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Case based discussions
Massive haemoptysis and ventilatory failure in pregnancy
  1. William G Flight1,
  2. Ivan Tang1,
  3. Alison Gates1,
  4. Joanna Snowball1,
  5. John M Wrightson2,
  6. Lucy Mackillop3,4,
  7. Stephen J Chapman1,4
  1. 1 Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  2. 2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  3. 3 Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4 University of Oxford, Oxford, UK
  1. Correspondence to Dr William G Flight, Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; william.flight{at}

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Ivan Tang, Core Medical Trainee (IT): A 36-year-old pregnant woman presented to her local hospital with massive haemoptysis. At the time of admission, she was at 34 weeks of gestation with her first pregnancy. She reported a 6-week history of breathlessness, productive cough and fatigue. On the day of presentation she had expectorated two cupfuls of fresh red blood.

The patient had been diagnosed with bronchiectasis in her teens in her native Lithuania before moving to the United Kingdom 15 years earlier. At the age of 21 years, she had an episode of pleural infection requiring thoracotomy and rib resection.

The patient’s body mass index (BMI) at booking was 16 kg/m2. Fetal nuchal translucency and a fetal morphology ultrasound scan were normal. Fetal abdominal circumference at 28 weeks was on the fifth centile.

Initial management included supplemental oxygen and intravenous antibiotic therapy with piperacillin–tazobactam to ensure coverage against potential Pseudomonas aeruginosa infection. A CT pulmonary angiogram showed severe bronchiectasis with a large cavity and consolidation in the left upper lobe (see figure 1). There was evidence of bronchial artery hypertrophy bilaterally. Transfer to our hospital as the regional tertiary centre for both respiratory and obstetric medicine was arranged.

Figure 1

CT pulmonary angiogram showing severe bilateral bronchiectasis with consolidation and a large left upper lobe cavity.

William G Flight, Consultant Respiratory Physician (WGF): Bronchiectasis is recognised as a frequent cause of massive haemoptysis, accounting for up to two-thirds of episodes in published case series.1 The source of haemoptysis in bronchiectasis is usually from the bronchial arterial circulation.1 Bronchial artery hypertrophy can be demonstrated through a contrast-enhanced CT scan or conventional angiography, whereas bronchoscopy is only rarely helpful in identifying the site of bleeding.

Gold standard treatment for massive haemoptysis in bronchiectasis is bronchial artery embolisation (BAE). BAE may …

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