Once the fragments of endometrium have implanted they begin to respond to the fluctuating levels of the menstrual cycle hormones in the same way as the endometrium lining the uterus. Thus, the implants thicken and swell with blood and then break down and bleed each month. This blood then cannot escape from the body so it bleeds directly onto the surface of the surrounding organs, causing irritation which leads to inflammation, scarring and, sometimes, the development of adhesions.

As the disease progresses the implants gradually enlarge in size and may form small cysts.

As a cyst enlarges, the pressure within the cyst may cause it to rupture during menstruation, spilling the contents onto the adjacent tissues. This may in turn lead to the development of new implants.

What does endometriosis look like

Classical implants

Until recently, endometrial implants were thought to be fairly uniform in appearance. However, in the last few years there has been a growing appreciation that they have a range of characteristic appearances.

It is now understood that what were traditionally recognized as being classical implants are, in fact, probably only one end of the spectrum of appearances and that they are probably only typical of older implants.

Classical implants usually appear as tiny dots, or clusters of dots, on the surface of the organ or ligament on which they have implanted. They are usually only pinhead in size but they may be up to a centimeter or more in diameter. They range in colour from brown to black depending on how much old blood they contain. When magnified they may look like clusters of black grapes.

Atypical implants

The newly recognized implants are often called atypical implants but they are probably younger implants which, as yet, have very little old blood deposited in them.

Atypical implants are usually very small and are sometimes difficult to see. They may occur alone or in clusters and may be clear, white, yellow, orange or red in colour.

Microscopic endometriosis

In the early stages of endometriosis the implants may be too small to be seen without the use of a microscope. This type of endometriosis is often referred to as microscopic endometriosis.

Endometriomas

Endometrial cysts on the ovary are also known as endometriomas. They are usually less than two or three centimeters in diameter but occasionally may be 10 or more centimeters in diameter. They may be embedded in the ovary itself or they may lie on its surface. They are sometimes referred to as ‘chocolate cysts’ because they contain old dark blood which often has the appearance and consistency of melted chocolate.

Adhesions

Adhesions are bands of tissue which bind or matt together organs of the pelvic cavity and they may be formed as a result of endometriosis. They may have the appearance of sticky toffee which has been stretched from one organ to another.

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‘Presentation’ means the part of the baby that passes through the birth canal first. Normal presentation is head first, facing backwards, and with the neck bent forward so that the crown leads the way through the birth canal. With the head in this position, its narrowest diameter passes through the pelvic outlet.

The most common abnormal presentation is breech, which is bottom first. There are two main reasons why breech presentation causes problems in delivery. First, the soft breech is effective as a dilator of the cervix sol the first stage of labour is usually prolonged. Second, the largest and least compressible part (the head) comes last and may have to pass through an inadequately dilated birth canal. When the head comes first it has plenty of’ mould to the shape of the pelvic during the first stage of labour: note breech presentation. If the head won’t fit through the pelvis, labour will be obstructed. If the body is already delivered,
this is a serious problem.

Some foetuses in the breech position
will spontaneously turn before labour begins, and sometimes a doctor or midwife can turn a breech by manipulations through the mother’s abdominal wall.

A breech delivery will need more intervention and birth injury to the baby more common, even in the best hands. If breech is suspected and confirmed ultrasound before labour commences, caesarean delivery is often advised, especially if the mother’s pelvis is smaller average. In vaginal breech delivery, forceps are usually needed to deliver the head and protect it from injury due to сcompression.

Less common abnormal head presentations include positions of the foetal h” (such as face or brow first, or the head facing the mother’s abdomen rather than her spine) that don’t direct its narrowest diameter through the mother’s pelvic оoutlet. Usually the head can be manipulated into the most favourable position for livery – facing the mother’s spine with crown coming first.