Volume 1 Issue 3, March 2014

Parulekar SV

Leiomyoma in a Bicornuate Uterus
Valvi D, Parulekar SV.

Yadav P, Warke HS, Gupta AS.

Epulis of Pregnancy
Desai R, Jangid N, Sharma R, Mirdha K.

Broad Ligament Lipoma
Rathi N, Gupta AS.

Atypical Mullerian Anomaly
Munge A, Satia M, Panchbudhe S, More V, Mali K.

Recurrent Uterine Rupture
Mali K, Panchbudhe S, More V, Satia M.

Excision of Hemihematometra
Parulekar SV


Parulekar SV

We are happy to present the March 2014 issue of the journal. In this issue we have eight unusual case reports - an even mix of obstetrics, gynecology, oncology, and imaging. Mullerian anomalies continue to make their mark at our center, and there are three of them in this issue. There is an unusual Mullerian anomaly of complete uterine septum, with duplicated cervix and longitudinal vaginal septum in a patient who presented with primary infertility. There is another one with a large leiomyoma in one horn of a bicornuate uterus. There is also a new operative technique for excision of a hemihematometra. With early antenatal registration and good antenatal care, obstetric mishaps have become rare. But a few patients do continue to present with complications like obstructed labor and uterine rupture. There is a case of insuperable pelvic obstruction due to a giant fecolith, and another one of spontaneous rupture in a primigravida, which was followed by a rupture in the next pregnancy. There are two other interesting cases - one is of a term gravid uterus in a complicated ventral hernia and the other of an endometrial stromal sarcoma. There is also a first of its kind - removal of a broad ligament lipoma vaginally during a vaginal hysterectomy. I hope the articles prove useful and enjoyable to our readers.

Leiomyoma in a Bicornuate Uterus

Author information
Valvi Durga*, Parulekar SV**
(*Assistant Professor, ** Professor and Head. Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


A 36 years unmarried female was presented with distension and chronic pain in abdomen which was more acute during menses. CT scan showed left sided broad ligament fibroid with right fused ectopic kidney, absent left kidney and both ureters on the same side. On exploration there was evidence of bicornuate uterus with fibroid in the left horn.  Removal of left horn of bicornuate uterus was done.


Abnormalities in the formation or fusion of the mullerian duct results in a variety of anomalies of the uterus and vagina. Mullerian anomalies are commonly associated with renal, spinal, cloacal anomalies.[1]  There is particular association of unilateral renal agenesis or ectopia, uterine duplication or unicornis, and vaginal agenesis.[2] The incidence of mullerian duct anomalies ranges from 0.5 to 5%. Bicornuate uterus results from incomplete fusion of uterovaginal horns at the level of the fundus and are thought to represent 25% ( range 10-39% ) of mullerian duct anomalies.[5,6] According to American Fertility Society, bicornuate uterus is class 4 mullerian anomaly.[2] The renal anomalies are always ipsilateral to rudimentary horn. Cytogenetic abnormalities in the form of spontaneous chromosomal rearrangements are known to occur in uterine leiomyomas. These chromosomal arrangements may be responsible for the initiation and progressive growth of the leiomyomas.[3] The possible reason for this uncommon occurrence could be a decreased concentration or sensitivity of the estrogen receptors or a lesser genetic predisposition for the clonal chromosomal abnormalities that are observed in women with normal uterus with leiomyomas.[3] Hysterosalpingography, hysteroscopy, laparoscopy, pelvic ultrasonography (USG) using the convex abdominal and transvaginal probes, computerized tomography and magnetic resonance imaging of the pelvic organs are increasingly being used as diagnostic modalities. MRI is the standard method for imaging uterine anomalies. It provides high-resolution images of the uterine body, fundus, and internal structure. In addition, it can help evaluate the urinary tract for concomitant anomalies.[4]

Case Report

A 36 years unmarried was woman presented with distension and pain in abdomen for 7-8 months. It was continuous, mild, in both lumbar region and iliac fossae, aggravated during menses. Her menses were regular. She had a history of kyphoscoliosis and right hip arthropathy. On examination she had a normal female body contour and normal secondary sexual characteristics. General and systemic examination showed no abnormality. On abdominal examination there was a nontender, and relatively fixed lump of the size of approximately 24 weeks of gestation. External genitalia were normal. Speculum vaginal examination showed no abnormality. Bimanual pelvic examination showed the cervix to be continuous with the abdominal mass. Her hemogram, blood sugar levels, renal and liver function tests were normal.  CT scan report was suggestive of left sided broad ligament leiomyoma, right ectopic fused kidney, and both ureter on the right side. Both ureters were catheterized prior to an exploratory laparotomy, so as to localize and safeguard them during surgery. The ureters were found to be on the right side that of the malrotated kidney crossing over the normal one as shown in figure 1.

Figure 1. Plain radiograph of the abdomen and pelvis, anteroposterior view. Two ureters are seen on the right side, the lower ureter belonging to the malrotated left kidney crossing the right ureter from lateral to medial side.

A bicornuate uterus with a leiomyoma in the left horn was found during laparotomy (figure 2). The leiomyoma measured about 18 cm in diameter and was wedged in the pelvis. However it could be lifted out of the pelvis. Left hemi-hysterectomy was done. A myomectomy was not performed because the right horn was well developed, and was more likely to carry a pregnancy to term or near term than a reconstructed but scarred left horn.  The ureteric catheters were removed after the operation.  She made an uneventful recovery. Histopathological examination showed leiomyoma with myxoid degeneration.

Figure 2. Leiomyoma in the left horn of a bicornuate uterus.


There are few cases of leiomyoma in mullerian anomalies reported in the literature. Most of theses presented with increasing dysmenorrhea, unilateral mass, and pain in abdomen, as did our patient. Usually the diagnosis is not made clinically, because of its low incidence. Cases of leiomyoma in bicornuate uterus has been reported previously.[7,8]  Occurrence of a leiomyoma in mullerian anomalies is rare, the possible reason for this uncommon occurrence could be a decreased concentration or sensitivity of the estrogen receptors or a lesser genetic predisposition for the clonal chromosomal abnormalities that are observed in women with normal uterus with leiomyomas.[3] If the degree of separation of the two horns is large, the leiomyoma can be relatively mobile. When mobile, the leiomyoma is mistaken for a subserous pedunculated leiomyoma, and when fixed, a broad ligament leiomyoma. If the horns are not widely separated, a leiomyoma in one of the horns may be mistaken for one in the lateral wall of a normal uterus. If it is lower in position in such a situation, it may be mistaken for a broad ligament leiomyoma. If it is in one of two widely separated horns of a bicornuate uterus, but is very large, it may be impacted in the pelvis and may be mistaken for a broad ligament leiomyoma. In the case described, the leiomyoma was of this last type. It may be missed on USG, but is usually diagnosed on CT or MRI. The diagnosis was missed in our patient on USG, because the endometrial cavity of the affected horn was not visualized. It was missed even on CT scan. It is important to make the diagnosis of mullerian anomalies accurately in view of the high risk of associated anomalies like spinal, renal and cloacal anomalies.[1] However it is not practical to perform a CT or MRI in every case of leiomyomas, because that would not be cost effective as a large number of such scans would have to be performed in order to pick up one case. Furthermore, a laparotomy would be required irrespective of the diagnosis, and surgical approach to the removal of the leiomyoma could be decided based on the findings without any deficiency in the results. Hence we do not recommend CT or MRI for patients with uterine leiomyomas. Leiomyoma usually undergo hyaline degeneration but our patient had myxoid degeneration.


1.      John A Rock,Howard W Johns,et al. Telinde of operative gynaecology, Mullerian abnormalities,vol 12, 2010; 540-544.
2.      Jaya Singhe Y, Rane A, Stalewki H, et al. The Presentation and Early Diagnosis of the Rudimentary Uterine Horn. Obstet Gynecol June 1, 2005; 105(6) : 1456-1467.
3.      Rein MS, Friedman AJ, Barbieri RL et al. Cytogenetic abnormalities in uterine leiomyomata. Obstet Gynecol 199; 77:923-6.
4.      Ibrahim Syed, Hero K Hussain, et al. Imaging in mullerian duct abnormalities. Mar 8,2013.
5.      Troiano RN, Mccarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology. 2004; 233 (1):19-34.
6.      Nahum GG. Uterine anomalies. How common are they, and what is their distribution among subtypes? J Reprod Med. 1998;43 (10): 877-87.
7.    Ly JQ. Rare bicornuate uterus with fibroid tumours: Hysterosalpingography- MR imaging correlation. Am. J. Roentgenol, 2002; 179:537-8.
8.    O Ayoola, O Alao, B Ibitoye, S Ma’aji. Bicornuate Uterus With Associated Bilateral Tubal Blockage And Fibroid Tumors: A Rare Combination Causing Infertility. The Internal Journal of Radiology. 2006; Vol 6; Number 1.


Valvi D, Parulekar SV. Leiomyoma in a Bicornuate Uterus. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/leiomyoma-in-bicornuate-uterus.html

Obstructed Labour Due to a Giant Fecolith

Author information
Yadav Pramila*, Warke HS**, Gupta AS***
(* Fourth Year Resident, **Associate Professor, *** Professor)


Obstructed labour due to a fecolith in the rectum and colon is very rare. Fecoliths cause many complications in pregnancy like dystocia, rupture uterus and malpresentation. It may also compress the bowel and cause bowel perforation. We are presenting a case of obstructed labour and malpresentation caused by a huge fecolith.

Fecolith is fecal impaction in the rectum and colon. It causes significant patient morbidity.[1] Patient commonly complaints of constipation. It is frequently secondary to poor bowel or dietary habits.[2] Bladder stone and rectal fecoliths have been implicated as cause of soft tissue dystocia.[3,4]

Case report

A 22 years old married woman, G4P3L1 IUFD2 with 26.5/7 weeks with IUFD with previous  LSCS was referred to our hospital with complaints of leaking per vaginum and decreased fetal movements since 12 hours. She had not passed stool since 5-6 days. There was  no history of bleeding per vaginum or pain in abdomen. On presentation her general and systemic examination were normal. Abdominal examination revealed a pfannensteil scar of previous LSCS, uterus was 26 weeks in size, deviated to right side, subserosal fibroid measuring 3x4 cm was felt in the suprapubic region and FHS was absent. Vaginal speculum could not be introduced due to a mass impacted in the vagina. On vaginal (PV) examination a 10x9 cm mass impacted in the vagina was felt. Cervix could not be felt. Provisional diagnosis of a 26 weeks pregnancy with IUFD with a large cervical fibroid or rectal mass was made.
On ultrasonography (USG) a dead fetus in transverse lie with extensive flexion of its body with spalding sign was seen. There was no free fluid in abdominal cavity and uterine rupture was ruled out. Uterine part of cervix could not be assessed on ultrasonography. CT scan was done. It showed a grossly distended rectum, descending and transeverse colon. Rectum and sigmoid colon were extensively loaded with faeces which appeared to be compressing the lower part of the uterus, cervix and vagina.

Figure 1 CT Image in Transverse Section. Showing the bladder stone (B.S.), fetal skeleton (F.S.) and fecolith (FL)

Figure 2 CT Image in Longitudinal Section: Showing the dilated bowel loops (D.B.L.), rectum (R), fetal head (F.H.) and fecolith (FL)

A 4.7 x 3.1 cm sized calculus was noted in the urinary bladder. Right kidney was 12.3 x 5.7cm and left kidney was 5.6 x 3.2 cm. There was bilateral hydronephrosis and hydroureter.    
Final diagnosis on CT scan was IUFD with transverse lie, fecal impaction, urinary bladder calculus, bilateral hydronephrosis and hydroureter .
Her Hb was 11.1gm%, WBC, platelet counts and DIC profile were within normal limits. Enema was given. There was incomplete evacuation of the bowel. Cervical Os could now be reached with difficulty. On PV she was 2-3cm dilated, 60% effaced, station was high up, pelvis was adequate and an indentable fecolith was felt through the posterior vaginal wall.
We watched for progress of labour. After 4 hours she developed signs of obstructed labour with scar tenderness and impacted shoulder with hand prolapse.
Patient was taken for emergency hysterotomy and anal dilation with manual removal of the fecolith with suprapubic cystolithotomy. A multidisciplinary team approach involving gynaecologist, surgeons, and anesthesiologists was undertaken. Abdomen was opened through an infra-umbilical midline incision. Intraoperatively bladder was advanced and distended with a calculus of  5x4cm size. Sigmoid and transverse colon were loaded and markedly distended with stools. Lower uterine segment was thinned out. Female baby of 780 g was delivered by breech extraction. Liquor was scanty and placenta was foul smelling. The uterus was sutured in a single layer.
Lithotomy position was given and surgeons noted a fissure in ano at 7 o’clock position, stricture 2-3cm from anal verge and grossly dilated sigmoid colon loaded with hard stools. Anal dilatation and manual removal of feces was done. Colon was milked from descending colon up to rectum and feces were evacuated till colon completely collapsed. Bowel was inspected and there was no evidence of any stricture, serosal tear or perforation.
The vesical calculus of 5x4 cm was removed by a cystotomy. Midline suprapubic catheter was placed and bladder was closed in two layers. Abdomen was closed in layers. One unit blood transfusion was given. Postoperatively patient was given antibiotics, analgesics. Postoperative course was uneventful. Suprapubic catheter was removed after three weeks.


Prolonged stasis of fecal matter causes impaction and a giant fecolith forms. This obstructs the colon necessitating surgery. [1]  Direct abdominal x-rays, ultrasosnography and CT scans are the imaging modalities to diagnose intestinal obstruction caused by fecal impaction. Emergent surgical intervention and removal of fecolith is life saving.[5] Urolith causing dystocia requires  caesarean section with cystolithotomy .[3] In this case, fecolith caused the malpresentation (transverse lie) and obstructed labor. As the urolith was not in the pelvis but suprapubically it did not contribute to the obstructed labor. A timely emergency hysterotomy with anal dilation, manual removal of feces, milking of descending, sigmoid colon and suprapubic cystolithotomy prevented a neglected obstructed labor and its consequences.[1,2,3,4,5] In this case the giant fecolith leading to obstructed labour was not diagnosed by the referral secondary care center. It was erroneously diagnosed as a large posterior cervical fibroid. In cases with obstructed labour with a mass felt per vaginum, large fecoliths should be considered in the differential diagnosis. Multidisciplinary team approach is essential for management of such cases.


We acknowledge Mantri Nilima, Tiruke Raviraj and Chaturvedi Pritali for performing emergency hysterotomy; Jadhav Sudhir and Patel Maitri for removal of fecolith; and Gajingi Ajay and Sharma Anand for performing suprapubic cystolithotomy on this patient


1.      Farshid AM.  Fecal Impaction. Clinics in colon and rectal surgery. 2005;18(2):116-119.
2.      Colapinto MN, Vowinckel EAM, Colapinto ND. Complete Currarino syndrome in an adult, presenting as a fecolith obstruction: report of a case. Can J Surg. 2003 Aug; 46(4):303-306.
3.      Ait Benkaddour Y, Aboulfalah A, Abbassi H. Bladder stone: uncommon cause of mechanical dystocia. Gynecol Obstet. 2006 Aug; 274(5): 323-4.
4.      Holt WA, Hendricks CH. Dysfunctional labour due to fecal impation: report of a case. Gynecol Obstet.  1969; 68: 502-504.
5.      Atahan K, Cokmez A, Durak E, Gur S, Tarcan E.  Colonic Obstruction Secondary to Giant Fecolith. J Colon Rectum disease. 2010; 20: 84-86.

Yadav P, Warke HS, Gupta AS. Obstructed labour due to a Giant fecolith. JPGO Volume 1 Issue 3, March 2014, available at:http://www.jpgo.org/2014/03/obstructed-labour-due-to-giant-fecolith.html

Epulis of Pregnancy

Author Information
Ranjana Desai*, Nalini Jangid**, Rashmi Sharma***, Kiran Mirdha****
(*Professor,  **3rd year P.G. Resident, Department of Obstetrics and Gynaecology; ***Assistant Professor, Department of Pathology; ****Medical Officer, Department of Obstetrics and Gynaecology; Dr. Sampoornanand Medical College, Jodhpur)


Epulis of pregnancy is a benign growth of the gingiva with a rare occurrence during pregnancy. This is a report of a case of epulis during pregnancy which showed spontaneous regression after delivery.


Epulis fissuratum or Granuloma fissuratum is an oral pathologic hyperplastic condition that appears in the mouth as an overgrowth of fibrous connective tissue mainly from gingivial tissues.[1] When it is associated with the edges of an ill fitting denture it is referred to as Inflammatory fibrous hyperplasia, Denture epulis or Denture induced fibrous hyperplasia. Epulis in a patient without dentures can also be diagnostic of Crohn's disease.[2]
Its occurrence in a pregnant woman is termed Epulis of Pregnancy or Granuloma gravidarum. Since it is rare during pregnancy and because its prevalence in pregnancy has not been well documented, the present case merits attention.

Case Report

A 24 year old third gravida with two full term normal deliveries presented to our antenatal clinic with amenorrhea of 7 months duration. While taking her history it was noted that she had an irregular fleshy growth over her teeth. On everting her upper lip and examining the gums of the upper jaw, a 2 centimeters long irregular fleshy mass was detected arising from the gums and growing over and between her incisor teeth (figure 1). On examining the oral cavity the lesion extended 3 centimeters posteriorly on the soft palate (figure 2). The lesion was firm to touch, non-tender. History revealed that the growth had slowly evolved from a small size to the present one over a period of 2 months. The lesion was asymptomatic and the patient refused a biopsy. A clinical diagnosis of epulis of pregnancy was made. No surgical intervention was advised and only oral hygiene in the form of mouth wash with a commercially available over-the-counter  mouth wash consisting of an aqueous solution containing bezoic acid, poloxamer 407, eucalyptol, thymol, sodium benzoate, and menthol mixed in alcohol twice a day and regular brushing of teeth twice daily was recommended. One month after delivery the mass had spontaneously regressed to half its size. And two months after delivery the lesion was one fourth its former size. After this the patient was lost to follow up.

Figure 1 : Anterior view of the epulis. Note the irregular fleshy growth emerging from between the incisors.

Figure 2 : Buccal view of the epulis. Note the dumbbell shape of the tumor displacing the incisors.


Epulis of pregnancy (synonyms: pregnancy tumor, granulaoma gravidarum, pyogenic Granuloma) is described as a gingival lesion that looks like a small, dome shaped hemangioma, often with a peripheral collarette of scales. The excess tissue is firm and fibrous; ulcerations may be present. It is usually pedunculated but may be sessile. It appears in gums around the alveolar vestibule, in either the mandible or maxilla (upper jaw) but is more commonly found in the frontal part of the maxilla during the third trimester. Often it has been referred to as pyogenic granulaoma in medical literature but the term is a misnomer, for this is not an infectious or pustular process.

The lesion is usually asymptomatic but appears cosmetically unsightly. It may interfere with mastication, closure of the oral cavity, brushing or flossing. The teeth adjacent to the epulis may loosen due to the pressure effect or may show migration.[3] Sometimes there may be recurrent bleeding from the lesion resulting in life threatening hemorrhage requiring blood transfusion.[4]
Etiologic factors responsible for epulis of pregnancy are improper maintenance of oral hygiene which leads to chronic gingivitis and the influence of hormones by a complex and partly understood mechanism on the gingival vasculature.[5,6]
Epulis has several histologic types. Granulomatous type is the prevalent type during pregnancy. It presents an inflammatory component characterized by lymphocytes, plasma cells and neutrophiles, an abundant vascular component with newly formed capillaries and a great proliferation of fibroblasts.[7]
The lesion usually resolves partially or completely post partum within 1 to 4 months[3] as it did in this case reported. Persistent lesion requires treatment by firstly removal of irritating factors and secondly surgical excision of the lesion, curettage, chemical or electric cauterization, cryo therapy or laser ablation.[5]


1.      Niville BW, Damm DD, Allen CM, Bouqout JE. Oral and maxillofacial Pathology, 2nd edition, Philadelphia,  W B saunders, 2002,  437- 495.
2.      Budtz-Jorgensen E. Oral mucosal lesions associated with wearing of removable dentures. J oral pathol 1981;10:65-80.
3.      Orosz M, Szende B, Gábris K. The clinical and pathological symptoms of pregnancy epulis. Fogorv Sz. 2007 Oct; 100(5):237-41, 233-6.
4.      Adeyemo WL, Ladeinde AL, Ajayi OF, Umeizudike K, et al. Pregnancy epulis associated with life threatening haemorrhage in a Nigerian woman. Nig Q J Hosp Med. 2010 Jan-Mar; 20(1):10-2.
5.      Saravanum T, Shakila KR, Shanthini K. Pregnancy Epulis, Ind  J of Multidiscp Dentistry. 2012;2(3):514-17.
6.      Rabinerson D, Kaplan B, Dicker D, Dekel A.  Epulis during pregnancy. Harefuah. 2002 Sep; 141(9):824-6.
7.      Tumini V, Di Placido G, D'Archivio D, et al.  Hyperplastic gingival lesions in pregnancy. I. Epidemiology, pathology and clinical aspects. Minerva Stomatol. 1998 Apr; 47(4):159-67.


Desai R, Jangid N, Sharma R, Mirdha K. Epulis of Pregnancy. JPGO Volume 1 Issue 3, March 2014, available at:  http://www.jpgo.org/2014/03/epulis-of-pregnancy.html

Broad Ligament Lipoma

Author Information
Parulekar SV.
(Professor and head of Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)


Broad ligament lipoma is a very rare tumor. There are only 11 cases reported in the English world literature.[1,2,3,4,5] This is the first case reported in which the lipoma was removed vaginally.


Primary retroperitoneal tumors account for 0.2% of all neoplasms, of which about 80% are malignant neoplasms.[6] Retroperitoneal benign lipomas are extremely rare, being 2.9% of all primary retroperitoneal tumors.[7] We present a case of a broad ligament lipoma diagnosed and removed during vaginal hysterectomy.

Case Report

A 58 year old postmenopausal woman presented with complaint of something coming out per vaginum for 6 months. She was found to have a third degree uterine prolapse, moderate cystocele and moderate rectocele. The uterus was small and the fornices were free. She was subjected to vaginal hysterectomy and repair of vaginal wall prolapse. During the operation, the right borad ligament was found to be bulging out after the uterosacral and uterine pedicles were clamped, cut, and ligated. The cornual structures of both sides were clamped, cut and ligated with No. 1 polyglactin, the clamp on the right side being applied medial to the broad ligament mass. Then the two leaves of the right broad ligament were separated. A well defined tumor measuring 7X4X3 cm was found in it, having the appearance of a lipoma (figure 1). It was dissected out of the broad ligament, taking care not to injure the ureter. There was no active bleeding from the bed of the tumoe after its removal. The pelvic peritoneal opening was closed with a purse-string suture of No. 1-0 polyglactin, leaving the right broad ligament partially open towards the vagina. The angles of the vagina were anchored to the pedicles of the uterosacral ligaments with No. 1 polyglactin sutures. The vagina was closed with No. 1-0 polyglactin sutures, leaving space for vaginal drainage of right broad ligament. The patient had no vaginal bleeding postoperatively. She made an uneventful recovery. Histopathological examination of the tumor showed it was lipoma.

Figure 1. Right broad ligament lipoma (L). The uterine corpus (Ut), cervix (Cx), and right ovary (black arrow) are shown.

Figure 2. The broad ligament has been opened and the lipoma is seen being enucleated out.

Figure 3. The lipoma.

Figure 4. The uterine corpus (Ut), cervix (Cx), and right broad ligament (black arrow) are shown after removal of the lipoma.


Pelvic lipomas are exceedingly rare. They can arise from the iliac vessels and paravaginal tissues.[8] A lipoma is a soft tumor, and it may be missed clinically in broad ligament location when it is small to medium in size. In the case presented, it was not palpable on bimanual examination. No imaging of the pelvis was done because no indication was perceived. Otherwise the tumor can be diagnosed by ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI). As there are no significant optical differences between a lipoma and a well-differentiated liposarcoma on CT or MRI, observed prior to surgery between lipomas and well-differentiated liposarcomas, one has to be prepared to deal with the latter when undertaking removal of a lipoma in this location. If the tumor is coincidentally diagnosed at the time of a laparotomy or a vaginal hysterectomy for a different indication, prior awareness of the possibility of a sarcomatous nature should help in better surgical management of the tumor.  Vaginal dissection of the lipoma can be difficult, and should be undertaken only if the tumor is diagnosed during a vaginal hysterectomy, and that too in presence of pelvic tissue relaxation, as in this case. Otherwise it is a lot safer to abandon the vaginal approach and remove the tumor abdominally by the extraperitoneal route. The ureter has to be isolated prior to any dissection and safeguarded during the dissection. As these lipomas are known to recur and undergo malignant transformation, these patients require a close follow-up.


I thank Dr Anil Mirchandani for the operative photographs.


1. Eltabbakh GH. Broad ligament lipoma presenting as a pelvic mass: a case report. J Reprod Med. 2007 Jun;52(6):543-4.
2. Cantin PFR. Lipoma of the Broad Ligament Br Med J 1959;1:1242.
3. Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a 25 year study. Indian J Med Sci 1995;49:139-41.
4. Gardner GH, Greene RR, Peckham B. Tumors of the broad ligament. Am J Obstet Gynecol 1957;73:536-8.
5. Hull WB, Blumenfeld ML, Jacques D. Large paravaginal pelvic lipoma: A case report. J Reprod Med 1999;44:636-8.
6. Armstrong JR, Cohen I. Primary malignant retroperitoneal tumors. Am J Surg 1965; 110:937-43.
7. Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a 25 year study. Indian J Med Sci 1995;49:139-41.
8. Genadry R, Parmley T, Woodruff JD. The origin and clinical behavior of parovarian tumor. Am J Obstet Gynecol 1977;129:873-6.


Parulekar SV. Broad Ligament Lipoma. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/broad-ligament-lipoma.html

Term Uterus in Complicated Ventral Hernia

Author Information
Nidhi Rathi*, Alka Gupta**
(* Second Year Resident, ** Professor; Department of Obstetrics and Gynecology, Seth G. S. Medical College & K.E.M. Hospital, Mumbai, India.)


Herniation of the gravid uterus in anterior wall abdominal hernia is rare. About 15-20 cases have been reported so far. There is no guideline to manage such cases. Management has to be individualized according to the patient’s presentation. We report a case of incisional hernia containing the gravid uterus with repeated excoriation of the overlying abdominal skin.


Incisional hernia is an abdominal wall defect that occurs at the site of previous surgical incision following breakdown in the continuity of the fascia closure.[1] Incidence of incision hernia is about 11% in abdominal laparotomies [2-3] and with wound infection incidence goes up to 26%.[4] Gravid uterus though a rare content of the hernia sac predisposes to serious complications like burst abdomen, preterm labor, spontaneous abortion, accidental hemorrhage, intrauterine growth restriction, dysfunctional labor, obstructed labor,uterine rupture and intrauterine fetal death.[5-6]  Initially these hernias are reducible however as pregnancy advances or diagnosis is delayed the gravid uterus is at a risk for incarceration and subsequent strangulation. [7, 8]

Case report

A 34-year-old second gravida para-1 (G2P1) presented at 24 weeks of gestation in emergency with omentum protruding through a thin shiny, excoriated and discolored overlying skin on an anterior abdominal wall hernia. She had a previous normal delivery 4 years back. On day 4 of that delivery she developed sub acute intestinal obstruction due to ileo caecal tuberculosis resulting in an ileal stricture. Exploratory laprotomy and ileo-ileal resection anastomosis was done. Her post operative course was uneventful. She completed 9 months anti tubercular chemotherapy under direct observation. Six Months following surgery she noted a swelling in her abdomen that would increase on standing and decreases on lying down. She again consulted the surgeon for the same and was diagnosed to have incisional hernia and was advised to continue conservative management in form of abdominal binder and to undergo elective mesh repair of the hernia after completion of her family. She conceived. Examination revealed a midline vertical infraumbilical scar extending 3-4 cms above umbilicus with a large hernial sac containing a 24-week-size gravid uterus, which was drooping down up to her waist.

Figure 1 Gravid uterus in the incisional hernia

The fascial defect measured 15cm x 15 cm. Skin was stretched, thin, shiny, discoloured with overlying ulceration and omentum protruding through it.

Figure 2 Excoriation of the overlying skin. Arrow indicates the site of the excoriation and the visible omentum

Figure 3 Excised prolapsed omentum

Figure 4 Sutures seen on the skin after surgical repair.

Uterus and the fetal parts were felt superficially. Uterus was reducible. There was no evidence of strangulation. Surgeons evaluated her. Ultrasonography (USG) of the abdomen was done. It showed a midline anterior abdominal wall defect of size 10 cms suggestive of anterior abdominal wall hernia with bowel, omentum and the gravid uterus as its content. All her blood investigations were normal. Surgeons excised the prolapsed part of the omentum and closed the skin defect under local anesthesia. The patient was discharged next post operative day. She was advised to wear the abdominal binder regularly and follow up weekly in the antenatal OPD. Again now at 33 weeks of gestation the skin overlying the hernia underwent necrosis and through a defect of 7 mm the omentum presented at the skin defect (Figure 2). Surgeons repeated the same conservative surgical procedure. She is scheduled for elective cesarean section with herniorraphy (mesh plasty) at 38 weeks of gestation.


The usual contents of the abdominal wall hernia sac are omentum and loops of small intestine. Herniation of gravid uterus through abdominal wall is an uncommon but grave condition. Incarceration of the gravid uterus with or without strangulation along with ulceration and excoriation of the overlying skin and bleeding from the ulcerated area can lead to shock. [7, 8, 9] However, ulceration of overlying skin of the hernia sac without incarceration or strangulation has also been reported. [10] Our case presented similarly as her pregnancy advanced. Diagnosis of the above condition is clinical and it can be confirmed on USG. In cases of doubt of strangulation an MRI can be diagnostic. [10]
Management of incisional hernia in pregnancy in mainly conservative, including manual reduction of hernia and use of abdominal binder during antenatal period and labor. [1, 5, 9, 11] Elective cesarean section is considered to be safest as the integrity of the weak anterior abdominal wall and or the scarred uterus during vaginal birth is uncertain. [11] Hernia repair can be done at the time of cesarean section or can be done at an interval of 6-8 weeks. Post partum elective herniorrhaphy allows an optimal repair as the overstretched abdominal wall skin can be fashioned to correct dimension. Further the repaired abdominal wall is not subjected to mechanical stresses of labor and there is no associated risk of wound disruption and infections.[11] However, incarceration, burst abdomen or strangulation will necessitate an immediate repair even in the antenatal period. The pregnancy then grows to term. [12,13] Elective antenatal hernia repair have been  reported during the 2nd and 3rd trimester of pregnancy with an outcome of normal term vaginal delivery. [7,13]  However such approach is associated with significant risk of anesthesia and surgical intervention during pregnancy. Moreover, the enlarged uterus itself may hinder optimal herniorrhaphy, and further enlargement with advancing gestation may disrupt the hernia repair. [6] In patients with very large defect or in remote areas an alternative, intermediate method of aggressive physiotherapy of abdominal wall muscles along with abdominal binder can be offered.

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Rathi N*, Gupta AS. Term Uterus in Complicated Ventral Hernia. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/term-uterus-in-complicated-ventral.html