Pneumomediastinum in the setting of hyperemesis gravidarum during the second trimester

SESSION TITLE: Disorders of the Mediastinum Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Pneumomediastinum (mediastinal emphysema) is the presence of free air in the mediastinum secondary to trauma or spontaneously due to elevated intra-alveolar pressure. Spontaneous pneumomediastinum in pregnancy is a rare entity with an incidence of less than 1:44.000, and there are very few case reports in the literature. We report a rare case of pneumomediastinum secondary to Hyperemesis Gravidarum during the second trimester. CASE PRESENTATION: A 21-year-old Female Gravida 1 Para O, at 15 weeks, with no significant past medical history, presented to the emergency department complaining of weeks of daily nausea and vomiting and two weeks of chest pain, cough, and difficulty breathing with minimal streaks of blood in her sputum. The patient's blood pressure was 92/72 mmHg, heart rate: 135/min, respiratory rate:20/min, saturating 100% on room air, and the temperature was 36.5 Celcius. Physical exam was significant for subcutaneous emphysema, and crepitus was noted near the clavicles bilaterally, regular rate, tachycardic, lungs were clear to auscultation bilaterally. Electrocardiogram showed sinus tachycardia and chest radiography was normal. Labs were significant for hypophosphatemia, hyponatremia, hypophosphatemia, elevated lactate (3.4 mmol/L), leukocytosis (19.2 x 103/mm3), transaminitis (AST 134/ALT 380 unit/L), elevated total bilirubin (4.6 mg/dL), acute kidney injury with Creatinine elevated to 1.36 (baseline Cretainine: 0.69) and elevated D-dimer (1.63 mcg/mL FEU). CT angiography was performed due to concern for pulmonary embolism and showed diffuse subcutaneous emphysema in the neck, pneumomediastinum and diffuse esophageal wall thickening. Gastrografin Esophagram showed no esophageal tear. Due to extensive pneumomediastinum and severe metabolic derangements, the patient went to the intensive care unit, remained NPO, and started on IV antibiotics, antiemetics, and proton pump inhibitors. An infectious workup did not reveal any infection. Partial parental nutrition was started at a half rate to prevent refeeding syndrome and the diet slowly advanced. Her electrolyte abnormalities and AKI improved. She was discharged after six days of inpatient care. DISCUSSION: Hyperemesis gravidarum (HG) is severe nausea and vomiting seen in only approximately 2% of all pregnancies in the United States. In HG, thoracic complications can occur, such as pneumothorax, pneumomediastinum, diaphragmatic tears, and thromboembolic events. Spontaneous pneumomediastinum typically presents during the second stage of labor resulting from increased intrathoracic pressure. Findings that may be seen are the Haaman sign, which is auscultation over the pericardium where a crunching or clicking sound, substernal pleuritic pain, fever, dyspnea, dysphagia, odynophagia, and dysphonia. Mackler Triad was seen in our patient, characterized by lower thoracic pain, vomiting, and subcutaneous emphysema. Diagnosis is confirmed by chest radiography. However, a CT scan is more sensitive in detecting pneumomediastinum. Management is supportive if it is uncomplicated by esophageal tear, pneumothorax, tension pneumomediastinum, or pneumopericardium. Most cases of pneumomediastinum are self-limiting and resolve within two weeks. CONCLUSIONS: Spontaneous pneumomediastinum secondary to hyperemesis gravidarum is rare, particularly in the first or second trimester. Distinguishing spontaneous pneumomediastinum from the esophageal rupture via appropriate imaging studies is vital. Monitoring and treating any complications is also crucial in decreasing morbidity and mortality. REFERENCE #1: MACIA I, MOYA J, RAMOS R, et al. Spontaneous pneumomediastinum: 41 cases. European Journal of Cardio-Thoracic Surgery. 2007;31(6):1110-1114. doi:https://doi.org/10.1016/j.ejcts.2007.03.008 REFERENCE #2: Wright C.D. (2015). Nonneoplastic disorders of the mediastinum. Grippi M.A., & Elias J.A., & Fishman J.A., & Kotloff R.M., & Pack A.I., & Senior R.M., & Siegel M.D.(Eds.), Fishman's Pulmonary Diseases and Disorders, Fifth Edition. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=1344§ionid=81193747 REFERENCE #3: Jennings LK, Mahdy H. Hyperemesis Gravidarum. [Updated 2022 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532917/ DISCLOSURES: No relevant relationships by Nida Ansari No relevant relationships by Robert Giannetti No relevant relationships by Patrick Michael No relevant relationships by Sacide Ozgur No relevant relationships by Faith Powell