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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 106-108

Spontaneous pneumothorax in pregnancy: A challenge for anaesthesiologist


Department of Anaesthesiology – Lifecare Anaesthesia Associates, Columbia Asia Hospitals, Bengaluru, Karnataka, India

Date of Web Publication7-Nov-2017

Correspondence Address:
R M Pinto
Department of Anaesthesiology – Lifecare Anaesthesia Associates, Columbia Asia Hospitals, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_29_17

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  Abstract 

Spontaneous primary pneumothorax (SPP) in pregnancy, though rare, can be a life threatening but easily treatable cause of pneumothorax. Only few cases have been reported till date. Early recognition and prompt treatment are keystones for preventing maternal and foetal complications. We report a case of a 32-year-old pregnant lady who developed right-sided large SPP in the third trimester. This case highlights the limitations of diagnostic aids in pneumothorax, challenges posed to an anaesthesiologist (for operative delivery and definitive lung surgery), and the importance of using multimodal pain management plan to improve the outcome.

Keywords: Primary spontaneous pneumothorax, spinal, thoracic paravertebral block, video-assisted thoracoscopic surgery


How to cite this article:
Pinto R M, Mahankali S, Prasanna B S, Ramkumar M M. Spontaneous pneumothorax in pregnancy: A challenge for anaesthesiologist. J Obstet Anaesth Crit Care 2017;7:106-8

How to cite this URL:
Pinto R M, Mahankali S, Prasanna B S, Ramkumar M M. Spontaneous pneumothorax in pregnancy: A challenge for anaesthesiologist. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 14];7:106-8. Available from: http://www.joacc.com/text.asp?2017/7/2/106/217772


  Introduction Top


Dyspnoea in pregnancy may be a benign symptom or it may herald more severe conditions like pulmonary oedema, embolism, pneumothorax, etc., Spontaneous pneumothorax, though rare, can be important treatable cause of acute dyspnoea in pregnancy. It can be primary or secondary. SPP is caused by rupture of undiagnosed pleural blebs or bulla. The reported incidence of SPP is 1.2–6/100000[1] in females and only a few cases have been reported during pregnancy. This can occur antenatal,[2],[3],[4] during labour [5] as well as postnatal.[6]


  Case Report Top


A 32-year-old female Gravida 1, Para 1 in her 34th week of gestation with spontaneous pneumothorax was transferred to our hospital from a rural clinic. She had mild dyspnoea from 20th week, an echocardiogram done at that time was normal. Dyspnoea had got worse over the previous 2 days and was now associated with chest pain. On examination SpO2 was 95% on room air, HR: 120/min, BP: 100/60 mmHg, decreased breath sounds and hyper-resonant note on right side. A chest radiograph (CXR) with abdominal shield protection revealed right-sided tension pneumothorax [Figure 1]a. The diagnosis of spontaneous primary pneumothorax (SPP) was made. An intercostal chest drain (ICD) was placed in the 5th intercostal space (ICS). Shortly after, patient complained of worsening of breathlessness. On examination HR: 110/min, BP: 100/60 mm Hg, SpO2 was 88% with O2 by face mask. Bilateral crepitations were heard and subcutaneous emphysema was noted on the right chest. A repeat chest X-ray (CXR) [Figure 1]b showed re-expanded right lung with bilateral diffuse alveolar infiltrates suggestive of re-expansion pulmonary oedema (REPO). This improved with partial clamping of the ICD, diuretics, and nebulization of beta-2 agonists.
Figure 1: Chest x-ray (a) Showing Right sided Pneumothorax. (b) Showing Right sided ICD in situ, Subcutaneous emphysema and Re-expansion pulmonary edema

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The patient's pain was initially managed with intravenous (IV) paracetamol, IV fentanyl, and intercostal nerve block (3 mL of 2% lidocaine with adrenaline 1:200,000 at 4th, 5th, and 6th ICS). Since patient continued to have severe pain (VAS: 6-7/10) over the right hemithorax, right-sided thoracic paravertebral block (TPVB) was performed at T5- 6 level with 18G Tuohy needle under ultrasound (US) guidance and a 20G catheter was threaded. A bolus of 15 mL of 0.1% bupivacaine with 2 μg/mL fentanyl followed by continuous infusion at 6 mL/h. With this patient's pain improved (VAS: 1/10 at rest and 3/10 on deep breathing).

Two days' post ICD, patient complained of worsening of breathlessness and chest pain. The clinical examination revealed HR: 106/min, BP: 100/60 mmHg, SpO2: 98% with O2 by facemask, RR: 26/min and subcutaneous emphysema which had now extended till the neck and face. A strong possibility of bronchopleural fistula was kept in mind. A multidisciplinary meeting involving patient's family was done and decision was taken to terminate pregnancy by caesarean section [lower segment caesarean section (LSCS)].

Subarachnoid block was performed in the sitting position with a 27G Whitacre needle at L3/4 space with 2 mL of 0.5% bupivacaine heavy. The patient was propped up to about 20° since the patient was having breathlessness and could not tolerate supine position. Her vitals remained stable and a healthy live male baby was delivered.

A high resolution computed tomography (HRCT) chest done postoperatively showed large apical bulla on right side with subcutaneous emphysema and mediastinal air [Figure 2]. The patient was shifted to thoracic unit and next day she underwent right-sided video-assisted thoracoscopic surgery (VATS). During the surgery it was discovered that patient had multiple ruptured bullae. She underwent stapled bullectomy, pleurodesis, pleural biopsy, and ICD insertion uneventfully. She was discharged home 5 days later.
Figure 2: CT chest showing large apical bulla and ICD

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  Discussion Top


Pneumothorax can be diagnosed clinically or by using diagnostic aids like CXR, computed tomography, or using a bedside US where one can demonstrate a “lung sliding” sign. The accepted safe cumulative dose of ionizing radiation during pregnancy is 5 rad. The amount of exposure to the foetus from a two-view CXR is only 0.00007 rad.[7] Therefore, when one suspects pneumothorax, a CXR or CT should not be held back. The clinical signs and a bedside CXR helped us to confirm the diagnosis. US scanning was of limited benefit due to extensive air shadow interference from subcutaneous emphysema; however, it can prove to be of great use when there is sudden development of pneumothorax.

The British Thoracic Society Pleural Disease Guideline 2010[1] states that pneumothorax that occurs during pregnancy can be managed by simple observation if the mother is not dyspnoeic with no foetal distress. Further, it states that there is level C evidence that simple observation and aspiration are usually effective during pregnancy, with elective assisted delivery and regional anaesthesia at or near term. VATS to be considered postnatal to avoid recurrence in future pregnancies.

The causes of acute worsening of breathlessness could be cardiac, respiratory, or due to pulmonary aspiration. In our patient, post-intercostal chest drain (ICD) insertion, breathlessness became worse and was associated with sudden desaturation. Aspiration as a cause was ruled out as our patient was awake and had good cough reflex. Though clinical signs did not match with cardiac causes, we gave a dose of diuretic to rule out any chance of accidental fluid overload. Meanwhile, CXR done revealed expanded right lung and bilateral diffuse infiltrates, which was not there in the initial CXR. This sudden worsening of breathlessness after ICD insertion and bilateral infiltrates on CXR led us to the possibility of Re-expansion pulmonary edema (REPO). REPO normally occurs due to rapid emptying of air or liquid from pleural space and has mortality rate of up to 20%.[8] This is usually seen in young patients or those with pulmonary collapse more than 3 days and it can affect the contralateral lung as well. There are no definitive guidelines to prevent REPO. However, targeting negative pleural pressure above - 20 cm H20 during thoracentesis can prevent it. The treatment is usually supportive. In severe cases endotracheal intubation, application of positive end expiratory pressure and differential two-lung ventilation may be required. Our patient showed good response to partial clamping of ICD and bronchodilators.

Anaesthesiologists may have to get involved in these patients for pain management following ICD insertion, labour analgesia, caesarean section as well as VATS. Pain following pneumothorax and ICD insertion can be severe. The suboptimal treatment of pain can lead to maternal and foetal morbidity. The techniques employed for providing pain relief include IV opioids, multiple intercostal nerve blocks, intrapleural analgesia, thoracic epidural, TPVB, and the novel serratus anterior plane (SAP) block.[9] Our patient had severe chest pain, even after IV paracetamol, IV fentanyl and intercostal nerve block. Thoracic epidural analgesia was considered but not used as bilateral sympathetic blockade and weakness of accessory muscles of respiration can worsen the clinical situation. The presence of extensive right-sided subcutaneous emphysema made the visualization of tissue planes difficult to perform US-guided SAP block. Hence, we chose to perform right-sided TPVB with catheter insertion under US guidance.

For LSCS, a subarachnoid block was chosen as the primary anaesthesia technique as positive pressure ventilation can increase air leak.

The pulmonary bullae can be more than one in number. HRCT showed up only one ruptured bulla in our patient; however, during VATS we noticed more than one ruptured bullae. During a normal HRCT, widely spaced thin sections are done,[10] because of which there is a chance that some bullae may be missed as happened in our case. The presence of such unrecognized bullae can result in their sudden rupture during positive-pressure ventilation and lead to bronchopleural fistula. Hence, due care must be taken while ordering HRCT and during positive pressure ventilation.


  Conclusion Top


Spontaneous acute pneumothorax, though rare, can happen during pregnancy. When SPP happens it can be life threatening for both the mother and the foetus. Early recognition and prompt treatment are keystones for preventing complications in the mother and child. Multimodal pain management plan employing newer techniques such as TPVB and SAP block can significantly improve the outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Macduff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii18-31.  Back to cited text no. 1
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2.
Gorospe L, Puente S, Madrid C, Novo S, Gil-Alonso JL, Guntiñas A. Spontaneous pneumothorax during pregnancy. South Med J 2002;95:555-8.  Back to cited text no. 2
    
3.
Reid CJ, Burgin GA. Video-assisted thoracoscopic surgical pleurodesis for persistent spontaneous pneumothorax in late pregnancy. Anaesth Intensive Care 2000;28:208-10.  Back to cited text no. 3
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4.
Van Winter JT, Nichols FC 3rd, Pairolero PC, Ney JA, Ogburn PL Jr. Management of spontaneous pneumothorax during pregnancy: Case report and review of the literature. Mayo Clin Proc 1996;71:249-52  Back to cited text no. 4
    
5.
Menon A, Anikin V. Spontaneous Pneumothorax During Labor. Internet J Gynecol Obstet 2006;7:2.  Back to cited text no. 5
    
6.
Harten JM, Brown AG, Davidson IT. Post partum pneumothorax: Two case reports and discussion. Int J Obstet Anesth 2000;9:286-9.  Back to cited text no. 6
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7.
Toppenberg KS, Hill DA, Miller DP. Safety of radiographic imaging during pregnancy. Am Fam Physician 1999;59:1813-8.  Back to cited text no. 7
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8.
Mahfood S., Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45:340-5.  Back to cited text no. 8
    
9.
Blanco R, Parras T, Mc Donnell JG, Prats-Galino A. Serratus plane block: A novel Ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.  Back to cited text no. 9
    
10.
Worthy S. High resolution computed tomography of the lungs. BMJ 1995;310:615-6.  Back to cited text no. 10
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