DISCUSSION
Primary spontaneous pneumothorax is defined as air in the pleural space, i.e., between the lung and the chest wall in otherwise healthy people without any lung disease. Spontaneous pneumothorax in pregnancy is extremely rare, with only 55 cases reported till now. Review of 56 cases showed that the patients were young (average age, 26.4 years), which is similar to the age group (20–30 years) of nonpregnant female in whom pneumothorax commonly occurs. Risk factors most commonly associated in these patients were asthma, cocaine use, hyperemesis gravidarum, history of previous pneumothorax (44%), and underlying infection (30%); whereas pulmonary tuberculosis is the most common cause in nonpregnant females. Pneumothorax occurred during the first or second trimester in 51% and during the perinatal period in 49% of patients. Initial treatment was observation in 29.6%, tube thoracostomy in 66.6%, and thoracotomy in 3.8% of patients. Of the total group of patients, 52% ultimately required thoracotomy for recurrence or persistent pneumothorax. The obstetric outcome was good, with 80.8% of patients having vaginal delivery, 17.3% having cesarean delivery, and one being fetal loss (1.9%). Typical pneumothorax symptoms such as chest pain and dyspnea are often attributed to paroxysmal tachycardia, neuralgia, or asthma exacerbation, thus contributing to under-reporting of spontaneous pneumothorax. Diagnosis of pneumothorax can be confirmed by chest radiograph and it is safe to proceed with the standard chest radiography with abdominal shield without placing the fetus at substantial risk from ionizing radiation. Shielded computed tomography (CT) is also a useful imaging technique that can help in defining the underlying anatomic abnormality and in planning an operative approach when surgical treatment is indicated. Treatment of acute pneumothorax in pregnancy or labor is identical to that of nonobstetric patients. Admission and close observation of the patients was usually done with small pneumothorax (<20% of hemithorax). Large pneumothorax (>20% of hemithorax) should be treated with tube thoracostomy. Recurrent, persistent, or bilateral pneumothorax necessitates thoracotomy or thoracoscopy. In order to avoid increased air leak secondary to valsalva maneuvers, delivery should be expedited and positive pressure anesthesia avoided. Cesarean section is not absolutely indicated and should be performed for obstetric reason only. Although surgery may be indicated for recurrent pneumothorax episodes, specific criteria for operative intervention are lacking. Thoracotomy or video-assisted thoracoscopic surgery (VATS) have been increasingly successful in the management of recurrent pneumothorax and no adverse outcome or mortality has been reported. Nevertheless, preventive measures should include smoking cessation and avoidance of rapid or drastic change in ambient pressure such as high altitudes, scuba diving, or flying in unpressurized aircraft. Pneumothorax warrants consideration in any pregnant patient with acute chest pain, dyspnea, or history of prior pneumothorax and must be confirmed radiographically. Neither pneumothorax nor its treatment causes serious adverse effects on the course of pregnancy or delivery, but prompt recognition and treatment of pneumothorax is essential for preventing complications.
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