The Obstetrical History in Patients with Pfannenstiel Scar Endometriomas – An Analysis of 81 Patients

Abstract

Introduction: The participation of immune tolerance during pregnancy was suggested to be an important factor predisposing to the implantation of decidual cells after cesarean section in Pfannenstiel scar. Delivery at term is related to the termination of immune tolerance to fetal antigens that is maintained throughout pregnancy. Substantial proportion of cesarean section deliveries is performed before the onset of true term labor. The aim of this study was to analyze the clinical symptoms of spontaneous beginning of labor in pregnant women in whom cesarean sections were performed and in whom Pfannenstiel scar endometriomas were observed during follow-up. Materials and Methods: We have retrospectively analyzed 81 patients following the surgical removal of scar endometrioma after cesarean section. Obstetrical histories of cesarean sections in the number of 5,370 preceding the occurrence of the scar endometrioma were analyzed. These data were collected in six different Gynecological and Obstetrical wards in Malopolska Province in Poland. Analysis of data was started by the retrospective evaluation of regular uterine contractions, uterine cervix ripening before cesarean section and the indications for surgery. Results: In 67 women from the group of 81 patients cesarean sections were performed with unripe uterine cervix and without the presence of regular uterine contractions. Elective indications for cesarean sections were predominant in this group of women. The relative risk of scar endometriomas occurrence following cesarean sections performed before onset of labor in comparison to cesarean sections following spontaneous onset of labor was statistically significantly higher [RR = 2.16, 95% CI = 1.21–3.83; OR = 2.18, 95% CI = 1.22–3.89]. Conclusions: Cesarean section performed before spontaneous onset of labor may increase substantially the risk of occurrence of scar endometriomas.

Scar endometrioma following obstetric surgical incisions: retrospective study on 33 cases and review of the literature

“…6 The current study evaluated the frequency of scar endometrioma over a six-year period, with 33 cases, which is a proportionally representative number and, when compared with larger studies in terms of absolute numbers, it is highly relevant. 6,[16][17][18][19][20] Furthermore, all the cases described in the present study underwent surgery performed by the same team, which means that the team acquired great experience in handling this disease. Even though there have recently been studies presenting larger numbers of cases, better understanding should be reached through profiling the disease, searching for more efficient actions for prevention, diagnosis and therapeutics, and publishing such information in the medical media.…”

“…18 In evaluating the obstetric history of 81 patients with endometrioma, Wicherek et al stated that performing cesarean sections without the presence of labor conditions more than doubles the risk in relation to situations in which cervical ripening and uterine contractions are present. 16 The use of laparoscopic examinations and biopsy puncture has been correlated with umbilical scar endometriomas. 15,[22][23][24] Other rarer general surgical procedures, such as congenital inguinal hernia, might lead to endometrioma at the incision site, even mimicking hernia recurrence.…”

“…Thus, labor onset with cervical ripening and regular contractions would be a marker for the end of immune tolerance, because in the absence of this condition (elective cesarean section), labor seems to be a factor related to the disease. 16 However, the ability of ectopic endometrial cells to resist cell apoptosis allows them to survive in the surgical scar. A recent study concluded that the expression of metallothionein through endometrial cells and receptor-binding cancer antigen through SiSo cells (RCAS1), i.e.…”

Abdominal wall endometriosis: an update in clinical, imagistic features, and management options

“…In evaluating the obstetric history of 81 patients with endometrioma, Wicherek et al stated that cesarean delivery performed before spontaneous onset of labor may substantially increase the risk of occurrence of scar endometriomas [16]. In a recent study of a series of 34 patients with histologically proved AWE after cesarean delivery, Khan et al noted a higher BMI in women with abdominal wall endometriosis compared with controls.…”

Scar endometriosis following hysterotomy: a case report

“…10 Elective caesarean section performed before the onset of labor doubles the risk of scar endometriosis. 11 The condition is caused by direct inoculation of endometrial cells into abdominal fascia or subcutaneous tissue. 12 Scar endometriosis can mimic conditions like stitch granuloma, inguinal hernia, lipoma, abscess, lymphoma etc.…”