Abstract
Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery.
Keywords: Pregnancy, Inguinal hernia, Ultrasound, Groin lump
Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery.
Case history
A 28-year-old woman was admitted acutely to hospital with a painful lump in her left groin. The patient was 20 weeks into an uncomplicated first pregnancy. She had first noticed the lump several days earlier and her pain had gradually increased in severity. The lump was most prominent when standing. There was no history of obstructive gastrointestinal symptoms. Her only past medical history was a previous laparotomy for a perforated appendix.
Examination revealed a soft, non-tender abdomen with a tender palpable lump approximately 5 cm in diameter in the region of the left inguinal canal. The lump was most noticeable on standing and appeared to reduce on lying flat. A provisional diagnosis of an inguinal hernia was made.
To confirm the diagnosis prior to consideration of surgery, an ultrasound scan of the left groin was performed. The scan revealed that the lump in fact corresponded with a leash of veins extending into the inguinal canal in keeping with round ligament varices (Fig. 1).
Figure 1.
Oblique ultrasound view showing a 2.5 cm by 1 cm cluster of low reflectivity varicosities extending into the left inguinal canal (marked by crosses).
The patient was re-assured and discharged from hospital. She was advised to seek medical help if the lump did not resolve after her pregnancy. Following delivery, however, the symptoms and lump resolved spontaneously.
Discussion
Pregnancy leads to pelvic vein dilatation which can extend to the veins draining the round ligament and inguinal canal causing round ligament varices. Whilst in part due to impingement of pelvic veins by the gravid uterus coupled with an increased circulating blood volume, the varices also relate to the action of increased progesterone levels in pregnancy on receptors within the round ligament veins.1
In all patients, a painful, tender groin lump requires prompt investigation to exclude the possibility of an underlying strangulated hernia. Whilst radiological imaging is available, the decision to proceed to surgical exploration is commonly based on clinical examination findings alone. Avoiding unnecessary surgery is important in all patients; however, it is of particular relevance in pregnant women due to the association of anaesthesia with additional risks to both mother and fetus.
Whilst clinical examination may be reliable in many patient groups, our case demonstrates that, in pregnant women, the features of round ligament varices may be indistinguishable from those of a symptomatic inguinal hernia. Round ligament varices may also mimic bilateral inguinal hernias.2 Grey-scale and colour Doppler ultrasonography is able to distinguish between the two diagnoses accurately.3 This differentiation is important, as the management of round ligament varices differs significantly from that of a symptomatic hernia. Surgical exploration of round ligament varices has been successfully performed;2 however, conservative management is recommended as the symptoms will usually resolve following delivery. There are, however, potential complications of round ligament varices that may require intervention. These include post-partum thrombosis4 and spontaneous rupture.5
Round ligament varices are a very important differential diagnosis in any pregnant woman presenting with a painful groin lump. With a tendency towards conservative management, failure to recognise this condition may lead to an unnecessary surgical risk to both mother and fetus. It is our opinion that the use of ultrasound should form part of the routine assessment of all acute groin lumps in pregnant women.
References
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