Gravid uterus herniating through a large infraumbilical incisional hernia in a woman with previous caesarean sections: successful medical termination of pregnancy with multidisciplinary management – a rare case report

Abstract

Incisional hernia complicating pregnancy is exceedingly rare but potentially life-threatening. Herniation of the gravid uterus through an anterior abdominal wall defect creates unique obstetric and surgical challenges, particularly when the patient requests termination of pregnancy. Fewer than 50 such cases have been documented in world literature, most occurring in the third trimester. A 28-year-old multiparous woman (G4P2L2A1) at 12 weeks gestation presented with a large infraumbilical incisional hernia (defect 120×90 mm) through which the gravid uterus, bowel, and omentum were herniating, following two prior lower segment caesarean sections and a dilatation and curettage. She requested medical termination of pregnancy. A stepwise multidisciplinary protocol was adopted: mifepristone 200 mg orally, misoprostol 400 mcg vaginally (two doses), intracervical Foley catheter ripening (18 hours), and low-dose oxytocin augmentation. Manual reduction of the herniated uterus under ultrasound guidance preceded ultrasound-guided curettage. Histopathological examination confirmed complete evacuation of products of conception. Elective hernia repair by the General Surgery team completed definitive management. A systematic pharmacological and mechanical approach with prior manual uterine reduction can safely achieve medical termination of pregnancy in the setting of gravid uterine herniation, avoiding emergency laparotomy. Elective post-termination hernia repair is preferred. Multidisciplinary coordination and vigilant antenatal surveillance are essential in women with prior abdominal wall surgery.