Acute peripartum pneumothorax after fundal Kristeller's expression

Fundal or Kristeller’s pressure (FP) is known to be associated with numerous reports of severe maternal and fetoneonatal injuries, although it is used in a variety of modifications in many maternity hospitals and there is no evidence based on medical evidence of its effect on good clinical practice (Habek et al. 2008; Gimovsky and Berghella 2022). Peripartum pneumothorax (PPT) is a life-threatening clinical curiosity most commonly associated with pre-existing lung disease (lung cysts, tumours and bronchiectasis) and increased intrathoracic pressure associated with peripartum induced Valsalva’s manoeuvre and distal alveolar rupture. It is more common in pregnancy than in childbirth alone or in combination with Hamman’s syndrome (pneumomediastinum, pneumothorax and subcutaneous emphysema) with also extremely rare incidence in 1:2000 to 1:100,000 births (Najafi and Guzman 1978; Oshovskyy and Poliakova 2020). From the non-litigating Croatian obstetric practice, the case of a PPT in healthy primipara, without comorbidity and normal course of pregnancy and spontaneous term delivery is known. The parturient somatogram was unfavourable in terms of short stature (156 cm) and body weight of 68 kg, orderly eutrophic newborn and the course of the first labour phase. During the end of the II labour stage, the obstetrician decided on FP and with episiotomy, a live eutrophic newborn was born with Apgar score 10/10. Immediately after the birth, the mother became tachydyspnoic, cyanotic, tachycardic, hypotonic, with signs of acute respiratory insufficiency, so obstetric embolism was suspected, which was excluded by radiographic, electrocardiographic and laboratory methods. However, right-sided complete PPT without pulmonary or other intrathoracic pathological condition was verified, and with thoracentesis and drainage, there was complete reexpansion of the lungs and recovery of the mother with several days of subcutaneous emphysema. In 1978, seven cases of spontaneous PPT were presented in a pulmonary comorbidity (pulmonary cyst) using forceps with episiotomy in childbirth (Najafi and Guzman 1978), and Oshovskyy and Poliakova (2020) recently demonstrated intrapartum development of the syndrome Hamman which fully recovered by thorakocenthesis. FP could certainly have been avoided due to the orderly course of labour and the absence of maternal pulmonary comorbidity, and its application has contributed to the emergence of a life-threatening condition of the mother, which is beyond the scope of good clinical obstetric practice. Based on many years of clinical and forensic practice, we agree with the opinion of the authors of numerous papers and reviews of cases of obstetric injuries (Habek et al. 2008; Hasegawa et al. 2015; Zaami et al. 2018; Malvasi et al. 2019; Habek 2021; Gimovsky and Berghella 2022), FP is not recommended in modern obstetrics as a method of assistention during delivery. In this case shown, it can certainly be interpreted as iatrogenic rather than spontaneous PPT due to unnecessary and inappropriate force in normal, spontaneous childbirth.