Diaphragmatic hernia: an unusual cause of postpartum collapse

Abstract

Case reportA 26 year old woman was in her first pregnancy. She had no past history of medical illness or any surgical intervention. She was obese and her pregnancy was complicated by mild gestational hypertension. At 39 weeks of gestation, she went into labour and 4 hours later delivered unaided to a baby girl weighing 2.4 kg.About 14 hours postpartum, she complained of burning epigastric pain associated with retching and vomiting. She was treated with an antacid and an anti-emetic. However, her symptoms persisted and were followed 6 hours later by severe shortness of breath. Her pulse rate was 170 beats per minute but her blood pressure and the peripheral oxygen saturation were normal. Examination of her lungs revealed reduced air entry in the left lung, but no adventitious sounds were noted. Her heart sounds were normal and there was no murmur. Abdominal examination revealed epigastric tenderness. Her uterus was involuting well. There was no abnormal vaginal bleeding.At this point, there was a high suspicion of pulmonary embolism with a possibility of pneumothorax. Serial arterial blood gas assessments showed progressive arterial hypoxaemia but there was no respiratory alkalosis or acidosis. Haemoglobin concentration was 9.8 g/dL and coagulation profile was normal. Electrocardiogram showed sinus tachycardia and there was no feature suggestive of pulmonary embolism. A chest radiograph revealed bowel shadows in the left lung. Within a short period of time she became hypotensive, restless and more severely dyspnoeic. She was electively ventilated but shortly after intubation she had a cardiac arrest. Cardiopulmonary resuscitation was started immediately and she revived well. A repeat chest radiograph again showed bowel shadows in the left lung and a marked mediastinal shift to the right (Fig. 1). A diagnosis of diaphragmatic hernia was made and an urgent laparotomy was performed.At operation the lower lobe of the left lung was collapsed. A large defect measuring 5 Â 5 cm with smooth circular edges was seen in the left dorsolateral part of the diaphragm. The greater omentum, fundus of the stomach, transverse colon, most of the small intestine (up to the terminal ileum) and the appendix (Fig. 2) were lying in the left thoracic cavity. The fundus of the stomach was gangrenous but the rest of the bowel was viable. No hernial sac was found. The central tendon of the diaphragm and the foramen of Morgagni were intact. The oesophageal hiatus was centrally located. The duodenum was traced from the pylorus to the jejunum and no associated Ladd's band was seen.The omentum, fundus of the stomach, small bowel and transverse colon were reduced into the peritoneal cavity. The gangrenous portion of the stomach was resected and appendicectomy was performed. The defect was closed with polypropylene sutures (Ethicon, Johnson & Johnson) in two layers. A chest tube was inserted into the left thoracic cavity.Post-operatively, the woman was ventilated. Her haemoglobin concentration was 8.9 g/dL. Her recovery was steady and satisfactory...

Maternal diaphragmatic hernia in pregnancy: A systematic review with a treatment algorithm

“…Recent literature reviews claim an overall fetal mortality rate of 13%-19%[ 25 , 26 ], similar to our results (13.8%). Mothers with cardiac arrest from DH have a fetal mortality rate of 50%[ 16 , 24 , 27 - 30 ]. DH type did not correlate to neonatal outcomes.…”