NOT SO NORMAL VAGINAL DELIVERY: TRAUMATIC DIAPHRAGMATIC RUPTURE

Abstract

INTRODUCTION: Traumatic diaphragmatic rupture after vaginal delivery is an extremely rare surgical emergency. There have been a total of 35 cases reported in the literature so far of maternal diaphragmatic hernias that complicate pregnancy or delivery. We report a case of a patient without previous history of congenital diaphragmatic hernia that presented in active labor and progressed to shock with mediastinal shift. CASE PRESENTATION: A 21-year-old previously healthy female presented to our hospital at 37 weeks of gestation in active labor. She delivered a healthy male infant by spontaneous vaginal delivery. About an hour after the delivery she developed nausea, vomiting, and sharp chest pain. On physical exam, gastric sounds were audible in the left chest with a clear exam in the right chest. Laboratory tests were remarkable for a WBC of 18,000/mL. She underwent a CT scan that showed bowel loops in the left chest. While in the CT scan, she developed progressive hypotension and severe abdominal pain. She had to be taken to the operative room for an emergent laporatomy which revealed a ruptured left hemidiaphragm. She was noted to have abdominal contents including the stomach and large bowel in the left chest and immediate surgical decompression relieved the mediastinal shift and relieved the strangulation of herniated viscera. Primary closure was done without any tension. Patient's hemodynamics improved after surgery and she recovered without any complications post-operatively. DISCUSSIONS: Diaphragmatic rupture is usually due to blunt or penetrating abdominal trauma. It is hypothesized that it is more common on the left side because of a stronger right hemidiaphragm and the cushioning effect provided by the liver. The mechanism proposed in rupture secondary to vaginal delivery is increased abdominal pressure resulting in avulsion of the diaphragm. There have been very few reports in the literature of spontaneous diaphragmatic rupture after vaginal delivery. The hernia of Bochdalek is a posterior lateral defect that occurs in the left diaphragm in most cases related to congenital diaphragmatic hernia. Most cases present in infancy, but there are cases that are asymptomatic and present later in life. Caesarian section is recommended in pregnant patients with congenital diaphragmatic hernia as increased abdominal pressure during active labor can result in strangulation of bowel loops. In cases where rupture is suspected, immediate chest radiography is the recommended diagnostic tool. CONCLUSION(S): Diaphragmatic rupture should be considered in obstetric patients while evaluating them for acute dyspnea.