Spontaneous pneumothorax complicating pregnancy — case report and review of the literature

TheJournal of Emergency Medune, Vol. 7. pp. 245-248,

Printed in the USA

1989

Copyright 0 1989 Pergamon Press plc

??

SPONTANEOUS PNEUMOTHORAX COMPLICATING PREGNANCYCASE REPORT AND REVIEW OF THE LITERATURE T. E. Terndrup,

MD, * S.

F. Bosco, tm,t and E. R. McLean,

MD*

**Department of Emergency Medicine and *Department of Surgery, Morristown Memorial Hospital, Morristown, New Jersey Reprint address: Thomas E. Terndrup. MD, Department of Critical Care and Emergency Medicine, SUNY Health Science Center, 750 East Adams Street, Syracuse, NY 13210

0 Abstract -Patients with a spontaneous pneumothorax frequently present for care in the emergency department. The occurrence of spontaneous pneumothorax during parturition occurs rarely. We describe a case of spontaneous pneumothorax during the first trimester of pregnancy, which resolved with tube thoracostomy. The patient delivered vaginally a healthy 4.3 kg male at term under epidural anesthesia. We discuss spontaneous pneumothorax and review reported cases during pregnancy.

CASE REPORT

A 25year-old primigravida patient presented at 12 weeks of gestation with the sudden onset of rightsided, pleuric chest pain associated with transient diaphoresis and dyspnea. The pain was sharp, began posteriorly, and within 20 minutes was anterior in location. The pain was increased by recumbancy. There was no history of trauma, fever, cough, hemoptysis, or genitourinary complaints. The past medical history was remarkable for 6 pack years of cigarette smoking. Also, there was a history of phlebitis and lower extremity edema one year previously, associated with the use of birth control pills. There were no allergies; medications were prenatal vitamins. Physical examination showed a well-developed, well-nourished white female in no acute distress who was alert and oriented. Vital signs were temperature 36.3”C, pulse 80/min, respirations 16/min, and blood pressure 108/58. Pertinent physical findings were decreased breath sounds over the right hemithorax, a trachea in the midline, a 12-week size uterus, and mild bilateral lower extremity edema. Cardiac, vascular, and neurological examinations were normal. The patient was placed on 6 liters of oxygen by nasal cannula. A peripheral IV of 0.9% saline was begun at a keep-open rate, and the patient was placed on a cardiac monitor. An arterial blood gas with the patient on room air showed a pH 7.47, PCOZ 30mmHg, PO, 78mmHg, HCO,-2lmmoM; the calculated alveolar-arterial gradient was 34.5. An ECG showed a normal sinus rhythm without acute changes. An upright portable chest x-ray study, with

0 Keywords-spontaneous pneumothorax; pregnancy; dyspnea; chest pain; complications

INTRODUCTION

Laennec, in 1819, was the first to describe the typical symptoms and signs of spontaneous pneumothorax (1). Spontaneous pneumothorax should always be considered in the patient between 20 and 40 years of age who presents with sudden pleuritic chest pain accompanied by mild to moderate dyspnea. The occurrence of spontaneous pneumothorax during parturition is uncommon. In reviewing the English literature in the past three decades, we have found only 18 reported cases (2-16). A review of these cases, their recognition, initial management, and outcome is discussed. *Dr Terndrup is currently Research Instructor, Department of Critical Care and Emergency Medicine, SUNY Health Science Center, Syracuse, New York. tDr. Bosco is currently Educational Coordinator, Department of Emergency Medicine, St. Peter’s Hospital, Albany, New York.

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Obstetrics and Gynecology is coordinated by Gait K Anderson,

RECEIVED: 18 April 1988; FINALSUBMISSIONRECEIVED: 13 July ACCEPTED: 6 September 1988

245

Jr., MD of Emory University School of Medicine.

1988;

0736-4679/89 $3.00 + .OO

T. E. Terndrup, S. F. Bosco, E. R. McLean

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the abdomen shielded with a lead apron showed a 30% pneumothorax on the right. CBC revealed a WBC 8.0/~L, hemoglobin 12.2/pL, hematocrit 38%, platelets 278/pL; differential showed 4 bands, 80 segmented neutrophils, 10 lymphocytes, 5 monocytes, and 1 eosinophil. Prothrombin time was 11 seconds, and activated partial thromboplastin time was 24 seconds. Electrolytes, BUN, and creatinine were within normal limits. A tube thoracostomy with a 28 French chest tube was placed in the right 6th intercostal space in the midaxillary line and attached to wall-suction. There was prompt reexpansion of the right lung. Because of the lower extremity edema and the history of phlebitis, a portable venous doppler study of both legs was performed to evaluate concurrent deep venous thrombosis. There was no evidence of venous thrombosis. The thoracostomy tube was removed on the second hospital day, the patient’s lung remained expanded, and she was discharged after a brief hospitalization. She underwent pitocin induction for postmaturity at 41 weeks of gestation. She delivered a healthy 4.3 kg male under epidural anesthesia. There was no recurrence of her pneumothorax through four months postpartum.

DISCUSSION The occurrence of dyspnea in the pregnant patient is the most common respiratory complaint during the first 28 weeks of pregnancy (17). In assessing the pregnant patient with dyspnea, the emergency physician must realize that because of altered maternal physiology, the fetus is at risk for a severe hypoxic insult should any maternal hypoxemia occur. During pregnancy, minute ventilation, tidal volume, and respiratory rate are increased. Despite a 20% increase in oxygen consumption and a 70% increase in alveolar ventilation, the functional residual capacity is decreased 17% to 20%; thus, any additional stress upon the maternal respiratory system represents a serious potential hazard to the fetus. Further, the fetal umbilical vein POZ is only 35 to 45 mmHg and any decrease in maternal 0, saturation is potentially life-threatening to the developing fetus (17). Ionizing radiation represents a potential risk to the fetus, particularly during the first eight weeks of development, that is, the period of organogenesis. The risk of childhood cancer may be increased by as much as 250% by receiving 1 rad during the first trimester (18). The early conceptus may be as much as 16 times as sensitive to the carcinogenic effects of radiation as the adult. Therefore, every reasonable attempt should be made to identify the pregnant patient and limit

uterine exposure as much as possible. The emergency physician must weigh the potential hazards associated with a radiologic examination against the benefit of obtaining the results of the study. Fortunately, for chest radiography with a shielded abdomen, the upper limit of the conceptus dose is <50 mrad. The actual estimated radiation dose to the uterus is 1 to 2 mrad per examination. Thus, when one suspects pneumothorax in a pregnant patient, it is safe to proceed with the usual chest radiogram study without placing the fetus at substantial risk from ionizing radiation (18). In reviewing the other 18 cases of spontaneous pneumothorax during parturition that have been reported in the English literature (2-16), we found that the patients were young (average age was 25.0 f 5.9 years old), average gravidity 1.2 f 1.0, and average parity 1.2h2.6, with 50% having a risk factor for spontaneous pneumothorax. The most common risk factors were an underlying respiratory infection (e.g., tuberculosis), asthma, or a history of pneumothorax. Twenty-two percent of patients were reported to have a prior history of pneumothorax. The mean gestation age for first occurrence was 26.0* 13.6 weeks, although 33 % occurred at term (~38 weeks gestation). There were 13 recurrences in 8 patients, a recurrence rate of 44% for individual patients. Twenty tube thoracostomies were placed for 31 total pneumothoraces, or 65% of cases (Table 1). The obstetrical outcomes were uniformly satisfactory; there were no reported neonatal complications. All patients delivered vaginally, although 10 of 17 vaginal deliveries were assisted with forceps. Seven patients (39%) required thoractomy, typically because of multiple episodes of pneumothorax. Based on the outcome of 4 patients, intrapartum thoracotomy appears safe for those recurrences. Two additional parous patients had bilateral pneumothorax associated with induction of general anesthesia and positive ventilation for caesarian section. Both of these patients developed sudden hemodynamic compromise associated with tension pneumothorax (19,20). Reported complications of pneumothorax during pregnancy include tension pneumothorax (10,19-20), subcutaneous emphysema, pneumomediastinum (19,21), catamenial pneumothorax (16), and Hamman’s syndrome (21). The only reported maternal deaths in women with pneumothorax or pneumomediastinum were prior to 1908 (21), with the last reported fetal mortality in 1949. Management of complications is generally supportive, with careful fetal monitoring. The typical symptoms of spontaneous pneumothorax occur in pregnant patients. Characteristically, patients complain of sudden pleuritic chest pain asso-

Pneumothorax

and Pregnancy

247

Table 1. Reports of Spontaneous Pneumothorax During Pregnancy

Author (Ref.)

Age

G*

Pt

Gass (14) Hsu (13) Brantley (7) Jonas (11) Vance (10) Brantley (12) Najafi (6) Burgener (3) Stewart (2) Freedman (5) Sending (9) Farrell (8) Karson (15) Dhalla (4) Dhalla (4) Dhalla (4) Schoenfeld (16) Terndrup

30

3

2

29

1

0

26

2

1

19 36 19 32 26 16 29 17 19 20 28 26 26 27 25

1 4 1 3 1

0 3 0 2 0

1

0

2 1 1 1 1 1 2 3 1

1 0 0 0 0 0 0 2 0

Weeks of Gestat. 15 39 31 39 39 26 41 40 34 10 40 39 11 14 8 4 24 12

PMH histoplasmo. tuberculosis URI negative bronchitis negative negative asthma negative rheu. fever thyroidecto. URI hyperemes. PTXl x 2 negative negative PTXx5 phlebitis

Pneumothorax Recurrence subsequent preg. none 32,33,38 wks 2 wks PP(I none 38 wks 2 wks PP none none none none 2 wks PP none none 11,13,18wks 5,6 wks none none

Pneumothorax Treatment observe TT§ TTx3 TT TT TTx2 TT :: ObSeNe observe TT observe observe observe l-fx3 thoracotomy TT

Obstetrical Outcome SVDS SVD forcep NSVD induct./forcep induct./forcep forcep forcep SVD SVD augment VD forcep forcep forcep forcep forcep not reported augment VD

Pulmonary Outcome resolve resolve TT bilat thoracotomy resolve TT resolve TT PP thoracotomy thoracotomy resolve TT resolve TT resolve resolve thoracotomy resolve thoracotomy thoracotomy thoracotomy not reported resolve TT

ABBREVIATIONS: ‘G = gravidity. tP = parity. SSVD = spontaneous vaginal delivery. §lT = tube thoracostomy. 1/PP = postpartum. IPTX = pneumothorax.

ciated with mild to moderate dyspnea. There may be a history of pneumothorax, since recurrence occurs in 30% of all patients with spontaneous pneumothorax. Physical examination may demonstrate tachypnea, cyanosis, and tachycardia. The ipsilateral hemithorax may have decreased breath sounds, decreased tactile fremitus, hyperresonance, and a hemithorax lag apparent on observation of inspiration. Diagnosis is confirmed by chest radiography, although an expiratory or decubitus film, with the affected side up, may be helpful to demonstrate smaller pneumothoraces (10 The management of simple pneumothorax during pregnancy is controversial. Many physicians would simply admit and observe otherwise healthy patients with a small pneumothorax (I 20%). The other treatment options are needle aspiration, tube thoracostomy, needle decompression (e.g., tension pneumothorax), pleurodesis, and thoractomy (22). Because of the usually high rate of recurrence of pneumothorax during paturition, noted in the literature review, thoracotomy, with resection of apical blebs, may be indicated prior to delivery of the fetus. Other compli-

cations of spontaneous pneumothorax include tension pneumothorax, hydrothorax, hemothorax, pneumomediastinum, hypoxemia, shock, reexpansion pulmonary edema, subcutaneous emphysema, air embolism, and failure to reexpand the lung. The mortality is reported to be 5% and is primarily a function of underlying lung disease (23).

SUMMARY A case of spontaneous pneumothorax during pregnancy is reported. Our patient had prompt resolution following closed tube thoracostomy and a favorable obstetrical outcome. A review of all reported cases in the English literature reveals that while this association is uncommon, recurrences are relatively frequent. Subsequent obstetrical outcomes are uniformly favorable. Recognition and management of pneumothorax during pregnancy is essentially the same as with any spontaneous pneumothorax, although thoracotomy with resection of apical blebs may be indicated for recurrences.

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T. E. Terndrup, S. F. Bosco, E. R. McLean

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pregnancy: two case reports and a review of the literature, pathophysiology, and management. Obstet Gynecol. 1984;64: 39s-43s. 16. Schoenfeld A, Ziv E, Zeelel Y, Oradia J. Catamenial pneumothorax-a literature review and report of an unusual case. Obst & Gyn Survey. 1986;41:20-34. 17. Leontic EA. Respiratory disease in pregnancy. Med Chn N Amer. 1977;61:111-28. 18. Wagner LK, Lester RG, Saldana LR, eds. Exposure of the pregnant patient to diagnostic radiations. Philadelphia: JB Lippincott; 1985. 19. Hubbert CH, Robertson WT, Solomon JA. Spontaneous tension pneumothorax and mediastinal emphysema associated with anesthesia for cesarean section. AANA. 1981 Feb;49:5962. 20. Galle PC, Servoss RL, Warren TL. Spontaneous pneumothorax occurring during labor and delivery. Am J Diag Gyn Ob. 1979;1:367-8. 21. Reeder SR. Subcutaneous emphysema, pneumomediastinum and pneumothorax in labor and delivery. Am J Ob Gyn. 1986; 154:487-9. 22. Guenter CA, Welch MH. Pulmonary medicine, 2nd ed. Philadelphia: JB Lippincott; 1982. 23. O’Hara VS. Spontaneous pneumothorax. Milit Med. 1978;143: 32-5.