Labor-Induced Diaphragmatic Hernia Causing Emergency

Introduction:

Any abnormal defect in the diaphragm that may cause protrusion of abdominal contents into the thoracic cavity is known as a diaphragmatic hernia. Diaphragmatic hernias may be congenital or acquired. Acquired diaphragmatic hernias may be traumatic or iatrogenic, while spontaneous diaphragmatic hernias are rare. The authors present the case of a spontaneous acquired diaphragmatic hernia.

Case Summary:

A 27-year-old woman presented to the emergency department with complaints of shortness of breath and cough with sputum for the last three days that had worsened since the morning of presentation. Her history was significant for gestational amenhorrea of 32 weeks. This was her second pregnancy. Her vital signs were within the normal limits. A physical exam revealed absent breath sounds on the left side and a gravid uterus of about 30 weeks. A chest x-ray was done which showed air fluid levels in the left chest with upward pointing meniscus. The authors’ differential included a diaphragmatic hernia, diaphragmatic eventration, hydatid cyst, and loculated empyema. An obstetrician was consulted, and after an examination, they declared that the patient was in labor. She delivered a healthy baby through normal vaginal delivery. After labor, she was comfortably lying in bed with normal vital signs and no active complaints. However, a little later, the patient started to become tachypneic and tachycardiac. Her respiratory rate was more than 50 per minute and heart rate was more than 140 per minute. An electrocardiogram was done which showed sinus tachycardia. She was shifted to the intensive care unit and was intubated for progressing respiratory failure. A nasogastric tube was passed and approximately more than two liters of gastric content was aspirated. An urgent echocardiogram was obtained which showed a right ventricle strain and a dilated Inferior vena cava without respiratory variation. The patient was urgently shifted for a computed tomography of the chest with intravenous contrast, which revealed a large diaphragmatic hernia on the left side. The stomach, omentum, splenic flexure of the colon, the descending colon, small bowel, spleen, and tail of the pancreas were all present in the left chest cavity. There was a mediastinal shift to the right, and the left lung was collapsed. The right lower lobe also showed signs of compression atelectasis.

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