Author Information
Puri J*, Desale S**, Gupta AS***, Valvi D****.
(* Second Year Resident, ** Fourth Year
Resident, *** Professor, Assistant Professor. Department of Obstetrics and
Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India)
Abstract
Endometriosis is
defined as presence of endometrium including the glands and the stroma at
locations other than the uterine cavity. It causes inflammation, scarring,
fibrosis, and adhesions resulting in distortion of pelvic anatomy, causing
infertility. Our patient had conceived spontaneously and was found incidentally
to have widespread endometriosis during cesarean section.
Introduction
Patients with
endometriosis usually present with symptoms of chronic pelvic pain,
dyspareunia, infertility, dysmenorrhea, inguinal pain, and or pain during
exercise. About 20-25% of women have asymptomatic endometriosis.[1]
Thirty to fifty percent of patients with endometriosis are infertile.[1]
Case Report
A 22-year-old primigravida,
married for one and a half year, conceived spontaneously without any history of
infertility was registered with us for antenatal care. Labor was induced at 40
weeks and 4 days of gestation. A trans cervical Foley’s catheterization was
done for cervical ripening as her Bishop’s score was less than 4. She was taken
up for lower segment cesarean section (LSCS) in view of failure of induction.
After the delivery of fetus, the right ovary was found to have an endometriotic
cyst measuring 4x4 cm. It got ruptured and chocolate like material flowed out
of the cyst. Cauterization of the base of the cyst and powder burn marks was
done. Two pearly white cysts of about 3x3 and 3x3 cm were also seen in the
right ovary. Right ovary was stuck to the posterior surface of right side of
uterus. Powder burns were seen on the right side, on the posterior surface of
uterus. Left fallopian tube and ovary were normal but stuck deep in the pouch
of Douglas . Our patient had Stage III
(moderate) endometriosis as seen in Figures 1, 2, and 3. Her course in the ward
was uneventful. Patient was discharged on Day 5 of LSCS.
Figure1.
Endometriotic Chocolate cyst in Right Ovary.
Figure 2. Powder
burn marks of active endometriotic lesions.
Figure 3.
Scarring of Endometriosis)
Discussion
The prevalence
of endometriosis is 6-10% in women of reproductive age group.[2] Nearly
20-25% of patients are asymptomatic.[1]
Short duration of menstrual cycle and longer duration of menstrual
flow are associated high risk for endometriosis as retrograde menstruation is
more commonly associated with such menstrual flow patterns. Pregnancy has a
protective effect as it decreases the menstruation. Two pearly white ovarian
cysts, seen intra-operatively were unlikely to be polycystic ovaries, as polycystic
ovaries are more common bilaterally. Moreover, patients with polycystic ovaries
usually do not ovulate spontaneously. The cysts could be probably due to
adhesions on the surface of the ovary due to endometriosis. Endometriosis most
frequently starts in the most dependent areas of the pelvis like, ovaries (most
common site)[3] posterior pouch of Douglas ,
uterosacral ligaments, posterior uterus and posterior broad ligaments. Women
with endometriosis are more likely to be delivered by caesarean section.[4]
The endometriotic lesions seen were active lesions, powder burn marks,
and chocolate cyst with its lining. Scarring was seen on the posterior surface
of the uterus, which was due to healing effects probably due to pregnancy. Decidualization of the endometrial tissue was
not seen. Histopathology of the tissue was not sent because of obvious findings
of endometriosis. One treatment modality for endometriosis is pseudo-pregnancy
with combined oral contraceptive pills for nine months. Interestingly, this
patient had active lesions even after nine months of amenorrhea. Rate of
conception after surgical laparoscopic treatment by removing the endometriotic
implants seen during laparoscopy and adhesiolysis as per different stages of
the disease is as follows, Stage I-35.7%, Stage II-44.4% and for Stage
III-53.3%. Rate of conception for Stage IV is 20%. However, the rates of
conception are not dependent on severity of endometriosis.[5] The
patient has been explained about the endometriotic lesions. The patient is
further expected to be in amenorrhea during her lactational period. The
treatment of endometriosis by cauterizing the powder burns and the
endometriotic cyst wall and the protective effect from pregnancy and lactation
increases the chances of patient being free from the disease and a good
obstetric career. The further plan of management for the patient is to follow
up with serial ultrasonography scans, if she becomes symptomatic when she
starts to menstruate and check if ovarian endometriosis recurs.
References
- Bulletti C, Elisabetta M, Battistoni CS, Borini A. Endometriosis and Infertility, Journal of Assisted Reproduction and Genetics. 2010;27(8):441-447.
- Raffi F, Amer S, “Endometriosis” Obstetrics, Gynaecology and Reproductive Medicine. 2011; 21(4):112-117.
- Gylfason JT, Kristjansson KA, Sverrisdottir G, Jonsdottir K, Rafnsson V, Gerisson RT. Pelvic endometriosis diagnosed in an entire nation over 20 years. Am J Epidemiol 2010;172 (3):237–243.
- Stephansson O, Kieler H, Granath F, Falconer H. Endometriosis, assisted reproduction technology and risk of adverse pregnancy outcome. Human Reproduction: Oxford Journals. 2009;24(9):2341-2347.
- Lee HJ, Lee JE, Ku SY, Kim SH, Kim JG, Moon SY, et al. Natural conception rates following laparoscopic surgery in infertile women with endometriosis. Clinical and Experimental Reproductive Medicine. 2013;40(1):29-32.
Citation
Puri J, Desale S, Gupta AS, Valvi D. Stage III
Endometriosis In Term Pregnancy. JPGO 2015. Volume 2 No. 2. Available from: http://www.jpgo.org/2015/02/stage-iii-endometriosis-in-term.html