Management of Labor in Pregnancy Complicated with Previous Tuberculosis with Giant Lung Bullae and Intrauterine Growth Restriction: A Case Report

Patient: Female, 22-year-old Final Diagnosis: Giant bullae • intrauterine growth restriction • pregnancy • tuberculosis Symptoms: giant bullae • history of tuberculosis • labour pain • underweight Clinical Procedure: Observation • vacuum assisted delivery Specialty: Obstetrics and Gynecology OBJECTIVE: Rare coexistence of disease or pathology BACKGROUND: Tuberculosis (TB) is the leading infectious cause of mortality in developing countries. In pregnancy, TB may cause complications including intrauterine growth restriction (IUGR) and vertical transmission of TB. Recurrent TB infection can cause permanent damage to lung tissue, and formation lung bullae can occur. Giant lung bullae may be harmless in normal conditions, but cause concern if the patient is pregnant. CASE REPORT: A 22-year-old G1P0A0 woman at 9 months of pregnancy came to our institution due to labor pain. She also presented with active TB from 1 month before admission. Chest X-ray findings suggestive of tuberculosis and giant bullae were found. She was diagnosed with active 1(st) phase of labor with active TB and giant lung bullae. The Cardiothoracic Surgery Department was on standby during labor to take countermeasures if bullae rupture occurred. The 2(nd) stage of labor was shortened with vacuum extraction. After delivery, the patient was shifted to an isolation room and started on antitubercular drugs. CONCLUSIONS: Tuberculosis in pregnancy leads to many adverse outcomes, both in maternal and fetal. Prolong TB infection also causes lung scaring, which leads to formation of bullae. Possible causes of rupture of bullae during pregnancy are Valsalva maneuver during labor, increased alveolar ventilation, and positive-pressure ventilation during general anesthesia. Normal vaginal delivery would increase the need for Valsalva maneuver, and vacuum extraction is advised to shorten the 2(nd) stage of labor to minimize the need of Valsalva maneuver and avoid increased intrapulmonal pressure.