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Nelson-Piercy C. 2007. Cardiac disease. Saving mothers lives: Reviewing maternal deaths to make motherhood safer (2003 2005). In: Lewis G, editor. The Condential Enquiry into Maternal and Child Health (CEMACH). 7th Report on Condential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. p 117130. NICE. 2008. Prophylaxis against infective endocarditis. NICE Clinical Guideline No. 64. London: National Institute for Health and Clinical Excellence. Patel A, Asirvatham S, Sebastian C et al. 1998. Polymicrobial endocarditis with Haemophilus parainuenzae in an intravenous drug user whose transesophageal echocardiogram appeared normal. Clinical Infectious Diseases 26:12451246. Raucher B, Dobkin J, Mandel L et al. 1989. Occult polymicrobial endocarditis with Haemophilus parainuenzae in intravenous drug abusers. American Journal of Medicine 86:16972. RCOG. 2009. Reducing the risk of thrombosis and embolism in pregnancy and the puerperium. Green-top Guideline No. 37. London: Royal College of Obstetricians and Gynaecologists.

Dayan V, Gutierrez F, Cura L et al. 2009. Two cases of pulmonary homograft replacement for isolated pulmonary valve endocarditis. Annals of Thoracic Surgery 87:19541956. Felice PV, Salom IL, Levine R. 1995. Bivalvular endocarditis complicating pregnancy A case report and literature review. Angiology 46:441444. Frontera JA, Gradon JD. 2000. Right-side endocarditis in Injection drug users: Review of proposed mechanisms of pathogenesis. Clinical Infectious Diseases 30:374379. Hanson GC, Phillips J. 1965. A fatal case of subacute bacterial endocarditis in pregnancy. A review of this condition in pregnancy including the incidence, diagnosis and treatment. Journal of Obstetrics and Gynaecology of the British Commonwealth 72:781784. Hecht SR, Berger M. 1992. Right-sided endocarditis in intravenous drug users Prognostic features in 102 episodes. Annals of Internal Medicine 117:560566. Henderson CE, Terribile S, Keefe D et al. 1989. Cardiac screening for pregnant intravenous drug abusers. American Journal of Perinatology 6:397399.

Correspondence: S. Basak, 17B Thirlstone Road, Luton LU4 8QT, UK. E-mail: sambitakar@yahoo.co.in
DOI: 10.3109/01443615.2010.533216

Spontaneous pneumothoraxa rare complication of pregnancy

T. K. ANNAIAH & S. F. REYNOLDS
Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, Bedford, UK

Case report
A 33-year-old woman presented to us in her third pregnancy. She had previously had two miscarriages. At 14 weeks gestation in this pregnancy, she presented to the acute admissions unit with gradual onset of central chest pain of 1-day duration radiating to the back and shoulder, associated with shortness of breath. She had no medical history of relevance and was a non-smoker. She was haemodynamically stable with a respiratory rate of 16/min and an oxygen saturation of 97% on room air. Auscultation revealed reduced air entry in the left hemithorax with increased resonance on percussion. A chest X-ray with abdominal shield revealed a large left-sided pneumothorax, with no evidence of blebs, bullae or cysts (Figure 1). This was initially aspirated with a needle in the mid-clavicular line in the 2nd intercostal space. A repeat X-ray the following day showed persistent pneumothorax. An intercostal 12f Seldinger drain was inserted under water seal and subsequently placed under suction. A repeat chest X-ray 4 days later revealed a well expanded lung with no evidence of pneumothorax (Figure 2). The chest drain was removed and she was discharged home with the advice not to y for 3 months, swim, lift heavy weights, push or pull for the next 68 weeks. She was reviewed 2 weeks later in the clinic when she was completely asymptomatic and clinical examination revealed equal air entry on both sides. Her pregnancy progressed uneventfully until 36 1 weeks, when she presented with ruptured membranes. She was managed conservatively. In view of the 2030% risk of recurrence of pneumothorax, the mode of delivery was discussed with her physician. It was felt that a caesarean section was not required except for obstetric indications. It was however advised that the second stage be shortened to avoid prolonged bearing down and Valsalva manoeuvre.

Four days later she went into spontaneous labour and elected to use Entonox for pain relief. She progressed through the rst stage of labour uneventfully and had a low cavity forceps delivery to shorten

Figure 1. Large left pneumothorax.

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Figure 2. Resolution of pneumothorax following intercostal drainage.

the second stage. Throughout the intrapartum and early postpartum period she showed no features of recurrent pneumothorax. She was reviewed by the physicians 10 weeks after delivery. A repeat chest X-ray was normal. No active intervention was planned. It was however decided that should her pneumothorax recur, surgical intervention would be considered.

Discussion
Primary spontaneous pneumothorax (PSP) is characterised by the presence of air in the pleural cavity resulting in collapse of the lung. It is thought to result from the rupture of a subpleural bulla or bleb in an otherwise healthy lung. It is more common in men than women and is rare during pregnancy (Tanase et al. 2007). A total of 56 cases in pregnancy have been reported in the literature thus far. The increase in minute ventilation in pregnancy and Valsalva manoeuvre during delivery can precipitate the rupture of a bleb or bulla (Lal et al. 2007). Oxygen consumption increases in pregnancy by 20% and up to 50% in labour. The partial pressure of oxygen in the fetal umbilical vein is low. Hence, any reduction in maternal oxygenation can adversely affect the mother and the fetus (Lal et al. 2007). In a review of 41 cases of spontaneous pneumothorax in pregnancy, 46% occurred in the 1st and 2nd trimester and 54% occurred in the perinatal period (Gorospe et al. 2002). The denitive diagnosis requires a chest X-ray with an abdominal shield to minimise radiation to the fetus. The radiation dose to the uterus from a single standard chest radiograph is 7 6 105 rad, which is well below the level safely permissible in pregnancy (5 rad) (Sills et al. 2006). A small pneumothorax with no breathlessness can be managed conservatively. The vast majority of cases in pregnancy have been managed successfully by this approach (Lal et al. 2007). Air is absorbed from the pleural cavity at the rate of 1.5%/day on room air. Administration of supplemental oxygen in high concentration through a partial re-breathing mask increases the rate of resorption four-fold and is hence an effective method to enhance resolution of pneumothoraces. Supplemental oxygen reduces morbidity and duration of hospitalisation and the need for invasive drainage procedures (Chadha 1983). When women are breathless or have a large pneumothorax (42 cm), aspiration is preferred to a chest drain as it is safer, less

painful and not associated with a greater risk of recurrence. Chest drain should be considered in women who have persistent air leak. Should a leak fail to resolve, the chest drain can be left in situ until near term (Lal et al. 2007). Conservative management carries a 3040% risk of recurrence. Surgical pleurodesis and bulla or bleb excision by means of thoracotomy and video-assisted thoracoscopy is reserved for those pregnant women who have recurrent or large persistent pneumothorax, despite adequate drainage. Surgical treatment during pregnancy carries a risk of hypoxaemia, postoperative pain and of pre-term labour, the incidence of which is not known. Thoracoscopic surgery has the advantage of decreased duration of anaesthesia, rapid lung expansion, decreased postoperative pain and reduced hospital stay (Nishida et al. 2005). Primary pneumothorax is usually well tolerated due to the absence of underlying lung disease. Secondary pneumothorax is a signicant marker of morbidity and mortality. The common causes of secondary pneumothorax include asthma, chronic obstructive pulmonary disease, cystic brosis, pneumonia, lung malignancies and tuberculosis (Sills et al. 2006). The recurrence risk in the absence of pleurodesis is 50%. A more aggressive approach to management is therefore recommended. Most patients require prolonged hospitalisation with intercostal chest tube and consideration of pleurodesis (Heffner et al. 2004). Vaginal delivery after management of spontaneous pneumothorax in pregnancy is thought to be safe. In those who have not had denitive surgical therapy, the advice is to administer epidural analgesia and to shorten the second stage (Tanase et al. 2007). Caesarean section is reserved for obstetric indications. Spinal anaesthetic is preferred to general anaesthesia as the intermittent positive pressure ventilation, and coughing during extubation can cause worsening or recurrence of pneumothorax (Lal et al. 2007). Women who have experienced pneumothorax during pregnancy, delivery or shortly after are said to be at a risk of recurrence in subsequent pregnancies and deliveries. It has been suggested that a CT scan be performed to identify and dene bullae and blebs in the lung and to plan surgery (Lal et al. 2007). However, detection of such dystrophic features on CT scan are not necessarily predictive of a risk of recurrence (Ounaes-Besnesab et al. 2007). Although surgery is often considered after the rst recurrent episode of pneumothorax, specic criteria for operative intervention are lacking (Garg et al. 2008). Preventative measures include smoking cessation, avoidance of sudden alteration in ambient pressure such as scuba diving, high altitudes and ying in unpressurised cabins (Garg et al. 2008). Our patient developed spontaneous pneumothorax early in pregnancy. This was successfully managed by an intercostal drain. A multidisciplinary team approach involving the obstetrician, respiratory physician and the obstetric anaesthetist leads to a successful vaginal delivery. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

References
Chadha TS. 1983. Noninvasive treatment of pneumothorax with supplemental oxygen inhalation. Respiration 44:147152. Garg R, Sanjay, Das V et al. 2008. Spontaneous pneumothorax: An unusual complication of pregnancy a case report and review of literature. Annals of Thoracic Medicine 3:104105. Gorospe L, Puente S, Madrid C et al. 2002. Spontaneous pneumothorax during pregnancy. Southern Medical Journal 95:555558. Heffner EJ. 2004. Management of secondary spontaneous pneumothorax. Theres confusion in the air. Chest 125:11901192. Lal A, Anderson G, Cowen M et al. 2007. Pneumothorax and pregnancy. Chest 132:10441048.

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Sills SE, Meinecke HM, Dixson GR et al. 2006. Management approach for recurrent spontaneous pneumothorax in consecutive pregnancies based on clinical and radiographic ndings. Journal of Cardiothoracic Surgery 1:35. Tanase Y, Yamada T, Kawaryu Y et al. 2007. A case of spontaneous pneumothorax during pregnancy and review of literature. Kobe Journal of Medical Science 53:251255.

Nishida Y, Yamaguchi M, Kaneko S. 2005. Thoracoscopic management of spontaneous pneumothorax during pregnancy. International Journal of Gynaecology and Obstetrics 91:175 176. Ounaes-Besnesab L, Gollia M, Knanib J et al. 2007. Prediction of recurrent spontaneous pneumothorax: CT scan ndings versus management features. Respiratory Medicine 101:230236.

Correspondence: T. K. Annaiah, Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, 44, Stone Hill, St. Neots, PE19 6AA, UK. E-mail: kat_sree@yahoo.co.in
DOI: 10.3109/01443615.2010.532247

Antenatal uterine rupture in a pregnancy following microwave endometrial ablation

R. P. HERATH, N. SINGH & N. OLIGBO
Department of Obstetrics and Gynaecology, James Paget University Hospital, Great Yarmouth, UK

Introduction
Microwave endometrial ablation is a commonly used endometrial ablation method in current gynaecological practice. We report the rst reported case of oligohydroamnios, placenta accreta, antenatal uterine rupture, postpartum haemorrhage and caesarean hysterectomy in one pregnancy following microwave endometrial ablation.

breaching the serosa, was noted extending down from the right uterine cornu. The placenta was densely adherent and only parts of the placenta could be removed, resulting in torrential haemorrhage. A subtotal hysterectomy was done. There were no broids close to the rupture site. The total blood loss was about 4,000 ml and seven units of packed cells were transfused. Her recovery was unremarkable. Histology conrmed a full thickness 9 cm defect of the anterior uterine wall with placenta accreta around the adjacent tissues. Multiple intramural broids were noted.

Case report
A 42-year-old, otherwise healthy, woman was found to be pregnant 3 years after microwave endometrial ablation. She had one uncomplicated previous pregnancy with normal labour. There was no history of any other gynaecological procedures, which could have led to myometrial injury. At the age of 39 years, she had microwave endometrial ablation for irregular menstrual bleeding after endometrial preparation with leuprorelin acetate. An ultrasound scan before the procedure showed three small broids, the largest 2.8 cm, but none of them was submucosal. Microwave endometrial ablation was completed in 3 min without complication. Despite medical advice she did not use any form of contraception after the procedure, as she was amenorrhoeic. Pregnancy was conrmed at 12 weeks and her rst two trimesters were uncomplicated. During the ultrasound scan at 28 weeks, the amniotic uid index was found to be less than the 2.5th centile, with normal growth of the baby and normal end diastolic ow in the umbilical arteries. The previously detected intramural broids were slightly enlarged (the largest 4.5 cm), and were in the left lateral and posterior walls. There was no evidence of ruptured membranes. She received two doses of betamethasone (12 mg each), intramuscularly, at 29 weeks gestation. She was monitored with weekly USS for liquor volume and umbilical artery end-diastolic ow and twice weekly fetal cardiotocography. At 32 weeks she developed vague abdominal discomfort, which suddenly became very severe after a few days. Her abdomen was tender and the fetal heart rate was 80 b.p.m. The cervix was unfavourable. With the clinical diagnosis of placental abruption, caesarean section was performed through Pfannenstiel incision. A haemoperitoneum of about 500 ml was noted. A baby boy weighing 1.68 kg in breech presentation was delivered through a lower segment transverse incision. The uterus was exteriorised to assess the haemoperitoneum. A bleeding uterine rupture, of about 9 cm,

Discussion
Pregnancy following endometrial ablation is well known, occurring with an incidence of 0.650.7% (Pugh et al. 2000; Roy and Mattox 2002). Most of these are following endometrial resection or roller ball ablation of the endometrium. A literature review produced reports of only four pregnancies following microwave endometrial ablation (Lo and Pickersgill 2006; Moukarram et al. 2006; Palep-Singh et al. 2007; Alabi 2009). Three ended with pregnancy termination and only one case continued as an uncomplicated pregnancy (Alabi 2009). This makes our case the rst to report oligohydroamnios, placenta accreta, postpartum haemorrhage, antenatal uterine rupture and caesarean hysterectomy all occurring in one pregnancy following microwave endometrial ablation. This is the second case of antenatal uterine rupture in a pregnancy following any form of endometrial ablation. The rst case was in a 29-year-old woman who had hysteroscopic endometrial resection with combined loop electrode and roller ball 4 years before admission with uterine rupture and died at 24 weeks gestation (Laberge 2008). All of the obstetric complications reported in the literature are following endometrial ablation methods other than microwave endometrial ablation. They include miscarriage (18.9%), extrauterine pregnancy (3.7%), pre-term labour (21.6%), premature rupture of membranes (17.6%), intrauterine growth restriction (12%) and morbidly adhered placenta (17.65 %) (Cook and Seman 2003; Lo and Pickersgill 2006). Placenta percreta in the absence of a uterine scar is extremely rare (Esmans et al. 2004). This poses the question whether we should consider that women after microwave or other endometrial ablation are regarded as having a myometrial scar.

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