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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 48-50

A rare case of pregnancy with primary spontaneous pneumothorax posted for emergency cesarean section


1 Department of Anaesthesiology, NEIGRIHMS, Shillong, Meghalaya, India
2 Department of Urology, NEIGRIHMS, Shillong, Meghalaya, India

Date of Submission05-Aug-2019
Date of Acceptance13-Sep-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Laltanpuii Sailo
Department of Anaesthesiology, NEIGRIHMS, Shillong -793 012, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_34_19

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  Abstract 


Spontaneous pneumothorax during pregnancy is a rare condition. Only 56 cases have been reported in the English literature. A primigravida at 32 weeks pregnancy presented with breathing difficulty, left chest pain, and cough for 2 days. She was diagnosed to have left primary spontaneous pneumothorax and multiple unruptured blebs and bullae of the right lung. A left chest tube was inserted which relieved her symptoms. However, after 3 weeks, she again developed breathing difficulty so she was planned for an emergency cesarean section. The anesthesia was challenging as she could lie down only in the 60° propped-up position. With spinal anesthesia, desired level of block could not be achieved. General anesthesia also could not be given as it will cause further rupture of blebs and bullae. Therefore, the operation was performed under epidural anesthesia using injection ropivacaine in the same 60° propped-up position.

Keywords: Cesarean section, epidural anesthesia, general anesthesia, spinal anesthesia, spontaneous pneumothorax


How to cite this article:
Sailo L, Sailo SL. A rare case of pregnancy with primary spontaneous pneumothorax posted for emergency cesarean section. J Obstet Anaesth Crit Care 2020;10:48-50

How to cite this URL:
Sailo L, Sailo SL. A rare case of pregnancy with primary spontaneous pneumothorax posted for emergency cesarean section. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Mar 28];10:48-50. Available from: http://www.joacc.com/text.asp?2020/10/1/48/269497




  Introduction Top


Spontaneous pneumothorax during pregnancy is a rare condition.[1] Only 56 cases have been reported in the English literature.[2] It is of two types: primary and secondary spontaneous pneumothorax.[3] Primary spontaneous pneumothorax occurs in patients with no obvious inherent lung disease while secondary pneumothorax occurs in patients with clinically obvious lung disease.


  Case Report Top


A 27-year-old primigravida at 32 weeks pregnancy presented to our institute with a history of breathing difficulty, left chest pain, and cough for 2 days. She was tachypneic with a respiratory rate of 28/min, pulse rate of 128/min, blood pressure of 120/80 mmHg and oxygen saturation (SpO2) of 96%. She was given oxygen at 4 L/min by face mask and she was kept in propped-up position. On clinical examination of the chest, left pleural effusion was suspected. But the physician was not sure of the diagnosis and he suspected that the condition could be due to a cardiac cause, hence she was referred to a cardiologist. The cardiologist suspected pulmonary embolism as a possible diagnosis therefore, he advised computed tomography (CT) pulmonary angiography. The risk of radiation to the fetus was explained to the patient and relatives and informed consent was taken. CT scan was done with protective lead shield placed over the abdomen. It showed no evidence of pulmonary embolism but it showed left-sided pneumothorax causing passive collapse of upper and lower lobes and multiple unruptured bullae and blebs of the right lung [Figure 1]. A left chest tube was then inserted and the chest X-ray was done to confirm the position of the tube and any residual pneumothorax [Figure 2]. After this intervention, her symptoms improved and she was stable. Ultrasound showed a single live pregnancy with fetal heart rate of 150/min. She was kept under observation in the hospital to wait for fetal maturity. Fetal well-being was also regularly monitored. After 3 weeks, she complained of breathing difficulty again. It was suspected that multiple unruptured bullae and blebs on the right lung and pressure on the lungs by the gravid uterus caused the symptoms of breathlessness. After the risk of operation was explained and informed consent obtained, the obstetrician decided to go for an emergency cesarean section. The anesthesia was challenging because she could lie down only in the 60° propped-up position. In this position, it was not possible to achieve the desired level of block with spinal anesthesia. Moreover, general anesthesia was best avoided as positive-pressure ventilation may cause rupture of bullae and blebs which would lead to further pneumothorax. Epidural combined with spinal anesthesia would cause profound hemodynamic changes compared with epidural anesthesia alone. Therefore, it was decided to go for epidural anesthesia using injection ropivacaine. Ropivacaine (20 ml, 0.5%) was injected at L3-L4 interspace with a catheter in place. The level of block achieved was up to T6. Cesarean section was conducted in the same 60° propped-up position with oxygen given by face mask at 6 L/min. The patient's heart rate, blood pressure, respiratory rate, SpO2, and electrocardiogram (ECG) were monitored during the entire operation. Although the patient was uncomfortable to some extent due to the awkward position, the operation was uneventful. A healthy baby with Apgar (appearance, pulse, grimace, activity, and respiration) scores of 7 and 9 at 1 and 5 min, respectively was delivered. The mother had a smooth recovery and the chest tube was removed on the fifth postoperative day.
Figure 1: Coronal CT scan showing left pneumothorax and multiple bullae and blebs of the right lung

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Figure 2: Chest X-ray with a left chest tube in situ

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  Discussion Top


Breathing difficulty and chest pain during pregnancy may be due to pulmonary embolism caused by venous thrombosis, amniotic fluid, or air embolism, pneumothorax, tension pneumothorax, pulmonary edema, asthma, pneumonia, and rarely spontaneous pneumothorax. Risk factors for primary spontaneous pneumothorax are bronchial asthma, cocaine abuse, hyperemesis gravidarum, previous pneumothorax, underlying lung infection, iatrogenic causes, (central venous line insertion) and endotracheal intubation with positive-pressure ventilation.[2] Pneumothorax complicating pregnancy has to be treated urgently due to elevated oxygen demand and reduced lung movement as a result of gravid uterus. It may cause poor function of the cardiovascular system and cause harmful effects to the fetus due to hypoxia.[4] The most common cause of spontaneous pneumothorax is rupture of apical blebs or bullae.[5] Possible causes of rupture of bleb during pregnancy are Valsalva maneuver during labor, increased alveolar ventilation, and positive-pressure ventilation during general anesthesia.[6] Ropivacaine was chosen for this patient as it has the most hemodynamic and cardiovascular stability among local anesthetics used for epidural anesthesia. It is a long-acting amide local anesthetic. It is used in 0.5–1% concentration for surgical anesthesia. It is unique among local anesthetics since it exhibits a vasoconstrictive effect at clinically relevant doses. It has excellent sensory blockade with low motor blockade.[7] Pneumothorax in pregnancy may be treated by observation, needle aspiration, and chest tube insertion. The chest tube is the recommended treatment for large pneumothorax (more than 20% of hemithorax).[2] The definitive treatment of pneumothorax due to rupture of bullae and blebs is surgical pleurodesis with or without bullectomy. This operation can be done by open thoracotomy or video-assisted thoracoscopic surgery (VATS). Recently VATS has become the preferred technique for treatment of pneumothorax as it is associated with smaller incision, decreased postoperative pain, and shorter hospital stay compared to thoracotomy.[8] Our patient later underwent VATS.

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.
Harten JM, Brown AG, Davidson IT. Post partum pneumothorax: Two case reports and discussion. Int J Obstet Anaesth 2000;9:286-9.  Back to cited text no. 1
    
2.
Garg R, Sanjay, Das V, Usman K, Rungta S, Prasad R. Spontaneous pneumothorax: An unusual complication of pregnancy-A case report and review of literature. Ann Thorac Med 2008;3:104-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Noppen M. Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. Eur Respr Rev 2010;19:217-9  Back to cited text no. 3
    
4.
Aye CYL, McKean D, Dark A, Akinsola SA. Bilateral primary spontaneous pneumothoraces postcaeserean section- another reason to avoid general anaesthesia in pregnancy. BMJ Case Rep 2012. pii: bcr0220125724. doi: 10.1136/bcr. 02.2012.5724.  Back to cited text no. 4
    
5.
Madan K, Singh N, Jain V, Aggarwal AN. Spontaneous pneumothorax following caesarean section under spinal anaesthesia. BMJ Case Rep 2013. pii: bcr2012008507. doi: 10.1136/bcr-2012-008507.  Back to cited text no. 5
    
6.
Lal A, Anderson D, Coven M, Lindow S, Arnold AG. Pneumothorax and pregnancy. Chest 2007;132:10448.  Back to cited text no. 6
    
7.
Brown DL. Spinal, epidural, and caudal anesthesia. In Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Miller's Anesthesia, 7th ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 1611-38.  Back to cited text no. 7
    
8.
Nwaejike N, Aldam P, Pulimood T, Giles R, Brocelsby J, Fuld J, et al. A case of recurrent spontaneous pneumothorax during pregnancy treated with video assisted thoracoscopic surgery. BMJ Case Rep 2012. pii: bcr0520114282. doi: 10.1136/bcr. 05.2011.4282.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2]



 

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