Author Information
Nidhi Rathi*, Alka
Gupta**
(* Second Year
Resident, ** Professor; Department of Obstetrics and Gynecology, Seth G. S. Medical College & K.E.M. Hospital,
Mumbai, India.)
Abstract
Herniation of the gravid uterus in anterior wall abdominal
hernia is rare. About 15-20 cases have been reported so far. There is no
guideline to manage such cases. Management has to be individualized according
to the patient’s presentation. We report a case of incisional hernia containing
the gravid uterus with repeated excoriation of the overlying abdominal skin.
Introduction
Incisional hernia is an abdominal wall defect that occurs at
the site of previous surgical incision following breakdown in the continuity of
the fascia closure.[1] Incidence of incision hernia is about 11% in
abdominal laparotomies [2-3] and with wound infection incidence goes
up to 26%.[4] Gravid uterus though a rare content of the hernia sac
predisposes to serious complications like burst abdomen, preterm labor,
spontaneous abortion, accidental hemorrhage, intrauterine growth restriction,
dysfunctional labor, obstructed labor,uterine rupture and intrauterine fetal
death.[5-6] Initially these
hernias are reducible however as pregnancy advances or diagnosis is delayed the
gravid uterus is at a risk for incarceration and subsequent strangulation. [7,
8]
Case report
A 34-year-old second gravida para-1 (G2P1) presented at 24
weeks of gestation in emergency with omentum protruding through a thin shiny,
excoriated and discolored overlying skin on an anterior abdominal wall hernia.
She had a previous normal delivery 4 years back. On day 4 of that delivery she
developed sub acute intestinal obstruction due to ileo caecal tuberculosis
resulting in an ileal stricture. Exploratory laprotomy and ileo-ileal resection
anastomosis was done. Her post operative course was uneventful. She completed 9
months anti tubercular chemotherapy under direct observation. Six Months
following surgery she noted a swelling in her abdomen that would increase on
standing and decreases on lying down. She again consulted the surgeon for the
same and was diagnosed to have incisional hernia and was advised to continue
conservative management in form of abdominal binder and to undergo elective
mesh repair of the hernia after completion of her family. She conceived.
Examination revealed a midline vertical infraumbilical scar extending 3-4 cms
above umbilicus with a large hernial sac containing a 24-week-size gravid
uterus, which was drooping down up to her waist.
Figure 1 Gravid uterus in the incisional hernia
The fascial defect measured 15cm x 15 cm. Skin was
stretched, thin, shiny, discoloured with overlying ulceration and omentum
protruding through it.
Figure 2 Excoriation of the overlying skin. Arrow indicates
the site of the excoriation and the visible omentum
Figure 3 Excised prolapsed omentum
Figure 4 Sutures seen on the skin after surgical repair.
Uterus and the fetal parts were felt superficially. Uterus
was reducible. There was no evidence of strangulation. Surgeons evaluated her.
Ultrasonography (USG) of the abdomen was done. It showed a midline anterior
abdominal wall defect of size 10 cms suggestive of anterior abdominal wall
hernia with bowel, omentum and the gravid uterus as its content. All her blood
investigations were normal. Surgeons excised the prolapsed part of the omentum
and closed the skin defect under local anesthesia. The patient was discharged
next post operative day. She was advised to wear the abdominal binder regularly
and follow up weekly in the antenatal OPD. Again now at 33 weeks of gestation
the skin overlying the hernia underwent necrosis and through a defect of 7 mm
the omentum presented at the skin defect (Figure 2). Surgeons repeated the same
conservative surgical procedure. She is scheduled for elective cesarean section
with herniorraphy (mesh plasty) at 38 weeks of gestation.
Discussion
The usual contents of the abdominal wall hernia sac are
omentum and loops of small intestine. Herniation of gravid uterus through
abdominal wall is an uncommon but grave condition. Incarceration of the gravid
uterus with or without strangulation along with ulceration and excoriation of
the overlying skin and bleeding from the ulcerated area can lead to shock. [7,
8, 9] However, ulceration of overlying skin of the hernia sac without
incarceration or strangulation has also been reported. [10] Our case
presented similarly as her pregnancy advanced. Diagnosis of the above condition
is clinical and it can be confirmed on USG. In cases of doubt of strangulation
an MRI can be diagnostic. [10]
Management of incisional hernia in pregnancy in mainly
conservative, including manual reduction of hernia and use of abdominal binder
during antenatal period and labor. [1, 5, 9, 11] Elective cesarean
section is considered to be safest as the integrity of the weak anterior
abdominal wall and or the scarred uterus during vaginal birth is uncertain. [11]
Hernia repair can be done at the time of cesarean section or can be done at an
interval of 6-8 weeks. Post partum elective herniorrhaphy allows an optimal
repair as the overstretched abdominal wall skin can be fashioned to correct
dimension. Further the repaired abdominal wall is not subjected to mechanical
stresses of labor and there is no associated risk of wound disruption and
infections.[11] However, incarceration, burst abdomen or
strangulation will necessitate an immediate repair even in the antenatal
period. The pregnancy then grows to term. [12,13] Elective antenatal
hernia repair have been reported during
the 2nd and 3rd trimester of pregnancy with an outcome of
normal term vaginal delivery. [7,13]
However such approach is associated with significant risk of anesthesia
and surgical intervention during pregnancy. Moreover, the enlarged uterus
itself may hinder optimal herniorrhaphy, and further enlargement with advancing
gestation may disrupt the hernia repair. [6] In patients with very
large defect or in remote areas an alternative, intermediate method of
aggressive physiotherapy of abdominal wall muscles along with abdominal binder
can be offered.
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Citation