FULL-TERM PREGNANCY IN AN INCISIONAL HERNIA: AN UNCOMMONOCCURRENCE

---

E. Tagar^1,2, LA. Ehiagwina^1,2, OE. Oigbochie³, AG. Tagar⁴

1. Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Nigeria.
2. Department of Surgery, Ambrose Alli University, Ekpoma, Nigeria.
3. Department of Obstetrics and Gynaecology, Irrua Specialist Teaching Hospital, Irrua, Nigeria
4. Edo Specialist Hospital, Benin City, Nigeria.

Abstract

Introduction: Herniation of a full-term pregnancy is a rare event that poses risks for both mothers and babies. This condition can lead to lower uterine segment rupture and intrauterine foetal death.

Case presentation: We present a case of an incisional hernia with a full-termpregnancy. Despite initial plans for elective surgery, she presented in labour, requiring emergency laparotomy, caesarean delivery, and simultaneous hernia repair with successful outcomes for both the mother and baby.

Conclusion: Emergency laparotomy with caesarean delivery and simultaneous hernia repair is a feasible option for a gravid patient with incisional hernia in labour.

Keywords: Incisional hernia, Full-term pregnancy, Labour, Emergency laparotomy, Caesarean delivery, Hernia repair

Introduction

An incisional hernia is a common complication that occurs when there is a weakness in the abdominal wall at the site of a previous surgical incision.¹ This can happen after any type of abdominal surgery, but it is most common with midline and transverse incisions. The incidence of herniation is often increased by a caesarean section due to the pressure of the gravid uterus on the fascia and poor repair technique. This hernia may become noticeable months or even years after the initial surgery.² In most cases, the contents of a hernial sac are small bowel loops or omentum. Herniation of a pregnant uterus is rare, and full-term pregnancy in an incisional hernia is even rarer.³ The low occurrence of a pregnant uterus herniating through an incisional defect is due to the uterus being too large by the time it reaches the hernial defect.⁴ This condition poses serious risks to both the mother and the foetus. There may be potential complications such as incarceration, strangulation, excoriation, and ulceration of the overlying skin with bleeding.³ Management requires meticulous planning and individualized handling to achieve favourable outcomes. It depends on the severity of the condition and the stage of pregnancy.⁴ While some hernias can be managed conservatively, others may require surgical intervention. In uncomplicated cases, hernia repair can be done simultaneously with a planned caesarean section at term.⁴

CASE PRESENTATION
A 37-year-old woman, gravida 5, para 4, presented in labour at 37 weeks gestation. She had booked earlier at 22 weeks gestation but was not compliant with her antenatal visits. She had two previous caesarean deliveries for foetal distress and macrosomia 6 and 8 years prior, which were performed through a midline infraumbilical incision. Both babies were born alive and healthy. She developed a surgical site infection (SSI) after her last caesarean section, requiring daily wound dressing with povidone iodine for 4 weeks. Four weeks later, she noticed swelling at the surgical site that was reducible. She had no features of intestinal obstruction. On physical examination, she was afebrile, not pale, anicteric, and well-hydrated. Her pulse rate was 90 beats/minute, and her blood pressure was 120/70mmHg. Cardiovascular and respiratory examinations were normal. Abdominal examination revealed abnormal protuberant abdominal swelling, with hyperpigmentation and ulceration of the overlying skin, areas of excoriation, focal necrosis, and a broad infraumbilical incisional scar (Figure 1). A large fascial defect measuring 25×20 cm was found on the anterior abdominal wall, with the uterus herniating through it. The symphysio-fundal height was 37 cm, and the foetus was in a longitudinal and cephalic position within the herniated uterus. The patient, a grand multiparous woman, was diagnosed with a large incisional hernia. Blood tests were normal, and ultrasound confirmed uterine herniation with a live foetus in cephalic position and no apparent congenital anomalies.

She underwent an emergency laparotomy and a caesarean delivery of a live female neonate with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively, and a birth weight of 2.4 kg. The hernia was repaired using a double-breasting technique with nonabsorbable sutures, and the redundant, necrosed, and hyperpigmented skin was excised, and apposed with nonabsorbable suture (Figure 2). Her postoperative recovery was uneventful, and she was discharged in good condition with a healthy baby. She had no complaints at her follow-up visits.