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CASE REPORT
Year : 2023 | Volume
: 13
| Issue : 1 | Page : 103-105
Fatal spontaneous pneumomediastinum complicating SARS-COV2 pneumonia in a pregnant women
Youssef Motiaa1, Siham Alaoui Rachidi2, Smael Labib1, Hicham Sbai1
1 Anesthesiology and Intensive Care Department, University Hospital in Tangier; Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier, Morocco
2 Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier; Radiology Department, University Hospital in Tangier, Morocco
Correspondence Address:
Dr. Youssef Motiaa
Anesthesiology and Intensive Care Department, University Hospital in Tangier, Faculty of Medicine and Pharmacy of Tangier, Abdelmalek Essaadi University, Tangier
Morocco
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_110_21
Pneumomediastinum was reported as a complication of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia in the general population. Data concerning the association of this complication with pregnancy are rare. We report a case of a parturient who presented with SARS-CoV-2 pneumonia complicated with pneumomediastinum. The management of Acute respiratory distress syndrome (ARDS) and obstetric approach are also discussed.
Keywords: COVID-19, pneumomediastinum, pregnancy
Spontaneous pneumomediastinum (PMD) or mediastinal emphysema is defined as the presence of air in the mediastinum. During pregnancy, pneumomediastinum is a known complication of hyperemesis gravidarum,[1],[2] It can also occur during labor also known as Hamman's syndrome.[3]
SARS-CoV-2 pneumonia has become a global pandemic causing a serious health problem. Spontaneous pneumomediastinum has been reported as a rare but serious complication of COVID-19 pneumonia in both the obstetric and general population. It can be isolated or associated with other complications such as pneumothorax,[4],[5] subcutaneous emphysema,[6] or pneumopericardium.[7] It may be associated with increased mortality in critically ill COVID-19 patients, especially those on mechanical ventilation.[8]
A few publications have reported this complication and discussed its management in pregnancy.[3],[9],[10] We report a case of spontaneous pneumomediastinum in a 20-week pregnant patient who was admitted with SARS-CoV-2 pneumonia and had an unfavorable outcome.
Case ReportA 30-year-old gravida 2, para 3 parturient with no significant medical history, vaccinated against SARS CoV-2, presented at 20 weeks of gestation to the emergency department with a 2-day history of worsening dyspnea. She tested positive for COVID-19 using the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test on nasopharyngeal swabs 6 days earlier. The symptoms at the onset of illness were fever, cough, and fatigue.
The patient was started on hydroxychloroquine 200 mg twice daily and azithromycin 500 mg on the first day, and then, 250 mg four times daily as recommended by the Moroccan Committee of Experts at the Ministry of Health.
On examination, she was very anxious, tachypneic with a respiratory rate of 35 breaths/min. Her pulse oxygen saturation was 50% on room air and improved to 75% on 15 L/min of oxygen via a non-rebreather mask. She was tachycardic at 100 beats/min. Her blood pressure was 120/67 mmHg. She was pyrexial (38.8°C) and the capillary blood glucose was 100 mg/dL. She weighed 69 kg and was 170 cm tall (body mass index = 23.58 kg/m2).
The obstetric ultrasound done on admission was normal. Computed tomography of the thorax showed multifocal bilateral ground-glass opacities affecting 90% of the pulmonary parenchyma and a pneumomediastinum [Figure 1]. The transthoracic echocardiography was normal. The laboratory tests revealed elevated lactate dehydrogenase (LDH) (1006 UI/L), normal ferritin (204.77 ng/mL), and elevated c-reactive protein (CRP) (151.3 mg/L). The leucocytes were 10600/mm3 with no lymphopenia (3650/mm3). Troponin was 504.3 ng/L. The renal function and coagulation were normal.
Figure 1: Chest computed tomography revealing multifocal bilateral ground-glass opacities associated with pneumomediastinum. (A) Pneumomediastinum. (B) Bilateral ground-glass opacities affecting 90% of pulmonary parenchymaThe patient was admitted to the intensive care unit (ICU) for severe coronavirus disease-2019 (COVID-19) pneumonia. She was initially started on high flow nasal (HFN) oxygen therapy, and then, non-invasive ventilation (positive end-expiratory pressure [PEEP] 7 cmH2O, pressure support [PS] 14 cmH2O; FiO2 100% oxygen). She was started on intravenous ceftriaxone and ciprofloxacin, methylprednisolone 80 mg daily, and a therapeutic dose of enoxaparin 1 mg/kg twice daily.
Despite the initial supportive measures, the patient's work of breathing continued to increase and arterial blood gas showed severe hypoxemia, hence, she was intubated using a rapid sequence induction. She was sedated with midazolam and fentanyl and paralyzed using a continuous infusion of rocuronium (4–8 μg/kg/min). The ventilator settings were those of lung-protective ventilation (tidal volume 420 mL, respiratory rate 18/min, FiO2 100%, PEEP: 8) and plateau pressure was 30 cmH2O.
The respiratory status, however, continued to deteriorate rapidly; oxygen saturation was 85% on 100% oxygen and the plateau pressure increased to 35–40 cmH2O. Twelve hours later, the patient developed subcutaneous emphysema over the neck and thorax. The chest ultrasound showed lung sliding with no signs of pneumothorax. Extracorporeal membrane oxygenation (ECMO) was not available. The patient sadly succumbed to refractory hypoxia 2 days following intubation.
DiscussionPneumomediastinum has been reported previously as a complication during pregnancy.[1],[2],[3] In the context of the COVID-19 pandemic, pneumomediastinum has also been described as a complication of SARS-CoV-2 pneumonia. But literature about the association of pneumomediastinum and COVID-19 in pregnancy is confined to a few case reports. The reported incidence of spontaneous pneumomediastinum in SARS-CoV-2 is 11.6%.[11] Kangas-Dick et al.[8] published a series of 36 COVID-19 patients with pneumomediastinum; 34 of which received mechanical ventilation and two had no ventilatory support. In this series, 12 patients developed a pneumothorax during their admission and two patients had the pneumothorax before the diagnosis of pneumomediastinum. At the endpoint of the study, 24 of the 34 patients had died. The median time to the development of pneumomediastinum was 6.5 from admission and 3 days from intubation.
In their article about spontaneous pneumomediastinum in the SARS-CoV-1 infection, Chu et al. describe the pathophysiological process of spontaneous pneumomediastinum as caused by diffuse alveolar damage that leads to interstitial emphysema, which then joins the mediastinum by dissecting along the bronchovascular sheaths, and progresses to the pneumothorax or subcutaneous emphysema. Peak serum lactate dehydrogenase (LDH) was associated with the development of pneumomediastinum. Other factors like alveolar damage and fragility increase the susceptibility to barotrauma in the infected patients.[11] There are no similar studies in pregnant women.
In our context, during the recent Delta wave of the COVID-19 pandemic, we observed a higher incidence of severe forms of SARS-CoV-2 in pregnant women compared to the previous waves. In our reported case, there was no single causative factor of pneumomediastinum such as hyperemesis gravidarum or trauma but it was rather multifactorial including alveolar damage, increased lung fragility, and barotrauma.
The risk was even higher during pregnancy due to decreased chest wall compliance. According to Kouritas et al., low-lung compliance is a known risk factor for non-trauma-related pneumomediastinum.[12]
CT thorax is the modality of choice for the diagnosis of pneumomediastinum and the assessment of the severity of SARS-CoV-2 pneumonia.
Cesarean section was not considered because of non-viable pregnancy and minor effects on the patient's respiratory and hemodynamic status. The cardiovascular and respiratory changes during pregnancy such as decreased functional residual capacity and increased oxygen consumption can render the management of ARDS in pregnant women infected by SARS-CoV-2 highly complicated. In addition, pregnant women are at an increased risk of developing ARDS and need mechanical ventilation compared to non-pregnant women.[13] The management of ARDS includes lung-protective ventilation, neuromuscular blockade, and proning. ECMO should be considered in refractory hypoxemia (PaO2/FiO2 ratio <80 mmHg for >6 h, or PaO2/FiO2 ratio <50 mmHg for >3 h).[14],[15] Other therapeutics that are recommended are corticosteroids, anticoagulation, and anti-inflammatory agents.[15]
ConclusionSpontaneous pneumomediastinum is a serious complication of the SARS-CoV-2 infection. It is due to extensive alveolar damage caused by COVID-19 pneumonia. The management is very challenging and the outcome is poor during pregnancy. Studies are needed to optimize the management of severe forms of COVID-19 in pregnant women.
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Written informed consent was obtained from the next-of-kin of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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