation 9. Lymph nodes – Lymphatic spread 10. Other- vascular genetic immunologic SCAR ENDOMETRIOSIS Scar endometriosis is a rare entity reported in gynaecology literature and presents in women who has undergone previous abdomen or pelvic surgeries . It is defined by the implantation or/and growth of endometrial tissue postsurgically at the incision site. Most commonly accepted theory for scar endometriosis is Direct endometrial implantation to wound edge during abdominal or pelvic surgeries. The incidence of scar endometriosis has been shown to be less than 2%with the most common subtype being post cesarean section. Symptoms : Dull aching abdominal pain Dysmenorrhea Dyschezia Disorders of menstruation Dyspareunia Only 20% of women will show up with symptoms 5Nagaraj and M: A Case Of P2L2 With Scar Endometriosis With Previous Two LSCSPublished by Research Connect, 2021DIAGNOSIS : *USG abdomen shows , irregular walls with low level echos within and occasional high level echogenic areas which are blood clots. *CT/MRI has no additional advantage than USG Haematological investigations will be normal However CA-125 is increased in endometriosis although levels are lower than they are in ovarian carcinoma *Laparoscopic findings : Powder burns / Gunshot lesion MANAGEMENT : This requires both surgical excision and hormonal suppression 1- Progestational drugs 20-100mg p/o for 6months, have been used to treat symptomatic endometriosis.medroxyprogesterone acetate is mostly used. Levonorgestrel containing IUDs has recently been used for treatment of rectovgainal endometriosis 2. Oral contraceptive pills ,can be given cyclic or continuous fashion, however monophasic formulation seems more logical than multiphasic pill for continuous therapy.the usual regime is continuous treatment with one pill daily for 6-12 months. 3. GNRH agonist – causes pseudomenopause and pseudo pregnancy.given for 6months. 4. Gestrinone – is a 19- nortestosterone derivative steroid having androgenic, antiprogestinic, antiestrogenic actions,thus extensively used in endometriosis.given 2.5mg-10mg On a twice or thrice weekly schedule. 5. Danazol can also be used. But not used now a days. It is believed that hormonal suppression is only partially effective. 6Digital Journal of Clinical Medicine, Vol. 3 [2021], Iss. 2, Art. 12https://rescon.jssuni.edu.in/djcm/vol3/iss2/12DOI: –For endometriosis hormonal suppression may be effective but in scar endometriosis hormonal supplements aren’t useful.surgery is the choice. Surgical treatment : Excision Most effective Surgery for the treatment of endometriosis can be performed via laparotomy or laparoscopy. Laparoscopy offers advantage over laparotomy in better visualisation,less time,less tissue trauma,desiccation,smaller incision and speedy postoperative recovery. Post operative adhesions and complications may also be less in laparoscopy. Peritoneal implants of endometriosis can be ablated with unipolar or bipolar electro surgical instruments or lasers or excised by sharp dissection. POST OPERATIVE MANAGEMENT In order to control the recurrence, progesterone can be given for 4-5 months. If the scar is relatively large then can be given up to 9months. ACKNOWLEDGEMENT: None  REFERENCES 1. Hugh S. Taylor , Lubna Pal , Emre seli. Speroff’s Clinical gynaecology, endocrinology and infertility. 9th ed. 2019. 2. Werner, Moschos , Griffith, Beshay,Rahn, Richardson,Hoffman. Williams gynaecology. Study guide.2nd ed. The McGraw-hill companies,2012. 3. Tanos B, Anteby SO. Caesarean scar endometriosis.Int J Gynaecol Obstet.1994;47:163-6 7Nagaraj and M: A Case Of P2L2 With Scar Endometriosis With Previous Two LSCSPublished by Research Connect, 20214. wolf G, Singh K. Cesarean scar endometriosis ;A review , Obstet Gynecol surv.1989;44:   8Digital Journal of Clinical Medicine, Vol. 3 [2021], Iss. 2, Art. 12https://rescon.jssuni.edu.in/djcm/vol3/iss2/12DOI: –

A Case Of P2L2 With Scar Endometriosis With Previous Two LSCS

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