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Rupture of a gravid uterus within an umbilical hernia.

The incidence of uterine rupture in pregnancy/labour in Sokoto, Nigeria, is one of the highest reported in the world literature, (1,2) while umbilical hernias occur more frequently in Africa than in the Western world. (3) We report a case of herniation of the gravid uterus into a longstanding umbilical hernia resulting in prolonged, obstructed labour and uterine rupture. We are unaware of any similar previous documentation despite review of the literature and a Medline search.

A 40-year-old woman (gravida 11, para 9 + 1) (4 alive)) presented at term with a 3-day history of labour pains. A few hours before presentation, she noticed frank vaginal bleeding. She did not receive orthodox antenatal care in any of her pregnancies, including the index one, and all her previous deliveries were at home. She first noticed the umbilical hernia during childhood, and it had been increasing in size since then. Three months before presentation the pregnant uterus descended into it and remained there.

Clinical examination revealed a slim, acutely ill-looking woman who had mild pallor, but was neither dehydrated nor febrile to touch. Her pulse rate was 140 beats per minute and blood pressure 130/90 mmHg. The respiratory rate was 28 cycles per minute and breath sounds were normal. Abdominal examination revealed a huge umbilical hernia with hypopigmentation and excoriation of the covering skin (Fig. 1). Fetal parts were easily palpable within the hernia; however, the lie and presentation were difficult to appreciate and the fetal heart could not be heard. On pelvic examination the vagina was found to be filled with blood clots, the cervix was 8 cm dilated and the presenting part could not be felt. An assessment of ruptured uterus with extrusion of the fetus into an umbilical hernia was made and she was prepared for emergency laparotomy.

[FIGURE 1 OMITTED]

The patient was resuscitated with normal saline infusion and intravenous antibiotics were started. An indwelling Foley's catheter was passed and 500 ml of bloody urine were drained. Her packed cell volume was 32%, urinalysis was negative for glucose and 4 units of compatible blood were made available for surgery. At laparotomy, a fresh, stillborn male fetus weighing 3.2 kg was found just beneath the skin incision on the inferior surface of the hernia (Fig. 2). There was an 8 cm-long, L-shaped rupture in the posterior aspect of the lower uterine segment; its long arm extended superiorly on the left to involve the upper segment. The uterus lay just posterior to the baby in the hernia. A total abdominal hysterectomy was done followed by repair of the anterior abdominal wall using Mayo's double-breasting (overlapping) technique. The postoperative period was uneventful.

[FIGURE 2 OMITTED]

Herniation of the gravid uterus into anterior abdominal wall hernias, including umbilical hernias, has previously been reported. (4,5) What makes our case unique is the patient's late presentation and the complications that consequently developed. Had she been seen during the antenatal period, conservative measures might have succeeded in spontaneous reduction of the hernia. Delivery would have been achieved by elective caesarean section, (5) with a better fetal and maternal outcome. In the absence of intervention in the antenatal period or in early labour, obstructed labour was inevitable owing to the acute angle between the uterine axis and plane of the vagina that the fetus was unable to negotiate.

The unusual features of this case did not delay the diagnosis of ruptured uterus or prevent appropriate treatment by resuscitation, laparotomy and total abdominal hysterectomy. Hysterectomy was performed owing to the site and extent of the rupture, risk of sepsis after prolonged labour, and ability to perform the procedure reasonably quickly. Ghatak1 also advocated the removal of the infected and torn uterus to reduce postoperative morbidity. Mayo's operation, double-breasting (overlapping) of the linea alba, was used for repair of the hernia. Although other forms of repair--Keel, da Silva--have been described, (6) these are less popular and now viewed as obsolete and of historical interest only. Abdominal wall repair was combined with emergency surgery for the ruptured uterus because the patient was judged to be in a fit condition to withstand both procedures during a single operation, to reduce the hazards of repeated general anaesthesia, and to avoid the cost of two procedures to a patient who had limited financial resources.

The extension of effective and affordable medical care, including obstetric services, to all communities is required to reduce the incidence of umbilical hernia, (5) facilitate its early treatment, and prevent the occurrence of life-threatening conditions such as ruptured uterus. (1,2)

References

(1.) Ghatak DP. Rupture of the uterus: A review of 146 cases. Trop J Obstetr Gynaecol 1989; 6: 41-44.

(2.) Ekele BA, Audu LR, Muyibi S. Uterine rupture in Sokoto, Northern Nigeria--are we winning? Afr J Med Sci 2000; 29:191-193.

(3.) Darko R. Hernia (excluding diaphragmatic hernia). In: Badoe EA, Archampong EQ, da Rocha-Afodu JT, eds. Principles and Practice of Surgery Including Pathology in the Tropics. 3rd ed. Tema: Ghana Publishing Corporation, 2000: 482-502.

(4.) Adetoro OO, Komolafe F. Gravid uterus in an umbilical hernia--a report of two cases. Cent Afr J Med 1986; 32: 248-251.

(5.) Malhotra M, Sharma JB, Wadhwa L, Arora R. Successful pregnancy outcome after Caesarean section in a case of gravid uterus growing in an incisional hernia of the anterior abdominal wall. Indian J Med Sci 2003; 57:501-503.

(6.) Devlin HB. Management of Abdominal Hernia. 1st ed. Oxford: Butterworth, 1988: 140-145.

L R AIREDE

D C NNADI

M GANA

Department of Obstetrics and Gynaecology Usmanu Danfodiyo University Teaching Hospital Sokoto Nigeria

J N LEGBO

Department of Surgery Usmanu Danfodiyo University Teaching Hospital Sokoto Nigeria
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Article Details
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Title Annotation:Case report
Author:Airede, L.R.; Nnadi, D.C.; Gana, M.; Legbo, J.N.
Publication:CME: Your SA Journal of CPD
Article Type:Case study
Geographic Code:6SOUT
Date:Jun 1, 2007
Words:938
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