Arch Gynecol Obstet (2007) 276:295–298 DOI 10.1007/s00404-007-0347-z
123
C A S E R E P O R T
A late post-traumatic diaphragmatic hernia revealed during pregnancy by post-partum respiratory distress
Saâd Rifki Jai · Fatimazahra Bensardi · Ahmed Hizaz · Farid Chehab · Driss Khaiz · Abdelmajid Bouzidi
Received: 10 January 2007 / Accepted: 23 February 2007 / Published online: 4 April 2007
© Springer-Verlag 2007
Abstract
Introduction
Diaphragmatic hernia during pregnancy is uncommon and is usually traumatic in origin, epigastric pain, and vomiting could be the initial symptoms of hernia- tion of gastrointestinal contents, with a risk of strangulation and ischaemia, leading to respiratory distress due to col- lapse of the lung.
Methods
Case report.
Results
A 27-year-old woman, with undiagnosed trau- matic diaphragmatic hernia who presented, at 32 weeks’
gestation, epigastric pain, vomiting and tachycardia, imme- diate post-partum course was complicated by respiratory failure. A chest X-ray showed an air
Xuid level in the left lung which was wrongly diagnosed as an hydropneumotho- rax, in front of respiratory symptoms exacerbation, an inap- propriate thoracic drainage tube was accidentally placed into the herniated stomach leading to perforation of this last. An emergency laparotomy discovered a 2/3 of the stomach, transverse colon and greater omentum herniated in the left hemithorax through a defect of the left hemidia- phragm.
Conclusion
The diagnosis should then be considered early, and chest radiography with a nasogastric tube is the
Wrst technique to prefer and may be helpful to conWrm thediagnosis.
Keywords Diaphragmatic hernia · Pregnancy · Surgery
Introduction
Maternal diaphragmatic hernia during pregnancy or the peripartum period is an unusual and severe disease, because the maternal and fetal prognoses are threatened [1]. The diagnosis and management are problematic because they present with variable clinical and radiological signs [2, 3].
Once diagnosis is made immediate surgery is needed, as there is danger of incarceration and gangrene of the herni- ated viscera [3–5]. We describe a case of a late post-trau- matic diaphragmatic hernia revealed during pregnancy by a post-partum respiratory distress.
Case report
A 27-year-old, primigravida woman, with a past history of penetrating injury of the left lower thorax 1 year ago, the stab wound was sutured in emergency without any radiological exploration. She was admitted in the department of obstetric and gynecology at 32 weeks’ gestation, with a 20 day history of epigastric pain, vomiting and tachycardia. On presenta- tion, her pulse rate was 120/min, blood pressure was 13/
8 mmHg, and haemoglobin concentration was 13,3 g/dl.
Electrocardiogram showed sinus tachycardia. Obstetric ultra- sound was normal. Symptomatic treatment was set up (antiacid and anti-emetic) and an appointment of oesogastro- duodenoscopy was taken. But the evolution was marked by a labour launching with vaginal delivery of baby weighing 2 kg. Immediate post-partum course was complicated by respiratory distress. A chest X-ray showed an air Xuid level in the left lung which was wrongly diagnosed as an hydro- pneumothorax (Fig.
1), in front of respiratory symptomsexacerbation, chest drain was introduced through the left hemithorax. Immediately following insertion of the chest
S. Rifki Jai (&) · F. Bensardi · A. Hizaz · F. Chehab ·D. Khaiz · A. Bouzidi
Department of Surgery III, Ibn Rochd University Hospital, Casablanca, Morocco
e-mail: saadjai@yahoo.fr
296 Arch Gynecol Obstet (2007) 276:295–298
123
drain, patient felt better but had digestive liquid through the drain. A repeat chest X-ray after nasogastric feeding showed extinction of the level with presence of the nasogastric tube into the left hemitorax (Fig.
2). A diagnosis of post-traumaticdiaphragmatic hernia was made, conWrmed on computed tomography scan of the chest which revealed the intercostal drain entering the herniated stomach (Fig.
3). The chest drainwas removed, and an emergency laparotomy was done which found a 2/3 of the stomach, transverse colon and greater omentum herniated in the left hemithorax through a large left-sided diaphragmatic defect, a phrenotomy was necessary for reducing the herniated viscera because of adherences to the lung. The herniated stomach was gangrenous with two iatrogenic perforations caused by the chest drain in gross tuberosity and angle small curve, the greater omentum was also ischemic, but the transverse colon was viable. The stom- ach was resected with excision of the greater omentum and oesojejunal anastomosis. The diaphragmatic defect was repaired, and an intercostal drain was left in situ (Fig.
4). Thepatient was admitted to intensive care postoperatively. The intercostal drain was removed 2 days later after normal chest X-ray (Fig.
5). At the Wfth post-operative day, the patientbecame dypnoeic and a repeat chest X-ray showed a Xuid level (empyema thoracis). A gastrograWn opaciWcation showed that the oesojejunal anastomosis was normal. A chest drain was reintroduced with drainage of purulent Xuid. The evolution was made by persistent purulent expectoration, and the patient was dead 2 months later.
Discussion
Maternal diaphragmatic hernia during pregnancy or the peri- partum period may be congenital or acquired. The acquired
form, usually results from trauma, occurs frequently after penetrating injuries (13–19%), blunt thoraco-abdominal trauma or iatrogenic causes are less common (5%) [5]. Dia- phragmatic rupture is present in 1,6% of major thoracic inju- ries [2]. The left hemi-diaphragm is ruptured in 70–80%, and the right in 15–24%, this is due to the protective e
Vect of the liver on the right hemi-diaphragm [2]. In penetrating injuries of the upper abdomen and lower thorax, possible diaphragmatic hernia should be kept in mind, because silent diaphragmatic ruptures due to previous injuries or congeni-
Fig. 1 Chest X-ray showing an air Xuid level in the left hemithoraxwhich was wrongly diagnosed as an hydropneumothorax
Fig. 2 Chest X-ray after insertion of chest drain and nasogastric tube
Fig. 3 Computed tomography scan of the chest revealing the intercos- tal drain entering the herniated stomach
Arch Gynecol Obstet (2007) 276:295–298 297
123
tal defects of the diaphragm have been known to become symptomatic during pregnancy or in the immediate post- partum period [3, 4]. It is the case of our observation.
The development of a hernia during pregnancy is multi- factorial, relating to the mass eVect of the gravid uterus in the second and third trimesters, to the hormonal eVect at smooth muscle relaxation and to softening of ligaments.
The diaphragm in pregnancy is stretched and vulnerable of increases in intra-abdominal pressure, and may lead to abdominal viscera being forced into with enlargement of diaphragmatic defect, and development of symptoms in a previously asymptomatic patient [5–8].
The clinical presentation of maternal hernias in pregnancy varies from acute or chronic upper gastrointestinal pain, vom- iting, dyspnea, and chest pain to life-threatening complica- tions including obstruction, strangulation, ischaemia or necrosis of herniated viscera with cardiovascular-respiratory decompensation caused by the presence and compression of the abdominal viscera in the chest [5, 6, 8]. In our case initial symptoms were epigastric pain, vomiting and tachycardia complicated in immediate post-partum by respiratory distress.
Various investigations may be used for establishing the diagnosis of traumatic diaphragmatic hernia, but only chest and abdominal X-ray are performed easily and eVectively in the emergency situation. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can occasionally be necessary for conWrmation of the diagnosis [2, 8]. However, a late diaphragmatic hernia may be misdiagnosed as pneu- mothorax hydro or haemopneumothorax on the initial chest X-ray, and an inappropriate insertion of a chest drain could accidentally be placed into the herniated organs and lead to perforation [2, 6, 9], as in our case. That’s why, if doubt exists after the initial chest radiography, repeating the Wlm after passage of a nosogastric tube may be enough to diag- nose the presence of an air Xuid level in the chest and con-
Wrm the presence of the stomach in the left chest [2, 8, 9].The management of the pregnant patient with a dia- phragmatic hernia is challenging and contentious. The approach taken depends on the clinical presentation and the period of gestation at which the diaphragmatic hernia is detected [8]. Asymptomatic patients in the third trimester of pregnancy required elective cesarean section once the fetus reaches maturity. In the symptomatic patients, immediate repair should be undertaken in order to avoid cardiorespiratory failure or visceral obstruction, which should occur at any time. A patient with signs of visceral strangulation presents a surgical emergency irrespective of fetal maturity [4].
Fig. 4 Peroperative photo showing a diaphragmatic hernia of: 2/3 of stom- ach with gangrenous and 2 iatrogenic perforations caused by the chest drain, greater omentum with ischaemia, and a viable transverse colon
Fig. 5 Operative photo showing the necrosis stomach resected with the ischaemic greater omentum
298 Arch Gynecol Obstet (2007) 276:295–298
123
However, the surgical
Wnding of adhesions between lung tissue and herniated organs implies that the tissues had been in contact before the onset of labour, possibly for many years [6]; so is our case.
Conclusion
Maternal post-traumatic diaphragmatic hernia complicating pregnancy or peripartum period is very rare, but potentially life-threatening condition, because the diaphragmatic defect may predispose to incarceration and strangulation of abdominal viscera within the thorax, as the gravid uterus enlarges. Early diagnosis of diaphragmatic hernia should be considered when upper gastrointestinal or respiratory symptoms exist during pregnancy, and requires emergency surgery for prevention of theses complications.
References
1. Desurmont S, Tariel D, Magnin G, Pierre F (2005) Hernie dia- phragmatique maternelle pendant la grossesse A propos de 2 cas.
J Gynecol Obstet Biol Reprod 34(cahier1):711–715
2. Eren S, Kantarci M, Okur A (2006) Imaging of diaphragmatic rupture after trauma. Clin Radiol 61:467–477
3. Dessolle L, Vibert E, Bernabé C, Chitrit Y, Saint-Léger S (2004) Syndrome occlusif chez une femme enceinte révélant une hernie di- aphragmatique post-traumatique méconnue. J Gynecol Obstet Biol Reprod 33:441–443
4. Hammoudi D, Bouderka MA, Benissa N, Harti A (2004) Diaphrag- matic rupture during labor. Int J Obstet Anesth 13:284–286 5. Dietrich, Cynthia LDO, Smith, Charles EMD (2001) Anesthesia for
cesarean delivery in a patient with an undiagnosed traumatic dia- phragmatic hernia. Anesthesiology 95(4):1028–1031
6. Williams M, Appelboam R, McQuillan P (2003) Presentation of diaphragmatic herniae during pregnancy and labour. Int J Obstet Anesth 12:130–134
7. Sharifah H, Naidu A, Vimal K (2003) Diaphragmatic hernia: an unusual cause of postpartum collapse. Br J Obstet Gynecol 110:701–703
8. Eglinton TW, Coulter GN, Bagshaw PF, Cross LA (2006) Dia- phragmatic hernias complicating pregnancy. ANZ J Surg 76:553–
557
9. Rege SA, Narlawar RS, Deshpande AA, Dalvi AN (2001) Iatro- genic gastric Wstula due to inappropriate placement of intercostal drainage tube in a case of traumatic diaphragmatic hernia. J Post- grad Med 47:108–110
