A case of recurrent spontaneous pneumothorax during pregnancy treated with video assisted thoracoscopic surgery

Abstract

SummaryPneumothorax during pregnancy is uncommon. Recently ambulatory chest drainage has been advised to treat the pneumothorax and to cover the delivery period. This imposes restrictions on the mother with associated co-morbidity. The authors present a case of recurrent chest-tube resistant pneumothorax during pregnancy which had persisted for 4-weeks .To guide management of a patient referred in the third trimester of pregnancy the authors undertook a systematic review. This led to defi nitive video assisted thoracoscopic surgery (VATS) for bullectomy and pleurodesis which was successful without either peri-operative or peri-partum complications or recurrence of pneumothorax. Our review suggests that a VATS approach during pregnancy is both safe and effective. chest drain insertion there was a continued air leak for 4 days. At this point, and after discussion between chest physicians and obstetricians, a high resolution CT (HR-CT) scan was performed. The HR-CT scan showed left apical bullae, the lung was not fully infl ated with the intercostal drain in situ (fi gure 2). Serial foetal ultrasound scanning over this period found a viable breech presentation singleton foetus with parameters in keeping with gestational age. Liquor volume and foetal movements and heart rate variability were within normal limits. She was then referred for thoracic surgery management. TREATMENTThe 2003 British Thoracic Society guidelines on the management of pneumothorax 2 did not include presentation in pregnancy suggesting the rarity of the condition. The 2010 guidelines for the management of pneumothorax 3 state 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. The guidelines also state level D evidence that a VATS procedure should be considered after birth.After discussion between the patient, her family and all professionals it was decided to offer a surgical resolution to this recurrent problem to which she gave informed consent.We chose to undertake VATS pneumothorax surgery because:It is our preferred technique for pneumothorax surgery ▶ as it has smaller incisions than open surgery A dose of 12 mg intramuscular betamethasone was given to aid foetal lung maturity in the event of operative complications necessitating delivery. Foetal ultrasound examination was again normal.At 34 weeks gestation the patient underwent a left sided VATS procedure. Three ports were used (2 × 1 cm and 1 × 1.5 cm). Peri-operative foetal cardiotocography remained normal. The surgical procedure took 15 min (after induction of anaesthesia) and was uncomplicated. The left apical bulla was resected and a mechanical pleural abrasion was performed. Two 24 French intercostal chest drains were inserted and connected to 4kPa suction. Chest x-ray confi rmed satisfactory placement of the chest tubes with full re-infl ation of the lung. Suction to the chest drains was applied continuously for 48 h and the drains were removed at 72...

Pneumothorax and Pregnancy: A Systematic Review of the Current Literature and Proposal of Treatment Recommendations

“…When pleurodesis was performed, there are several different approaches: mechanical abrasion, pleurectomy, partial pleurectomy and abrasion, argon beam coagulation of the apical parietal pleura, autologous blood, and freezedried concentrated human thrombin. 3,7,25,32,34,37,42,47,62,64 Onodera et al performed awake VATS with bulla resection under local and epidural anesthesia. 54 There is limited experience with chemical pleurodesis.…”

Neumotórax espontáneo primario durante el embarazo

“…El uso de drenaje prolongado se estima como una medida segura y efectiva para el tratamiento, en especial al final del embarazo (3) . Otras opciones terapéuticas incluyen aspiración y descompresión con aguja, pleurodesis, toracostomía con tubo, toracotomía y toracoscopia, en especial para casos recurrente, persistente o bilateral (10)(11)(12) . El tratamiento quirúrgico durante el embarazo tiene el riesgo de hipoxemia, dolor postoperatorio y parto pretérmino (6) .…”

“…El tratamiento quirúrgico durante el embarazo tiene el riesgo de hipoxemia, dolor postoperatorio y parto pretérmino (6) . Las ventajas del tratamiento quirúrgico toracoscópico comparado con la toracotomía son: disminución del tiempo de exposición a anestésicos, expansión pulmonar rápida, disminución del dolor postoperatorio, período postoperatorio potencialmente más breve y disminución del dolor (10)(11)(12)(13)(14)(15) . El parto vaginal espontáneo después del tratamiento quirúrgico parece seguro.…”

Forensic Considerations of Spontaneous Pneumothorax in Sudden Unexpected Natural Death

“…Up to 24% of cases of spontaneous pneumothoraces in women are associated with thoracic endometriosis; when a catamenial timing of pneumothorax is present, thoracic endometriosis is found in 50% of cases (56). Pneumothorax may also be a spontaneous event in pregnancy, where it is seen in women with or without underlying lung disease (57, 58) and has a 30% to 44% risk of recurrence, particularly during labor (59).…”