August 18, 2012

Image of the Day 14: Pulmonary Hypertension secondary to Chronic Lung Disease

These are the x ray and ECG of a 40 years old lady, G6P5 at 26 weeks of POG with history of treated pulmonary tuberculosis for four years who presented with shortness of breath and lethargy. She denied any history of prolong cough, night sweat, loss of appetite, loss of weight and fever.

Induced sputum for Acid fast bacilli was negative X 3, mantoux test negative, no recorded high temperature in wards. Arterial blood gas shows type 2 respiratory failure with retention of PCO2 that improves with oxygen via nasal prong 1L /min. Ultrasound abdomen shows viable fetus of 26 weeks of POG with estimated birth weight of 900g. 

 The chest X rays shows 1) Trachea deviated to the right side, 2) Dense fibrosis especially at the right lung field, 3) Presence of two apical bullae in right and left hemithorax with the largest one being at right side.

The ECG shows tall T wave (Right atrial hypertrophy). Otherwise, no right axis deviation, no ST depression or T inversion in anterior lead and no feature to suggest right ventricular hypertrophy. ( 1) right axis deviation, 2) predominant R wave in lead V1 - in a normal ECG the S wave is dominant in V1, 3) Deep S in V6 - in a normal ECG the QRS complex is predominantly upwards in V6, 4) Inverted T waves in right praecordial leads - V2, V3 - will be present in severe cases; it is normal to have inverted T waves in V1, 5) QRS <0 .12.=".12.""" span="span">

A diagnosis of Pulmonary hypertension secondary to Chronic Lung Disease was made. This patient is a high risk patient as pregnancy will worsen the lung condition. Apart from that, the period of gestation of the baby will affect the management.

It is a dilemma to choose whether to terminate the pregnancy or not. While in the UK, the baby with 22 weeks of POG can survive in view of advanced neonatal care, it is almost impossible in Malaysia for it. The option is either to terminate or wait until a period of high chance of survival which is about 32 weeks. 

Even if decided for termination, the only suitable method for this patient is caesarian section as induction with prostaglandin may pose hazard. Another dilemma to be faced is anticipation of difficult anaesthesia during the caesarian section. Spinal block is the option but if anything happen, it is risky to proceed with general anesthesia in view of the bad lung condition. This patient would be benefited from treatment in highly specialized center.

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