Published on December 31, 2008
i Subcutaneous emphysema and Pneumomediastinum during labour. Dr. Sujnanendra Mishra MD (O&G) S.D. Hospital, Patnagrh Balangir (Orissa) Introduction: Pneumomediastinum and Subcutaneous emphysema usually follow chest injuries or esophageal trauma and few cases have been recorded to have been caused in labour. It is a rare, but serious situation, which requires prompt diagnosis, appropriate management and o avoid unnecessary investigations and procedures. Through, incidence rate is not known about 200 cases have been purported in world literature. This report describes one 28 years old primi who had an uneventful pregnancy and child birth in a remote community health center. Case Report : A 20 years old primi gravida (Smt. Chandrakanti) was admitted to S.D. Hospital, Patnagarh with the complaints of severe Retrosternal pain, dyspnoea and swelling of anterior chest wall, breasts, neck and face 2 hours following child birth. She was admitted to a community health center for delivery. She delivered a full term live birth_male child weighing 3000 Gms. Her antenatal period was uneventful. The duration of first stage of
labour was around 10 hours and second stage lasted for 2 hours. Third stage was uneventful. There was history of forceful straining during second stage of labour. She complained of dyspnoea and swelling of neck within an hour of delivery for which she was referred to our Hospital which is one F.R.U. – (1st referral Unit). At the time of admission history revealed that she was not suffering from any lung diseases earlier nor was she a smoker. There was no history of any cardiac diseases. She was complaining of swelling of neck, anterior chest wall, painful swelling of the both the breasts, severe dyspnoea. On clinical examination she was afebrile, pulse rate was 150/minute, BP was 106/90 mm of Hg. There was marked soft swelling and palpable crepitations on her neck, supraclavicular regions anterior and posterior chest wall and face. Both brests are filled with air. X-ray of neck and chest were taken. Neck X-ray showed evidence of bilatarel emphysema and pneumomedistinum. The lungs were fully expanded, no pneumothorax were found her haemogram was within normal range except leucocyte count which was 12,300. Management : The patient was administrated antibiotics, anxiolytics and she was urged not to cough violently and was kept under closed observation in the ward on the following morning. Swelling of face,
neck and chest walls increased enormously. She became restless and her heart rate was as high as 160/Minute. The BP was 100/90mm.Hg. Deep multiple incision were given on both sides of the anterior chest wall after which the patient showed signed and symptoms of marked improvement. She was discharged from the Hospital on day 5 (five) postpartum. A follow up X-ray was taken after two weeks, which revealed no sign of emphysema. Discussion : The syndrome of Pneumomedistinum and Subcutaneous emphysema is a rare but serious complication of labour though first case was recorded in the year 1783 by simmons. Since that time about 200 cases have been published in the world literature. However, the first published reference to this condition might have been made in 1680 when Louise Boursis midwife to queen of France quoted “I saw, she tried to stop crying out, I implored her not to stop fear that her neck would swell”. The condition was subsequently described by Hamman in 1945. Women at higher risk are typically primigravida with prolonged and difficult labour. Delivering little larger babies with some degree of C.P.D, though there are exceptions to it. Interestingly such syndrome (Hamman’s syndrome) has also been reported with case of hyperemisis gravideraum. Differential diagnosis includes amniticfluid embolism, pulmonary and myocardial infractions, pneumothorax and medistinitis. A chest radiograph and palpable crepitations over the neck is pathognomonic and the appearance of cervical emphysema during labour indicate pneumomediastinum.
Rarely, a mediastinotomy is required. The prognosis appears to be quite good with only two reports on maternal death in last century. Spontaneous emphysema usually resolves within 2 weeks. Conclusion : The diagnosis of subcutaneous emphysema is not difficult but one must be aware of such complication which can happen during pregnancy and labour. prognosis is favourable. Familiarity with the presenting symptoms of pneumomedistinum is imperative for timely intervention.
Illustration 1Suryakanti on9thAug2006 after giving 6multiple microincisions
Illustration 2RECOVERING SURYAKANTI 13thAug2006
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