Tension pneumothorax from large bowel herniation and perforation as a late presentation of traumatic diaphragmatic hernia during pregnancy: a case report

Abstract

Background: Diaphragmatic hernias can be congenital or acquired, with trauma being the primary cause of the latter. Both types may have delayed presentations, with abdominal organs protruding into the thoracic cavity, causing symptoms of varying severity. Pregnancy can sometimes precipitate the condition. Tension pneumothorax resulting from bowel perforation into the thorax is exceptionally rare, with only a few cases reported. To the best of the authors knowledge, this is the third documented case of a late-presenting trauma-related diaphragmatic hernia during pregnancy, complicated by tension pneumothorax.

Case presentation: A 30-year-old woman, 29 weeks pregnant, was referred to Semmelweis University emergency department with moderate dyspnea. Initial investigation revealed tension pneumothorax. Chest tube placement released air, pus, and feces. Computer tomography identified a diaphragmatic hernia with bowel incarceration and perforation as the underlying cause. The patient underwent a delayed cesarean section and surgical repair, with a good outcome. A history of thoracic trauma eight years prior was later revealed.

Conclusion: Evaluating pregnant patients with shortness of breath in the emergency department is challenging. Identifying a history of thoracic or abdominal trauma is crucial, as this can raise the suspicion of diaphragmatic hernia, which can present with a wide range of symptoms. Spontaneous tension pneumothorax in pregnant women is extremely rare and requires cautious management. A multidisciplinary approach is crucial for the successful treatment of maternal diaphragmatic hernia.

Keywords: Diaphragmatic hernia; Dyspnea; Empyema; Large bowel perforation; Pregnancy; Tension pneumothorax.

Fig. 1

Scout image from the first CT attempt shows missing normal pulmonary pattern on the left with significant mediastinal right shift indicating high tension PTX and the reason of the poor respiratory condition

Fig. 2

Multiplanar reconstruction of the hernia gate on the left side of the diaphragm. The gate measures 35 mm across. Pleural drain indicated dorsal along the ribs

Fig. 3

Multiplanar reconstruction of the perforation on the colon, which is highlighted with lime in the (near) axial plane. The perforation measures 44 mm across

Fig. 4

3D reconstruction with shaded surface display (SSD) in a slightly rotated position. The blue arrows point to the normal right lung and the compressed left lung. The brown arrow points to the normal transverse colon. Red arrows point to the gases contained within and around the herniated and perforated part of the colon

Fig. 5

The necrotized and perforated part of the colon

Fig. 6

The diaphragmatic injury, after it had to be slightly enlarged to facilitate the withdrawal of the bowel from the thoracic cavity. Original size was 35 mm. (Grade III traumatic diaphragm hernia according to the AAST - American Association for the Surgery of Trauma - classification). It is in the central portion of the diaphragmatic dome, at the junction of the central tendon (centrum tendineum) and the muscular part, slightly posterolateral on the left side and medial to the spleen, which is the most common location for traumatic diaphragmatic ruptures. It has been repaired with simple knotted stitches using size „0” absorbent braided surgical suture. The use of mesh was contraindicated due to the septic condition, but it was also unnecessary, as the surrounding tissues were adequately pliable to allow for primary closure

Fig. 7

Chest X-ray on the first (a) and 14th (b) postoperative day