|Year : 2022 | Volume
| Issue : 2 | Page : 163-166
Diaphragmatic Hernia in Pregnancy – A Case Report
Anjali Tempe, Vedika Bali, Devender Kumar, Chaithanya Guguloth
Department of Obstetrics and Gynaecology, Maulana Azad Medical College and Lok Nayak Hospital, India
|Date of Submission||07-Feb-2022|
|Date of Decision||26-Jun-2020|
|Date of Acceptance||13-May-2022|
|Date of Web Publication||11-Jul-2022|
572, Abhinav Apartments, Vasundhara Enclave, New Delhi-110096
Source of Support: None, Conflict of Interest: None
Background: Maternal diaphragmatic hernias (DH) identified during pregnancy are rare and pose significant management challenges with respect to the timing of delivery, mode of delivery, and hernia repair. Case presentation: We describe a case of traumatic maternal DH, diagnosed at 31 weeks of gestation presenting with multiple episodes of vomiting. Owing to no evidence of visceral compromise and a stable maternal and fetal condition, the patient was conservatively managed allowing further fetal maturation and was delivered by cesarean section at 34 weeks. This was followed by laparoscopic intraperitoneal mesh hernial repair at 6 weeks postpartum. The patient had an uncomplicated recovery. Conclusion: Maternal DH in pregnancy require multidisciplinary care and individualized management for the optimal outcome for mother and fetus.
Keywords: Diaphragmatic hernia, multidisciplinary care, visceral compromise
|How to cite this article:|
Tempe A, Bali V, Kumar D, Guguloth C. Diaphragmatic Hernia in Pregnancy – A Case Report. MAMC J Med Sci 2022;8:163-6
| Background|| |
Diaphragmatic hernia (DH) is a defect within the diaphragm causing protrusion of abdominal contents into the thoracic cavity. It is classified into congenital, acquired, and traumatic. The majority of DH are diagnosed in the antenatal period or within the first few years of life. Presentation during pregnancy is extremely rare with only 56 cases reported in the literature so far., They pose significant management challenges with regard to timing and mode of both delivery and hernia repair.
A pregnant woman at 31 weeks period of gestation diagnosed with traumatic DH is described here.
| History|| |
A 23-year-old lady, G2P1L1 at 31 weeks period of gestation, presented to Gynae causality with multiple episodes of vomiting, 12 to 15 per day for 3 days. This vomitus consisted of food particles but was nonbilious/nonblood tinged. It was associated with epigastric pain. There was a history of a similar episode at around 28 weeks for which conservative treatment was undertaken. There was no complaint of fever, cough, chest pain, bladder/bowel symptoms, outside food intake, itching, or yellowish discoloration of the body. The patient was perceiving adequate fetal movements with no history of any leaking/bleeding per vagina. The patient’s first and second trimester history was uneventful and as reported her complaints started at 28 weeks in the third trimester.
Her first pregnancy was unremarkable, and was an institutional full term normal vaginal delivery with birth weight of child being three thousand grams (3000gm). There was no significant past medical, surgical history, or family history. Upon further review, the patient recalled a robbery at home 2 years back that resulted in a stab injury in her left subcostal region. However, no treatment was undertaken for it and records were not available.
During the physical examination, the patient showed stable vital signs with the saturation of 99% on room air, respiratory rate of 18 per minute, and pulse rate of 86 per minute. Her systemic examination including respiratory, cardiovascular, and central nervous system was unremarkable. Upon abdominal examination, the uterus was distended, dextro rotated with fundal height, symphysial-fundal height, and abdominal girth of 32 weeks, 32 cm, and 30 inches, respectively, all corresponding to the period of gestation. We observed a single live fetus at 31 weeks period of gestation in cephalic presentation.
The patient was admitted and laboratory tests ordered revealed elevated liver function tests with a deranged sugar profile and positive urinary ketones, suggesting a probable case of hyperemesis/starvation/diabetic ketosis. A medicine consultation was taken and an ultrasound of whole abdomen as well as serum amylase and lipase (as advised) was reported normal. The patient was managed conservatively with intravenous fluids, injectable antacids, and antiemetics but no improvement was observed.
Suspecting a possibility of intestinal tuberculosis or subacute intestinal obstruction, a chest X-ray and abdominal X-ray were ordered and to our surprise the radiologist reported a left DH [Figure 1]. Further confirmation with computed tomography (CT) revealed left-sided DH with herniation of stomach, jejunal loops, transverse colon, splenic flexure, and descending colon including mesenteric and omental fat and passive atelectasis of left lower lobe, but there were no ischemic intestinal signs ([Figure 2] and [Figure 3]).
|Figure 1 Chest X-ray Elevation of the left dome of the diaphragm with the contralateral right mediastinal shift. Radio-opacity in the left side with air-fluid levels suggestive of left diaphragmatic hernia. Right lung fields, cardiophrenic angle clear with normal bony cage|
Click here to view
As the conditions of the mother and fetus were stable, we decided to continue with expectant management. Four doses of dexamethasone were given for fetal maturation and intravenous hydration, and antiemetics with proton pump inhibitors were administered. As the patient was not tolerating orally, a nasogastric tube was inserted but the patient refused, so we started her on total parenteral nutrition to meet her nutritional requirements for pregnancy. At 34 weeks, a cesarean section was performed (infraumbilical midline vertical incision) delivering a male baby weighing 1670 g. However, the baby was admitted into nursery in view of the low birth weight. The patient was followed up in gastrointestinal surgery and laparoscopic intraperitoneal mesh hernioplasty was performed after 6 weeks postpartum ([Figure 4],[Figure 5],[Figure 6]). The surgery went uneventful and the patient was discharged on postoperative day four.
|Figure 5 Hernial of abdominal contents including stomach, transverse colon, jejunal loops, and descending colon|
Click here to view
|Figure 6 Laparoscopic intraperitoneal hernial mesh repair by 15 by 15 cm graft using continuous prolene sutures|
Click here to view
| Discussion|| |
DH are classified as congenital (Bochdalek and Morgagni), hiatal, and traumatic., The presentation of maternal hernia for the first time in pregnancy is rare and poses a management dilemma regarding the timing of delivery and repair. A pregnant patient with a DH can remain asymptomatic until advancing pregnancy. However, as the pregnancy progresses, abdominal pressure increases and further herniation is produced resulting in gastrointestinal symptoms such as heartburn, nausea, and vomiting known as tension gastrothorax. The main life-threatening complications are severe dyspnea and visceral strangulation, which may cause maternal or fetal death. However, such complaints are extensive during pregnancy, making diagnosis difficult, and refractory response to their usual conservative approach should alert the clinician to a differential diagnosis. The key test for diagnosis is chest X-ray (sensitivity 70%), showing air-fluid levels or gas in the herniated part of the intestinal tract (over diaphragm) with CT and magnetic resonance imaging to confirm the diagnosis.
The management of a pregnant patient with symptomatic DH is a challenge. The treatment is decided based on the clinical symptomatology of the patient and the period of gestation. For DH diagnosed in the first and second trimester, elective surgical repair is planned in the second trimester as the risk of teratogenesis, abortions, and preterm births is minimal during this gestation. However, for presentations in the third trimester, as in our case, expectant management with gastric decompression (nasogastric tube) to meet the caloric requirements of pregnancy and antenatal corticosteroids (24–34 weeks) for fetal maturity till 34 weeks followed by hernial repair is recommended. In case of symptoms and signs suggestive of strangulation, immediate surgical repair is to be undertaken.
The most appropriate way to end a pregnancy in these patients remains unclear. It has been demonstrated that uterine contractions without Valsalva do not increase intra-abdominal pressure, and so they are unlikely to cause hernia incarceration or repaired hernia rupture. Therefore, a patient with a repaired DH can deliver vaginally, without bearing down. But in the case of non-repaired DH, most authors accept elective cesarean section to prevent further herniation or strangulation with vaginal delivery,,,,; hernia repair can be done at the same time, but it is not mandatory. The repair can be undertaken by laparoscopy, laparotomy, or thoracotomy in the same setting during cesarean or postpartum as per the surgical expertise and patient’s decision. In our case, laparoscopic intraperitoneal mesh hernioplasty using a 15 by 15 cm mesh was performed at 6 weeks postpartum by a team of experienced gastro-surgeons.
| Conclusion|| |
In summary, maternal DH in pregnancy is a rare presentation, which requires a multidisciplinary approach for optimal management. While expectant management should be considered, the potential challenges of malnutrition, visceral obstruction, and respiratory compromise need to be carefully evaluated. This case report highlights the importance of keeping this as a differential diagnosis potentially leading to improved maternal and neonatal outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Reddy M, Kroushev A, Palmer K. Undiagnosed maternal diaphragmatic hernia-a management dilemma. BMC Pregnancy Childbirth 2018;18:1–5.
Debergh I, Fierens K. Laparoscopic repair of a Bochdalek hernia with incarcerated bowel during pregnancy: report of a case. Surg Today 2014;44:753–6.
Eglinton TW, Coulter GN, Bagshaw PF, Cross LA. Diaphragmatic hernias complicating pregnancy. ANZ J Surg 2006;76:553–7.
Sano A, Kato H, Hamatani H et al.
Diaphragmatic hernia with ischemic bowel obstruction in pregnancy: report of a Case. Surg Today 2008;38:836–40.
Chen Y, Hou Q, Zhang Z, Zhang J, Xi M. Diaphragmatic hernia during pregnancy: a case report with a review of the literature from the past 50 years. J Obstet Gynaecol Res 2011;37:709–14.
Brygger L, Fristrup CW, Harbo FS, Jorgensen JS. Acute gastric incarceration from thoracic herniation in pregnancy following laparoscopic antireflux surgery. Case Reports. 2013;2013:bcr2012008391
Toorians AW, Drost-Driessen MA, Snellen JP, Smeets RW. Acute hernia of Bochdalek during pregnancy Hyperemesis for the first time in a third pregnancy? Acta obstetricia et gynecologica Scandinavica 1992;71:547–9.
Slesser AA, Ribbans H, Blunt D, Stanbridge R, Buchanan GN. A spontaneous adult right-sided Bochdalek hernia containing perforated colon. JRSM Short Reports 2011;2:1–5.
Kurzel RB, Naunheim KS, Schwartz RA. Repair of symptomatic diaphragmatic hernia during pregnancy. Obstet Gynecol 1988;71:869–71.
Kumar A, Maheshwari V, Ramakrishnan Ts Sahu S (2009) Caecal perforation with faecal peritonitis - unusual presentation of Bochdalek hernia in an adult: a case report and review of literature. World J Emerg Surg 4:16.
Gedik E, Tuncer MC, Onat S et al.
A review of Morgagni and Bochdalek hernias in adults. Folia Morphol (Warsz) 2011;70:5–12.
Fleyfel M, Provost N, Ferreira JF, Porte H, Bourzoufi K. Management of diaphragmatic hernia during pregnancy. Anesth Analg 1998;86:501–3.
Genc MR, Clancy TE, Ferzoco SJ, Norwitz E. Maternal congenital diaphragmatic hernia complicating pregnancy. Obstetrics & Gynecology 2003;102:1194–6.
Sharma BN, Gupta D. Right sided Bochdalek hernia in an adult: a case report and review of literature. Nepal J Radiol 2018;8:44–7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]