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EP1.11

Diaphragmatic Hernia with ischemic bowel obstruction during pregnancy

Monday, 24 June, 2013 - 12:30
Board 01

Maternal Diaphragmatic Hernia(DH) with ischemic bowel obstruction during pregnancy
Case Report
A 21 year old lady , had a previous 10 month old child delivered normally, presented at 15 weeks of gestation with sever left sided loin pain of 2 weeks duration , started as a colicky and became persistent
, she vomitted many times and couldn’t pass motion for 10 days, she was treated before us a UTI but the pain increased, Her Ultrasound revealed mild left hydronephrosis , a ureteric stent applied to relieve
the pain but the stent removed after 48 hours because of increasing pain. She left the hospital against medical advice seeking for second opinion
Two days later ,She was readmitted with severe pain with repeated vomiting , not able to lie flat in bed, she was dehydrated PR 110/min BP125/77 Temp 36.5 , tender left hypochondrium ,her bowel sound
was normal ,her investigation revealed elevated CRP and White cell counts . Repeat US revealed normal kidneys, upper abdominal mass possible distended stomach , Chest X Ray revealed a dilated bowel inside
the left chest.
Laparotomy were performed, reduction of the content of the Hernia and Transverse Colon resection with end Colostomy and mucus fistula. Patient discharged
after 10 days with colostomy.
Following literatures review with the surgical team and discussion with the patient . We planned for trial of vaginal delivery and repair the colostomy after the purperium.
Patient presented with spontaneous labour at 38 w at 8 cm , delivered vaginally after 1 hour, a live male of 2.8 kg .
She had reversal of the colostomy 6 weeks after delivery and she was discharged 5 days later.
Causes
It’s a birth defect of three types
1. Bochdalek Hernia : ,involve an opening in the posterolateral part of the diaphragm(right or left).with herniation of stomach , intestine up to the chest cavity .
2 - Morgangi Hernia : involves an opening in the anterior part of the diaphragm.
3. Hiatus Hernia : part of the stomach herniated through the hiatus opening in the diaphragm at the gastro-oesophageal junction
Discussion
Symptomatic maternal DH during pregnancy is a surgical emergency required high index of suspicion (1). ) Chest radiograph and chest CT showing air filled bowel loop inside of the chest .It's associated
with high morbidity & mortality, particularly if surgical intervention is delayed. If signs of respiratory distress or of obstruction arise at any time, immediate repair should be undertaken regardless the
gestational age (2) During surgery, the herniated abdominal viscera were reduced through the opening in the diaphragm, resection of the ischemic segment of the bowel and repair of the diaphragmatic
defect with tow layers non absorbable suture. (5 During pregnancy in asymptomatic patient surgery should be performed promptly on elective basis in the first and second trimester while during third 3rd
trimester should be repaired at the time of elective caesarean section (CS). Prolong Active labour should be avoided (2, 4).
Vaginal delivery after antepartum repair is a reasonable alternative to immediate CS. (3).
Induction of labour at 39 weeks also tried and it was successful (3).
Delivery by Elective CS at 39 weeks is another alternative option if vaginal birth is not imminent (1).
A Hernia operated before the pregnancy could recur during pregnancy and it is possible that some DH not complicated during previous pregnancies could be aggravated without symptoms and are complicated
during a further pregnancy (2).
Conclusion
Symptomatic maternal DH is a surgical emergency and require immediate intervention . Expectant management and vaginal birth is a possible alternative to elective CS in certain circumstances.
Reference
1. Congenital DH a cause of cardio respiratory failure and visceral obstruction in late pregnancy's Gastrointestinal Liver Dis.2006Jun; 15(2); 185-8
2. DH and pregnancy, Dumont M, J Gynaecology Obstetric Biol Report (Paris) 1990; 19(4); 395-9.
3. Maternal congenital DH complicating pregnancy ,Genc MR,Clancy TE, Obs Gyn. 2003 Nov;102 (5 Pt 2);
4. Repair of symptomatic DH during pregnancyKurzel RB, Naunheim KS Obs& Gyn.1988 June; 71(6 Pt 1); 869-71
5. DH with ischemic bowel obstruction in pregnancy Sono A, Kato H, Surgery today .2008; 38(9):836-40. Epub 2008 Aug 28
Dr. Nada Aziz MRCOG ARAB BOARD, Consultant Obstetrics&Gynaecology
Dr. F . AL Haj Edris FRCS , DIM, Consultant general surgery,ALQassimi Hospital ,Sharjah ,UAE