Maternal diaphragmatic hernia in pregnancy: A systematic review with a treatment algorithm

Table 1 Distribution of studies by publication period

Year	Counts	% of Total
To 1956	35	22.2
1965-2000	30	19.0
2001-2010	43	27.2
2011-2020	50	31.6

Table 2 Hernias by publication period

Period		Congenital	Posttraumatic	Hiatal	During labor
Until 1956	n	7	1	14	3
	%	4.4	0.6	8.9	1.9
1965-2000	n	11	7	4	4
	%	7.0	4.4	2.5	2.5
2001-2010	n	18	17	2	4
	%	11.4	10.8	1.3	2.5
2011-2020	n	23	9	4	2
	%	14.6	5.7	2.5	1.3
Total		59	34	24	13

Table 3 Hernias by side

Side	Congenital	Posttraumatic	During labor	Total
Left	52	27	10	89
Right	6	6	2	14
L/R ratio	8, 7	4, 5	5, 0	6, 4
Total	58	33	12	103

Table 4 Abdominal and respiratory symptoms at presentation

Abdominal symptoms		Respiratory symptoms		Total
		No	Yes
No	n	0	29	29
	%	0.0	19.7	19.7
Yes	n	93	25	117
	%	63.3	17.0	80.3
Total	n	93	54	147
	%	63.3	36.7	100.0

Table 5 Organ ischemia and perforation

Organ ischemia		Organ perforation		Total
		No	Yes
No	n	94	10	104
	%	63.9	6.8	70.7
Yes	n	24	19	43
	%	16.3	12.9	29.3
Total	n	118	29	147
	%	80.3	19.7	100.0

Table 6 Herniated organs

Levels	Counts	% of total
Stomach	101	67.3
Colon	82	54.7
Small intestine	45	30.0
Omentum	32	21.3
Spleen	30	20.0
Pancreas	6	4.0
Liver	5	3.3
Eventration	5	3.3
Gallbladder	1	0.7
Kidney	1	0.7

Table 7 Working diagnosis at presentation

Diagnosis	Counts	% of total
Diaphragmatic hernia	57	40.7
Other	20	14.3
Pneumothorax/hemothorax	14	10.0
Hiatal hernia	13	9.3
Pneumonia/empyema	11	7.9
Labor/pregnancy	8	5.7
Gastroenteritis/GERD	5	3.6
Urinary tract infection	3	2.1
Placental abruption	3	2.1
Preeclampsia	3	2.1
Pancreatitis	2	1.4
Gastroenteritis/pancreatitis	1	0.7

GERD: Gastroesophageal reflux disease.

Table 8 Diagnostic imaging methods

Method	Counts	% of total	The year of the 1st mention
Initial chest X-ray	123	80.4	1943
Obstetric ultrasound	34	22.2	1988
Contrast radiography	33	21.6	1941
Abdominal ultrasound	26	17.0	1991
GI endoscopy	21	13.7	1953
Abdominal CT	15	9.8	2001
Abdominal radiography	12	7.8	1945
Thoracic ultrasound	10	6.5	1988
Thoracic MRI	7	4.6	2011
Fluoroscopy	7	4.6	1941
Abdominal MRI	4	2.6	2003
Thoracic CT	1	0.7	1999

GI: Gastrointestinal; CT: Computed tomography; MRI: Magnetic resonance imaging.

Table 9 Surgical access

Levels	Counts	% of total
Laparotomy	53	52.5
Thoracotomy	34	33.7
Laparoscopy	13	12.9
Thoracoscopy	1	1.0

Table 10 Type of cruroplasty sutures

Type	Counts	% of total
Nonabsorbable	31	48.4
Sutures and mesh	11	17.2
Sutures - unspecified	9	14.1
Mesh	8	12.5
Absorbable	5	7.8

Table 11 Delivery type by observed period

Period		Delivery type
		Elective CS	Emergent CS	Vaginal	Total
Until 1956	n	0	2	27	29
	%	0.0	6.9	93.1	100.0
1965-2000	n	5	4	20	29
	%	17.2	13.8	69.0	100.0
2001-2010	n	6	10	24	40
	%	15.0	25.0	60.0	100.0
2011-2020	n	15	17	16	48
	%	31.3	35.4	33.3	100.0
Total	n	26	33	87	146
	%	17.8	22.6	59.6	100.0

CS: Cesarean section.

Table 12 Neonatal outcomes

Complication	Counts	% of total
No complications	128	84.2
Intrauterine death	14	9.2
Neonatal death	4	2.6
Miscarriage	3	2.0
Fetal growth restriction	2	1.3
Complications of prematurity	1	0.7

Table 13 Neonatal outcome related to the timing of surgery

Time of operation		No complications	Complications	Total
After delivery	n	41	0	41
	%	100.0	0.0	100.0
During pregnancy	n	36	11	47
	%	76.6	23.4	100.0
During delivery	n	19	6	25
	%	76.0	24.0	100.0
Total	n	96	17	113
	%	85.0	15.0	100.0

Table 14 Maternal outcome by delivery type

Delivery type		Alive	Dead	Total
CS elective	n	26	0	26
	%	20.3	0.0	17.9
CS emergent	n	30	2	32
	%	23.4	11.8	22.1
Vaginal	n	72	15	87
	%	56.3	88.2	60.0
Total	n	128	17	145
	%	100.0	100.0	100.0

CS: Cesarean section.

Table 15 Neonatal outcome by delivery type

Delivery type		No complications	Complications	Total
CS elective	n	26	0	26
	%	21.0	0.0	17.9
CS emergent	n	26	6	32
	%	21.0	28.6	22.1
Vaginal	n	72	15	87
	%	58.1	71.4	60.0
Total	n	124	21	145
	%	100.0	100.0	100.0

CS: Cesarean section.

Table 16 Abdominal symptoms by hernia side

Symptoms		Left	Right	Sliding	Total
No	n	28	4	0	32
	%	22.8	25.0	0.0	21.9
Yes	n	95	12	7	114
	%	77.2	75.0	100.0	78.1
Total	n	123	16	7	146
	%	100.0	100.0	100.0	100.0

Table 17 Respiratory symptoms by hernia side

Symptoms		Left	Right	Sliding	Total
No	n	75	8	7	90
	%	62.5	50.0	100.0	62.9
Yes	n	45	8	0	53
	%	37.5	50.0	0.0	37.1
Total	n	120	16	7	143
	%	100.0	100.0	100.0	100.0

Table 18 Operated vs nonoperated hernias by type

Hernia type		Not operated	Operated	Total
Congenital	n	5	53	58
	%	8.6	91.4	100.0
Posttraumatic	n	4	30	34
	%	11.8	88.2	100.0
During labor	n	3	10	13
	%	23.1	76.9	100.0
Hiatal	n	13	10	23
	%	56.5	43.5	100.0
Total	n	25	103	128
	%	19.5	80.5	100.0

Table 19 Neonatal weight at surgery

Surgery	N	M	Med	SD	Min	Max
After pregnancy	12	2811	2910	812	1370	3640
During pregnancy	16	2676	2880	948	500	4100
During delivery	8	1819	1995	487	960	2390