Maternal Strangulated Diaphragmatic Hernia with Gangrene of the Entire Stomach During Pregnancy: A Case Report and Review of the Recent Literature

Figures & data

Figure 1 (A and B) Coronal T2-weighted fast spin-echo MR images showing herniation of the stomach (arrowhead) and splenic flexure of the distal transverse colon(arrows) in the left intrathorax. (C) Transaxial magnetic resonance (MR) imaging showing severe anterior diaphragmatic hernia (arrow) of the spleen.

Figure 2 (A) Perioperative photograph showing a large defect in the left posterior dome of the diaphragm. (B) Postoperative photograph showing necrosis of the entire stomach.

Figure 3 (A) Early postoperative coronal computed tomography (CT) scan after total gastrectomy and splenectomy due to incarcerated left diaphragmatic hernia. (B) After postoperative and delayed delivery, upper gastrointestinal (UGI) series with gastrografin swallow show no evidence of contrast leakage or passage disturbance at the anastomosis site.

Table 1 The Current Literature on a Diaphragmatic Hernia During Pregnancy

Author and Date	Age (Years)	Type	Side	Defect Size (cm)	Herniated Organs	Bowel Obstruction, Ischemia, Perforation of Herniated Organs	Surgical Procedure	Delivery Type	GA at Delivery (wks)	GA at Diagnosis of Hernia (wks)	GA at Surgical Repair (wks)	Maternal Survival	Fetal/Neonatal Survival
Diddle et al, 1941^Citation58	23	Traumatic	Lt	13	Stomach, duodenum, ileum, appendix, T-colon, cecum	Positive	Conservative treatment	NA	38.6	38.6	Non-operative	Death	Stillborn
DeLee et al, 1941^Citation46	20	NA	Lt	NA	Intestine	Negative	Conservative treatment	VD	40.3	Postpartum	Non-operative	Alive	Alive
Thompson et al, 1945^Citation12	31	Congenital (Bochdalek hernia)	Lt	10	Stomach, intestine, pancreas	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Bourgeois et al, 1949^Citation59	31	NA	Lt	NA	NA	Negative	Conservative treatment	Vaginal C/S	38.7	38.6	Non-operative	Alive	Alive
PEARSON et al, 1950^Citation13	31	Congenital (Bochdalek hernia)	Lt	7	Stomach	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Hushlan et al, 1951^Citation14	25	Congenital (Bochdalek hernia)	Lt	NA	NA	Negative	Conservative treatment	VD	NA	Postpartum	Non-operative	Alive	Alive
Osborne et al, 1953^Citation7	25	Congenital (Bochdalek hernia) Hiatal	Lt	6	Stomach, T-colon	Positive	Conservative treatment	NA	27.4	17.6	Non-operative	Death	Stillborn
Hobbins et al, 1953,^Citation15	18	Congenital (Bochdalek hernia)	Lt	1	Colon (splenic flexure and the T-colon with mesentery and omentum)	Negative	Reduction and diaphragmatic hernia repair	VD	Term	1st tri.	1st tri.	Alive	Alive
Gorbach et al, 1956^Citation40	45	Hiatal	NA	NA	NA	NA	NA	VD	36.5	36	Postpartum	Alive	Alive
Bernhardt et al, 1966^Citation47	26	Traumatic	Lt	7–8	Stomach, SB, colon, spleen	Negative	Reduction and diaphragmatic hernia repair	VD	37	37	Postpartum	Alive	Alive
Craddock et al, 1968^Citation41	17	Hiatal	Lt	1	Small gut	Positive	Resection of gangrenous SB and double-layered anastomosis	VD	31.4	31	31	Alive	Stillborn
Dudley et al, 1979^Citation48	16	Traumatic	Lt	NA	Stomach	Positive	Partial gastrostomy, gastrogastrectomy, and hernia repair	Non-delivery	Non-delivery	18	18	Death	FDIU
Dudley et al, 1979^Citation48	41	Traumatic	Lt	NA	Omentum.colon (splenic flexure)	Positive	Partial omentectomy, reduction, and closure of the hernia	VD	NA	Postpartum	Postpartum	Alive	Alive
Gimovsky et al 1983^Citation9	20	Congenital (Bochdalek hernia)	Lt	NA	T-Colon	Positive	Colon resection, colostomy	C/S	28	Postpartum	Postpartum	Alive	Death after birth
Mitchell et al, 1983^Citation49	18	Traumatic	Lt	NA	T-Colon	Positive	Double-barrel colostomy	C/S	32	24	32	Alive	Alive
FARDY et al, 1984^Citation42	25	Hiatal	Lt	NA	Stomach	Negative	Reduction and diaphragmatic hernia repair	VD	38	30	30	Alive	Alive
Rabinovici et al, 1986^Citation50	21	Traumatic	Lt	10	Stomach, T-colon, SB	Negative	Reduction/bladder tear - repair, cystostomy	C/S	28	28	28	Alive	Stillborn
REED et al, 1987^Citation16	18	Congenital (Bochdalek hernia)	Lt	12	Stomach	Positive	Repair of stomach tear by chest drain, reduction, and diaphragm repair	C/S	36.4	Postpartum	Postpartum	Alive	Alive
Wolfe et al, 1988^Citation60	40	NA	Lt	8	Stomach, SB, T-colon, omentum	Positive	SB resection, partially?	C/S	31	30	30.4	Alive	Death after birth
KURZEL et al, 1988^Citation10	27	Congenital (Bochdalek hernia)*	Lt	14	Stomach, SB, T-colon, A-colon, pancreas, spleen, Left kidney	Negative	Reduction and marlex mesh patch repair	C/S	36	33	33	Alive	Alive
Henzler et al, 1988^Citation51	25	Traumatic	Lt	7	Stomach, T-colon	Negative	NA	VD	33	33	Postpartum	Alive	Alive
Maddox et al, 1991^Citation52	33	Traumatic	Lt	7	Stomach, T-colon, spleen	Negative	Reduction and diaphragmatic hernia repair	VD	39	Postpartum	Postpartum	Alive	Alive
Toorians et al, 1993^Citation17	29	Congenital (Bochdalek hernia)	Rt	7	T-colon, greater omentum	Positive	Reduction, partial omentectomy	VD	Term	15	15	Alive	Alive
Lacayo et al, 1993^Citation53	20	Traumatic	Lt	NA	Mild transverse colon with perforation	Positive	Colon resectomy, omentectomy, reduction and repair	C/S	41	Postpartum	Postpartum	Alive	Alive
Hill et al,1996^Citation18	30	Congenital (Bochdalek hernia)	Lt	5	SB, large bowel	Positive	Reduction and detorsion and resection and repair of ischemic herniated bowel, 2nd look laparotomy	VD	NA	Postpartum	Postpartum	Alive	Alive
Fleyfel et al, 1998^Citation43	29	Hiatal	Lt	8	Stomach	Negative	Reduction and diaphragmatic hernia repair	C/S	39	28.?	28.?+3	Alive	Alive
Ortega et al, 1998^Citation19	23	Congenital (Bochdalek hernia)	Lt	6	SB, T-colon	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Dietrich et al, 2001^Citation54	19	Traumatic	Lt	NA	T-colon	Positive	T-colectomy, gastrostomy tube placement	C/S	36.1	36.1	Postpartum	Alive	Alive
Ilaloo et al, 2001^Citation61	32	NA	Lt	NA	T-Colon	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Indar et al, 2001^Citation55	24	Traumatic	Lt	8	Colon	Positive	Double-barreled colostomy	VD	34	34	34	Death	Stillborn
Indar et al, 2001^Citation55	25	Traumatic	Lt	7	Stomach, SB, colon	NA	Died in 1 hours after admission	Non-delivery	Non-delivery	36	Non-operative	Death	FDIU
Indar et al, 2001^Citation55	21	Traumatic	Lt	3	Stomach, SB	Negative	Reduction and diaphragmatic hernia repair	C/S	35	35	35	Alive	Alive
Indar et al, 2001^Citation55	29	Traumatic	Lt	4	Colon	Negative	Reduction and diaphragmatic hernia repair	VD	38	20	20	Alive	Alive
Williams et al, 2003^Citation21	36	Traumatic	Lt	6	Stomach, small bowel, T-colon	Negative	Reduction and diaphragmatic hernia repair	VD	33	28	28	Alive	Alive
Williams et al, 2003^Citation21	32	Congenital (Bochdalek hernia) *	Lt	2	Stomach, omentum	Negative	Reduction, partial omentectomy	VD	NA	Postpartum	Postpartum	Alive	Alive
Genc et al, 2003^Citation20	30	Congenital (Bochdalek hernia)	Lt	8	Stomach., T-colon	Negative	Reduction and diaphragmatic hernia repair	VD	39	29	31	Alive	Alive
Hamoudi et al, 2004^Citation62	41	NA	Lt	7	Stomach, T-colon, spleen	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Luu et al, 2006^Citation24	34	Congenital (Bochdalek hernia)	Lt	2	Stomach with perforation	Positive	Resection of a necrotic portion of the stomach	VD	34	Postpartum	Postpartum	Alive	Alive
Eglinton et al, 2006^Citation23	30	Congenital (Bochdalek hernia) *	Lt	NA	Stomach	Positive	Reduction, suture of perforation site of stomach due to chest tube	C/S	28	28	28	Alive	Alive
Eglinton et al, 2006^Citation23	27	Congenital (Bochdalek hernia) *	Lt	NA	Stomach, T-colon, spleen	Positive	Resection of stomach	C/S	37	27	27	Alive	Alive
Eglinton et al, 2006^Citation23	32	Traumatic	Rt	NA	Liver, colon	Negative	Reduction and diaphragmatic hernia repair	C/S	34	34	34	Alive	Alive
Barbetakis et al, 2006^Citation22	31	Congenital (Bochdalek hernia)	Lt	7	Stomach, large segment of T-colon, Rt-colon, omentum	Positive	Segmental resection of large intestine and end-to-end anastomosis	C/S	39	23	23	Alive	Alive
Hanekamp et al, 2006^Citation63	26	NA	Lt	NA	Stomach with perforation, colon, spleen	Negative	Reduction. Repair of perforated stomach	NA	NA	5 m	5 m	Alive	?
Osman et al, 2007^Citation65	32	NA	Lt	NA	Stomach	Negative	Reduction and diaphragmatic hernia repair	VD	35	27	27	Alive	Alive
Rajasingam et al, 2007^Citation26	24	Congenital (Bochdalek hernia) *	Lt	NA	Stomach	Positive	Partial gastrostomy (Polya type)	C/S	33.6	33.6	33.6	Alive	Alive
Jai et al, 2007^Citation56	27	Traumatic	Lt	NA	Stomach, T-colon, omentum	Positive	Resection of stomach, excision of omentum, esojejunal anastomosis	VD	32	Postpartum	Postpartum	Death	Alive
Agarwal et al, 2007^Citation64	28	NA*	Lt	NA	Stomach, SB, colon, spleen	Positive	Partial gastrectomy and gastrojejunostomy diaphragmatic hernia repair	VD	27.4	27.4	Postpartum	Alive	Alive
Pai et al, 2007^Citation25	26	Congenital (Bochdalek hernia)	Rt	NA	Liver. A-colon, hepatic flexure, T-colon	Negative	Reduction and diaphragmatic hernia repair	C/S	Term	Postpartum	Postpartum	Alive	Alive
Palanivelu et al, 2008^Citation27	23	Congenital (Bochdalek hernia)	Lt	5	Stomach, colon, omentum	Negative	Reduction/ to fix (stomach-peritoneum, colopexy)	NA	9 m	6 m	6 m	Alive	Alive
Sano et al, 2008^Citation28	25	Congenital (Bochdalek hernia)	Lt	2	SB. Omentum	Positive	Resection of ileum and cecum	C/S	28	28	28	Alive	Alive
Ting et al, 2008^Citation66	42	NA	Lt	NA	Stomach, SB	Positive	Partial gastrectomy	NA	NA	19	19	Alive	Alive
Hunter et al, 2009^Citation29	31	Congenital (Bochdalek hernia)	Lt	NA	Stomach, SB, T-colon, spleen	Negative	Reduction and diaphragmatic hernia repair	C/S	27	27	27	Alive	Stillborn
Riad et al, 2009^Citation57	27	Traumatic	Lt	NA	SB, large bowel, spleen	Positive	Large and small bowel resection, ileostomy, splenectomy,	C/S	37	Postpartum	Postpartum	Death	Alive
Rubin et al, 2009^Citation44	27	Hiatal	Lt	NA	Stomach. Duodenum, colon	Positive	Reduction, omental wrapping section, diaphragm repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Islah et al, 2010^Citation30	30	Congenital (Bochdalek hernia)	Lt	6	Stomach, SB, colon, appendix	Positive	Sleeve gastrectomy	C/S	NA	30	30	Alive	Alive
Morcillo et al, 2010^Citation31	35	Congenital (Bochdalek hernia)	Lt	15	Stomach, greater omentum, colon	Negative	Reduction and diaphragmatic hernia repair	C/S	38	15	15	Alive	Alive
Schwentner et al, 2011^Citation67	30	NA	Lt	NA	Stomach	Positive	Reduction and diaphragmatic hernia repair	C/S	38.5	12	12	Alive	Alive
Chen et al, 2011^Citation11	26	NA	Lt	8	Stomach, SB, T-colon, spleen	Negative	Reduction and diaphragmatic hernia repair	VD	24.3	23.3	23.3	Alive	Artificial abortion
Ngai et al, 2012^Citation32	31	Congenital (Bochdalek hernia)	Lt	NA	MRI findings: stomach, SB, colon, spleen, pancreatic body	Negative	Reduction and diaphragmatic hernia repair	C/S	31	29	Postpartum	Alive	Alive
Chen et al, 2012^Citation45	18	Hiatal	Lt	20	Stomach, SB, omentum	Negative	Reduction and diaphragmatic hernia repair	VD	15	Postpartum	Postpartum	Alive	Stillborn
Flamée et al, 2012^Citation69	33	NA	Lt	NA	NA	Negative	NA	NA	NA	21	NA	?	Stillborn
Benson et al, 2012^Citation68	23	NA	Lt	NA	Colon	Negative	Reduction and diaphragmatic hernia repair	C/S	38	20	30	Alive	Alive
Hamaji et al, 2013^Citation33	39	Congenital (Bochdalek hernia)	Lt	5	T-colon, omentum	Negative	Reduction and diaphragmatic hernia repair	VD	NA	Postpartum	Postpartum	Alive	Alive
Kawashima et al, 2013^Citation34	26	Congenital (Bochdalek hernia)	Lt	10	Stomach, T-colon, spleen	Negative	Reduction and diaphragmatic hernia repair	C/S	NA	26	26	Alive	Alive
Wieman et al, 2013^Citation35	42	Congenital (Bochdalek hernia)	Rt	7	Colon, cecum (several serosal tears in colon, cecum)	Positive	Reduction/serosal tear-suture	NA	NA	27	27	Alive	Alive
Ali et al, 2014^Citation36	25	Congenital (Bochdalek hernia)	Rt	NA	Small bowel	Negative	Reduction and mesh diaphragmatic repair	NA	NA	2nd tri.	2nd tri.	Alive	Alive
Debergh et al, 2014^Citation37	28	Congenital (Bochdalek hernia)	Rt	5	Small bowel	Positive	Reduction and mesh diaphragmatic repair	NA	Term	16	16	Alive	Alive
Hernández et al, 2015^Citation38	32	Congenital (Bochdalek hernia)	Lt	6	A-colon, T-colon, SB	Negative	Reduction and diaphragmatic hernia repair	C/S	32	29	32	Alive	Alive
Reddy et al, 2018^Citation39	30	Congenital (Bochdalek hernia)	Lt	NA	Stomach, SB, colon, appendix, spleen, omentum	Negative	Reduction and diaphragmatic hernia repair	C/S	32.3	31.3	32.3	Alive	Alive

Notes: The first trimester is defined as 0–13 6/7 weeks of gestation from the last menstrual period; the second trimester is defined as 14 0/7–27 6/7 weeks of gestation from the last menstrual period; the third trimester is defined as 28 0/7–42 0/7 weeks of gestation from last menstrual period. *Six patients were diagnosed with a diaphragmatic hernia before their pregnancies.

Abbreviations: Rt, right; Lt, left; NA, not available; T-colon, Transverse colon; A-colon, ascending colon; SB, small bowel; C/S, cesarean section; tri., trimester, Wks, Weeks BH, Bochdalek hernia; NA, not available; VD, vaginal delivery; C/S, cesarean section.

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