How is an umbilical hernia managed during pregnancy?

Management of Umbilical Hernia During Pregnancy

Umbilical hernias during pregnancy should be managed conservatively with watchful waiting unless complications occur, with surgical repair typically postponed until after delivery.

Incidence and Risk Factors

• Umbilical hernias are more common in women than men, with pregnancy potentially causing new hernias or making existing ones apparent due to increased intra-abdominal pressure 1
• The incidence of umbilical hernia among pregnancies is approximately 0.08% 1
• Pregnancy-related factors that contribute to hernia development include progressively increasing intra-abdominal pressure and hormonal changes affecting tissue integrity 1

Clinical Presentation and Assessment

• Pregnant women with umbilical hernias may present with varying symptoms ranging from asymptomatic bulges to pain and discomfort 2
• The majority of pregnant patients requiring surgical intervention (58%) present with incarceration or strangulation at the time of diagnosis 2
• Assessment should focus on hernia size, reducibility, and presence of complications such as incarceration or strangulation 1
• Diastasis recti (separation of abdominal muscles) frequently occurs during pregnancy and may coexist with umbilical hernias, potentially increasing recurrence risk after repair 1

Management Algorithm

For Uncomplicated Umbilical Hernias

• Asymptomatic or mildly symptomatic hernias:

  • Conservative management with watchful waiting during pregnancy is recommended 3
  • Regular monitoring throughout pregnancy to detect potential complications 3
  • Plan for elective repair after delivery (typically 8-52 weeks postpartum) 3

• Symptomatic but non-complicated hernias:

  • Pain management and activity modification 1
  • If surgery is deemed necessary during pregnancy, the second trimester is the optimal timing for intervention to minimize risks to both mother and fetus 1

For Complicated Umbilical Hernias

• Incarcerated or strangulated hernias:
  • Emergency surgical repair is necessary regardless of gestational age 2, 1
  • Open repair is the most common approach (95% of cases) with minimal 30-day morbidity to the mother 2

Timing of Elective Repair

• During pregnancy:

  • Generally avoided unless complications occur 3
  • If necessary, second trimester is preferred (lower risk of spontaneous abortion and preterm labor) 1

• After delivery:

  • Can be performed as early as 8 weeks postpartum 1, 3
  • A 1-year interval after delivery provides optimal conditions including hormonal stabilization and return to normal body weight 1
  • May be postponed until after subsequent pregnancies if the patient plans to have more children 1

• During cesarean section:

  • May be considered if cesarean delivery is performed for other indications 4, 1
  • Primary repair during cesarean section has been reported with successful outcomes 4

Surgical Approach Considerations

• Open repair is the most common approach for pregnant patients (95%) 2
• Mesh repairs should be considered in patients with diastasis recti due to high recurrence risk with suture-only repairs 1
• Superficial surgical site infection is the most common complication following open repair during pregnancy 2
• Postpartum repairs can typically be performed in an ambulatory setting under local anesthesia with sedation 3

Potential Complications

• Untreated complicated hernias may result in serious obstetric complications including:

  • Antepartum hemorrhage 4
  • Intrauterine fetal demise 4
  • Preterm labor 4
  • Incarceration or strangulation of abdominal contents 2, 1

• Surgical repair during pregnancy carries risks of:

  • Anesthetic complications to mother and fetus 1
  • Increased risk of preterm labor 1
  • Potential for hernia recurrence during the same or subsequent pregnancies 1

Follow-up Considerations

• Regular monitoring for recurrence, especially if planning subsequent pregnancies 3
• Patients who have undergone repair can have subsequent uncomplicated pregnancies 3
• Long-term studies show minimal recurrence rates with appropriate surgical technique and timing 3