The incidence of caesarean section is rising1 and there is evidence that women who have a caesarean section may be at increased risk of complications in a subsequent pregnancy2. Compared with vaginal delivery in the first pregnancy, caesarean section has been found to be associated with significantly increased rates of: uterine rupture in labour;3 placenta previa and placental abruption;4 placenta previa leading to peri-partum hysterectomy;5 stillbirth;6 and perinatal death7. Sometimes some unusual complication develops with which, we are not familiar. Here an uncommon complication following caesarean section in a post caesarean pregnancy has been reported.

A 25 years old lady P 1+4 presented at the emergency department of NRS Medical College & Hospital, Kolkata as an unbooked sixth gravida with the complaint of leaking per vagina for last 4 hours and the period of amenorrhoea was 38weeks. Her past obstetric history revealed that she had caesarean section 4 years earlier (indication of caesarean section was not known to the patient) and 4 successive M.T.Ps, the last being done 1 year back. The baby was alive. The couple wanted ligation operation.

On examination, she was mildly anemic. Pulse was 88/min and BP was 126/80 mm Hg. She was free of any medical or surgical complications like morbid obesity, COPD and umbilical hernia. Per abdominal finding revealed a term size uterus with cephalic presentation and average liquor. FHS was 144/min and regular. Her previous caesarean section scar was low transverse and there was no scar tenderness.

Per speculum examination showed dribbling of clear liquor. Vaginal examination revealed cervix was 1.5 cm dilated, tubular, station was high up (-3) and membranes were absent.

An emergency L.S.C.S. was performed under spinal anesthesia. The skin incision was Pfannenstiel with excision of the previous scar. On opening the abdomen, uterus was found to be adherent with anterior abdominal wall from which uterus was separated for delivery of the baby (a living male baby of 2.75

Kg) and bilateral tubectomy operation. Bladder was also pulled high up which was dissected and pushed down before opening the uterus. Parietal peritoneum was not closed and rectus sheath was repaired with no 1 chromic catgut. Duration of operation was one hour which was longer than usual operation time of 35 minutes.

Figure I showing omentum like structure protruding through umbilicus

Figure II showing omental tag held during herniorrhaphy operation

First two post operative days were uneventful. On the 3rd day there was a small amount of serosanguinous discharge from the umbilicus. The caesarean section wound, which was located much below the umbilicus, was healthy. Methylene blue dye was introduced into the bladder to rule out any communication with umbilicus, through which no dye came out. On 4th post operative day a mass was seen protruding through the umbilicus and on gentle prodding it seemed to be omentum like structure (Fig-I) A provisional diagnosis of omental hernia through umbilicus was made.

On the 5th post operative day, she underwent herniorrhaphy operation under general anesthesia. A tag of omentum was seen to herniate through anterior rectus sheath and skin (Fig-II). The protruding tag of omentum (sent for histopathological examination and confirmed) was excised and a double breasting of rectus sheath was done, keeping a drain which was removed after 48 hours. Her subsequent recovery was uneventful. She came for checkup after 6 weeks, when no abnormality was detected.

A review of literature has failed to demonstrate the type of complication mentioned above. Intra operative complication like dense intra-abdominal adhesion resulting in injury to the bladder and the bowel is not uncommon8. Probably this case report presents an unusual complication for the first time. Probable explanation is that during too much dissection of anterior rectus sheath (to get access to the fallopian tubes) which was firmly adherent with uterus, there was inadvertent injury to the anterior rectus sheath and skin through which omentum had protruded.

Competing Interests: None Declared

1. Arjun, G. "Caesarean Section: Evaluation, Guidelines and Recommendations." Indian Journal of Medical Ethics, 2008, www.ijme.in/163co117.html. Accessed 29 Sept. 2008.
2. Taylor, M. K., Simpson, J. M., Roberts, C. L., Olive, E. C., and Henderson-Smart, D. J. "Risk of Complications in a Second Pregnancy Following Caesarean Section in the First Pregnancy: A Population-Based Study." Medical Journal of Australia, vol. 183, no. 10, 2005, pp. 515-519. DOI: 10.5694/j.1326-5377.2005.tb07084.x.
3. Gregory, K. D., Korst, L. M., Cane, P., et al. "Vaginal Birth After Cesarean and Uterine Rupture Rates in California." Obstetrics & Gynecology, vol. 94, 1999, pp. 985-989. DOI: 10.1016/S0029-7844(99)00344-7.
4. Lydon-Rochelle, M., Holt, V. L., Easterling, T. R., and Martin, D. "First-Birth Cesarean and Placental Abruption or Previa at Second Birth." Obstetrics & Gynecology, vol. 97, 2001, pp. 765-769. DOI: 10.1016/S0029-7844(00)01221-4.
5. Crane, J. M., Van den Hof, M. C., Dodds, L., et al. "Maternal Complications with Placenta Previa." American Journal of Perinatology, vol. 17, 2000, pp. 101-105. DOI: 10.1055/s-2000-8771.
6. Smith, G. C. S., Pell, J. P., and Dobbie, R. "Caesarean Section and Risk of Unexplained Stillbirth in Subsequent Pregnancy." Lancet, vol. 362, 2003, pp. 1779-1784. DOI: 10.1016/S0140-6736(03)14718-2.
7. Smith, G. C. S., Pell, J. P., Cameron, A. D., and Dobbie, R. "Risk of Perinatal Death Associated with Labour After Previous Cesarean Delivery in Uncomplicated Term Pregnancies." JAMA, vol. 287, 2002, pp. 2684-2690. DOI: 10.1001/jama.287.20.2684.
8. Sobande, A., and Eskander, M. "Multiple Repeat Caesarean Sections: Complications and Outcomes." Journal of Obstetrics and Gynaecology Canada, vol. 28, no. 3, 2006, pp. 193-197. DOI: 10.1016/S1701-2163(16)30303-4.