Incarcerated Gravid Uterus in an Incisional Hernia

Introduction

It has been frequently reinforced during medical discussions and teaching sessions that the eyes do not see what the mind does not know. It is perhaps equally important to realize that when eyes do see something that a mind does not know, it is time to search and interact with minds that do know. When the lady who is the focus of this case study walked into the antenatal clinic, the resident doctor was completely bewildered as to what the abdominal “lump” was that was found on clinical examination. The lady had a history of amenorrhoea and fetal heart sounds could be heard on auscultation. The question the doctor asked is: “Is this an abdominal pregnancy?” That is a pregnancy that is outside the uterus. A search on the internet not only helped us to establish a diagnosis it also enabled us predict complications and manage the patient. We feel we owe it to our colleagues to share our experience with them.

Why did we write it up:

• 1.

  Incarceration of gravid uterus is a rare complication of an incisional hernia but can be diagnosed easily if one is aware.

• 2.

  There are predictable but preventable complications so it is important to add to the information and case reports available in published literature.

• 3.

  There are no established management guidelines for such rare conditions; however, reported cases form a good database for taking treatment decisions.

• 4.

  With a rising rate of caesarean deliveries the world over, we may come across this condition more often, especially in the resource poor settings with prevalent malnutrition and high wound infection rates.

Case Details

A thirty year old lady presented to antenatal clinic of our hospital in the seventh month of her pregnancy. She complained of discomfort in her lower abdomen and was concerned about the peculiar pendulous shape of her abdomen which had developed during the previous two weeks. She could perceive fetal movements well. There was no associated vaginal discharge and she had no symptoms of urinary or bowel conditions.

The lady belonged to the lower socioeconomic class and came from a nearby village in central India. She had not received antenatal care anywhere except for the tetanus booster vaccination and iron supplementation tablets provided by the health care worker of her village. (The local health care workers in villages include the Auxiliary Nurse Midwives (ANM) in addition to a woman from the village community called the ‘Anganwadi’ worker. They pay home visits to pregnant women for distribution of iron tablets and for tetanus immunization.)

This was her fifth pregnancy. She had had two normal vaginal deliveries 12 and 9 years prior to this pregnancy. She subsequently had a term delivery by caesarean section about eight years ago. Sadly the child died soon after birth. There were no health records and the patient could not tell us the reason for the caesarean delivery or the cause of neonatal death. Postoperatively, she developed skin wound infection that was managed conservatively. In the following months she became aware of an abnormal bulge (the incisional hernia) in the lower abdomen but did not seek medical help. She went on to have an uneventful pregnancy and normal vaginal delivery (Vaginal Birth After Caesarian or VBAC) about 6 years ago. So she had three living children.

Following the last delivery, she got concerned about the persistent abdominal bulge. She underwent a surgery for repair of incisional hernia about 5 years ago at another centre but it failed and she noticed recurrence of hernia within three months of repair. She did not follow up at that centre or elsewhere for hernia recurrence.