SESSION TYPE: Pleural Global Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Spontaneous massive hemothorax is uncommon. We report a case of massive hemothorax in a female with no past medical history or trauma. The patient presented with sudden epigastric pain and right massive hemothorax. Emergency thoracotomy revealed holes at right diaphragm and blood entering from peritoneal cavity via these holes were observed. Laparotomy showed hemoperitoneum and ruptured right tubal pregnancy.
CASE PRESENTATION: A 39-year-old woman with no past medical history or recent trauma presented to the emergency department with sudden epigastric pain. The dull-aching pain originated from pelvis and radiated to the epigastrium. She also had sudden dyspnea and fainting. On examination, the patient was afebrile, restless, sweating and markedly pale. The blood pressure was 90/60 mmHg, pulse rate was 112/min and respiratory rate was 30/min. Chest examination revealed decreased breath sounds and dullness on percussion at right lower lung up to 2/3. Abdomen revealed mild tenderness at epigastrium and right upper quadrant without guarding or rigidity. Other examinations were unremarkable. Chest X-ray showed moderate right pleural effusion. Complete blood count disclosed hematocrit of 12.7%, leukocyte count of 25,020 cells/mL with normal platelet count and coagulogram. Right thoracentesis yielded unclotted bloody pleural fluid with hematocrit of 28%. Chest tube drained 1,000 cc of unclotted blood. After resuscitation, she underwent emergent right posterolateral thoracotomy. Another 1,000 cc of dark blood found in the pleural cavity. Multiple tiny holes at the right diaphram and blood entering from peritoneal to pleural cavity via these holes were observed. The diaphramatic holes were repaired followed by laparotomy. Five-thousand cc of hemoperitoneum was removed and a ruptured right tubal pregnancy was discovered. Right salpingectomy was done. The patient's condition was gradually improved with multiple blood transfusion. She was discharged home on the eighth day after the operation.
DISCUSSION: Spontaneous hemothorax secondary to ruptured ectopic pregnancy is very rare. There were only four reported cases from the literature review. Two of these had bleeding from ruptured tubal pregnancy(1), one from abdominal pregnancy(2) and another one from extratubal pregnancy with diaphramatic implantation(3). Most of these cases could not demonstrate the passage of blood from peritoneal to pleural cavity as in our report case. The etiology of hemothorax in this case is probably due to congenital diaphramatic defects which act as the communicating pathway between pleural and peritoneal cavity. Hemoperitoneum from rupture ectopic pregnancy causing increased in abdominal pressure which enlarges the defects. Herniated peritoneum protrude through these defects and then burst, resulted in a communication between peritoneal and pleural space. Owing to negative pleural pressure, there is a pressure gradient between peritoneal and pleural spaces that favors the unidirectional passage of fluid into the chest. The congenital diaphramatic holes are frequently seen in the tendinous portion of the right diaphragm and less frequently seen in the left diaphragm, which is thicker and more muscular than the right. Moreover, on the left diaphram, omentum or bowels usually protrude through the opening and seal the passage of fluid. Other more common causes of diaphragmatic defects are trauma or surgery(1). Recognition of this potential connection between the pleural and peritoneal cavity would prompt clinicians to carefully exam both chest and abdomen in patients presented with acute right pleural effusion and would lead to proper investigation and management.
CONCLUSIONS: Hemoperitoeum from ruptured ectopic pregnancy is a very rare cause of spontaneous massive hemothorax. It should be considered in the differential diagnoses of females in child-bearing age with abrupt hemothorax.
1) Pratt JH, Shamblin WR. Spontaneous hemothorax as a direct complication of hemoperitoneum. Ann Surg 1968; 167: 867-71.
2) Mc Nulty JJ. Hemothorax as a presenting symptom in abdominal pregnancy : markedly elevated chorionic gonadotropin titer findings associated with abdominal pregnancy and secondary hemothorax. Obstet Gynec 1960; 16: 615.
3) Fishman DA, Padilla LA, Joob A, Lurain JR. Ectopic pregnancy causing hemothorax managed by thoracoscopy and actinomycin D. Obstet Gynecol 1998; 91: 837-8.
DISCLOSURE: The following authors have nothing to disclose: Suree Sompradeekul, Pasakorn Jitruckthai
No Product/Research Disclosure InformationSiriraj Hospital Mahidol University, Bangkok, Thailand