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Spontaneous pneumomediastinum of delivery, also known as Hamman’s syndrome, is a rare complication of childbirth occurring in around one in 2,000–100,000 vaginal deliveries.[[1]] More sinister pathology, including oesophageal rupture, must be excluded in these patients, and general surgical and cardiothoracic surgery teams are often consulted as a result. It is important that obstetric and surgical teams are aware of the presenting features of this condition and are wary of a diagnosis of Hamman’s syndrome without appropriate investigation.

Detailed below is a case report of pneumomediastinum of delivery that occurred at Dunedin Hospital.

Case report

A 26-year-old primiparous woman with a gestational age of 40+1 had a normal vaginal delivery of a 3,930g baby and developed chest tightness a few hours afterwards. She did not experience hyperemesis during her labour and the second stage of her labour lasted 93 minutes. She suffered a second-degree perineal tear requiring suturing. She had no past medical history, including of respiratory disease, and was a lifelong non-smoker and not a user of illicit drugs.

The patient subsequently developed swelling over her right cheek and eye with vocal change but no shortness of breath. On examination, she had normal observations with no oxygen requirement and breath sounds were present and equal.

Chest radiograph confirmed pneumomediastinum and cervical subcutaneous emphysema (Figure 1). Although there was concern regarding undue radiation to this patient’s lactating breasts, CT chest was organised as the serious and life-threatening condition of oesophageal rupture could not be ruled out on plain film. Subsequent CT chest showed a large volume pneumomediastinum with subcutaneous emphysema extending along the chest wall and neck (Figure 2). There were small bilateral pneumothoraces, best appreciated in the oblique fissures. There was no defect seen along the tracheobronchial tree and no pleural effusion to suggest oesophageal rupture.

Figure 1: Chest radiograph depicting pneumomediastinum and bilateral subcutaneous emphysema in the neck.

Figure 2: CT chest coronal plane demonstrating pneumomediastinum and bilateral neck subcutaneous emphysema.

The patient’s pneumothoraces were managed conservatively and there was improvement in her symptoms and chest x-ray within 24 hours. She was subsequently discharged and advised it was unlikely she would have another episode of pneumomediastinum in her next pregnancy.

Discussion

Spontaneous pneumomediastinum of delivery should be a diagnosis of exclusion. It presents most commonly with pleuritic chest pain, but also shortness of breath, cough, dysphonia, dysphagia and abdominal discomfort.[[2]] Subcutaneous emphysema is often the first obvious sign of this condition.[[2]] Other important differential diagnoses in recently labouring women include oesophageal rupture, pneumothorax, pulmonary embolism and acute asthma.[[2]]

Pneumomediastinum of delivery is due to increased intrathoracic pressure produced during labour, causing alveolar and small bronchiolar rupture.[[3]] This leads to air tracking through the bronchovascular planes towards the hilum and then being released into the mediastinal space.[[3]] Air preferentially travels towards the mediastinum due to the Macklin effect, which describes a declining pressure gradient from the lung interstitium to the mediastinum.[[3]] Air may also come between the layers of the pleura and cause a pneumothorax.[[4]]

Pneumomediastinum can frequently be seen during the second stage (but not necessarily with obstruction) in women who have exaggerated pushing or Valsalva movement during labour.[[5]] Pneumomediastinum is more likely to occur in primiparous women who may not fully appreciate the appropriate times to bear down during their delivery.[[6]]

There should be high index of suspicion for oesophageal rupture in any labouring patient who has pneumomediastinum, whether or not they have emesis.[[7]] This is the most significant surgical diagnosis that may also present with pneumomediastinum. Contrast CT chest with IV or oral contrast is the gold standard of investigation used to identify an oesophageal perforation.[[7]] A risk–benefit analysis should be made for each individual patient regarding the likelihood of oesophageal rupture, as there is increased chance of future breast cancer from the exposure of lactating breasts to ionizing radiation.[[8]]

In the absence of obvious oesophageal, airway or lung injury, management of spontaneous pneumomediastinum is conservative, consisting of analgesia and oxygen (if required) and serial imaging to ensure resolution.[[2]] Patients are not at greater risk of recurrence in subsequent labours, but it has been suggested, without significant evidence, that epidural anaesthetics to reduce inappropriate straining may be of benefit.[[5]] Additionally, nitric oxide for analgesia may increase intra-alveolar pressure, and so should be omitted.[[5]]

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin.

Acknowledgements

Correspondence

Sally Harrison, 201 Great King Street, Dunedin 9016, Otago New Zealand, +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

1) Segev T, Thor JA, Lentz J, Hong E. Spontaneous Postpartum Pneumomediastinum: Presentation of a Rare Case and Literature Review. Obstetrics and Gynaecology. 2015;125 Suppl 1:58.

2) Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg. 2007;31:1110-4.

3) Wintermark M, Schnyder P. The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest. 2001;120:543-7.

4) Kuruba N, Hla TT. Postpartum spontaneous pneumomediastinum and subcutaneous emphysema: Hamman’s syndrome. Obstet Med. 2011;4:127-8.

5) Cho C, Parratt JR, Smith S, Patel R. Spontaneous pneumomediastinum (Hamman’s syndrome): a rare cause of postpartum chest pain. BMJ Case Rep. 2015;2015:1-3.

6) Mahboob A, Eckford SD. Hamman’s syndrome: An atypical cause of postpartum chest pain. J Obstet Gynaecol. 2008;28:652-3.

7) Hamilton S, Nicholson SC, Beattie GJ. Spontaneous oesophageal rupture in the second stage of labour. J Obstet Gynaecol. 2003;23:668-9.

8) Tirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics. 2015;35:1751-65.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Spontaneous pneumomediastinum of delivery, also known as Hamman’s syndrome, is a rare complication of childbirth occurring in around one in 2,000–100,000 vaginal deliveries.[[1]] More sinister pathology, including oesophageal rupture, must be excluded in these patients, and general surgical and cardiothoracic surgery teams are often consulted as a result. It is important that obstetric and surgical teams are aware of the presenting features of this condition and are wary of a diagnosis of Hamman’s syndrome without appropriate investigation.

Detailed below is a case report of pneumomediastinum of delivery that occurred at Dunedin Hospital.

Case report

A 26-year-old primiparous woman with a gestational age of 40+1 had a normal vaginal delivery of a 3,930g baby and developed chest tightness a few hours afterwards. She did not experience hyperemesis during her labour and the second stage of her labour lasted 93 minutes. She suffered a second-degree perineal tear requiring suturing. She had no past medical history, including of respiratory disease, and was a lifelong non-smoker and not a user of illicit drugs.

The patient subsequently developed swelling over her right cheek and eye with vocal change but no shortness of breath. On examination, she had normal observations with no oxygen requirement and breath sounds were present and equal.

Chest radiograph confirmed pneumomediastinum and cervical subcutaneous emphysema (Figure 1). Although there was concern regarding undue radiation to this patient’s lactating breasts, CT chest was organised as the serious and life-threatening condition of oesophageal rupture could not be ruled out on plain film. Subsequent CT chest showed a large volume pneumomediastinum with subcutaneous emphysema extending along the chest wall and neck (Figure 2). There were small bilateral pneumothoraces, best appreciated in the oblique fissures. There was no defect seen along the tracheobronchial tree and no pleural effusion to suggest oesophageal rupture.

Figure 1: Chest radiograph depicting pneumomediastinum and bilateral subcutaneous emphysema in the neck.

Figure 2: CT chest coronal plane demonstrating pneumomediastinum and bilateral neck subcutaneous emphysema.

The patient’s pneumothoraces were managed conservatively and there was improvement in her symptoms and chest x-ray within 24 hours. She was subsequently discharged and advised it was unlikely she would have another episode of pneumomediastinum in her next pregnancy.

Discussion

Spontaneous pneumomediastinum of delivery should be a diagnosis of exclusion. It presents most commonly with pleuritic chest pain, but also shortness of breath, cough, dysphonia, dysphagia and abdominal discomfort.[[2]] Subcutaneous emphysema is often the first obvious sign of this condition.[[2]] Other important differential diagnoses in recently labouring women include oesophageal rupture, pneumothorax, pulmonary embolism and acute asthma.[[2]]

Pneumomediastinum of delivery is due to increased intrathoracic pressure produced during labour, causing alveolar and small bronchiolar rupture.[[3]] This leads to air tracking through the bronchovascular planes towards the hilum and then being released into the mediastinal space.[[3]] Air preferentially travels towards the mediastinum due to the Macklin effect, which describes a declining pressure gradient from the lung interstitium to the mediastinum.[[3]] Air may also come between the layers of the pleura and cause a pneumothorax.[[4]]

Pneumomediastinum can frequently be seen during the second stage (but not necessarily with obstruction) in women who have exaggerated pushing or Valsalva movement during labour.[[5]] Pneumomediastinum is more likely to occur in primiparous women who may not fully appreciate the appropriate times to bear down during their delivery.[[6]]

There should be high index of suspicion for oesophageal rupture in any labouring patient who has pneumomediastinum, whether or not they have emesis.[[7]] This is the most significant surgical diagnosis that may also present with pneumomediastinum. Contrast CT chest with IV or oral contrast is the gold standard of investigation used to identify an oesophageal perforation.[[7]] A risk–benefit analysis should be made for each individual patient regarding the likelihood of oesophageal rupture, as there is increased chance of future breast cancer from the exposure of lactating breasts to ionizing radiation.[[8]]

In the absence of obvious oesophageal, airway or lung injury, management of spontaneous pneumomediastinum is conservative, consisting of analgesia and oxygen (if required) and serial imaging to ensure resolution.[[2]] Patients are not at greater risk of recurrence in subsequent labours, but it has been suggested, without significant evidence, that epidural anaesthetics to reduce inappropriate straining may be of benefit.[[5]] Additionally, nitric oxide for analgesia may increase intra-alveolar pressure, and so should be omitted.[[5]]

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin.

Acknowledgements

Correspondence

Sally Harrison, 201 Great King Street, Dunedin 9016, Otago New Zealand, +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

1) Segev T, Thor JA, Lentz J, Hong E. Spontaneous Postpartum Pneumomediastinum: Presentation of a Rare Case and Literature Review. Obstetrics and Gynaecology. 2015;125 Suppl 1:58.

2) Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg. 2007;31:1110-4.

3) Wintermark M, Schnyder P. The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest. 2001;120:543-7.

4) Kuruba N, Hla TT. Postpartum spontaneous pneumomediastinum and subcutaneous emphysema: Hamman’s syndrome. Obstet Med. 2011;4:127-8.

5) Cho C, Parratt JR, Smith S, Patel R. Spontaneous pneumomediastinum (Hamman’s syndrome): a rare cause of postpartum chest pain. BMJ Case Rep. 2015;2015:1-3.

6) Mahboob A, Eckford SD. Hamman’s syndrome: An atypical cause of postpartum chest pain. J Obstet Gynaecol. 2008;28:652-3.

7) Hamilton S, Nicholson SC, Beattie GJ. Spontaneous oesophageal rupture in the second stage of labour. J Obstet Gynaecol. 2003;23:668-9.

8) Tirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics. 2015;35:1751-65.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Spontaneous pneumomediastinum of delivery, also known as Hamman’s syndrome, is a rare complication of childbirth occurring in around one in 2,000–100,000 vaginal deliveries.[[1]] More sinister pathology, including oesophageal rupture, must be excluded in these patients, and general surgical and cardiothoracic surgery teams are often consulted as a result. It is important that obstetric and surgical teams are aware of the presenting features of this condition and are wary of a diagnosis of Hamman’s syndrome without appropriate investigation.

Detailed below is a case report of pneumomediastinum of delivery that occurred at Dunedin Hospital.

Case report

A 26-year-old primiparous woman with a gestational age of 40+1 had a normal vaginal delivery of a 3,930g baby and developed chest tightness a few hours afterwards. She did not experience hyperemesis during her labour and the second stage of her labour lasted 93 minutes. She suffered a second-degree perineal tear requiring suturing. She had no past medical history, including of respiratory disease, and was a lifelong non-smoker and not a user of illicit drugs.

The patient subsequently developed swelling over her right cheek and eye with vocal change but no shortness of breath. On examination, she had normal observations with no oxygen requirement and breath sounds were present and equal.

Chest radiograph confirmed pneumomediastinum and cervical subcutaneous emphysema (Figure 1). Although there was concern regarding undue radiation to this patient’s lactating breasts, CT chest was organised as the serious and life-threatening condition of oesophageal rupture could not be ruled out on plain film. Subsequent CT chest showed a large volume pneumomediastinum with subcutaneous emphysema extending along the chest wall and neck (Figure 2). There were small bilateral pneumothoraces, best appreciated in the oblique fissures. There was no defect seen along the tracheobronchial tree and no pleural effusion to suggest oesophageal rupture.

Figure 1: Chest radiograph depicting pneumomediastinum and bilateral subcutaneous emphysema in the neck.

Figure 2: CT chest coronal plane demonstrating pneumomediastinum and bilateral neck subcutaneous emphysema.

The patient’s pneumothoraces were managed conservatively and there was improvement in her symptoms and chest x-ray within 24 hours. She was subsequently discharged and advised it was unlikely she would have another episode of pneumomediastinum in her next pregnancy.

Discussion

Spontaneous pneumomediastinum of delivery should be a diagnosis of exclusion. It presents most commonly with pleuritic chest pain, but also shortness of breath, cough, dysphonia, dysphagia and abdominal discomfort.[[2]] Subcutaneous emphysema is often the first obvious sign of this condition.[[2]] Other important differential diagnoses in recently labouring women include oesophageal rupture, pneumothorax, pulmonary embolism and acute asthma.[[2]]

Pneumomediastinum of delivery is due to increased intrathoracic pressure produced during labour, causing alveolar and small bronchiolar rupture.[[3]] This leads to air tracking through the bronchovascular planes towards the hilum and then being released into the mediastinal space.[[3]] Air preferentially travels towards the mediastinum due to the Macklin effect, which describes a declining pressure gradient from the lung interstitium to the mediastinum.[[3]] Air may also come between the layers of the pleura and cause a pneumothorax.[[4]]

Pneumomediastinum can frequently be seen during the second stage (but not necessarily with obstruction) in women who have exaggerated pushing or Valsalva movement during labour.[[5]] Pneumomediastinum is more likely to occur in primiparous women who may not fully appreciate the appropriate times to bear down during their delivery.[[6]]

There should be high index of suspicion for oesophageal rupture in any labouring patient who has pneumomediastinum, whether or not they have emesis.[[7]] This is the most significant surgical diagnosis that may also present with pneumomediastinum. Contrast CT chest with IV or oral contrast is the gold standard of investigation used to identify an oesophageal perforation.[[7]] A risk–benefit analysis should be made for each individual patient regarding the likelihood of oesophageal rupture, as there is increased chance of future breast cancer from the exposure of lactating breasts to ionizing radiation.[[8]]

In the absence of obvious oesophageal, airway or lung injury, management of spontaneous pneumomediastinum is conservative, consisting of analgesia and oxygen (if required) and serial imaging to ensure resolution.[[2]] Patients are not at greater risk of recurrence in subsequent labours, but it has been suggested, without significant evidence, that epidural anaesthetics to reduce inappropriate straining may be of benefit.[[5]] Additionally, nitric oxide for analgesia may increase intra-alveolar pressure, and so should be omitted.[[5]]

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Sally Harrison: Cardiothoracic Surgery Registrar, Department of Cardiothoracic Surgery, Dunedin Hospital, Dunedin.

Acknowledgements

Correspondence

Sally Harrison, 201 Great King Street, Dunedin 9016, Otago New Zealand, +64226444409

Correspondence Email

sally_harrison@hotmail.com

Competing Interests

Nil.

1) Segev T, Thor JA, Lentz J, Hong E. Spontaneous Postpartum Pneumomediastinum: Presentation of a Rare Case and Literature Review. Obstetrics and Gynaecology. 2015;125 Suppl 1:58.

2) Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg. 2007;31:1110-4.

3) Wintermark M, Schnyder P. The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest. 2001;120:543-7.

4) Kuruba N, Hla TT. Postpartum spontaneous pneumomediastinum and subcutaneous emphysema: Hamman’s syndrome. Obstet Med. 2011;4:127-8.

5) Cho C, Parratt JR, Smith S, Patel R. Spontaneous pneumomediastinum (Hamman’s syndrome): a rare cause of postpartum chest pain. BMJ Case Rep. 2015;2015:1-3.

6) Mahboob A, Eckford SD. Hamman’s syndrome: An atypical cause of postpartum chest pain. J Obstet Gynaecol. 2008;28:652-3.

7) Hamilton S, Nicholson SC, Beattie GJ. Spontaneous oesophageal rupture in the second stage of labour. J Obstet Gynaecol. 2003;23:668-9.

8) Tirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics. 2015;35:1751-65.

Contact diana@nzma.org.nz
for the PDF of this article

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