Massive Hemoptysis with Pneumothorax and Lung Collapse in a Case for Cesarean Section

Dear Editor, Massive hemoptysis can be life-threatening, especially when it results in lung collapse and pneumothorax. We present a case of a pregnant patient who presented with hemoptysis with pneumothorax and lung collapse for Cesarean. A 29-year-old woman at 34 weeks gestation presented with respiratory distress and two episodes of severe hemoptysis. There was an expectorated blood amount of 100 mL in each episode. She had an oxygen saturation (SpO2) of 88%, a respiratory rate (RR) of 40/min, a blood pressure (BP) of 122/76 mmHg, and a heart rate of 106/min, with no prior history of fever, cough, or weight loss. She was diagnosed with left-sided lung collapse and immediately intubated for respiratory support. Laboratory investigations revealed a hemoglobin level of 9.5 g/dL, a platelet count of 103,000/mm3, a fibrinogen level of 242 mg/dL, a prothrombin time of 12 seconds, and an international normalized ratio of 1.2. Due to maternal instability, an emergency cesarean section was performed under general anesthesia. Intraoperatively, she developed hypotension (BP 72/46 mmHg), managed with right jugular vein cannulation, noradrenaline infusion, and 3L intravenous fluids, and with blood loss of 900 mL requiring two units of blood. The patient developed sudden desaturation (SpO2 70%) and decreased right-sided air entry at the end of surgery. A right-sided tension pneumothorax was diagnosed and managed with intercostal drainage [Figure 1a]. Fiberoptic bronchoscopy revealed multiple endobronchial mucinous clots as the cause of the lung collapse, which were subsequently cleared from the left bronchus [Figure 1b]. Bronchial wash cultures and GeneXpert confirmed tuberculosis (TB). She was extubated after 48 hours. Chest X-ray showed no cavitary lesions, suggesting vessel erosion as the likely cause of haemoptysis.Figure 1: Chest X-ray showing right-sided pneumothorax with left lung collapse (a) and image after aspiration of clot from the left lung and removal of intercostal drain, showing clear lung fields and resolution of collapse (b)Pregnancy induces physiological changes that make women more susceptible to hemoptysis due to airway mucosal hyperemia, edema, and mucosal friability.[1,2] Other causes of hemoptysis may be pulmonary embolism, fetal adenocarcinoma, and oropharyngeal carcinomas. HELLP syndrome was ruled out in our case as there was no evidence of hemolysis, and both liver enzyme levels and platelet counts were within normal limits. Disseminated intravascular coagulation was ruled out as coagulation parameters were within normal limits. TB in pregnancy can present atypically, including with recurrent hemoptysis and even unilateral lung collapse.[3] Maintaining a high index of suspicion and ensuring timely diagnosis and intervention are crucial to achieving favorable outcomes for both mother and fetus. A course of steroids can be started for fetal maturity in case of preterm pregnancy.[2] Pneumothorax during pregnancy is a rare but potentially life-threatening condition. It is important to address this promptly as pregnancy increases maternal oxygen demand by 20–50%.[1,2,4] It is likely that the blood clot in the left bronchus led to left lung collapse, and the use of invasive ventilation resulted in elevated airway pressures, causing barotrauma to the right lung, which subsequently led to a right-sided pneumothorax. Other possible causes include underlying lung disease or, more rarely in women, thoracic endometriosis involving the pleura. Immediate chest tube insertion, initiation of invasive mechanical ventilation, avoidance of nitrous oxide, and timely delivery are critical components of the management strategy.[5] 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. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.