Spontaneous pneumothorax during pregnancy. (Case Histories).ABSTRACT: Spontaneous pneumothorax spontaneous pneumothorax n. A pneumothorax occurring secondary to parenchymal lung disease. Spontaneous pneumothorax Air in the chest cavity that occurs because of disease or other naturally occurring cause. complicating pregnancy is rare. Only 41 cases have been previously published. We describe a case of spontaneous pneumothorax successfully treated with tube thoracostomy during the 38th week of pregnancy. Under epidural anesthesia epidural anesthesia n. Regional anesthesia produced by injection of a local anesthetic into the epidural space of the lumbar or sacral region of the spine. , the patient had vaginal delivery of a healthy male infant 36 hours after tube thoracostomy. ********** Spontaneous pneumothorax is an uncommon condition during pregnancy. (1) We have found only 41 cases previously reported. We present a case of this rare entity during the third trimester (2 days ante partum). Tube thoracostomy resolved the pneumothorax pneumothorax (n  mōthôr`ăks), collapse of a lung with escape of air into the pleural cavity between the lung and the chest wall. The cause may be traumatic (e.g. , a with good outcome for
both mother and infant.
CASE REPORT A 27-year-old primigravida primigravida /pri·mi·grav·i·da/ (pri?mi-grav´i-dah) a woman pregnant for the first time; gravida I. pri·mi·grav·i·da n. A woman in her first pregnancy. at 38 weeks' gestation presented with the sudden onset of cough and left-sided, pleuritic pleu·rit·ic adj. Of or relating to pleurisy. pleuritic pertaining to or emanating from pleurisy. See also pleural. pleuritic ridge chest pain radiating to the back and left arm associated with mild dyspnea dyspnea /dysp·nea/ (disp-ne´ah) labored or difficult breathing.dyspne´ic paroxysmal nocturnal dyspnea . There was no history of fever, chills, trauma, nausea, or vomiting. Her medical history was unremarkable. She was a nonsmoker and had no family history of pulmonary disease. Physical examination at the time of admission showed an afebrile afebrile /afe·brile/ (a-feb´ril) without fever. a·feb·rile adj. Apyretic. afebrile without fever. afebrile adjective Feverless , well-nourished woman in moderate distress, without cyanosis cyanosis (sī'ənō`sĭs), bluish coloration of the skin, mucous membranes, and nailbeds, resulting from a lack of oxygenated hemoglobin in the blood. . Vital signs were stable except for maternal tachycardia tachycardia: see arrhythmia. tachycardia Heart rate over 100 (as high as 240) beats per minute. When it is a normal response to exercise or stress, it is no danger to healthy people, but when it originates elsewhere, it is an arrhythmia. of 120 beats per minute beats per minute Cardiac pacing The unit of measure for the frequency of heart depolarizations or contractions each minute–or pulse rate , and respiratory rate respiratory rate, n the normal rate of breathing at rest, about 12 to 20 inspirations per minute. systemic inflammatory response syndrome A term that ' of 28/min. Chest examination was notable for decreased breath sounds and hyper-resonance over the left hemithorax. Abdominal examination abdominal examination Clinical medicine A hands-on evaluation of the abdominal cavity to identify abnormalities, if any, based on any change in size, shape, consistency, or sound on percussion of the organs found therein. See Abdomen. revealed a term-sized intrauterine intrauterine /in·tra·uter·ine/ (-u´ter-in) within the uterus. in·tra·u·ter·ine adj. Within the uterus. Intrauterine Situated or occuring in the uterus. pregnancy with vertex presentation vertex presentation n. Head presentation of the fetus during birth in which the upper back part of the fetal head is the presenting part. vertex presentation and fetal heart tones at 140 beats per minute. The cervix was dilated dilated a state of dilatation. dilated cardiomyopathy see congestive cardiomyopathy. dilated pupil syndrome see feline dysautonomia (Key-Gaskell syndrome). 2 cm. Chest radiograph radiograph /ra·dio·graph/ (-graf?) the film produced by radiography. ra·di·o·graph n. with the abdomen shielded showed an almost complete pneumothorax of the left lung (Figure). Peripheral pulse oximetry pulse oximetry Oxygen saturation measurement, SaO Critical care A method used to determine the O2 saturation–SaO2 and desaturation of blood in a continuous noninvasive fashion, through the noninvasive assessment of arterial Hb-bound showed 90 % oxygen saturation oxygen saturation sO2 The O2 concentration of blood expressed as a ratio of its total O2-carrying capacity; the OS is a measure of the utilization of O2 transport capacity; sO2 with oxygen (3 L/min) via nasal cannula nasal cannula Critical care An O2 delivery device loosely attached to the head with 2 prongs inserted in the nose; the FiO2 delivered by an NC is 24–35% . A chest tube was placed and connected to a closed suction device shortly after admission to the emergency room. Repeated chest film revealed complete reexpansion of the left lung. The patient had immediate clinical improvement. Approximately 36 hours after this episode, there was spontaneous onset of labor. Continuous lumbar epidural anesthesia was instituted, and after a normal labor progression, the patient gave birth to a normal male infant with a birth weight of 3,100 g and Apgar scores of 9 at both 1 and 5 minutes. The patient's postpartum course was normal. The thoracostomy tube was removed 3 days later, the patient's left lung remained expanded, and she was discharged home without further complications on hospital day 7. DISCUSSION Acute respiratory failure Respiratory Failure Definition Respiratory failure is nearly any condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly. in pregnancy is a major cause of maternal and fetal morbidity and mortality Morbidity and Mortality can refer to:
respiratory system Organ system involved in respiration. In humans, the diaphragm and, to a lesser extent, the muscles between the ribs generate a pumping action, moving air in and out of the lungs through a may lead to hypoxia hypoxia Condition in which tissues are starved of oxygen. The extreme is anoxia (absence of oxygen). There are four types: hypoxemic, from low blood oxygen content (e.g., in altitude sickness); anemic, from low blood oxygen-carrying capacity (e.g. more readily than in a nonpregnant patient. Furthermore, fetal umbilical vein [PO.sub.2] is only 32 to 45 mm Hg, so any decrease in maternal partial pressure of oxygen is potentially life-threatening to the developing fetus. (4) The typical symptoms of spontaneous pneumothorax, regardless of cause, include pleuritic chest pain associated with dyspnea. (3,5) Physical examination may show tachypnea tachypnea /tach·yp·nea/ (tak?ip-ne´ah) very rapid respiration. tach·yp·ne·a n. Rapid breathing. Also called polypnea. , tachycardia, cyanosis, or ipsilateral ipsilateral /ip·si·lat·er·al/ (ip?si-lat´er-al) situated on or affecting the same side. ip·si·lat·er·al adj. Located on or affecting the same side of the body. decreased breath sounds; however, chest radiographs are required for definitive diagnosis. Reliance on "classic" clinical findings and traditional presentation may lead to misdiagnosis mis·di·ag·no·sis n. pl. mis·di·ag·no·ses An incorrect diagnosis. mis·di  ag·nose in some cases of spontaneous pneumothorax on initial presentation. (6)
Furthermore, in some cases of radiographically confirmed pneumothorax
during pregnancy, chest pain and dyspnea have been initially (and
erroneously) attributed to paroxysmal tachycardia, neuralgia neuralgia (n răl`jə, ny–), acute paroxysmal pain along a peripheral sensory nerve. , or asthma
exacerbation. (7) This may also explain why spontaneous pneumothorax
during pregnancy has been so infrequently reported in the scientific
literature. (7) Awareness that this condition may occur during pregnancy
and may resemble other causes of thoracic pain may avoid misdiagnosis
and aid prompt treatment.
Ionizing radiation represents another potential risk to the fetus, particularly during the first 8 weeks of development, that is, the period of organogenesis organogenesis /or·ga·no·gen·e·sis/ (or?gah-no-jen´e-sis) the origin and development of organs.organogenet´ic or·gan·o·gen·e·sis n. The formation and development of the organs of living things. . (8) The potential hazards associated with a radiologic examination must be weighed against the possible benefits of the results of the study. The dose to the uterus from standard chest radiography with a shielded maternal abdomen is estimated to be 1 mrad per examination. Therefore, when one suspects pneumothorax in a pregnant patient, it is safe to proceed with the standard chest radiography without placing the fetus at substantial risk from ionizing radiation. (3,8) Shielded computed tomography (CT) is also a useful imaging technique that can help in defining the underlying anatomic abnormality and in planning an operative approach when surgical treatment is indicated. (4) Previously reported cases of spontaneous pneumothorax during pregnancy are detailed in the Table. (3,9-23) Review of these 41 cases shows that the patients were young (average age 26.5 years) and of low gravidity gravidity Obstetrics The state of being, or having been, pregnant. Cf Gravity. (mean gravidity 1.6), with 51% having an identifiable risk factor for spontaneous pneumothorax. Risk factors most commonly noted were an underlying infection (15%), asthma, history of pneumothorax, and cocaine use (7.7%). Pneumothorax occurred during the perinatal period in 54% and during the first or second trimester in 46%. Initial treatment was observation in 22%, tube thoracostomy in 75%, and thoracotomy thoracotomy /tho·ra·cot·o·my/ (-kot´ah-me) pleurotomy; incision of the chest wall. tho·ra·cot·o·my n. Incision into the chest wall. Also called pleurotomy. in 3%. Of those treated by observation only, 78% had resolution, compared with 40% of those treated by tube thoracostomy. Of the total group of patients, 40% ultimately required thoracotomy for recurrence or persistence of the initial alveolar alveolar /al·ve·o·lar/ (al-ve´o-lar) [L. alveolaris ] pertaining to an alveolus. al·ve·o·lar adj. Relating to an alveolus. leak. The obstetric outcome was good, 87% of patients having vaginal delivery and 13% having elective cesarean cesarean /ce·sar·e·an/ (se-zar´e-an) see under section. ce·sar·e·an or cae·sar·e·an or cae·sar·i·an or ce·sar·i·an adj. Of or relating to a cesarean section. delivery. No neonatal complications were reported. Treatment of simple pneumothorax during pregnancy is controversial. Admission and close observation of the patient is usually done with small pneumothoraxes (less than 20% of the hemithorax). (3) Other treatment options are needle aspiration, needle decompression (eg, in tension pneumothorax), pleurodesis, tube thoracostomy, thoracotomy, and thoracoscopy. (3) If the initial pneumothorax is large (more than 20% of the hemithorax), it should be treated with tube thoracoscopy. The same treatment criteria used for nonpregnant patients apply to pregnant patients--ie, recurrent, persistent, or bilateral pneumothorax necessitates thoracotomy or thoracoscopy. The former has been the traditional treatment approach to recurrent pneumothorax; however, during the past decade, use of thoracoscopy has increased because of its advantages over thoracotomy (decreased time of exposure to anesthetic drugs, rapid lung expansion, decreased postoperative pain, and a shorter postoperative period). (4) On the basis of a successful maternal and fetal outcome in 10 patients treated with prenatal thoracotomy and in 3 patients treated with prenatal thoracoscopy, surgical intervention during pregnancy when pneumothorax is persistent or recurrent seems safe. Levine and Collins (16) favor conservative management of spontaneous pneumothorax during pregnancy with the use of a long-term intercostal intercostal /in·ter·cos·tal/ (-kos´t'l) between two ribs. in·ter·cos·tal adj. Located or occurring between the ribs. n. A space, muscle, or part situated between the ribs. drainage device, delaying definitive treatment of the pneumothorax until after delivery. Allowing spontaneous vaginal delivery A spontaneous vaginal delivery (SVD) occurs when a pregnant woman goes into labor without use of drugs or techniques to induce labor, and delivers her baby in the normal manner, without a cesarean section. after operative treatment of pneumothorax during pregnancy also seems safe. For patients who have not received definitive surgical therapy, epidural anesthesia and forceps assistance are recommended to prevent increased intrathoracic pressure due to the expulsive efforts during the second stage of labor and possible worsening or recurrence of pneumothorax. (3,4,16) CONCLUSION Spontaneous pneumothorax during pregnancy is probably not such an extremely remote possibility. Pneumothorax should be considered in any pregnant woman with chest pain and/or dyspnea and must be confirmed radio-graphically. Neither the condition nor its treatment causes serious adverse effects on the course of pregnancy or delivery, but a heightened index of suspicion index of suspicion Medtalk A phrase broadly used to indicate how seriously a particular disease is being entertained as a diagnosis; as an example, there is a high IOS that rapid and unexplained weight loss in an elderly Pt is due to pancreas CA, and a low IOS that is essential for prompt recognition of pneumothorax during pregnancy and for preventing complications.
TABLE.
Reported Cases of Spontaneous Pneumothorax During Pregnancy
Patient Weeks of
Reference Age Gravidity Gestation
Gass (3) 30 3 15
Hsu (3) 29 1 39
Brantle (3) 19 1 26
Jonas (3) 19 1 39
Vance (3) 36 4 39
Branton (3) 26 2 31
Najafi (3) 32 3 41
Burgener (3) 26 1 40
Stewart (3) 18 1 34
Bending (3) 17 1 40
Freedman (3) 29 2 10
Farrell (3) 19 1 39
Karson (3) 20 1 11
Dhalla (3) 28 1 14
26 1 8
26 2 4
Schoenfeld (3) 27 3 24
Temdrup (3) 25 1 12
van Winter (4) 26 2 23
Chan (5) 39 4 31
27 4 29
Guerin (7) 27 2 37
31 1 36
25 1 39
Wennergren (9) 23 2 30
Warren (10) 32 1 12
Lacayo (11) 20 1 Postpartum
Brodsky (12) 28 1 12
Giampaglia (13) 23 1 32
Chiner (14) 27 1 8
Bernasko (15) 30 3 15
Levine (16) 26 1 32
Ishikawa (17) -- -- 32
Miyasita (18) 37 -- 13
Schwartz (19) 26 1 10
Murata (20) 35 1 21
Atkinson (21) 29 1 Midtrimester
Tolck (22) 24 1 9
Davidova (23) 18 1 40
29 1 12
Present report 27 1 38
Medical Treatment of Pulmonary
Reference History Pneumothorax Outcome
Gass (3) Histoplasmosis Observation Resolved
Hsu (3) Tuberculosis TT Resolved, TT
Brantle (3) None TT x 2 Thoracotomy
Jonas (3) None TT Resolved, TT
Vance (3) Bronchitis TT Resolved, TT
Branton (3) URTI TT x 3 Thoracotomy
Najafi (3) None TT Thoracotomy
Burgener (3) Asthma TT Resolved, TT
Stewart (3) None TT Resolved, TT
Bending (3) Thyroidectomy Observation Resolved
Freedman (3) Rheumatic fever Observation Resolved
Farrell (3) URTI TT Thoracotomy
Karson (3) Hyperemesis gravidarum Observation Resolved
Dhalla (3) Pneumothorax x 2 Observation Thoracotomy
None Observation Thoracotomy
None TT x 3 Thoracotomy
Schoenfeld (3) Pneumothorax x 5 Thoracotomy Not reported
Temdrup (3) Phlebitis TT Resolved, TT
van Winter (4) None TT x 3 Thoracotomy
Chan (5) Cocaine use TT VAT
Cocaine use TT Thoracotomy
Guerin (7) Asthma TT Resolved, TT
None TT Resolved, TT
Bronchitis TT Resolved, TT
Wennergren (9) None TT x 6 Thoracotomy
Warren (10) None TT Thoracotomy
Lacayo (11) Left lower hemithorax TT Thoracotomy
stab wound
Brodsky (12) Pneumothorax x 2 TT x 5 VAT
Giampaglia (13) None TT Thoracotomy
Chiner (14) None TT Resolved, TT
Bernasko (15) Cocaine use TT Thoracotomy
Levine (16) None TT Thoracotomy
Ishikawa (17) -- TT VAT
Miyasita (18) -- TT Thoracotomy
Schwartz (19) Hyperemesis gravidarum Observation Resolved
Murata (20) None TT Pleurodesis
Atkinson (21) [[alpha].sub.1]- TT Resolved, TT
antitrypsin deficiency
Tolck (22) None -- --
Davidova (23) Asthma Observation Resolved
None Observation Resolved
Present report None TT Resolved
Obstetric
Reference Outcome
Gass (3) SVD
Hsu (3) SVD
Brantle (3) FD
Jonas (3) SVD
Vance (3) FD
Branton (3) FD
Najafi (3) FD
Burgener (3) FD
Stewart (3) SVD
Bending (3) SVD
Freedman (3) SVD
Farrell (3) FD
Karson (3) FD
Dhalla (3) FD
FD
FD
Schoenfeld (3) Not reported
Temdrup (3) SVD
van Winter (4) SVD
Chan (5) SVD
SVD
Guerin (7) Cesarean
SVD
SVD
Wennergren (9) Cesarean
Warren (10) SVD
Lacayo (11) Cesarean
Brodsky (12) SVD
Giampaglia (13) Cesarean
Chiner (14) SVD
Bernasko (15) SVD
Levine (16) SVD
Ishikawa (17) SVD
Miyasita (18) Cesarean
Schwartz (19) SVD
Murata (20) SVD
Atkinson (21) FD
Tolck (22) --
Davidova (23) SVD
SVD
Present report SVD
SVD = Spontaneous vaginal delivery,
TT = tube thoracostomy,
FD = forceps delivery,
URTI = upper respiratory tract infection,
VAT = video-assisted thoracoscopy
Ellipses indicated missing data.
References (1.) Hollingsworth HM, Irwin RS: Acute respiratory failure in pregnancy. Clin Chest Med 1992; 13:723-740 (2.) Heffner JE, Sahn SA: Pleural Pleural Pleural refers to the pleura or membrane that enfolds the lungs. Mentioned in: Pneumothorax pleural emanating from or pertaining to the pleura. disease in pregnancy. Clin Chest Med 1992; 13:667-678 (3.) Terndrup TE, Bosco SF, McLean ER Spontaneous pneumothorax complicating pregnancy. case report and review of the literature. J Emerg Med 1989; 7:245-248 (4.) van Winter JT, Nichols FC, Pairolero PC, et al: Management of spontaneous pneumothorax during pregnancy: case report and review of the literature. Mayo Clin Proc 1996; 71:249-252 (5.) Chan L, Pham H, Reece EA: Pneumothorax in pregnancy associated with cocaine use. Am J Perinatol 1997; 14:385-388 (6.) Kadokura M, Nonaka M, Yamamoto S, et al: Five cases of asymptomatic spontaneous pneumothorax. Ann Thorac Cardiovasc Surg 1999; 5:187-190 (7.) Guerin JM, Barbotin-Larrieu F, Meyer P, et al: Pneumothorax in pregnancy. a propos of 3 cases. Rev Pneumol Clin 1988; 44:297-299 (8.) Wagner LK, Lester RG, Saldana LR (eds): Exposure of the Pregnant Patient to Diagnostic Radiations: A Guide to Medical Management. Philadelphia, Lippincott, 1985, pp 41-50 (9.) Wennergren M, Jorgensen C, Bugge M, et al: Pneumothorax in pregnancy. Acta Obstet Gynecol Scand 1990; 69:441-442 (10.) Warren SE, Lee D, Martin V, et al: Pulmonary lymphangiomyomatosis causing bilateral pneumothorax during pregnancy. Ann ThoracSurg l993; 55:998-1000 (11.) Lacayo L, Taveras JM, Sosa N, et al: Tension fecal pneumothorax in a postpartum patient. Chest 1993; 103:950-951 (12.) Brodsky JB, Eggen M, Cannon WB: Spontaneous pneumothorax in early pregnancy: successful management by thoracoscopy. J Cardiothorac Vasc Anesth 1993; 7:585-587 (13.) Giampaglia F, de Placido G, Santopaolo O, et al: Pneumothorax in pregnancy. Minerva Ginecol 1994; 46:353-358 (14.) Chiner E, Blanquer R, Blanquer J, et al: Spontaneous pneumothorax in pregnancy: description of a case and review of the literature. Ann Med Interne in·terne n. Variant of intern. (Paris) 1990; 7:86-88 (15.) Bernasko JW, Brown G, Mitchell JL, et al: Spontaneous pneumothorax following cocaine use in pregnancy (Letter). Am J Emerg Med 1997; 15:107 (16.) Levine AJ, Collins FJ: Treatment of pneumothorax during pregnancy. Thorax thorax, body division found in certain animals. In humans and other mammals it lies between the neck and abdomen and is also called the chest. The skeletal frame of the thorax is formed by the sternum (breastbone) and ribs in front and the dorsal vertebrae in back. 1996; 51:338-339 (17.) Ishikawa N, Sawa S, Fujii 5, et al: A case of spontaneous pneumothorax in pregnancy. Kyobu Ceka 2000; 53:83-85 (18.) Miyasita M, Koga A, Kiyonari N, et al: Spontaneous pneumothorax in pregnancy: a case report and review of the literature. Kyobu Geka 1991; 44:576-578 (19.) Schwartz M, Rossoff L: Pneumomediastinum and bilateral pneumothoraces in a patient with hyperemesis gravidarum. Chest 1994; 106:1904-1906 (20.) Murata A, Takeda Y, Usuki J, et al: A case of pulmonary lymphangiomyomatosis induced by pregnancy. Nippon Kyobu Shikkan Cahkai Zasshi 1989; 27:1106-1111 (21.) Atkinson AR: Pregnancy and alpha-1 antitrypsin deficiency alpha-1 antitrypsin deficiency An inherited condition–frequency, ±1:10,000, characterized by low or absent production of alpha-1 antitrypsin, an enzyme which is critical to tissue remodeling Clinical The PiZZ phenotype is characterized by early-onset . Post gad Med J 1987; 63:817-820 (22.) Tolck S: Spontaneous pneumothorax and pregnancy. Schweiz Med Wochenschr 1979; 109:655-657 (23.) Davidova RI: Two cases of spontaneous pneumothorax in pregnancy. Pediatr Akush Ginekol 1972; 3:62 RELATED ARTICLE: KEY POINTS * Spontaneous pneumothorax is a rare condition during pregnancy, and a heightened index of suspicion is essential for prompt diagnosis. * The same diagnostic and therapeutic criteria used for non-pregnant patients apply to pregnant patients. * Neither the condition nor its treatment causes serious adverse effects on the course of pregnancy or delivery. From the Departments of Radiology, Thoracic Surgery, and Obstetrics and Gynecology obstetrics and gynecology Medical and surgical specialty concerned with the management of pregnancy and childbirth and with the health of the female reproductive system. , La Paz University Hospital, Madrid, Spain. Reprint requests to Luis Gorospe, MD, P[degrees] de La Habana 109, 28036 Madrid, Spain. |
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