A Uterine Fibroid Presenting as an Incarcerated Umbilical Hernia During Pregnancy

Introduction

Umbilical hernias comprise ∼5–7% of all primary hernias. ¹ An increase in intra-abdominal pressure, as in pregnancy or ascites, may cause a dilatation of the umbilical ring, which may lead to abdominal viscera herniation, especially in the presence of incomplete development or weakness of the umbilical ring.^1,2 The potential complications of herniation include rupture, incarceration, and strangulation. Incarceration and strangulation are considered relatively uncommon, but, when they do occur, these complications are responsible for 10%–20% of the indications for umbilical hernia repair. ²

Uterine leiomyomas (fibroids) are common benign smooth-muscle tumors. It is believed that up to 25% of women >35 years of age have fibroids. ³ The precise etiology is unknown, and they are known to increase in size during pregnancy as a result of estrogen stimulation. Large fibroids may contribute to complications during pregnancy and delivery. ³

A rare case of a fibroid in an incarcerated umbilical hernia in a pregnant woman is presented in this article.

Case

A 38-year-old woman in her third pregnancy at 33 weeks' gestation was admitted to the emergency department complaining of increasing abdominal pain and a palpable mass in the umbilical region during the last 24 hours. She had no other medical or surgical history, and, up to this point, had had an uncomplicated pregnancy. Physical examination showed a fixed 7-cm spherical mass in the umbilical region, which was painful on palpation and irreducible manually under analgesia. A consultation by an obstetrician showed no pathology for the fetus or the mother. The patient was taken to the operating room with the diagnosis of an incarcerated umbilical hernia.

The patient underwent an emergency operation under local anesthesia and sedation. An elliptic infraumbilical incision was made. A hernia sac was found originating from the umbilical ring, with a diameter of 2 cm at its neck. After mobilization and opening of the hernia sac, a large pedunculated fibroid was found originating from the anterior uterine wall, which was resected (Fig. 1). The hernia defect was repaired using the Mayo technique.

OPEN IN VIEWER

FIG. 1.

The anterior (A) and the posterior (B) surfaces of the fibroid after it was removed from the patient.

Results

The patient had an uneventful postoperative course and was discharged on the fourth postoperative day. Histologic examination of the resected specimen showed a uterine leiomyoma with no evidence of malignancy. The remainder of the pregnancy was reported to be normal. The patient proceeded to have a normal full-term pregnancy ending in vaginal delivery of a 2980-g male baby.

Discussion

Although the increase in intra-abdominal pressure caused by pregnancy may be a contributing factor to the development of umbilical hernias, ⁴ the incidence of fibroids during pregnancy is only ∼1–4%. ⁵ The majority of fibroids are asymptomatic and do not require operative treatment. ⁶ Although fibroids are estrogen-dependent, only a small percentage of them actually enlarge during pregnancy. ⁷ Symptomatic fibroids may cause menorrhagia, dysmenorrhoea, infertility, and pregnancy loss. ³

Umbilical changes during pregnancy are very common, but only a few of them progress to umbilical hernias. In this case, the fibroid appeared to have been trapped in the umbilical hernia and became symptomatic when it was stretched, as the pedicle of the fibroid moved cranially with the expanding uterus. Complications in pregnancy that may be related to fibroids include abdominal pain, miscarriage, premature delivery, intrauterine growth restriction, abruptio placentae, postpartum hemorrhage, fetal malpresentation, and increased necessity for a cesarean section. ⁷ Rarely, fibroids during pregnancy can cause uterine torsion, urinary retention, ureteric obstruction, and incarcerated inguinal hernias.^8–11 Ehigiegba and Selo-Ojeme reported a case of a 31-year-old woman at 28 weeks' gestation presenting with a fibroid in an incarcerated umbilical hernia, which was treated by myomectomy and hernia repair. ⁴

Wong reported the case of a 30-year-old woman at 32 weeks' gestation with a fibroid in an incarcerated umbilical hernia, which was reduced. The hernia was repaired. ¹² Uludag and colleagues reported a case of a 30-year-old woman in her 32nd gestational week with an incarcerated umbilical hernia that was mobilized and repaired by the Mayo technique. ¹³

Conclusions

This unusual case is the fourth reported presentation of a fibroid in an incarcerated umbilical hernia during pregnancy. Pregnancies associated with fibroids will be seen more frequently as the average childbearing age increases. Clinicians need to be aware of the complications that may arise in seemingly innocent hernias, in order to prevent potential complications. If the contents of the hernia sac cannot be reduced into the abdominal cavity easily, surgical intervention should be undertaken to prevent further obstetrical complications, such as premature births or spontaneous abortions.