* K Sivanesan , J Tierney
*Primary and corresponding author: Specialist Registrar in Obstetrics and Gynaecology Department of Obstetrics and Gynaecology University Hospitals of Morecambe NHS Trust Ashton Road, Lancaster LA1 4RP. Email: sivanesank@doctors.net.uk
Consultant in Obstetrics and GynaecologyDepartment of Obstetrics and Gynaecology South Glasgow University Hospitals NHS Trust Govan Road, Glasgow G51 4TF.
SMJ 2006 52(1): 55
Introduction
Pneumomediastinum
has been well documented in conditions where there are high intra-alveolar or
intra-oesophageal pressures, such as forceful or excessive coughing, use of
inhalation drugs, persistent emesis with alcohol abuse. In pregnancy, it has
been described with labour, hyperemesis as well as in the postpartum period. In
this case report we present an unusual case of hyperemesis gravidarum
complicated by pneumomediastinum as well as pulmonary embolism.
A 24-year-old primigravida was admitted with hyperemeis gravidarum. She
had been vomiting for 5 days prior to admission. On arrival to the ward, she
appeared dehydrated. Ultrasound scan of abdomen
confirmed a viable, singleton, intrauterine pregnancy of 8 weeks gestation. She
was treated with intravenous fluids, anti-emetics and graduated compression
stockings (TEDS).
Twelve hours after admission she developed sudden onset of central chest
pain (tightening in nature) which was worse on
inspiration with shortness of breath and haematemesis. She did not have any
cough, dysphagia or epigastric pain. On clinical examination, there was no
cyanosis. Temperature was 36.4 C, pulse 112/min, BP 110/65 mmHg. Examination of
respiratory, cardiovascular system and abdomen were entirely normal. Clinically
there was no evidence of deep vein thrombosis in the legs. ECG showed sinus
tachycardia. As pulmonary embolism was a differential diagnosis, she was
commenced on therapeutic dose of low molecular heparin (LMWH). Her symptoms
settled later that day.
A
shielded antero posterior chest x-ray was taken. It showed presence of
pneumomediastinum. CT Pulmonary angiogram confirmed presence of bilateral,
multiple pulmonary emboli in the upper lobes of the lungs, the presence of
peumomediastinum and subcutaneous emphysema (see Figure 1). The CT did not show
any evidence of oesophageal perforation. CT findings were limited as low dose
contrast agent was used. Doppler ultrasound scan of lower limbs and
Echocardiogram were reported as normal. Respiratory physicians and surgeons
reviewed patient. She did not have any clinical features suggestive of
mediastinitis. She was managed conservatively with antiemetics, intravenous
fluids, broad-spectrum antibiotics and low molecular weight heparins. Repeat
chest radiography was not performed to limit radiation exposure.
Screening
of thyroid function suggested transient hyperthyroidism associated hyperemesis
gravidarum. She was trained to self-administer LMWH. She was allowed home 10
days after admission. At three weeks review after discharge, she had persistent
tachycardia and fine tremors. She was commenced on Propylthiouracil. Rest of her
antenatal period was uncomplicated. She had a spontaneous labour at 41 weeks.
She had an emergency low segment caesarean section for non-reassuring CTG at
first stage of labour. She continued her LMWH for six weeks postpartum. Her
thrombophilia screen was normal and biochemical surveillance of thyroid
functions was continued.
Discussion
Fortunately hyperemesis associated with pneumomedistinum is rare. To our
knowledge so far, there are six reported cases in the literature1, 2, 3, 4,
5, 6 (Medline 1966- March 2006). Pneumomediastinum can originate from
oesophagus, lungs, airways and abdominal cavity.
In
our patient, pneumomediastinum likely to have originated from small oesophageal
rupture and Computer tomography has either failed to locate or the perforation
was transient. We did not elect to do upper gastrointestinal endoscopic
examination as our patient recovered quickly as well as negative CT. As reported
in other cases of pneumomediastinum after Hyperemesis gravidarum, our patient
was successfully managed conservatively.
As per unit protocol chest X ray was done prior to CT pulmonary angiogram.
Pneumomediastinum was an incidental finding of these investigations. But as
reported in previous cases, although rare, it should be considered as a
differential diagnosis for chest pain with hyperemesis gradvidarum. Also
pulmonary embolism need to be considered accordingly depending on the clinical
situation. As suggested by Yamamoto et al2, we believe that the
incidence of pneumomediastinum associated with hyperemesis gravidarum might be
higher than presumed.
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