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Ann Thorac Surg 2002;73:314-315
© 2002 The Society of Thoracic Surgeons

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Case report

Pneumomediastinum during spontaneous vaginal delivery

^a Department of Cardiothoracic Surgery, The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK

Accepted for publication March 23, 2001.

* Address reprint requests to Mr Sutherland, Department of Cardiovascular Surgery, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA
e-mail: sutherlandfraser{at}hotmail.com

	Abstract

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We report two rare cases of spontaneous pneumomediastinum that presented shortly after childbirth and resolved without treatment. Spontaneous pneumomediastinum has been described in a wide range of seemingly unrelated but recurrent clinical scenarios. We highlight their common etiologic factors and provide the anatomic and physiologic bases for the radiologic signs that are common in all these conditions.

	Introduction

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The first description of pneumomediastinum is attributed to Laennec in the context of chest trauma [1]. Spontaneous pneumomediastinum as a clinical entity was first described, however, by Hamman in 1939 [2]. Since then a gradually increasing number of reports have appeared in the literature relating to the etiology, diagnosis or treatment of this condition.

We report two cases of spontaneous pneumomediastinum in patients associated with spontaneous vaginal delivery and presumed to arise during the second stage of labor. Both patients received no treatment beyond reassurance.

	Case reports

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Patient 1
A 32-year-old woman was referred to the Department of Cardiothoracic Surgery with subcutaneous emphysema in the neck, dysphonia, and anterior chest discomfort noted several hours after spontaneous vaginal delivery of a healthy 3.65 kg child. The patient was para 1 + 0 without antenatal complication or medical history of note. Presentation was occipitoanterior and the duration of labor was 8 hours during which the patient refused analgesia and sustained a second-degree vaginal tear. There was no history of vomiting. Emphysema in the neck and a slightly high-pitched dysphonia were the only positive findings on examination. A chest roentgenogram confirmed the presence of mediastinal air spreading into the soft tissues of the neck (Fig 1) and the findings of a contrast swallow showed no evidence of an esophageal tear.

View larger version (126K): [in this window] [in a new window]   Fig 1. (Patient 1.) Chest roentgenogram showing an air tissue interface (arrows).

Neither patient received treatment. The emphysema receded over the ensuing few days and at follow-up 10 days later the findings of both chest x-ray films were normal.

	Comment

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Spontaneous pneumomediastinum is a rare occurrence reported only a few times previously during the second stage of labor [3]. Spontaneous pneumomediastinum in general presents with anterior chest pain and is indeed the most common cause of anterior chest pain in the young adult after spontaneous pneumothorax [4]. However, a variety of other symptoms have been described including dyspnea, dysphonia, and rarely dysphagia [5]. Most patients subsequently develop subcutaneous emphysema which is palpable in the neck. Its somewhat alarming presentation is out of proportion to its significance in most cases as it almost invariably follows a benign self-limiting course with resolution by 7 to 10 days. An esophageal tear in the nature of Boerhaave’s syndrome can also present with surgical emphysema in the neck. It has been described previously during pregnancy in association with vomiting [6] but has not been described around the time of labor. Therefore, contrast radiology is probably not justifiable if emphysema develops during or after labor in the absence of vomiting.

Air can enter the mediastinum by a number of anatomic routes from sources inside or outside the chest. Not surprisingly, air can track to the mediastinum after breaching pleural/peritoneal membranes at thoracoscopy/laparoscopy or by perforation of an air-containing viscus in the neck, chest, or abdomen. A common source of air in spontaneous pneumomediastinum is from the lung itself. This would appear to arise from rupture at the small bronchiolar or alveolar level and can be the result of barotrauma from positive pressure ventilation in the perinatal period, during vigorous resuscitation of the newborn, or from increased intraluminal pressure developed through a Valsalva-type maneuver. The latter has been described in a variety of circumstances from simple vomiting associated with diabetic ketoacidosis to the vocal exercises practiced during Xaio-lin temple boxing or during the use of illicit recreational drugs such as cocaine. However, alveolar rupture is classically associated with asthmatic crises in which the association with pneumomediastinum is well known. In all of these circumstances air is presumed to track along the peribronchial and perivascular tissue planes toward the hilum of the lung and into the mediastinum. The latter has been elegantly demonstrated quite recently with radiopaque perfluorocarbon after initiating liquid ventilation in a child with spontaneous pneumomediastinum attributed to asthma [7]. The absence of transverse fascial planes in the mediastinum then allows the unobstructed passage of air along tissue planes into the neck and around the larynx whereupon the familiar symptoms and signs become apparent to the patient and physician.

Air that separates tissue planes in this way functions as a natural radiologic contrast to outline structures within the chest which were hitherto hidden by apposition to tissues of similar radiologic density. In addition to the common appearance of air beneath the mediastinal pleura just above and to the left of the cardiac silhouette seen in this patient, a variety of other radiologic signs has been described in association with pneumomediastinum. A useful collation of these signs has been presented in the literature [8]. It is pertinent to all physicians who might encounter patients with pneumomediastinum as the consistency of anatomy between individuals makes this repertoire of potential signs common to all patients, although the permutation of signs in the individual may be specific to the individual patient and his or her pathologic process.

In summary, we report two cases of spontaneous pneumomediastinum in patients associated with spontaneous vaginal delivery and presumed to arise during the second stage of labor. This is a rare but recognized condition associated with abdominal straining and the Valsalva maneuver, but one that in general follows a benign course without intervention. Contrast radiology is useful only if there is reason to suspect an esophageal tear. If pneumomediastinum is detected during labor, then common sense would suggest that a rapid delivery should be sought without resort to positive pressure ventilation. There is, however, little evidence to support such guidance. Although there are no data on the rate of recurrence of this condition, the etiologic factor appears to be one of high airway pressures during Valsalva-type maneuvers. This contrasts with that of spontaneous pneumothorax in which the pathology is clearly focused in the lung. For this reason, patients should be discharged home if all traces of mediastinal air have resorbed.

	References

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1. Laennec RTH. A treatise on diseases of the chest and on mediate ausculation. Translated by John Forbes. 2nd edition. London: T & G Underwood, 1819.
2. Hamman L. Spontaneous mediastinal emphysema. Bull Johns Hopkins Hosp 1939;64:1.
3. Bard R., Hassini N. Pneumomediastinum complicating pregnancy. Respiration 1975;32:185-188.[Medline]
4. Okereke U.N., Weber B.E., Israel R.H. Spontaneous pneumomediastinum in an 18-year-old black Sudanese high school student. J Natl Med Assoc 1999;91:357-359.[Medline]
5. Ralph-Edwards A.C., Pearson F.G. Atypical presentation of spontaneous pneumomediastinum. Ann Thorac Surg 1994;58:1758-1760.[Abstract]
6. Woolford T.J., Birzqalis A.R., Lundell C., Farrington W.T. Vomiting in pregnancy resulting in oesophageal perforation in a 15-year-old. J Laryngol Otol 1993;107:1059-1060.[Medline]
7. Jamadar D.A., Kazerooni E.A., Hirschi R.B. Pneumomediastinum: elucidation of the anatomic pathway by liquid ventilation. J Comput Assist Tomogr 1996;20:309-311.[Medline]
8. Bejvan S.M., Godwin J.D. Pneumomediastinum: old signs and new signs. Am J Roentgenol 1996;166:1041-1048.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fraser W.H. Sutherland Ciro Campanella Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sutherland, F. W.H. Articles by Campanella, C. Search for Related Content PubMed PubMed Citation Articles by Sutherland, F. W.H. Articles by Campanella, C. Related Collections Mediastinum