Spontaneous acute pneumothorax during pregnancy is extremely rare and potentially serious for both the patient and fetus [
A 37-years-old primigravida at 40 weeks gestation was brought to our hospital by ambulance following collapse at home. No obstetric notes were brought in. On admission she was anxious, apyrexial, dyspnoeic, and distressed.
On clinical examination she was hypoxic, with oxygen saturation of 68% on air and respiratory rate of 30/minutes. Blood pressure was 150/90, and Glascow coma scale was 11/15. There were no signs of labour. Soon after arrival she had a seizure. Following the seizure there was an episode of fetal bradycardia and an urgent caesarean section was performed under GA. The baby was delivered in good condition. There was no evidence of placental abruption or any other cause for fetal bardycardia. Patient’s vitals were stable during the caesarean section. She was transferred to Intensive Care Unit, where she was intubated and ventilated. A CT chest showed extensive bilateral pnenumothoarces of greater than 70% in the left side and extensive opacities in the semicollapsed right lower lobe (see Figures
Pnemothorax postchest drains insertion, new left chest drain in situ. There has been good re-expansion of the left lung. No definite right pneumothorax seen.
Extensive bilateral pneumothoraces.
Following the caesarean section the family arrived. At this stage we found that the patient had longstanding right pleural endometriosis with multiple pneumothoraces and hydrothoraces and underwent right-sided pleurodesis in 2003. This lady was booked in at tertiary hospital for pregnancy care. She had regular followups with a Chest physician and Obstetrician. At 29 weeks gestation the patient had presented with mild dyspneoa and the chest X-ray revealed a small effusion but no significant pneumothorax. The cardiothoracic surgeon suggested that since the pleura was well stuck down, there was a low risk for expanding pnuemothorax. This patient still presented with severe hypoxia with pneumothorax. The Cardiothoracic surgeon further advised assistance with instrumental delivery as small risk of increased pneumothorax in the second stage of labour during pushing. Epidural or spinal anaesthesia was recommended and to avoid General anaesthesia. If general anaesthesia was needed then intermittent positive pressure ventilation should be used. The Obstetrician had planned for induction of labour at 41 weeks gestation. On the 4th day of postcaesarian section, the patient again complained of shortness of breath. On general examination the patient was dyspneic and tachypneic. Her blood pressure was normal, she had no proteinuria, and her liver function and platelets were within normal limits.
Chest X-ray showed that she had left-sided lower lobe pneumonia and was started on intravenous tazocin, IV gentamicin, and then on oral erythromycin. Patient recovered well and was transferred to a tertiary hospital.
This patient presented with dyspnoea and severe hypoxia at a district general hospital without any clinical notes and was brought by ambulance. No relatives accompanied her which made the clinical management difficult. She needed intubation and ventilation as an emergency measure to manage her severe hypoxia.
In pregnancy there is a 20% increased oxygen demand and during labour this is 50%. Consequently any impairment of ventilation in pregnant women may lead to hypoxia more readily than nonpregnant women [
Maternal collapse with severe hypoxia and seizures in a patient with previous history of pnenumothorax is highly suggestive of tension pneumothorax. Other differential dignosis is massive pulmonary embolism, eclampsia, cerebral haemorrhage, and epilepsy. Most patients with spontaneous pneumothorax require only conservative management consisting of reassurance, oxygen supplement, and analgesics [
Surgical management of spontaneous pneumothorax during pregnancy is well recognised. Indication for surgical treatment is persistent, or multiple recurrent pnemothoraces [
Thorocotomy incision and resultant pain severely limit mother’s mobility and result in impaired bonding. There is a reported increase in incidence of postpartum depression in such cases [
In labour, the use of epidural is recommended in patients with pneumothorax as it avoids futher exertion and provides good analgesic that can easily be converted to anesthesia for forceps or caesarean delivery. A subarachnoid block should be administered cautiously if required as high spinal block may compromise respiratory function. If general anesthesia is indicated, facilities for chest drain should be immediately available and nitrous oxide must be avoided [
In any future pregnancy due to high risk of recurrence of pneumothorax one should strongly consider delivery when fetal pulmonary maturity can be documented. Contemporary obstetric management should determine the method of delivery, continuous, lumbar; epidural anesthesia should be used if at all feasible [
Studies describe an increased risk of recurrence both in pregnancy and during childbirth in patients with pneumothorax. Patients with a history of pneumothorax who are contemplating pregnancy need to be aware of the risk of recurrence during pregnancy, parturition, or shortly after normal delivery or cesarean section [