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Spontaneous rupture of the diaphragm during pregnancy: a case report
Abstract Number: T-62
Abstract Type: Case Report/Case Series
Introduction: ‘Spontaneous’ rupture of the diaphragm during pregnancy is extremely rare but is associated with a poor or complicated outcome. The increased intra-abdominal pressure is suspected to be a cause of the aggravation of congenital deficit in the diaphragm. We present a survived case of pregnant woman who was diagnosed as rupture of the diaphragm with herniation of the viscera in the second trimester.
Case report: A 26-year-old nulliparous woman (162 cm, 47.0 kg) at 13 weeks’ gestation had mild degree of low back pain without any signs of abdominal disorders. At 21 weeks she frequently complained of nausea and vomiting simultaneously with epigastric pain in addition to low back pain, however an X-ray examination of the chest was not performed under the diagnosis of constipation and esophagitis. The patient was brought to the emergency department at 26 weeks and 2 days’ gestation. She had experienced a dramatic increase in epigastric and left-sided upper back pain immediately after straining during defecation. A chest radiograph and computed tomography of the thorax showed the nasogastric tube to be in the stomach in the left hemithorax and marked mediastinal shift to the right. Her heart rate was 112 per minute and blood pressure was 123 / 67 mmHg. Pulse oximeter presented 97 % under room air condition. The patient was promptly taken to the operating room, where a laparotomy was performed after rapid-sequence induction of anesthesia with propofol and remifentanil. The diagnosis was confirmed as a hernia of transverse colon and stomach together with spleen through a damaged muscle wall of the dorsolateral part of the left diaphragm, which corresponds to the favorite site of Bochdalek hernia. The defect was about 10 x 5 cm and repaired with sutures. The patient was successfully extubated a couple of hours after operation. A healthy 2801-g infant was delivered at 37 weeks by elective Caesarean section, which was chosen to prevent diaphragmatic re-rupture due to intra-abdominal pressurization associated with vaginal delivery.
Discussion: Spontaneous rupture of the diaphragm of pregnant women is seldom encountered. Maternal death due to ruptured diaphragmatic herina was reported in some literatures. Fortunately our patient was diagnosed correctly and managed before developing cardiopulmonary symptoms, even though her early presentations such as back pain and digestive symptoms should had been carefully observed in earlier times. Although uncommon, spontaneous rupture of the diaphragm should be suspected in any pregnant or postpartum woman with back pain and digestive symptoms.