CASEREPORT
Management of Diaphragmatic
Maher Fleyfel, MD*, Nathalie Provost, MD*, Jorge F. Ferreira,
Karim Bourzoufi, MD*
Departments of *Anesthesiology 2 and tGenera1 Surgery, Hopital Huriez, University
D iaphragmatic hernia, with the exception of hiatal
hernia, is an uncommon condition during preg-
nancy. Although one third of the patients are
symptom-free, it can lead to a high mortality rate,
ranging from 22% to 80%, if strangulation occurs (1).
We describe the management of a pregnant woman
with a left diaphragmatic hernia associated with a
right pneumothorax; diaphragmatic rupture resulted
from previous surgical trauma.
Case Report
A 29-yr-old woman, secundigravida, primapara was admit-
ted to our emergency department at 28 wk gestation for
acute dyspnea. The patient had been suffering for 15 days
from severe abdominal pain and intractable vomiting, unre-
lieved by metoclopramide. Her weight decreased from 45 kg
to 43 kg. Vital signs showed moderate distress and shortness
of breath, a respiratory rate of 25 bpm, a systolic blood
pressure of 90 mm Hg and a diastolic blood pressure of
60 mm Hg, heart rate at 100 bpm, and body temperature at
37°C. Physical examination revealed reduced breath sounds
over the lungs and tympany to percussion on the left side.
The abdomen was soft and the uterine fundal height was
28 cm. The remainder of the clinical examination was nor-
mal. A chest radiograph demonstrated a left diaphragmatic
hernia with a herniation of the stomach into the chest and a
right pneumothorax (Fig. 1). The patient’s medical history
revealed temporal epilepsy, depression, two episodes of
spontaneous right pneumothorax secondary to pulmonary
blebs, and constipation associated with megacolon. The pa-
tient’s first pregnancy, 10 yr previously, had been entirely
uneventful. She denied any previous trauma but had under-
gone a laparotomy with left nephrectomy for left adrenal
adenoma 3 yr previously. A splenectomy was performed for
tumor infiltration and was complicated by hemorrhage from
diaphragmatic vessels. Since that time, she had complained
of postprandial abdominal pain radiating to the left shoul-
der. An ultrasound demonstrated a normal gallbladder,
liver, and biliary ducts. Recurrence of adrenal tumor was
ruled out, and a hiatal hernia was diagnosed. Antacid ther-
apy was given. Pneumothorax was aspirated with a chest
tube introduced via the right fifth intercostal space, and a
Accepted for publication October 21, 1997.
Address correspondence and reprint requests
MD, Department of Anesthesiology 2, HBpital Huriez, 59037 Lille
Cedex, France.
01998 by the International Anesthesia Research Society
0003-2999/98/$5.00
Hernia During Pregnancy
MD*, Henri Porte, Mm, and
of Lille, France
nasogastric tube was inserted to decompress the stomach.
The patient’s general condition was improved initially by
reducing this mediastinal compression. Fetal growth, as as-
sessed by ultrasonography, was normal. The patient was
then transferred to the surgical ward, and conservative man-
agement with nasogastric aspiration and IV fluid and total
parenteral nutrition by a central venous line was started.
The chest tube was removed 3 days later. Because the pa-
tient‘s condition showed no symptoms of infection, and in
the absence of abdominal obstruction, conservative treat-
ment was planned until fetal maturity was reached.
During the following days, nausea and vomiting recurred
despite nasogastric aspiration. A barium meal showed par-
tial volvulus of the stomach (Fig. 2), and repair of the dia-
phragmatic hernia was believed to be necessary. The patient
was premeditated with sublingual midazolam 5 mg and
oral cimetidine 400 mg. In the operating room, the patient
was placed in supine position, with a wedge for uterus
displacement. Fetal cardiac rate was monitored with a
stethoscope placed on the periumbilical area throughout the
surgery. The arterial blood pressure was 120/70 mm Hg,
heart rate was 85 bpm, and fetal heart rate was 140 bpm.
Once the surgeon was ready to operate, 100% oxygen was
given, and a rapid sequence induction with thiopentone
200 mg, sufentanyl20 pg, and vecuronium 6 mg was accom-
plished. Cricoid pressure was applied and the trachea was
intubated with a double-lumen endotracheal tube. The lungs
were ventilated with 50% oxygen in air with the peak airway
pressure kept below 15 cm H,O and minute ventilation
adjusted to maintain carbon dioxide end-tidal pressure at
35-40 mm Hg. The patient was carefully positioned to lie
with the left side placed uppermost by watching arterial
blood pressure and fetal heart rate. No change in fetal car-
diac rate was noted during the patient’s positioning. A left
thoracotomy was performed with findings of an g-cm tear in
the left hemidiaphragm with herniation of the dilated stom-
ach. No evidence of ischemic damage was noted. The viscera
was returned to the peritoneal cavity, and the defect in the
diaphragm was closed. There were no major hemodynamic
or fetal heart rate changes during surgery. The chest was
closed with left pleural drainage, which was removed on
Postoperative Day 5. Pain relief was achieved with a patient-
controlled analgesia device with morphine chlorydrate (bo-
lus of 1.5 mg, lockout 5 min). Prophylactic tocolysis with IV
salbutamol infusion at a rate of 0.2 mg/h was instituted
postoperatively and maintained for 36 h. The patient was
discharged at 31 wk with normal fetal ultrasound. She re-
mained well, and delivery was accomplished by cesarean
to Maher Fleyfel, section at 39 wk gestation under epidural anesthesia because
of the risk of rupture of a pulmonary bleb and pneumotho-
rax during labor. Postoperative pain was managed with
Anesth Analg 1998;86:501-3 501
502 CASE REPORT ANESTH ANALG
1998;86:501-3

Figure 1. Chest radiograph at admission showing left diaphrag- Figure 2. Barium meal on Day 4 demonstrating partial volvulus of
matic herniation of the stomach and a right pneumothorax. the herniated stomach.

morphine by the same protocol of patient-controlled and congenital hernia have been discovered in the
analgesia.
second part of pregnancy (7). In our case, the postero-
central location of the tear suggested a traumatic ori-
gin of the hernia. We believe that an unnoticed tear
Discussion occurred during the previous splenectomy or that the
Diaphragmatic hernias during pregnancy are classi- left leaflet was weakened by the hemorrhagic surgical
fied into three categories (2): paraesophageal or hiatal, procedure (8,9). Since this patient’s surgery, repeated
congenital, and traumatic hernia. Hiatal hernias are 6 increases in intraabdominal pressure (caused by
times more common than the other two types, and coughing, sitting positions, constipation, and strain-
occurs from increased intraabdominal pressure dur- ing) likely enlarged the unnoticed tear (1) or contrib-
ing the second and third trimesters of pregnancy (up uted to further stretching of the weakened diaphragm
to 18% of multipara and 5% of the primipara) (3). fibers, eventually resulting in a rent. Pregnancy pro-
Congenital hernias are caused by defects in the dia- vides additive factors of increased intraabdominal
phragm arising from faulty embryologic development pressure: nausea and vomiting until the 16th week
in the posterolateral (Bochdalek) or the substernal and the enlarged pregnant uterus in the second tri-
(Morgagni) portion of the diaphagm. Symptoms may mester. With advancing pregnancy, as the uterus en-
occur during pregnancy (4). Traumatic diaphragmatic larges, it forces an increasing amount of abdominal
hernia results from blunt trauma, which increases in- content into the chest. All these factors may convert an
traabdominal pressure and tears diaphragmatic fibers occult defect to one that is symptomatic and increase
(5). In the nonpregnant patient, 90% of these hernias the risk of twisting and torsion of herniated viscera.
occur on the left side, because the liver offers protec- Surgical closure is required before delivery, because
tion to the right side (6). Thirty-two cases of traumatic spontaneous rupture of the diaphragm might occur
ANESTH ANALG CASE REPORT 503
1998;86:501-3

during labor (10). Cesarean section can be performed surgeon must be ready to operate before ventilation is
simultaneously once fetal maturity is documented (7). begun (16).
Clinical findings vary. In our case, the stomach
alone was involved; hence, the symptoms were sug-
gestive of vague postprandial epigastric distress (11).
Radiographs provided the diagnosis and showed a References
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