Gravid uterus in an anterior abdominal wall hernia and successful repair at the time of caesarean section

Snehamay Chaudhuri, Sankar Nath Mitra, Abhishek Daga and Debasish Bandopadhyay

Introduction

The herniation of a gravid uterus through an incisional hernia site is a rare occurrence. Incisional hernia is a frequent complication of abdominal wall closure and the management of pregnancy with a large incisional hernia with gravid uterus in its sac is challenging. The following is a case report of gravid uterus through an incisional hernia of a midline incision. Case Report
 Mrs LB, 35 years, Parity 2, period of amenorrhea of 34 weeks 3 days, married for 12 years was admitted to the hospital from the outpatient department due to  the ulceration of abdominal skin as a result of herniation of gravid uterus through the midline longitudinal incision of a previous caesarean section . She was a booked case of our hospital and had been receivingantenatal care since 20 weeks of gestation. At 20 weeks  there was no herniation of the uterus through the incision line. In her subsequent visits she came with the uterus protruding through the incisional hernia. She was referred to the General Surgeon who recommended elective Caesarean section with repair of hernia. Her past obstetric history revealed that she had her first emergency caesarean section eight years before because of a breech presentation and a second caesarean section, due to thepremature rupture of membranes at term. Both the babies were living & well. On both occasions she was operated on through infra umbilical midline vertical incision. There was no history of caesarean section wound infection during the post operative period in the previous two pregnancies. On examination, she was moderately built and adequately nourished. There was mild pallor. Her pulse rate was 88 beats per minute and her blood pressure was 126/86 mm Hg. Heart and chest were normal. Abdominal examination revealed distention of the abdomen in thecentral area. The uterus was felt just underneath the skin with acomplete lack of anterior abdominal wall. (Figure I)   Figure 1- Photograph showing gravid uterus lying in the incisional hernia sac The overlying skin was necrosed with evidence of ulceration and the presence of engorged veins. The fetus was lying in the herniated gravid uterus outside the abdominal cavity. Routine investigations were within normal limits. Ultrasound examination showed the uterus herniated in the incisional hernia of the anterior abdominal wall with the live fetus in cephalic presentation without any gross congenital malformation. The placenta was located in the upper uterine segment. She was kept in the hospital for bed rest with abdominal support. Emollients & antiseptic skin ointment were applied over the skin of the anterior abdominal wall. An elective caesarean section was planned for 37 weeks but she went into labour at 36 weeks. The abdomen was opened by elliptical incision. The uterus was visualized just beneath the skin and there was no evidence of the rectus sheath in the vicinity of the incision. A uterineincision was made over the previous caesarean scar and the baby was delivered with APGAR 7/10 at 1 minute and 9/10 at 5 minutes. The uterus was repaired in layers and a bilateral tubal ligation was done. Herniorraphy was performed in double buttress fashion. She was given a course of antibiotics. Her post operative period was uneventful and she went home with a healthy baby weighing 2.25 Kg. During her follow up visits she was found to be problem free. Discussion The remote complication of a caesarean section could be an incisional hernia due to defective abdominal wound healing and herniation of gravid uterus through the abdominal wall. This is a rare complication.¹ The complications that have been reported in literature in association with this complication include strangulation, abortion, pre-term labour, accidental haemorrhage, intrauterine fetal death and rupture of the lower uterine segment.²  Excessive stretching of the skin may cause ulceration of the skin as in this present case due to friction between the hernia sac and other parts of the patient’s body. Caesarean section should be performed and herniorrhaphy can be performed during the caesarean section as in the present case.¹ Herniorrhaphy can be performed during pregnancy if there is evidence of morbid incarceration or the skin is necrosed.³  However, herniorrhaphy can be postponed until delivery, as the enlarged uterus may interfere with healing of the repair.

References

1.Malhotra M,Sharma J B, Wadhwa L,Arora R. Successful pregnancy outcome after cesarean section in a case of gravid uterus growing in an incisional hernia of the anterior abdominal wall. Ind J Med Sci 2003,57: 501-03

2. Dare F O, Makinde OO, Lalwal OO. Gravid uterus in an anterior abdominal wall hernia of a Nigerian woman Int J Gynecol Obstet 1990;32:377-93. Deka D, Banerjee N, Takkar D. Incarcerated pregnant uterus in an incisional hernia. Int J Gynaecol Obstet 2000;70:377-9

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