Maternal Diagphragmatic Hernia: Multidisciplinary Management

Background: Early recognition, diagnosis, and treatment are critical in the management of the pregnant  patient with a diaphragmatic hernia (DH).  DH occurs when abdominal viscera shift into the thoracic cavity.  Signs and symptoms mimic normal pregnancy and include: nausea, vomitting, abdominal pain, dyspnea, radiating shoulder pain and chest pain.

Case: A 30 year old woman, G2P2 at 29 3/7 weeks  presented complaining of nausea, dry heaves, abdominal and back pain, constipation and an inability to get comfortable.   Her medical history included gastric bypass surgery, strangulated hernia repair and a C/S at 34 weeks gestation with twins.  A CT scan revealed a 7 inch diameter incarcerated diaphragmatic hernia.  Treatment required a two surgical interventions.   First was an immediate diaphragmatic hernia repair, next abdominal hernia repair and C/S  

A nurse coordinated multidisciplinary team convened to discuss the plan of care, identify potential risks and possible emergency interventions.   Team members included the general surgeon and assistant, the OR team, OB anesthesiologist, L&D nurse, and obsterician.  The NICU team and other speacilist were on standby.  Planned interventions included both general and epidural anesthesia, dual lumen intubation with two ventialtors and intermittent fetal monitoring. The patient and her husband were involved discussions of the plan of care.  The diaphragmatic hernia repair was completed without incident, recovery occured in the ICU with care provided by both ICU and L&D nursing staff to monitor central lines, PICC lines, TPN, ventilators, sedation, epidural, wound vaccuums, chest tubes, g-tube, foley catheter and fetal heart tones. 

Weekly multidisciplinary meetings were held to discuss maternal and fetal progress, update the plan of care and identify interventions for emergency situations including a C/S in the ICU for a prolapsed cord (fetus in transverse lie)  The adjacent ICU room was set up as an NICU.  Both C/S and anesthesia equipment were available.  The team leads for L&D and ICU created a "to do" list in case of emergency.  The goal was to monitor mother and baby until 34 weeks gestation when the second surgery was planned.

The C/S and hernia repair were done at 34 6/7 weeks in the main OR with the patient's husband present.  She recovered in the PACU and transferred to a med/surg unit.  The baby was admitted to the NICU.  Detailed post-operative instructions for the L&D and med/surg team leads were outlined.  A triage phone list was posted in the patient's room.  Both mother and baby recovered without complications. 

Conclusion: Multidisciplinary teamwork, communication and care coordination resulted in the discharge of a healty mother and baby.

Keywords: Maternal diaphragmatic hernia, pregnancy