|Year : 2017 | Volume
| Issue : 2 | Page : 112-114
Wheeze in pregnancy: Sometimes a pain in the neck to diagnose
Nikki Higgins, Tasneem Pirani, Stefan Braunecker
Department of Critical Care, Kings College Hospital, Denmark Hill, London, United Kingdom
|Date of Web Publication||7-Nov-2017|
Departments of Critical Care and Anaesthesia, St George's Hospital, Blackshaw Road, London
Source of Support: None, Conflict of Interest: None
Background: Upper airway obstruction can present with stridor or wheeze and is sometimes misdiagnosed as asthma. As asthma is common amongst pregnant women, upper airway obstruction can remain hidden. Case: We describe the case of goitre-related life threatening upper airway obstruction which was initially thought to be poorly controlled asthma in a pregnant woman. Careful history, high clinical suspicion and directed imaging was required to make the diagnosis. A multi-disciplinary team and meticulous planning was required to safely treat the parturient. Conclusion: As asthma has an incidence of 3%-12% among pregnant woman; wheezing is likely to be diagnosed as asthma. Our case illustrates the importance of detailed history, examination and imaging in the parturient who presents with wheeze. It also highlights the added complexity of managing a patient with a life threatening airway problem while she is pregnant.
Keywords: Asthma, goitre, maternity, obstetric, thyroid
|How to cite this article:|
Higgins N, Pirani T, Braunecker S. Wheeze in pregnancy: Sometimes a pain in the neck to diagnose. J Obstet Anaesth Crit Care 2017;7:112-4
|How to cite this URL:|
Higgins N, Pirani T, Braunecker S. Wheeze in pregnancy: Sometimes a pain in the neck to diagnose. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 12];7:112-4. Available from: http://www.joacc.com/text.asp?2017/7/2/112/217777
| Introduction|| |
Wheezing is a high-pitched whistling sound produced by oscillation of opposing airway walls., Wheeze can appear during expiration and inspiration and is usually caused by narrowing of some part of the airway. This includes not only smaller lower airways but also larger upper airways. As asthma is common among pregnant woman (3–12%) and can worsen in one-third of the cases during pregnancy, wheezing is more likely to be diagnosed as 'poorly controlled asthma'., We describe a case of an extrathoracic upper airway obstruction, highlighting the importance of careful examination in assessing pregnant patients who present with wheeze.
| Case Report|| |
We present the case of a 31-year-old female who presented at 33 weeks gestation, with a 6-week history of progressive dyspnoea with a background history of childhood asthma. Associated symptoms included coryza, 'wheeziness', and orthopnoea. Of note, she did not report cough, pyrexia, stridor, sore throat or hoarseness of voice at this time. She had attended her general practitioner on three separate occasions during her pregnancy with wheeze and shortness of breath, and had been prescribed inhalers, which had only temporarily helped to relieve her symptoms. She had been treated for a chest infection with antibiotics 2 weeks prior to her admission to hospital, however, experienced increasingly more pronounced symptoms, particularly nocturnal, as her pregnancy progressed. She was admitted to our institution following a severe episode of symptoms not relieved by inhalers.
Her medical history comprised a body mass index (BMI) of 40 kg/m2 and asthma diagnosed in childhood after a chest infection. She had not required the use of inhalers for over 10 years, but did report wheeze caused by exertion, especially in cold weather, or after a cold or flu-like illness. The patient was an otherwise healthy 33-week primagravida with a Jamaican father and a mother from Barbados. She was a homemaker living in London, had no pets, and denied recent foreign travel.
Examination of the chest revealed bilateral symmetrical chest expansion, somewhat limited by the gravid uterus. Auscultation revealed quiet bases bilaterally and bilateral widespread wheeze, with transmitted upper airway sounds. The chest radiograph [Figure 1] was unremarkable showing normal cardiac size and outline, no collapse, consolidation, effusion, pneumothorax or hyperexpansion. Oxygen saturations were 98% on room air. She was apyrexial and the rest of her examination, including neck and legs, was unremarkable. Blood results were within normal limits with a haemoglobin of 10.9 g/dL, white cell count of 7.75 × 109/L and a CRP of 2.8 mg/L. Her respiratory virus screen revealed her to be positive for Respiratory Syncytial Virus (RSV) at admission, and a presumptive diagnosis of asthma exacerbated by viral illness was made. She was commenced on a tapering dose of steroids and regular nebulisers.
|Figure 1: Normal chest radiograph without obvious goitre or tracheal deviation|
Click here to view
She began to feel better over the following 5 days, but on the 5th night became extremely dyspnoeic with desaturation to 73% on room air. Oxygen saturations promptly recovered to 98% on room air with nebulisers and re-positioning of the patient to the upright sitting position. During this episode, a distinct stridor and hoarseness of voice was noted by the attending physician. This resolved promptly on sitting up.
Upon questioning the patient about neck swelling, she admitted that her husband had pointed out some swelling which he felt had become more prominent over the last few weeks.
Subsequent ultrasound scanning of the neck revealed large left and right lobes of thyroid anterior to the trachea but no suggestion of compression. Thyroid function tests were normal with thyroid stimulating hormone (TSH) of 0.76 mIU/L and free thyroxine of 12.9 ρmol/L.
Computed tomography (CT) of the neck was performed [Figure 2], which showed a grossly enlarged thyroid gland bilaterally, with severe posterior displacement and compression of the trachea resulting in the smallest diameter of the trachea of 1.3 cm at the level of C6. There was also evidence of retrosternal extension.
|Figure 2: Computed Tomograghy (CT) of neck in transverse plane showing compression of the trachea (block arrow) by large thyroid goitre (multiple arrows)|
Click here to view
In view of the severity of nocturnal symptoms in the context of advanced pregnancy, a multi-disciplinary team discussion involving obstetrics, anaesthesia, ear nose and throat (ENT) surgeons, adult and neonatal intensivists took place. It was decided that it would be safer for the mother to have an urgent caesarean section and total thyroidectomy performed simultaneously. The obstetric team considered not delivering the baby, and allowing the patient to continue her pregnancy after her thyroidectomy was performed, but they decided that there was no benefit to the foetus to this approach. In the interests of having full control over this volatile clinical situation, and having all required staff available, the joint surgery was planned for the following day. Steroids for foetal lung maturation were administered. The ENT surgeons assessed the patient and advised that surgical tracheostomy would not be possible should the airway become compromised on induction. Thus, anaesthesia was induced after an awake fibre-optic intubation had taken place. Elective preparation for extracorporeal support was arranged, and perfusionists were kept on standby in the theatre. The patient delivered a healthy female uneventfully at 34 + 1 weeks gestation by caesarean section under general anaesthesia. She subsequently underwent total thyroidectomy during the same theatre session. Mother and baby were taken to the appropriate intensive care areas post-operatively and recovered well. Both were discharged from the hospital 2 weeks after the procedures. Pathology results from the thyroid tissue showed nodular hyperplasia, with no evidence of malignancy.
On further questioning, the patient volunteered that her mother had suffered similar, albeit less severe symptoms during pregnancy with her sister. In the post-partum period, she was discovered to have a goitre which also required total thyroidectomy. Interestingly, the surgeon who performed her mother's thyroidectomy 40 years ago also performed our patient's surgery this year at our institution.
| Discussion|| |
In our case report, we presented a 31-year-old pregnant woman with symptoms consistent with asthma but who in fact had a goitre-related upper airway obstruction. As asthma has an incidence of 3–12% among pregnant woman, wheezing is likely to be diagnosed as asthma. Our case illustrates that asthma is not the only cause of wheeze among pregnant woman. It is important to characterise the nature of the wheeze and the exacerbating factors such as recumbent positioning. Thyroid enlargement during pregnancy is a recognised phenomenon, which can lead to upper airway obstruction and symptoms similar to asthma. However, enlargement of the thyroid gland is relatively rare in those without pre-existing thyroid dysfunction, and even more rarely does it progress to life-threatening tracheal compression. Hyperthyroid state can cause thyroid enlargement and worsening of asthma-like symptoms and needs to be ruled out., In addition, hyperactive thyroid may aggravate side effects of beta agonists or theophylline. Problematic goitres during pregnancy are more likely to occur in mothers living in iodine deficient areas of the world, which was not the case with our patient.
To confirm the diagnosis, imaging has an important role. Ultrasound is helpful in assessing the size of the goitre and to characterize possible thyroid nodules. If a malignancy is suspected, a fine needle aspiration biopsy is indicated. In our case, ultrasound scanning failed to reveal a compression of the trachea but clinical suspicion was high, and given the severity of the presentation and relatively low radiation risk to the 33-week-old foetus, we performed a CT neck which was able to show a large goitre compressing the trachea.,
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loudon R, Murphy RL, Jr. Lung sounds. Am Rev Respir Dis 1984;130:663-73.
Forgacs P. The functional basis of pulmonary sounds. Chest 1978;73:399-405.
Vatti RR, Teuber SS. Asthma and pregnancy. Clin Rev Allergy Immunol 2012;43:45-56.
Murphy VE, Gibson P, Talbot PI, Clifton VL. Severe asthma exacerbations during pregnancy. Obstet Gynecol 2005;106 (5 Pt 1):1046-54.
Mokoka MC, Ullah K, Curran DR, O'Connor TM. Rare causes of persistent wheeze that mimic poorly controlled asthma. BMJ Case Rep 2013;2013.
Saberi S, Doherty GM, Esfandiari NH. Stridor due to an unsuspected parathyroid cyst in a thirty-two-year-old woman with goiter. Thyroid 2010;20:1315-6.
Luong KV, Nguyen LT. Hyperthyroidism and asthma. J Asthma 2000;37:125-30.
White NW, Raine RI, Bateman ED. Asthma and hyperthyroidism. A report of 4 cases. S Afr Med J 1990;78:750-2.
Nakazawa T, Kobayashi S. Influence of antithyroidal therapy on asthma symptoms in the patients with both bronchial asthma and hyperthyroidism. J Asthma 1991;28:109-16.
Hunt VJ, English JD. The use of prone CT in the perioperative management of airway obstruction caused by multinodular goitre. Anaesthesia 2013;68:779-80.
Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: Algorithms and radiation dose considerations. Radiographics 2007;27:1705-22.
[Figure 1], [Figure 2]