- Original Article
- Open Access
Scar endometriosis after a caesarean section: a perhaps underestimated complication
© Springer-Verlag Berlin Heidelberg 2013
- Received: 7 April 2013
- Accepted: 15 July 2013
- Published: 18 August 2013
The exact incidence of scar endometriosis is unknown. The aim of this study is to determine the incidence of endometriosis in the abdominal wall following a caesarean section. Women who underwent surgery for scar endometriosis after a caesarean section and the total number of women with caesarean sections in The Haga Teaching Hospital, a gynaecologic centre in The Netherlands, were identified by the national obstetric registration and pathology archive in the period January 1995 to December 2008. Clinical data were collected from the existing hospital records. Twenty-nine women were diagnosed with scar endometriosis after a caesarean section, and 3,047 women underwent one or more caesarean sections, resulting in an incidence of scar endometriosis of 0.95 %. None of the women had a history of endometriosis. Symptoms were pain (94.0 %), cyclic with menstruation (50.0 %) and swelling of the scar (89.0 %). Mean time between caesarean delivery and symptoms was 4.1 years. No recurrence occurred. This study reveals a higher incidence of endometriosis in the scar of a caesarean section than described in current literature. To improve the detection rate, more attention to medical history and physical examination is mandatory. A higher incidence warrants research into the pathophysiology and prevention of endometriosis in the scar of a caesarean section.
- Caesarean section
- Abdominal wall
Endometriosis is defined as functioning endometrium outside the cavum uteri and is found in 8–15 % of all menstruating women [1–3]. The most common site is the ovarium and less frequent sites include peritoneum, intestine, bladder, inguinal region, lungs, pleura, pancreas, central nervous system and vertebrae [1, 2, 4]. Furthermore, endometriosis can be seen in the abdominal wall after surgery, in particular, in women with a caesarean section in history. Currently, no exact incidence rate of scar endometriosis after a caesarean section has been described and rates range from 0.03–1.73 % [5–12] with an average rate of 0.50 % (see Table 1). There are, however, only five studies [6, 8–11] available that calculated the incidence rate in a study group of more than 3,000 women with caesarean sections each. When we combine the total number of cases with scar endometriosis from these studies, the average incidence rate is 0.15 %. It is generally believed that scar endometriosis is a rare complication of a caesarean section, but the question remains whether the actual incidence is as low as been stated in most of the current literature or that the complication is underestimated.
Symptoms of endometriosis are frequently not recognised which results in delay in the diagnosis and therapy of the scar endometriosis [13, 14]. A higher incidence justifies more attention to the diagnosis and requires research into pathophysiology and prevention. The aim of this study is to investigate the incidence of scar endometriosis after a caesarean section.
This retrospective observational cohort study was performed in the Haga Teaching Hospital, The Hague, The Netherlands. All women with the pathological diagnosis ‘endometriosis in abdominal scar’ were collected by searches in the nationwide pathology registry database Pathologic Anatomic National Automated Archive (PALGA). The following terms were used for the search: endometriosis, endometriosis cyst and external endometriosis. All women who were diagnosed in the period of 1995 until 2008 were selected. The number of women who delivered by caesarean section in the Haga Teaching Hospital in the same period was determined by data of the national obstetric registration. For detailed information, records of the selected women with scar endometriosis after caesarean section were examined. The following items were recorded: surgical history, number of caesarean deliveries in history, method of caesarean delivery (Pfannenstiel/median incision), age at time of caesarean delivery, body mass index (BMI) at time of caesarean delivery, endometriosis in history (yes/no), symptoms, time between the caesarean section and symptoms of scar endometriosis, specialist who diagnosed the scar endometriosis and operated the woman, size of endometrioma and recurrence of scar endometriosis (yes/no).
Characteristics of women with abdominal wall endometriosis after caesarean section
Interval CS—symptoms (years)
Size endometrioma (cm)
CS in history (number)
Overview of literature concerning incidence of scar endometriosis after caesarean section
Women with scar endometriosis
Nominato et al. 
Leite et al. 
Minaglia et al. 
Singh et al. 
Bottino et al. 
Wolf et al. 
Field et al. 
Unfortunately, the pathophysiology is still not clear. Scar endometriosis after caesarean section is most likely caused by iatrogenic dissemination of decidual tissue. However, this will not explain the existence of endometriosis in the abdominal wall without any previous surgery. Different pathophysiological theories for abdominal wall endometriosis have been described. Sampson’s theory postulated the implantation or retrograde menstruation hypothesis which states that endometrial tissue from the uterus is shed during menstruation and transported retrograde through the fallopian tubes, thereby gaining access to and implanting on pelvic structures [20–24]. Another theory suggests lymphatic or vascular dissemination, and a third explanation states that cells in the abdomen undergo metaplasia induced by hormonal manipulation . Still, in our opinion, most of the cases can be explained by iatrogenic dissemination of decidual tissue.
Removing decidual tissue from the wound before closing and cleansing with NaCl (normal saline solution) has been described as a preventive measure . Intraoperative contamination of the surrounding tissue with the endometrial cells is a situation that should be taken into account during operations in the pelvis. Therefore, sweeping the uterus with a gauze during a caesarean delivery should be limited since it could be an important factor in the pathogenesis of scar endometriosis . Further research is necessary to determine the exact role of this factor. In addition, preventive measures could have consequences for other types of surgery as oncologic surgery, where the mechanism of cancer recurrence in a scar, shows many similarities with scar endometriosis . Given the magnitude of caesarean sections performed, studies on preventive measures could thus have importance for other fields of surgery.
A limitation of this study is the restriction of research to only one hospital in the Netherlands. Therefore, not all women with scar endometriosis had their caesarean section in the Haga Teaching Hospital. We assumed, however, that this number of women is comparable to the number of women who had their caesarean section in the Haga Teaching Hospital and surgery for scar endometriosis in another hospital. Moreover, this methodology was also used in the studies referred to in Table 2. This is the one of the first studies which described a higher incidence than has been established previously. Additional research by other groups is needed to confirm our data and conclusions. Furthermore, our study only describes the incidence of women who underwent surgery, not the women with scar endometriosis who did not undergo surgery. Therefore, the incidence is even higher than described in the present study.
In conclusion, this study reveals a higher incidence of endometriosis in the scar of a caesarean section than described in current literature. To improve the detection rate of scar endometriosis, more attention to medical history and physical examination is mandatory. The higher incidence warrants research into the pathophysiology and prevention of abdominal wall endometriosis after a caesarean section.
Conflict of interest
No disclosure of interest.
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