Diaphragmatic hernias complicating pregnancy

Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life-threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non-hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports.

The presentation, management and outcomes of a series of three recent cases are described. A review of all other reported cases of diaphragmatic hernias complicating pregnancy was also carried out.

All three cases were emergency presentations in the third trimester of pregnancy, resulting from compression of thoracic contents. All cases required emergency laparotomy and one also required thoracotomy. Delivery was by Caesarean section at the time of emergency surgery in two cases and was delayed in the third case. There was one fetal and no maternal deaths. One mother suffered persistent pleural infection. One baby also had a diaphragmatic hernia requiring postnatal repair. Published reports showed only 36 previously reported cases of diaphragmatic hernias identified in pregnancy. There is a consensus that hernias presenting with evidence of strangulation represent a surgical emergency and mandate operative management, irrespective of fetal maturity. Elective management of asymptomatic hernias is more controversial and both conservative and operative approaches have been suggested.

Diaphragmatic hernias can cause life-threatening complications in pregnancy. Consideration should be given to operative repair in the second trimester if asymptomatic hernias are identified during pregnancy. If vaginal delivery is attempted in the presence of a hernia, this should only be carried out under closely monitored conditions.