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Counselling on Delivery options & Surgical challenges

Authors: Dr Wan Idoracaera Calisa binti Ikhwan, Miss Hoda Elmoniry, Miss Nuha Yassin, Dr Aligha Purushothaman

Case Report

A 35-year-old G2P1 woman of Nigerian descent with a BMI of 28 presented at 40+2 weeks' gestation with a history of one caesarean section for fetal

compromise. The caesarean section scar healed with a massive keloid scar that required three revisions by plastic surgery in-between pregnancies.

During the current pregnancy, the keloid grew further forming a large fungating mass extending throughout the lower abdomen down to the Mons pubis.

The mass has dimensions of 33 cm width, x 15 cm length and up to 4 cm depth .

During the first and second trimester, the keloid scar was missed by the obstetric team. At 36+3 weeks, the keloid scar was identified in the antenatal

clinic. She had a macrocosmic baby. The patient requested VBAC and was admitted at 40+1 for Induction of Labour. At 40+2 weeks, She was seen by

the obstetric team including the consultant on delivery suite. The keloid scar was explored thoroughly. The patient was re-counselled about the mode of

delivery including

• The risk of emergency caesarean section during VBAC delivery which would require swift entry into the abdomen. The keloid scar will delay this

entry resulting in fetal compromise

• The risk of acquiring a vaginal tear or needing an episiotomy which will likely heal with a large keloid interfering with the patient’s sexual life and

normal defecation

The patient opted for an elective caesarean section. A MDT discussion on the day was arranged among the obstetric consultant, the plastic surgeon

and the general surgeon. The operation was carried out jointly by the obstetric consultant and the general surgery consultant due to unavailability of the

plastic surgeon on the day.

Intraoperatively, the anterior abdominal wall entry was carried out transversely through the middle of the keloid using monopolar diathermy. This is to

avoid incising unscarred skin and development of another keloid. A haemostatic approach was ensured to reduce the risk of infection and poor healing.

The duration from knife-to-skin to knife-to-uterus took 30 minutes. The baby was delivered in a good condition. Saline wash of the abdomen and pelvis

was carried out. Estimated blood loss was 700 mls. The parietal peritoneum was closed, The rectus muscle was approximated with prolene sutures,

the rectus sheath with Loop PDS and Subdermal tissue with Monocryl 3-0. The hard solid keloid edges were approximated with glue. A Mefix water

resistant dressing was applied. IV Abx were prescribed for 48 hours and the patient was discharged on Day 2 with a referral to skin plastics.

Discussion

This is a rare case of massive

keloid during pregnancy. Inspection

of the abdomen and Assessment of

the keloid antenatally is vital. Early

planning and multidisciplinary team

collaboration including plastic

surgery is essential to provide

comprehensive antenatal

counselling, safe surgical planning

and delivery, and to ensure an

optimum recovery with a good

quality of life for the mother.

Counselling for VBAC in this case

requires an individualized risk

assessment approach with

discussion of the additional risks

involved; the development of new

keloids at the site of perineal tears,

the barriers to swift entry to the

abdominal cavity in the case of an

emergency, and post-operative

scar complications.

Conclusion

Managing high-risk pregnancies with

Massive keloid scarring demands

proactive planning, multidisciplinary

teamwork, and surgical expertise.

This case highlights the value of

timely decision-making and

comprehensive care protocols in

mitigating maternal and neonatal

risks while improving long-term quality of life