Kathryn Shaia and Christine R. Isaacs
History of present illness
A 34-year-old gravida 2, para 2 woman presented to the emergency room with complaint of severe, acute-onset lower abdominal pain (described as 10 out of 10 on the pain scale) associated with severe nausea and vomiting. The patient notes that for the previous two days she had some intermittent lower abdominal pain, but was able to do her normal activities including caring for her newborn. The pain is now constant and stabbing, and she describes it “worse than any labor pains.” She denied fevers, chills, or dysuria. She reported no flatus or bowel movements in over 36 hours.
Two weeks earlier she had a successful planned vaginal birth after Cesarean (VBAC). She presented in spontaneous labor and had a normal labor course with an epidural.
Following three hours of pushing, she had an uncomplicated vaginal delivery with spontaneous delivery of the placenta. The patient’s postpartum course was unremarkable and she was discharged home on postpartum day 2 with the usual precau- tions. At time of discharge, her abdominal examination noted a firm fundus at the level of the umbilicus with no other abnormalities.
Three years earlier she had undergone Cesarean delivery for second-stage arrest. She had no other prior surgeries. Her medical history was unremarkable. Her only medications were ibuprofen and a prenatal vitamin.
Physical examination
General appearance:Generally well-nourished and healthy woman but in marked distress
Vital signs:
Temperature: 37.0°C Pulse: 100 beats/min
Blood pressure: 132/92 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 98% on room air HEENT:Unremarkable
Neck:Supple
Cardiovascular:Regular rate and rhythm without rubs, murmurs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:A well-healed Pfannenstiel surgical scar was noted in lower abdomen from the previous Cesarean. There
was moderate distension throughout the lower abdomen with diffuse lower abdominal tenderness. Rebound and guarding was noted bilaterally. Bowel sounds were high-pitched. No palpable masses were appreciated, but examinationfindings were limited due to the patient’s extreme discomfort
Pelvic:External genitalia normal. The uterus wasfirm, minimally tender and was palpable at the level of the pubic symphisis
Rectal:Normal tone. No masses
Extremities:No clubbing, cyanosis, or edema Neurologic:Nonfocal
Laboratory studies:
WBCs: 15 200/μL (normal 3500–12 500/μL) Neutrophils: 82% (normal 50–70%)
Hemoglobin and electrolyte levels were normal
Imaging:CT scan of the abdomen and pelvis was obtained (Fig. 47.1)
How would you manage this patient?
The patient has a strangulated hernia causing a small bowel obstruction. The abdominal/pelvic CT shows a midline ventral hernia through the rectus abdominis muscles in the lower abdomen/pelvis with small bowel findings concerning for a
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 47.1Axial CT image through the pelvis at the level of the iliac crest after administration of intravenous and oral contrast.
closed-loop obstruction. The arrows inFig. 47.1highlight the fascial defect revealing the closed loop of small bowel entering and exiting through the strictured area. There is no contrast visualized within the contained small bowel and surrounding colon, reflecting the obstructive process.
The general surgery service was consulted and the patient underwent emergent exploratory laparotomy with repair of an incarcerated ventral hernia and small bowel resection with primary reanastomosis. The abdomen was entered through the previous Pfannenstiel surgical incision until the incarcer- ated segment of small intestine was encountered. The fascia around the defect was widened and an end-to-end bowel reanastomosis was performed followed by fascial closure.
There were no intraoperative complications. Surgical path- ology confirmed small bowel with ischemic mucosa.
The remainder of the patient’s postoperative/postpartum course was unremarkable. By postoperative day 3, she was tolerating a general diet, was afebrile, and met criteria for discharge.
Strangulated hernia and vaginal birth after Cesarean
An abdominal wall hernia is an abnormal protrusion of a peritoneal-lined sac through the musculo-aponeurotic covering of the abdomen. Umbilical and para-umbilical hernias are up to five times more common in women, and pregnancy is thought to be a significant risk factor. Things that increase the intra-abdominal pressure, such as intense muscu- lar exertion, may produce a hernia by stretching the abdominal musculature. Obesity is another factor in hernia development as adipose tissue separates muscle bundles and weakens aponeuroses [1].
An incarcerated hernia is one that cannot be reduced. If the blood supply to the incarcerated bowel becomes com- promised, the hernia is then described as strangulated, and the ensuing ischemia may lead to infarction, obstruction, and perforation [2]. A closed-loop obstruction indicates that a segment of intestine is obstructed both proximally and dis- tally. In such cases, the accumulating gas and fluid cannot escape either proximally or distally from the obstructed seg- ment. Closed-loop obstruction leads to a rapid rise in luminal pressure, rapid progression to strangulation, and is a surgical emergency.
Patients may present with nausea, vomiting, colicky abdominal pain, and obstipation. Vomiting is a more promin- ent symptom with proximal compared to distal intestinal obstructions [2]. On physical examination, marked abdominal distention is typically present, but may be absent if the obstruction is in the proximal small intestine [2]. Bowel sounds will initially be hyperactive and become hypoactive over time. Laboratory findings typically reflect intravascular volume depletion with an elevated blood urea nitrogen (BUN).
Patients may have an increased lactate dehydrogenase (LDH)
due to bowel ischemia, and a mild leukocytosis is common [2].
In the setting of an acute abdomen, CT scanning is the test of choice as it can detect the presence of a closed-loop obstruction and strangulation [2]. If this patient’s hernia had been redu- cible and lacked obstructive symptoms, her surgery may have been managed electively rather than emergently.
Incisional hernia formation through a Pfannenstiel incision after Cesarean delivery has reported rates from 0 to 3.1% [3]. Factors that significantly contribute to the develop- ment of an incisional hernia include a history of abdominal distension, intra-abdominal sepsis, wound infection or dehis- cence, and postoperative fever. While there is limited data specific to hernia formation after Cesarean, one Nigerian study of 701 women who underwent Cesarean concluded that patient age, parity, and indication for Cesarean did not sig- nificantly influence the development of post-Cesarean inci- sional hernia formation [4]. The ability to generalize the results of this retrospective study conducted in a limited resource setting to settings with more extensive resources is uncertain.
The American College of Obstetricians and Gynecolo- gists Practice Bulletin on VBAC recommends that a Trial of Labor after Cesarean (TOLAC) be offered to most women with a history of one prior low transverse Cesarean delivery [5]. Providers must weigh the risks and benefits of a TOLAC versus a repeat Cesarean while considering the patient’s obstetrical issues and personal birth plans. This case describes an incarcerated hernia after VBAC, a rare compli- cation that should not alter counseling expectant mothers about TOLAC. Our patient, having had a proper surgical repair of the ventral hernia, remains a good candidate for a future TOLAC.
Key teaching points
Umbilical and para-umbilical hernias are up tofive times more common in women, especially in
those who are pregnant, obese, or undergoing physical strain.
Postoperative abdominal distension, intra-abdominal sepsis, wound infection or dehiscence, and
postoperative fever may contribute to incisional hernia formation.
A patient with a strangulated hernia causing a small bowel obstruction may present with abdominal distention, vomiting, paroxysmal abdominal pain, and inability to pass flatus and stool. CT scan of the abdomen and pelvis is the imaging test of choice.
Incisional hernia formation through a low transverse Pfannenstiel incision after Cesarean has reported rates from 0 to 3.1%. Patient age, parity, and indication for Cesarean section have not been shown to significantly influence the development of post-Cesarean incisional hernias.
References
1. Dabbas N, Adams K, Pearson K, Royale GT. Frequency of abdominal wall hernias: is classical teaching out of date?
J R Soc Med Sh Rep2011;2:1–6.
2. Tavakkolizadeh A, Whang EE, Ashley SW, Zinner MJ. Small intestine. In Brunicardi FC, Andersen DK, Billiar TR, et al., eds.Schwartz’s Principles of Surgery, 9th edn. New York, McGraw-
Hill, 2010. Available athttp://www.
accessmedicine.com.proxy.library.vcu.
edu/content.aspx?aID=5017621.
3. Luijendijk RW, Jeekel J, Storm RK, et al.
The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment.Ann Surg 1997;225(4):365–9.
4. Adesunkanmiv ARK, Faleyimu, B.
Incidence and aetiological factors of
incisional hernia in post-Caesarean operations in a Nigerian hospital.
J Obstet Gynaecol2003;23(3):
258–60.
5. American College of Obstetricians and Gynecologists. Vaginal birth after previous Cesarean delivery. Practice Bulletin No. 115.
Obstet Gynecol2010;116:
450–63.
Case 47: Acute abdominal pain two weeks after successful vaginal birth after Cesarean