Pregnancy complicated by traumatic rupture of the diaphragm

Pregnancy

Complicated

Rupture

of the Diaphragm

LOUIS C. BERNHARDT, M.D., Madison,

Marshfield,

From the Muvshjield Clinic and Maush$eld Clinic Foundation for Medical Research and Education. Marshfield. Tl~iscokin. ”

YMPTOMS of diaphragmatic hernia follow two patterns in pregnancy: either heartburn, nausea, and occasional emesis, or that which results in an intestinal obstruction. The most common type of hernia, the esophageal hiatus hernia, is due to a short esophagus or patchulous opening in the esophageal hiatus, which results in protrusion of the upper part of the stomach above the diaphragm [I-%]. The incidence of esophageal hiatus hernia in the general population is 5 per cent as opposed to a 12.8 per cent incidence during pregnancy [5]. The other pattern which diaphragmatic hernias may follow is noted in the small number of patients who during labor or shortly thereafter become acutely ill with abdominal pain, nausea and emesis, dyspnea. and possible cyanosis and shock [6]. Physical examination of these patients reveals bowel sounds heard over the left hemithorax, from which the diagnosis of diaphragmatic hernia with incarceration can be made; SO to 90 per cent of such diaphragmatic hernias are traumatic in origin [7]. The traumatic diaphragmatic hernia may manifest itself in three states: the initial stage, shortly after trauma; the latent stage, in which there may be vague gastrointestinal complaints or no symptoms; and the obstructive stage, which may occur many years after the original trauma. Roentgenographiccriteriafortraumatic diaphragmatic hernia have been suggested by Carter, Giusefi, and Felson [8] and are (1) an archlike shadow resembling an abnormally elevated diaphragm; (2) extraneous shadows,

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by Traumatic

Wisconsin, AND BEN R. LAWTON, M.D., Wisconsin

densities, or gases in the chest; (3) a shift of the mediastinum away from the affected hemithorax; (4) platelike atelectasis above the injured diaphragm. The purpose of this communication is to present a case of traumatic rupture of the diaphragm complicating pregnancy, to discuss the possible modes of treatment, and to review briefly the literature. CASE

REPORT

The patient (C. C.), a t\vcnt!--six year old primigravida, was admitted to St. Joseph’s Hospital on September 24, 1’362 at midnight. Her last menstrual period had begun on December 10, 1961, and the expected date of confinement was October !I, 1962. Twenty-four hours prior to admission the patient experienced nausea and retching accompanied by severe pain in the left shoulder radiating to the precordium and epigastric region. An intramuscular analgesic temporarily relieved pain and the patient was admitted to another hospital early September 21, at which time a roentgenogram of the chest showed an air-fluid level in the left hemithorax. Two thoracenteses were performed; both yielded a small amount of vellow acidic fluid. The patient was given Gastrogra& which demonstrated the intestinal tract in the left hemithorax. She was then transferred to St. Joseph’s Hospital. The patient reported substcrnal pprosis with excessive eating, occurring after the fourth month of pregnancy. Substernal burning was aggravated by excitement and by lying in a recumbent position, was relieved by sitting erect and by antacids, and it usually persisted from three to four hours. These episodes occurred approximately once a week. The patient denied any emesis, hematemesis, dyspnca, or other cardiorespiratorv complaints. Pertinent medical tiistory included an automobile accident at the age of eleven, at which time the patient experienced “a collapsed left Jung” which

Pregnancy and Traumatic Rupture of Diaphragm

919

re-expanded before discharge from the hospital. She recovered fully and had no symptoms after that accident. Hospital records and roentgenograms were unobtainable. The patient had been thrown against the steering wheel in another automobile accident in tW&l but suffered no other injury and sought no medical attention. She had also been hospitalized at Madigan General Hospital in Tacoma, Washington in December lS60 for dysfunctional uterine bleeding. -4 roentgenogram of the chest taken during this hospitalization revealed “an elevated immobile left diaphragm probably as the result of previous trauma 191.” She did not experience anv cardiorespiratory or gastrointestinal symptoms until the fourth month of pregnancy, as mentioned previously. Physical examination revealed a pregnant Caucasian woman, uncomfortable but in no acute distress: her color was good, pulse was 104 per minute,

respiration 23 per minute, blood pressure 1:%‘8(i mm. I-Ig, and temperature !lY”~;. The trachea deviated :3 cm. to the right at the suprasternal notch. Pertinent physical findings on examination of the left hemithorax included limitation of motion, dullness to percussion with the patient in the sitting position and tympany when she was recumbent, decreased tactile fremitus and vocal resonance, absent breath sounds, and hyperactive bowel sounds. The left border of cardiac dullness was percussed at the left parasternal line, indicating a mediastinal shift. The uterus was 2 fingerbreadths below the xiphoid; the fetal heart tones were 1-E per minute and regular in the left lower quadrant. .4 sterile vaginal exam&tion revealed a soft cervix which was -10 per cent effaced and dilated 1 to 2 cm., with the vertex of the fetal skull at the level of the ischial spines. Hemoglobin on adtnission was l-l..5 gtn. per cent, hematocrit -K per cent, white blood cell count I5,:100 per cu. mm. with a normal differential. Electrolytes and l~lood urea nitrogen were within nornral limits. An x-ray film of the chest (Fig. 1) revealed an airfluid level at the second left anterior rib, the mediastinum was shifted to the right, and stnall air-fluid levels were faintly visible through the opaciticd lower portion of the left part of the chest. .4 nasogastric tube was passed into the stomach and a large amount of fluid was aspirated, affording some relief to the patient. Repeat roentgcnograms of the chest (Fig. 2 A, R, and C) showed a decrease in the size of the air-fluid level and that the colon contained the previously administered Gastrografin. A small pneumothorax was present and large pleural adhesions extended toward the apex of the left thoracic cage. Intravenous fluids were started and the patient rested comfortably during the remainder of the morning. An x-ray film of the abdomen revealed a single intrauterine pregnancy with a normal fetus in cephalic presentation. However, the distal femoral epiphysis and the proximal tibia1 epiphysis could

FE. I. Large air-fluid lcvcl is at the level of 1IN,wconti rib anteriorly, the rnediastinutn is sllifted to the right. and small air-fluid levels arc noted through thv trl)acificd lower l)ortion of the, I& part of the chest. not be identified. Fourteen hours after admission an amniotomy was I)erformed and the patient began active labor. Eleven hours later, under pudendal block regional anesthesia, the patient v as delivered of a male infant wvcighing (i pounds with an AI)gar rating of 10. Low forceps were used to elitninate \oluntar)contractiors of the abdominal tnusculature. Eight hours 1)ost partutn a left thoracototny was performed through the eighth intercostal space; the stomach, spleen, small intestine, and colon wcrc’ rcturned to the abdominal cavily and a rent. of 7 to s cm. in the dome of the left diaphragmatic leaf was repaired. The patient’s postpartum and I)ostoperativc course was satisfactory. The chest tube was removed on the first postoperative day and an x-ray film of the chest showed re-expansion of the left lung. (Fig. 3.) The patient was dischar,ged on the seventh postoperative day in good condltlon. COMMENTS

This case illustrates an interesting set of circumstances which raise many questions concerning proper management. At the outset several alternatives were considered, the first of which was to control the condition medically and wait for delivery. This was unsatisfactory on all counts ; nothing would be gained by the

920

Bernhardt

and Lawton

FIG. 2. A, B, and C, air-lluid level is decreasing with aspiration of stomach contents. The colon contains the previously administered Gastrografin. iTo mediastinal shift is noted, but a small pneumothorax and large pleural adhesions extend toward the apex of the left lung.

passage of time. The patient’s electrolytes were within normal limits, the fetus was full-term, there was no evidence of toxicity due to strangulation, and signs of infection of the left hemithorax due to thoracenteses were absent. These facts plus the possibility of thoracogastric fistula made immediate treatment a better course. Such fistulas have been reported to result in fatal empyema [10,11]. The second

FIG. 3. Fihn taken four weeks postoperatively.

alternative was to perform a cesarean section with repair of the hernia by an abdominal route. The advantage of this course would be the elimination of increased intra-abdominal pressure incident to labor, the elimination of possible perforation of a viscus which could occur with a vaginal delivery [I,?], the single operative procedure, and the relatively empty abdominal cavity into which the displaced viscera could be replaced. The disadvantages of this treatment would be the compromise of the preferred route for repairing a diaphragmatic hernia, the possible necessary extension of an abdominal incision to repair the hernia, and the risk of a cesarean section. The last alternative was to induce labor and deliver the infant vaginally, followed by a thoracotomy and repair of the diaphragmatic hernia. This method, which we selected, included only a slight increase in intra-abdominal pressure, because the second stage of labor was shortened by the use of forceps. Possible nausea and vomiting from a general anesthetic were factors to be avoided. Thoracotomy provided maximal exposure of the abdominal contents in the thorax and repair of the diaphragmatic rent was accomplished with relative ease. Granzow [13] in 192i cited three cases of fatal strangulated diaphragmatic hernias and added another case of his own. Other fatal cases have been reported by Fishbach [14] in 1928, Diddle and Tidrick [15] in 1041, Yenen

Pregnancy and Traumatic [16] in 1945, Levy [17] in 1953, and Osborne and Foster [18] in 1953. Fishbach’s patient had a rent of I1 cm. in the dome of the left diaphragm with all of the gastrointestinal tract in the left hemithorax except for the sigmoid colon. Diddle and Tidrick’s patient had had three previous pregnancies without incident, and the hernia in Yenen’s patient occurred during the sixth month of pregnancy. In 1941 DeLee and Gilson [I 9 ] reported a case in which the patient experienced pain in the left upper and lower quadrants thirteen hours postpartum accompanied by nausea and emesis which were treated medically; the patient survived. Salgado [ZO] in 1944 reported a case in which the symptoms were relieved after cesarean section, but in 1!443 it was Thompson and LeBlanc [ZI] who carried out the first successful surgical intervention for the treatment of strangulating diaphragmatic hernia complicating pregnancy. Their patient experienced epigastric pain, nausea, and vomiting, and was cyanotic five and a half hours postpartum of the second pregnancy (her first pregnancy was without incident). a1t surgery the gastrointestinal tract was noted in the left thorax through a congenital diaphragmatic hernia. Later cases of survival were reported by Bourgeois and Hood 1221 in I!J49. Pearson, Pillsbury, and McCallum (231 in l%O, Hobbins and Hurwitz [24] in 1953, and Gorbach and Reid [25] in 19%. In 1953 M?lliams and Whicker [26] presented two patients whose pregnancies were complicated by congenital absence of the left diaphragmatic leaf; one patient survived, the other died from incarceration of the stomach with perforation. Grage, MacLean, and Campbell [27] reported a series of traumatic diaphragmatic hernias in 1959 and discussed two cases of pregnant women, both in their second trimester at the time of the trauma. One hernia was repaired less than forty-eight hours after trauma and the other four weeks after trauma. These patients presented with the picture of intermittent small bowel obstruction. Both women went to term and delivered viable fetuses. CONCLUSIONS

A case of diaphragmatic hernia complicating pregnancy is presented with a discussion of the various choices of treatment. Conditions which determine the course of treatment include electrolyte balance. evaluation of the respira-

Rupture of Diaphragm

921

tory reserve, and the degree of intestinal obstruction and its toxicity. The age of the fetus must be noted as well as the outcome of previous pregnancies. The roentgenologic criteria for traumatic diaphragmatic hernia as suggested by Carter, Giuseffi, and Felson are included. In reviewing the literature, we have found several case reports, each unique. To insure a successful outcome, therefore. each demands a unique approach. REFERENCES

1. EDGERTOX, C. D. and RUARK, R. J. Hiatus hernix in pregnancy. .-ln7. J. Ohsl. b Gynrc.. 70: 1216. 1955. 2. EVANS, J. R. and BOWSLOG,J. S. Intractable heartburn of pregnancy. Rndioloxy. 34: 530, 1940. 3. GOODSON,J, H. Hiatus hernia in pregnancy. Obst. b Gyner., 7: 332, 1956. 4. SCHNEPP, I(. H. Diaphragrnatic hernia as cause of intractable heartburn of pregnancy. .lw. .1. Ohst. b Gynec., 46: 142, 1943. 5. PENMAN. R. Hiatal hernia: a cause of prrsistcnt gastrointestinal disturbances in pregnancy. Il’esl. -1. Surg,, 59: 622, 1951. 6. JOURNEY, K. W. and PAYNE, F. L. Nonobstctric surgical complications during obstetric wrc: a review of tlw recent litrraturc. .lw. .I. .%I. .Sci., 232: 695, 1956. 7. CARTER, B. K. and GIUSEFFI, J. Strangulated diaphragmatic hernia. ilnn. .%r,q.. 128: 210, 1948. 8. CARTER, B. N., GIUSEFFI. J.. and FELSON, R. Traumatic diaphragmatic hernia. .1 V. .I. Rwntyenol., 65: 56, 1951. 9. Records from Madigan General Hospital, Tacoma. Washington, December 1960. 10. LINKSKOG, G. E. and LA~VRENCE,E. A. Treatment of thoracogastric fistula. I. Uzovac-ic- Surg. 16: 477, 1947. 11. SOMMER, G. K. J., JR. and MILLS, W. 0. Tl~oracogastric fist& and multilocular empyema conplicating posttraumatic diaphragmatic hrrnia. J. Thovncir Sury., 16: 265, 1947. 12. KUSHLAN, S. D., D. Diaphragmatic hernia in prcgand danger. 17onnrc!jc-r/f wdncy ; significance 64. J., 15: 969, 1951. 13. GRANZOIV,J. Tod unter der Geburt durch Trxr~atische Zwcrfellhernie. Fortschr. Geb. Kc nt:mstrahlen, 35: 1246, 192T. 14. FISHBACH, H. R. A fenestra of the diaphragm. .Arch. P&h., 6: 867, 1928. 15. DIDDLE, A. W. and TIDRICK, R. T. Diaphraprxatic hernia associated with pregnancy. :l m. J. Obsr. b Gyner., 41: 31i, 1941. 16. YENEN, E. Diaphragmatic hernia complicating pregnancy. Tiirk tib cem. nzec., 12: 236, 1946. 17. LEVY, H. Pregnancy complicated by diaphragm&c hernia. J. III. Ser. New Jersey, 50: 72, 1953. 18. OSBORNE, W. W. and FOSTER, C. D. Diaphragmatic hernia complicating pregnancy. .I~M. J. Obst. & Gyzec., 66: 6S2, 1953. 19. DELEE, S. T. and GILSON, B. I. Diaphragmatic

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hernia complicating the puerpcrium. .4nr. J. Obst. b Gynec., 41: 904, 1941. SALGADO, C. Casareana por hernia diaphragmatica. .In. brasil ginec., 17: 225, 1944. THOMPSON, J. W. and LEBLANC, L. J. Congenital diaphragmatic hernia; visceral strangulation complicating pregnancy. ;1 no. J. S~rg., 67: 123, 1945. BOURGEOIS,G. E. and Hook, W. T. Strangulated diaphragmatic hernia complicating pregnancy, New England J. Med., 241: 150, 1949. PEARSOX, S. C., PILLSBURY, S. G., and MCCALLUM,

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M. Strangulated diaphragtnatic hernia COmpliating delivery, J..-l.M.~l., 144: 22, 1950. HOBBINS, W. and HURIVITZ, C. Incarcerated diaphragmatic hernia of the colon occurring during pregnancy. New England J. Af~d., 249: X3, 1953. GORBACH, A. C. and REID, D. E. Hiatus hernia in pregnancy. New England J. Xed.. 225: 517, 1956. WILLIAMS, G. A. and WHICKER, C. F. Absence of left diaphragn-an unusual complication of pregnancy and labor. Obst. & Gynec., 6: 272, 1953. GRAGE, T. B., MACLEAN, L. D., and CAMPBELL, G. S. Surgery, 46: 669, 1959.