Herniation of Gravid Uterus: Report of 2 Cases and Review of Literature

Abstract

Anterior abdominal wall hernias are uncommon, and herniation of a gravid uterus into these hernias is even rarer. Although reducible initially, the herniation of pregnant uterus may be complicated by incarceration and subsequent strangulation within the hernial sac, late in the course of pregnancy. There is no consensus over the management of this rare condition. Each case should be individualized. If uncomplicated, a conservative approach until term followed by delivery and herniorrhaphy is a good option. Here, 2 cases of herniation of gravid uterus into the anterior abdominal wall are described along with a brief review of literature pertaining to its presentation, complications, and management.

Introduction

Anterior abdominal wall hernias are uncommon in pregnancy; herniation of gravid uterus through the abdominal wall is an even rarer and potentially serious condition due to its antecedent complications.[1,2] It is usually associated with umbilical or incisional hernia of the anterior abdominal wall. Initially, these hernias may be reducible, but delay in recognition of this condition can lead to incarceration and subsequent strangulation of gravid uterus.[3,4] Approximately 10 cases of gravid uterus in incisional hernia and 5 cases of gravid uterus in umbilical hernia have been reported in the world literature, of which 8 developed incarceration with or without subsequent strangulation.[1–14] We, herein, report 2 cases, 1 uncomplicated and 1 incarcerated, of herniation of gravid uterus in an incisional abdominal hernia as well as a brief review of literature.

Report of Cases

Case 1

A 28-year-old third gravida para-2 (G₃P₂₀₀₂) presented with an overdistended abdomen and pendulous belly at 30 weeks of gestation. Although her antenatal period was so far unsupervised, her general condition and fetal growth were satisfactory. Her obstetric history revealed a term vaginal delivery 5 years back and a lower-segment cesarean section (LSCS) 2 years back, done for suspected cephalopelvic disproportion and thick meconium-stained liquor. Although apparently she had not developed an obvious incisional hernia, she had a history of postoperative wound infection, which was managed with daily dressings and antibiotics without secondary suturing.

Examination revealed a midline vertical infraumbilical scar with a large hernial sac containing a 30-week-size gravid uterus, which was dropping down up to midthighs (Figure 1). Skin looked stretched, thin, and shiny but no ulceration or excoriation was observed. Uterus was easily palpable. Uterus was irreducible through hernia, but there were no features suggestive of strangulation. Patient has been admitted to the hospital since 30 weeks in view of irreducible (incarcerated) uterus through hernia and kept under supervision to look for any evidence of strangulation-like pain in the abdomen.

Figure 1.

Lateral view of the gravid uterus lying in an incisional hernia.

Her hemoglobin and urine were normal. Her VDRL test for syphilis was nonreactive. Ultrasonography at 35 weeks of gestation revealed polyhydramnios (amniotic fluid index = 25 cm), fundal implantation of placenta, and no obvious congenital malformation. It also showed uterus herniated in the incisional hernia of the anterior abdominal wall. Her glucose tolerance test was performed in view of polyhydramnios. Glucose tolerance test with 100 g glucose revealed normal plasma sugar (fasting sugar = 86 mg%, first hour = 142 mg%, second hour = 135mg%, third hour= 108 mg%). The patient was monitored for any evidence of strangulation-like pain in the abdomen and vomiting. A biophysical profile was done every week.

An elective LSCS with herniorrhaphy was performed at 38 weeks in view of the incarcerated uterus and cephalopelvic disproportion. Gravid uterus was reduced through the hernial ring by incising the hernial sac, and an LSCS with bilateral tubal ligation was performed. She delivered a male baby of 3.4 kg with APGAR score of 7 and 9 at 1 and 5 minutes, respectively. There was no evidence of rectus sheath in the vicinity of incision. Anatomical repair (suture repair) of the sheath was done with 1-0 nylon running locking suture, and prolene mesh was also placed anterior to the rectus sheath as the defect was quite big and the sheath was weak. Several stay sutures were placed with 3,0 prolene to affix the mesh to the rectus sheath. Redundant skin and subcutaneous tissue were excised and skin was sutured (Figure 2). An abdominal binder was used in the postoperative period. The patient received ampicillin for 7 days, and her postoperative period was uneventful. Stitches were removed on the 12th postoperative day in view of big hernial repair, and both mother and the infant were discharged on the 13th postoperative day. Both the patient and her baby were doing well at the 6-week follow-up visit, and no complications were noted at the 9-month follow-up examination.

Figure 2.

Abdominal scar after surgery.

Case 2

A 26-year-old gravida 4 para2 with no live issue (G₄P₂₀₁₀) presented with similar herniation of gravid uterus through an incisional scar at 28 weeks of gestation. The patient had a poor obstetric history and controlled noninsulin-dependent diabetes mellitus for the last 2 years. She had undergone LSCS twice previously with apparently normal postoperative periods. There was no history of incisional hernia between pregnancies. Examination revealed midline vertical scar with reducible herniation of gravid uterus. Skin was stretched and thin. Uterus and fetal parts were easily palpable, as was the hernial sac. There was no history of pain, tenderness, or ulceration in the abdomen. She was on insulin during this pregnancy. Her fasting and postprandial sugar, hemoglobin, and urine routine investigations were normal. Her VDRL tests for syphilis and HbsAg were nonreactive. Obstetric ultrasound revealed a normal growing fetus without any obvious congenital malformation, normal amniotic fluid levels, and the herniation of uterus was in an incisional hernia. The patient was admitted at 34 weeks in view of her obstetric history. Fetal biophysical profiles were performed every week beginning at 34 weeks. Blood sugar levels were also monitored every week and were controlled. Progress of her gestation until the time of delivery was uneventful, without any features suggestive of incarceration or strangulation.

An elective LSCS was performed at 38 weeks and 3 days with an indication of the previous 2 cesarean sections. The gravid uterus was reduced through the hernial sac before making an incision on the uterus. She delivered 3.2-kg male baby with APGAR score of 9 at 1 minute and 9 at 5 minutes. Operative findings revealed a partially reducible gravid uterus and a few loops of bowel within the hernial sac. Anatomic hernial repair (suture repair) was also conducted after the delivery of the child. However, mesh was not required in this case as deficiency of the rectus sheath was smaller than that described in the previous case, and the sheath was not weak. An abdominal binder was provided for the postoperative period. Her postoperative period was uncomplicated. She received ampicillin and gentamicin for 7 days because of her diabetes. Stitch removal was done on the 11th postoperative day in view of her diabetes and previous 2 LSCSs. She was discharged on the same day. She and her child were doing well on 6-week follow-up visit, and no recurrence of hernia was noted at a 14-month follow-up examination.

Discussion

The importance of abdominal hernias in relation to pregnancy is perhaps not sufficiently understood because of their infrequent occurrence. They do, however, occasionally become a real obstetric problem, when complications like herniation of gravid uterus leading to incarceration, strangulation, or burst abdomen develop.[1–4,11] Herniation of gravid uterus is probably rare because of the fact that by the time the uterus reaches the level of hernial aperture, it is usually too large to enter the hernial sac.[5] Careful management is necessary due to potential complications like spontaneous abortion, preterm labor, accidental hemorrhage, intrauterine fetal death, and rupture of lower uterine segment during labor.[1–5] An infrequent but more serious complication is incarceration of gravid uterus with or without strangulation along with ulceration and excoriation of the overlying skin and bleeding from the ulcerated area leading to shock.[1–6,13] However, ulceration of overlying skin on the hernial sac without incarceration or strangulation has been reported.[7]

Herniation of gravid uterus has been reported sporadically as incisional hernia and umbilical hernia of pregnancy. A search of the literature reveals only 15 reported cases of anterior abdominal wall hernias complicated by pregnancy, of which 8 developed incarceration with or without subsequent strangulation.[1–4,6,8–10] Cases with variable onset of herniation at gestation ranging from 4 to 8 months have been reported in the literature.[1,7,11,13]

Cesarean section accounted for most of the incisional hernia, accounting for 3.1% of all cesarean sections.[14] The incidence of incisional hernia was influenced by midline vertical incision, the need for additional operative procedures, more potent and higher quantities of antibiotic administration, postoperative abdominal distension, intraabdominal sepsis, residual intra-abdominal abscess, wound infection, wound dehiscence, postoperative fever, and abdominal incision of previous cesarean section healing with secondary intention.[1,2,5,15] There was infection in the first case. However, the previous 2 midline vertical weak scars from previous cesarean sections in the second case may be implicated for hernia. Diagnosis of a gravid uterus in an incisional hernia is made by the history of hernia between pregnancies, presence of an unusual bulge of the abdomen with stretched skin,[5,9] and easily palpable uterus and fetal parts.[7,12] Imaging studies like ultrasound and magnetic resonance imaging can also assist in diagnosis.[7,4] In our case, we made the preliminary diagnosis by clinical examination, and it was confirmed using ultrasound. The uterus was easily palpable in both cases, and fetal parts were easily palpable in the second case. Because of polyhydramnios, fetal parts were not palpable in the first case. Similarly, possible factors associated with incarceration and strangulation are advancing age of gestation, polyhydramnios, and twin pregnancy.[2] If there is incarceration, the uterus would be irreducible without any other symptoms; if there is strangulation, the patient can have severe abdominal pain and vomiting.[2,3] Fortunately, the first patient never developed the features of strangulation, and the second patient did not develop incarceration, even late in the course of pregnancy.

Recurrence of hernia in subsequent pregnancies has also been described in 1 patient, in whom 3 consecutive pregnancies were managed successfully with use of abdominal binder but the fourth pregnancy was complicated by incarceration, strangulation, and ulceration of the overlying skin, culminating in cesarean section.[3]

The management of these pregnant patients with incisional hernia poses a dilemma as no consensus approach has been described. A conservative approach, including manual reduction of hernia and use of an abdominal binder during the antenatal period and labor, has been applied with varying success.[1,3,5,13] Surgical intervention in the form of antenatal hernial repair in the second and third trimesters has also been undertaken in 2 patients by carrying the pregnancy to term and allowing for normal vaginal delivery.[2,3] This approach, however, is associated with a 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.[5] Strangulation at or near term appears to be a genuine indication for early hospitalization and elective cesarean section, possibly combined with hernial repair, which has successfully been applied in 2 patients.[3,5] If the uterus is strangulated early in pregnancy, immediate repair should be undertaken and pregnancy may be successfully taken to term.[2,13] Normal vaginal delivery has been accomplished in pregnant patients with uterus lying in a hernia.[2,13] It may not be feasible to perform LSCS in some patients due to unusual shape and contour of the uterus and an inapproachable lower segment; for these patients, a classic approach may be easier.[3,4] However, in our cases, access to the lower segment was not difficult. The uterus could have been reducible initially in the first patient, but development of polyhydramnios may have played a role in making it irreducible and thus incarcerated. Fortunately, the first patient never developed the features of strangulation and the second patient did not develop incarceration, even late in the course of pregnancy.

Great care must be taken to avoid injuring any vital structures during incision of the abdomen, such as the small or large bowel, as it can be contained in the hernial sac, and the skin and peritoneum covering it may be very thin.[16] There were few loops of bowel present in the hernial sac in second case.

Many studies in the literature have focused on the role of type of repair, mesh repair vs suture repair (without mesh), in patients with hernias. Among patients with midline abdominal incisional hernias, mesh repair is superior to suture repair in preventing recurrence of hernia, regardless of the size of the hernia.[17,18] In our case, mesh was applied in the first case as the defect was very large and the sheath was weak. Suture repair was performed in the second case in view of the small defect; however, mesh repair should have been done in this case also. Fortunately, none of our patients experienced recurrence. The role of abdominal binder during the postoperative period is not known. However, in our experience, we used abdominal binder during the postoperative period in a case of hernia repair with good results. It probably promotes healing as it prevents excessive tension on the site of repair.

Conclusion

It appears from the current literature review that the management of pregnant patients with uterus lying in incisional hernia needs to be individualized depending upon the severity of complications and the gestational age at presentation. Diagnosis is mainly based on history, clinical examination and ultrasound examination. Conservative management until term is recommended, and herniorrhaphy should be postponed until after the delivery as optimum repair is not possible during the antenatal period because of gravid uterus. But if strangulation of the uterus occurs at or near term, emergency laparotomy cesarean delivery followed by repair of hernia may be the best option.

If the uterus is strangulated early in pregnancy, immediate repair should be undertaken and pregnancy may be taken to term. Incisional hernia during pregnancy is not an indication for cesarean section per se. Mesh repair is superior to suture repair in preventing the recurrence of hernia, regardless of the size of the hernia. Abdominal binder can be used postoperatively. Complications can occur, but a successful pregnancy can be achieved with conservative management, as in the cases presented here.