Anesth Analg 2000;90:1173-1174
© 2000 International Anesthesia Research Society
OBSTETRIC ANESTHESIA
Tension Pneumothorax in a Parturient Undergoing Cesarean Delivery
Eric A. Harris, MD
Department of Anesthesiology, University of Miami, Miami, Florida
Address correspondence and reprint requests to Eric A. Harris, MD, University of Miami Department of Anesthesiology (R-370), PO Box 016370, Miami, FL 33101. Address e-mail to eharris{at}pol.net
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Introduction
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Spontaneous pneumothorax during pregnancy is a rare complication, with few reports in the obstetric and anesthesiology literature. It is often related to underlying medical conditions such as cancer or pulmonary disease (1). This case report describes an otherwise healthy parturient who developed a tension pneumothorax after the initiation of general anesthesia. The absence of any precipitating factors suggests the presence of a clinically silent, spontaneous pneumothorax during the antepartum period.
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Case Report
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The patient is a 40-yr-old, previously healthy, nonsmoking female, gravida 3, para 2, admitted with a triplet pregnancy at 23 wk of gestation. She had experienced preterm contractions 1 wk earlier, and one of the triplets was delivered vaginally. A cervical cerclage was applied to delay the delivery of the remaining fetuses, and tocolytic therapy with magnesium sulfate was started. She presented with fever of 38.9°C and chills, but did not complain of any further symptoms. The obstetric team decided to deliver the remaining fetuses, suspecting chorioamnionitis had developed after 7 days of ruptured membranes. The cervical cerclage was subsequently removed, allowing the second of the triplets to deliver vaginally. However, when the third fetus remained in the breech position and the patient’s labor failed to progress, a cesarean delivery was planned. Because of the patient’s strong preference for general anesthesia and her likely bacteremia (later confirmed by blood cultures), a regional technique was not considered.
After denitrogenation for 3 min, anesthesia was induced with thiopental and succinylcholine by using a rapid-sequence induction with cricoid pressure. Continuous left uterine displacement was maintained. Intubation was smooth and atraumatic, and ventilation via the endotracheal tube with O2 34%, N2O 65%, and isoflurane 0.9% was started. Five minutes later, immediately before uterine incision, the patient’s saturation abruptly decreased from 100% to 84%. Oxygen 100% was administered with no improvement of desaturation. Auscultation of the chest revealed bilateral breath sounds, and heart rate and blood pressure remained unchanged from preinduction values. Within the next 2 min, however, the patient’s saturation precipitously declined to 68%, during which time her pulse increased to 164, and blood pressure dropped to 68/22 mm Hg. During this time, the baby was delivered without difficulty. Repeat auscultation of the chest after delivery revealed an absence of breath sounds in the right hemithorax, although deviation of the trachea was not noted. A 14-gauge angiocatheter was inserted into the chest wall at the second intercostal space, midclavicular line. Although there was no audible rush of air, the patient’s saturation rapidly increased to 100%, and blood pressure and pulse returned to normal values within 30 s. A chest tube was placed and attached to suction. A subsequent chest radiograph showed no evidence of residual pneumothorax, bullae, or any pulmonary pathology. The chest tube was removed on postoperative Day 3. The patient continued antibiotic therapy for 5 days postpartum and was discharged in stable condition 7 days postpartum.
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Discussion
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Most cases of tension pneumothorax have well defined etiologies, including external causes (blunt or penetrating trauma,) medical conditions [chronic obstructive pulmonary disease, Acquired Immune Deficiency Syndrome (2)], or therapeutic endeavors [central venous line insertion, radiation therapy (3)]. Pneumothoraces associated with menses have been described in women diagnosed with endometriosis (4); however, in this case, the hormonal milieu of pregnancy should have suppressed this occurrence. Spontaneous pneumothoraces of unknown etiology are less frequent, and when present, the incidence is significantly higher among male patients (5). Spontaneous pneumothorax in pregnancy is extremely rare, with only 23 cases reported from 1957–1997 (1). Most of these patients were symptomatic, and none progressed to develop a tension pneumothorax. Two of these 23 patients required a cesarean delivery, but there is no reference to the type of anesthetic administered.
The dangers of an unrecognized pneumothorax during pregnancy are clear. Oxygen consumption increases 20% during the gravid state (6), and the pregnant woman is ill-suited to handle this amplified demand in the presence of a significantly increased shunt. Restricted diaphragmatic excursion caused by the gravid uterus places a further strain on a single functioning lung. In addition, the circulatory complications that develop from a tension pneumothorax can precipitate severe hypotension (resulting in poor uteroplacental perfusion) and ultimately cardiovascular collapse.
It is likely that this patient had a small asympto- matic pneumothorax on induction of anesthesia. Alternatively, she may have developed a pneumothorax secondary to positive pressure ventilation via the endotracheal tube, even though ventilation seemed easy and atraumatic. Regardless of etiology, the continued use of positive pressure ventilation, in conjunction with the use of nitrous oxide, resulted in the progression to a tension pneumothorax. Other items that were considered in the differential diagnosis in this patient include venous air embolus, pericardial effusion, and amniotic fluid embolus. The rapidity of her full recovery after insertion of a large bore needle supports the diagnosis of tension pneumothorax and argues against an embolic event. The diagnosis of pneumothorax should be considered whenever a parturient presents with an episode of desaturation, especially if the event evolves suddenly in an otherwise asymptomatic patient.
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References
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Blanco S, Hernando F, Gomez A, et al. Catamenial pneumothorax caused by diaphragmatic endometriosis. Cardiovasc Surg 1998;116:179–80.
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Accepted for publication January 26, 2000.
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[Abstract]
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Introduction
Case Report
