Copyright 

Patient Information:

Name: M.N.M

Age: 26 years old

Parity: Para 1+0

Ante-natal Clinic (ANC): 8 visits, no comorbidities

Infection Status: HIV, Hepatitis B, and VDRL negative

Date of Referral: November 6, 2022

Primary Diagnosis: Strangulated umbilical hernia discovered post-partum

Initial Presentation

The patient was referred with complaints of severe lower abdominal pain after spontaneous vaginal delivery (SVD) on November 5, 2022. She delivered a live male infant (LMI) weighing 3350g, with Apgar scores of 6, 6, and 7. The infant was admitted to the NICU for asphyxia management. During delivery, the patient experienced a perineal tear that was repaired at the referring facility. Post-delivery, the patient began experiencing persistent lower abdominal pain but denied other symptoms such as dizziness, headache, vomiting, diarrhea, or fever.

Clinical Findings on Examination

General: In pain, but no pallor, jaundice, cyanosis, or lymphadenopathy.

Vitals: Not recorded at the time of admission.

Abdominal Examination: Soft abdomen, with tenderness in both the lower left and right quadrants. Uterus well contracted at 22 weeks post-delivery. Normal bowel sounds.

Other Systemic Examination: Unremarkable.

Initial Management Plan:

Admit for observation and manage pain with analgesics.

Investigations: Abdominopelvic ultrasound to evaluate the abdomen and pelvis.

Medications:

• Ketorolac 30mg BD
• Paracetamol 1g TDS
• Ondansetron 4mg TDS

Postnatal Care: Sitz baths and continued observation.

Ultrasound Findings:

• Bulky uterus with a volume of 1218cc, clear endometrium measuring 3mm.
• Multiple well-defined intramural fibroids ranging from 2.06 cm to 3.09 cm.
• Mild ascites.
• Impression: Multiple intramural fibroids, mild ascites.

Subsequent Course of Admission

November 7 - Postpartum Endometritis

Complaints: Severe lower abdominal pain, foul-smelling vaginal discharge, and chills.

Examination: Abdomen distended with tenderness, particularly in the suprapubic region.

Impression: Postpartum endometritis.

Plan:

• Abdominopelvic MRI with contrast
• Intravenous (IV) antibiotics: Clindamycin 900mg TDS and Gentamicin 350mg OD
• Pain management: IM Morphine 10mg TDS

November 9 - Lower Limb Swelling

The patient presented with lower limb swelling, raising concerns for deep vein thrombosis (DVT).

Doppler ultrasound: Negative for DVT but noted subcutaneous edema in the inguinal region.

Plan: Continue antibiotics and supportive care.

November 10 - Improvement

Day 6 of antibiotics: Abdominal tenderness reduced, and the patient was afebrile.

Plan: Discharged on analgesics and hematinics, with a follow-up review scheduled for 2 weeks.

November 12 - Readmission

Presenting Complaints: Recurrent abdominal pain, loss of appetite, and epigastric tenderness.

Ultrasound: Revealed multiple fibroids and a possible supraumbilical hernia.

Plan: Surgical review and abdominopelvic MRI.

November 14 - Surgical Review

Complaints: Severe abdominal pain and swelling.

MRI Findings: Uterine rupture with a large abscess causing peritonitis, a strangulated umbilical hernia, and moderate hydroureter and hydronephrosis.

Plan: Emergency exploratory laparotomy.

Surgical Findings (Exploratory Laparotomy)

General Surgery: Omentum was reduced from the hernia, with no bowel involvement. Hemorrhagic collection and fibrous adhesions noted.

Obstetrics and Gynecology: A 10cm posterior uterine rupture was found, and uterine fibroids were managed. The uterine wall was repaired.

Postoperative Course

November 15 - ICU Admission: The patient was admitted to the ICU for hemodynamic monitoring. She was afebrile but presented with abdominal distension and mild pallor.

Plan: Monitor vitals closely, ensure postoperative care, and administer blood transfusion.

November 16-19 - Recovery and Complications

• The patient continued to experience pain at the incision site and mild hyponatremia, but her condition stabilized.
• By November 19, she developed copious discharge from the incision site, although an ultrasound ruled out abscess formation.

Final Outcome:

The patient was discharged on November 19, 2022, with compression stockings and anticoagulation therapy (Clexane 80U nocte). She was advised on wound care and scheduled for a follow-up review in one week.

Discussion:

This case highlights the complex postpartum complications associated with uterine rupture, intramural fibroids, and a strangulated umbilical hernia. Prompt surgical intervention and multidisciplinary care, including obstetric, surgical, and intensive care management, were crucial in stabilizing the patient. Continuous monitoring and early detection of complications, such as infection and thromboembolism, were vital for the patient’s recovery.