Ventral hernia containing a term gravid uterus: A rare challenge in surgical and obstetric management

Abstract

A 28-year-old woman at 34.5 weeks of gestation presented with an incarcerated ventral hernia containing the gravid uterus and overlying skin ulceration, one year after a cesarean section. Magnetic resonance imaging revealed a large infraumbilical defect with herniation of the uterus and small bowel. Given the risk of rupture and infection, an urgent cesarean delivery followed by primary abdominal wall repair without mesh was performed. Both maternal and neonatal outcomes were favorable. Gravid uterine herniation through an incisional defect is extremely rare and requires individualized multidisciplinary management, with primary repair being a safe option in contaminated or high-risk settings.

Introduction

Incisional hernia following abdominal surgery occurs in approximately 5%-15% of cases, being pregnancy an independent risk factor for the development of such hernias [1,2]. However, herniation of a gravid uterus through an incisional defect is an exceptionally rare event; at present, the literature describes only 21 cases of gravid uterine herniation through incisional hernias and 5 through umbilical hernias, of which 8 were complicated by incarceration, with or without strangulation [3]. We present an interesting case of an incarcerated gravid uterus herniation, as well as the diagnostic-therapeutic approach.

Case report

A 28 year old woman at 34.5 weeks of gestation with a medical history of hypothyroidism under levothyroxine replacement therapy and class III obesity, who developed a post-incisional ventral hernia secondary to a cesarean section performed 1 year and 7 months earlier. The hernia sac contained the gravid uterus and exhibited overlying skin ulceration (Fig. 1). Magnetic resonance imaging of the abdomen and pelvis revealed a large infraumbilical defect measuring 16 × 14 cm, with herniation of the uterus and small bowel loops (Fig. 2). In view of the high risk of cutaneous rupture, secondary infection, and obstetric complications, an urgent cesarean delivery followed by simultaneous abdominal wall reconstruction was performed (Fig. 3, Fig. 4, Fig. 5). A live female neonate was delivered, weighing 2460 grams and measuring 43.5 cm in length, with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, and a gestational age of 35 weeks as estimated by the Capurro method. The immediate postoperative course was uneventful, with satisfactory maternal and neonatal outcomes.

Fig. 1.

Large incisional hernia containing gravid uterus (A) and overlying skin ulceration (B).

Fig. 2.

Magnetic resonance imaging of the abdomen and pelvis revealed a large infraumbilical defect measuring 16 × 14 cm, with herniation of the uterus and small bowel loops. (A) Sagital view and (B) Axial view.

Fig. 3.

C-section is performed, hernia content with gravid uterus inside.

Fig. 4.

Primary closure of the aponeurosis with X-shaped sutures using Prolene 1.

Fig. 5.

Abdominal wall closure after resection of ulcerated skin.

Discussion

The occurrence of incisional hernias during pregnancy is rare, and their true incidence has not been clearly established, particularly in Western populations. Due to the scarcity of reported cases, standardized management guidelines are lacking, and therapeutic decisions are typically tailored to the condition of the mother, the fetus, and the stage of gestation [4].

On physical examination, a palpable defect in the abdominal wall may be identified, sometimes accompanied by a reducible or non-reducible mass and abdominal distension. In most cases, an abdominal ultrasound is sufficient to determine the contents of the hernial sac, while magnetic resonance imaging may be indicated when ultrasonography fails to provide a definitive diagnosis and planning surgical repair [5].

Herniation of the gravid uterus can result in serious maternal and fetal complications, such as intrauterine growth restriction, preterm labor, miscarriage, uterine rupture in the lower segment, and impaired placental perfusion leading to fetal demise. Progressive enlargement of the uterus within the hernial sac may increase intra-abdominal pressure, compromising blood flow to the overstretched skin and resulting in ulceration, necrosis, or even complete evisceration of the uterus. Extensive ulceration with significant bleeding can predispose the patient to anemia and hypovolemic shock. Uterine strangulation—most often occurring during the late second trimester—requires prompt hospitalization and delivery by cesarean section because of the high risk of maternal and fetal morbidity [6]

Gravid uterine herniation through an incisional defect is an exceptionally rare condition associated with significant maternal and fetal risks, requiring prompt multidisciplinary management. In this case, urgent cesarean delivery followed by primary abdominal wall repair without mesh was performed, with favorable maternal and neonatal outcomes. The decision to avoid mesh placement was based on the contaminated surgical field due to overlying skin ulceration and the increased risk of postoperative infection following delivery. Primary tissue repair offered a safe and effective alternative, achieving satisfactory anatomical restoration and uncomplicated recovery. This case underscores the importance of individualized management, emphasizing that primary repair without mesh may be appropriate in contaminated or high-risk obstetric settings.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.