Undiagnosed maternal diaphragmatic hernia - a management dilemma

Abstract

Background: Maternal diaphragmatic hernias identified during pregnancy are rare and pose significant management challenges with regards to timing and mode of both delivery and hernia repair.

Case presentation: We describe a case of a maternal diaphragmatic hernia diagnosed at 31 weeks gestation in the setting of acute upper abdominal pain. Due to no evidence of visceral compromise and a stable maternal condition, the patient was conservatively managed, allowing for further foetal maturation. Delivery by caesarean section occurred following concerns of malnutrition and partial bowel obstruction. This was followed by immediate surgical repair of the hernia. The patient had an uncomplicated recovery.

Conclusion: Maternal diaphragmatic hernias in pregnancy require multidisciplinary care and individualised management in order to allow for the optimal outcome for mother and foetus.

Keywords: Antenatal management; Diaphragmatic hernia; Intrapartum management.

Fig. 1

Chest Xray from first presentation at 13 weeks showing left lower lobe opacification. While initially thought to be left lower lobe pneumonia this is likely to represent the diaphragmatic hernia even at this early gestation

Fig. 2

Chest Xray from presentation at 31 + 3 weeks showing a raised or ruptured left hemi-diaphragm with bowel visible in chest and displacement of the mediastinum to the right

Fig. 3

CT chest confirming a large diaphragmatic defect with herniation of stomach, small and large bowel and spleen into the chest cavity and almost complete collapse of the left lung