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Parturient with Congenital Diaphragmatic Hernia
Abstract Number: T 56
Abstract Type: Case Report/Case Series
Congenital diaphragmatic hernias in adulthood are rare, with an incidence of 0.17% (1). Approximately, 90% of cases occur on the left side and are the result of herniation of the gut through the posteroleteral defect of Bochdalek (2). Less than 40 cases of parturients with diaphragmatic hernias have been documented in the literature since 1928 (1).
A 31yo G1P0 with a known Bochdalek’s hernia was admitted at 29 weeks gestation for acute dyspnea. The patient presented with worsening early satiety, heartburn, nausea, and epigastric abdominal pain. On admission, the vital signs were stable. The physical exam was remarkable for mild tenderness of the abdomen and labs revealed no electrolyte disturbances. An MRI of the abdomen revealed enlargement of the hernia with no evidence of obstruction. The patient was started on 40% oxygen via facemask and treated with Morphine, Sodium Citrate, and Metoclopramide. Given that the patient remained stable, conservative management was initiated with nasogastric decompression, IV fluids, and total parenteral nutrition by a central venous line. Antenatal corticosteroids were administered to promote fetal lung maturity.
At 30 weeks 4 days gestation, the nausea and vomiting recurred despite nasogastric aspiration. Due to the concern of life threatening visceral strangulation, a decision was made to proceed with a cesarean section. The patient was brought to the operating room the following day in stable condition. A combined spinal epidural was placed at the L4-5 interspace using a 27g spinal needle with intrathecal Bupivcaine 7.5mg, Tetracaine 0.2mg, Morphine 0.1mg, and Fentanyl 10mcg. An additional 5ml of 2% Lidocaine was administered epidurally to achieve a T6 level. The patient tolerated the procedure well and did not require assistance with ventilation. Postoperatively, the patient was transferred to the ICU for observation of respiratory function. The diaphragmatic hernia was repaired eleven days later.
The management of parturients with CDH can be extremely challenging. Anesthetic considerations from the extravasation of the bowel into the thorax include respiratory failure from compression atelectasis, severe reflux, ileus, and bowel incarceration. Vaginal delivery without assistance is usually contraindicated as the Valsalva maneuver can worsen bowel herniation into the thorax (3). If gastric decompression does not relieve the symptoms at presentation a cesarean section with immediate repair of the hernia is usually indicated. Alternatively, as we report in this case, expectant management prolongs pregnancy allowing for the administration of corticosteroids. The repair of the hernia can be performed in the post partum period.
1 Barbetakis, N. et al. World J Gastroenterol 2006 21: 12(15):2469-2471
2 Fleyfel, M. et al. Anesth Analg 1998:86:501-503
3 Genc MR. et al. Obstet Gynecol 2003; 102: 1194-1196