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Ann Thorac Surg 2007;84:2085-2086. doi:10.1016/j.athoracsur.2007.07.005
© 2007 The Society of Thoracic Surgeons
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Case Reports

Massive Hemoptysis in an Immunocompromised Pregnant Woman With Human Immunodeficiency Virus Disease and Active Pulmonary Tuberculosis

David F. Blyth, FRCSEda,*, Mahomed A. Soni, MB ChBa, Neil F. Moran, FCOGb

a Department of Cardiothoracic Surgery, Wentworth Hospital, Nelson R. Mandela School of Medicine, Durban, South Africa
b Division of Cardiothoracic Anaesthesia, Wentworth Hospital, Nelson R. Mandela School of Medicine, Durban, South Africa
c Department of Obstetrics and Gynaecology, Wentworth Hospital, Nelson R. Mandela School of Medicine, Durban, South Africa

Accepted for publication July 3, 2007.

* Address correspondence to Dr Blyth, Department of Cardiothoracic Surgery, Inkosi Albert Luthuli Central Hospital, PB X03, Mayville, 4058, South Africa (Email: blyth{at}worldonline.co.za).


   Abstract
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 Abstract
Introduction
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Massive hemoptysis during pregnancy has been infrequently reported. The management of massive hemoptysis in an immunocompromised 22-year-old woman positive for human immunodeficiency virus undergoing treatment for cavitating pulmonary tuberculosis in the last trimester of pregnancy is reported. The difficulties encountered in applying our standard protocol for massive hemoptysis in this instance are described. The patient was managed by emergency cesarean section and lobectomy.


   Introduction
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Massive hemoptysis has been variously defined to include 250 mL of blood expectorated in one bout, or 600 mL in 48 hours [1]. We use 250 mL in one bout or 600 mL in 24 hours [2]. Clear statements were made many years ago about appropriate surgery being definitive and giving superior results to medical treatment [1].

A 22-year-old woman, gravida 3, para 2, and 34 weeks pregnant, undergoing in-hospital treatment for pulmonary tuberculosis was referred after three bouts of massive hemoptysis, each measuring about 450 mL. She had received antituberculosis treatment for 1 month. She had undergone two previous cesarean sections. She was positive for human immunodeficiency virus (HIV).

On admission to intensive care, she was noted to not be in distress and was well nourished. The size of her uterus corresponded to her gestational age. She showed no clinical stigmata of acquired immunodeficiency syndrome (AIDS).

A chest roentgenogram showed a cavity in the left upper lobe, possibly containing a fungal ball, but no other features of chest disease. A high-resolution computed tomography (HRCT) scan of her chest performed immediately according to protocol confirmed disease localized to the left upper lobe, certainly the most likely source of bleeding (Fig 1). She was anemic (hemoglobin, 9 g/dL), with a normal platelet count and no coagulation abnormalities. Repeat enzyme-linked immunosorbent assay antibody test confirmed her positive HIV status. Result of a blood gas analysis was normal.


Figure 1
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  		Fig 1. High-resolution computed tomography scan shows the left upper lobe cavity containing blood clot.

 
In view of repeated massive hemoptysis and her suitability for operation, urgent left upper lobectomy was advised and discussed with her. She refused any surgical intervention. The radiologist rejected the alternative, bronchial artery embolization (BAE), because of concern about the contrast medium affecting the baby. Although some minor hemoptysis did occur, it was not indicative of active bleeding. She was therefore managed by strict bedrest, sedation with morphia, intravenous broad-spectrum antibiotics, antituberculosis therapy, and careful monitoring. An absolute CD4 cell count measured 449 (normal 550 to 1955/µL). An elective cesarean section was planned for 2 weeks later, at 37 weeks’ gestation, by the obstetrics service.

At 36 weeks’ gestation, the patient had a massive hemoptysis in which she coughed up more than 500 mL of blood in one bout. She now agreed to the operation. She was sedated with morphia to suppress coughing—it being recognized sedation of the baby would result—and was prepared for immediate surgery. Bronchoscopy revealed clot and fresh blood in the left main bronchus. This was left undisturbed. A double lumen tube was placed for lung separation. A 2.9-kg baby was rapidly delivered by cesarean section, but it failed to breathe immediately (1 minute Apgar 4), probably morphia induced. With intramuscular naloxone and oxygen administration, the baby was rapidly resuscitated.

The patient was repositioned, and through a left posterolateral thoracotomy the somewhat shrunken left upper lobe containing a firm sausage-shaped mass was removed by standard lobectomy. The bronchus was securely covered with surrounding mediastinal pleura and pericardium. The chest was washed out with an antibiotic suspension, closed, and drained.

At postoperative bronchoscopy a large clot was removed from the left lower lobe bronchus together with some blood in the bronchi of the right lung, suggesting spill. In view of the two procedures that had been done, the patient was electively ventilated overnight. Recovery was uncomplicated. At 1 month, the patient and baby were thriving. At 14 months, the mother was entirely well, with a satisfactory result on chest roentgenogram.

The resected specimen showed a cavity filled with blood clot and no evidence of fungal infection. Histology revealed necrotizing granulomatous inflammation and caseous necrosis consistent with tuberculosis. No acid-fast bacilli were identified.


   Comment
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The most frequently reported causes of pulmonary hemorrhage in pregnancy are ruptured pulmonary arteriovenous malformations (PAVMs), manifesting as hemothorax or hemoptysis [3, 4], pregnancy being recognized to cause progression and complications of PAVMs [3, 4]. Ference and coworkers [3], reporting 143 patients with PAVM referred with pulmonary hemorrhage, encountered only 1 patient with massive hemoptysis during pregnancy. Management was by emergency cesarean section and embolotherapy [3].

Other rare causes of massive hemoptysis in pregnancy include Takayasu’s arteritis [5]. Hemoptysis due to pulmonary embolus and mitral stenosis are now seldom seen. DePace and colleagues [6] reported "postmortem" cesarean section in late pregnancy after cardiorespiratory arrest due to massive hemoptysis. Both mother and child survived. Further massive hemoptysis was managed by left pneumonectomy, histology not revealing a clear cause [6].

In our province of KwaZulu-Natal, South Africa, said to be the epicenter of the HIV/AIDS pandemic and where tuberculosis is rife, referral of HIV positive patients with significant hemoptysis to our department, the only Public Service Thoracic facility, has become frequent. Non-pregnancy-related infections have been noted to be the most common cause of maternal deaths in South Africa, more than half of these deaths being due to AIDS or tuberculosis, or both [7]. Such deaths are increasing in number. Massive hemoptysis in pregnancy, related to tuberculosis, may well become more common.

Following protocol, the patient’s suitability for operation is rapidly determined by history, physical examination, chest roentgenogram, HRCT, blood gas analysis, and a coagulation screen [2]. Sputum is examined for acid-fast bacilli. This patient was eminently suitable for left upper lobectomy as an immediate definitive procedure and would require cesarean section because of the two previous cesarean sections. Bronchoscopy, which may precipitate bleeding, is delayed until surgery, experience having shown that where inflammatory lung disease is localized, that locality is the source of bleeding [2]. Careful screening of the fetus from radiation is mandatory. Where an iodinated compound is used as in BAE, thyroid function can be tested and managed in the newborn.

We have found BAE may be definitive in controlling bleeding from a pneumonic tuberculous area, but not so effective in massive hemoptysis with an associated fungal ball, which was initially suspected in this patient. Nevertheless, the operation having been refused, BAE may well have removed the need for emergency operation in the face of possible ongoing bleeding with all its attendant risks. Its use in controlling massive hemoptysis with pregnancy carried to term has been once reported [8].

Combined cesarean section and lobectomy was here of benefit. With pregnancy at term, it could be assumed a normal infant could be delivered by cesarean, the safest mode of delivery according to local protocol in all women with a history of two cesarean sections. Had massive hemoptysis occurred earlier in pregnancy, it might have been necessary to delay cesarean section until some time after lobectomy.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Crocco JA, Rooney JJ, Fankushen DS, DiBenedetto RJ, Lyons HA. Massive haemoptysis Arch Intern Med 1968;121:495-498.[Abstract/Free Full Text]
  2. Blyth DF. The management of haemoptysis S Afr Respir J 1996;2:28-30.
  3. Ference BA, Shannon TM, White Jr RI, Zawin M, Burdge CM. Life-threatening pulmonary hemorrhage with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia Chest 1994;106:1387-1390.[Medline]
  4. Esplin MS, Varner MW. Progression of pulmonary arteriovenous malformation during pregnancy: case report and review of the literature Ob Gyn Surv 1997;52:248-253.
  5. Rocha MP, Guntupalli KK, Moise Jr KJ, Lockett LD, Khawli F, Rokey R. Massive hemoptysis in Takayasu’s arteritis during pregnancy Chest 1994;106:1619-1622.[Medline]
  6. DePace NL, Betesh JS, Kotler MN. ‘Postmortem’ cesarean section with recovery of both mother and offspring JAMA 1982;248:971-973.[Abstract/Free Full Text]
  7. National Committee for Confidential Enquiries into Maternal Deaths in South Africa. "Saving Mothers Report 1999–2001." National Department of Health.
  8. Downs TW, Chao CR. Massive hemoptysis in pregnancy treated with bronchial artery embolization Am J Perinatol 1997;14:51-53.[Medline]




This Article
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