View Article PDF

This case highlights the diagnostic conundrum when women present with non-specific symptoms for a surgical acute abdomen in post-partum period.

Case report

A 31-year-old mother (KS) was booked under the midwives. Her pregnancy was low risk and she had a normal delivery. However, a post-partum haemorrhage followed and she was conservatively managed with syntometrine and syntocinon infusion. Bleeding settled and her vital signs were normal.

KS was on regular analgesics and normal diet by day 1. However, she made limited progress with pubic symphisis pain and was unable to be discharged even by day 3.

By day 4, KS developed a gradual onset of right upper quadrant pain. Her abdomen was soft on palpation. Blood results were unremarkable. Ten hours later, midwifery team sought further medical review. KS started complaining of vomiting and worsening pain. Bloods suggests stable haemoglobin, rising white cell count (11.5/L), normal Neutrophil and serum lactate. CRP was 17. Abdomen was felt to be tender but not peritonitic. Thirty minutes later, KS started bilious vomiting.

Her care was discussed with obstetric consultant on call and an urgent CT scan was arranged. Working diagnosis was of probable endometritis. CT finding is as below.

The general surgical team was immediately consulted. KS was taken to theatre for a diagnostic laparoscopy. Intraoperative finding revealed a perforated anterior duodenal ulcer with bilious and fibrin material within the abdomen. Repair was done through a small midline laparotomy with transverse closure of the defect with omental patch over the duodenum.

Figure 1: Axial CT scan suggested duodenal perforation with trans-luminal air and localised fat stranding in front of duodenum.

Figure 2: Coronal: Trans-luminal gas identified. Note post-partum uterus.

Figure 3: The suction canula in the duodenum demonstrating the perforation.

Discussion

Peptic ulcer perforation disease is rare in post-partum period. Literature search suggests less than 50 cases published in English language.1,6,7 Though the true Incidence of PUD in post-partum may be more common than reported due attribution of common PUD symptoms to those of which are experienced during post-partum,3 mortality and morbidity rates are universally high.1,5–7 Common risk factors still apply to the post-partum mothers including Helicobactor pylori infection, use of non-steroidal anti inflammatory medication (NSAID), alcohol consumption and smoking.3 In this case, apart from the stress of childbirth, only post-partum use of NSAID was noted.

There are a number of unproven hypotheses for lowered incidence of peptic ulcer in pregnancy, namely related with high oestrogen concentration and increased plasma histaminase secreted from placenta.4 These effects will be lacking in the post-partum period.

Post-partum abdominal laxity is known to mask the classical sign of peritonism. The immediate post-partum period can also distract from traditional symptoms and signs. However, perforated peptic ulcer is associated with high maternal mortality and morbidity. Prompt surgical intervention is necessary to limit morbidity.5,6The case report highlights need of prompt and targeted imaging when necessary and multi-disciplinary team approach. In this case, the mother underwent surgery within two hours of CT scans, emphasising the above learning points.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Angelo Di Bartolo, House Officer, Mid Central District Health Board, Palmerston North; Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North; Rose Mitchell, Trainee Intern, Mid Central District Health Board, Palmerston North.

Acknowledgements

Correspondence

Dr Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North.

Correspondence Email

sikhar.sircar@midcentraldhb.govt.nz

Competing Interests

Nil.

1. Baird R. Peptic ulceration in pregnancy: report of a case with perforation. Can Med Assoc J. 1966 Apr 16; 94(16):861–862.

2. Sandweiss DJ, et al. Deaths from perforation and hemorrhage of gastroduodenal ulcer during pregnancy and puerperium. American Journal of Obstetrics and Gynaecology. January 01, 1943; volume 45, issue 1: p 131–136,

3. Nelson-Piercy C, Frise C. Peptic Ulcer in pregnancy. OBSTETRIC CASE REPORTS. Page 804 | Published online: 17 Oct 2012.

4. Cappell MS. Gastric and duodenal ulcers during pregnancy. Gastroenterology Clinics of North America. 2003; 32(1):263–308.

5. Dua S, Morrison C, Farrant J, Rolles K. Postpartum pneumoperitoneum: an important clinical lesson BMJ Case Rep. Published online Dec 3. 2012;

6. Engemise S, Oshowo A, Kyei-Mensah A. Perforated duodenal ulcer in the puerperium. Arch Gynecol Obstet. 2009; 279:407–410.

7. Essilfie P, Hussain M, Bolaji I. Perforated duodenal ulcer in pregnancy-a rare cause of acute abdominal pain in pregnancy: a case report and literature review. Case Rep Obstet Gynecol. 2011; 2011:263016. Epub 2011 Jul 18.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

This case highlights the diagnostic conundrum when women present with non-specific symptoms for a surgical acute abdomen in post-partum period.

Case report

A 31-year-old mother (KS) was booked under the midwives. Her pregnancy was low risk and she had a normal delivery. However, a post-partum haemorrhage followed and she was conservatively managed with syntometrine and syntocinon infusion. Bleeding settled and her vital signs were normal.

KS was on regular analgesics and normal diet by day 1. However, she made limited progress with pubic symphisis pain and was unable to be discharged even by day 3.

By day 4, KS developed a gradual onset of right upper quadrant pain. Her abdomen was soft on palpation. Blood results were unremarkable. Ten hours later, midwifery team sought further medical review. KS started complaining of vomiting and worsening pain. Bloods suggests stable haemoglobin, rising white cell count (11.5/L), normal Neutrophil and serum lactate. CRP was 17. Abdomen was felt to be tender but not peritonitic. Thirty minutes later, KS started bilious vomiting.

Her care was discussed with obstetric consultant on call and an urgent CT scan was arranged. Working diagnosis was of probable endometritis. CT finding is as below.

The general surgical team was immediately consulted. KS was taken to theatre for a diagnostic laparoscopy. Intraoperative finding revealed a perforated anterior duodenal ulcer with bilious and fibrin material within the abdomen. Repair was done through a small midline laparotomy with transverse closure of the defect with omental patch over the duodenum.

Figure 1: Axial CT scan suggested duodenal perforation with trans-luminal air and localised fat stranding in front of duodenum.

Figure 2: Coronal: Trans-luminal gas identified. Note post-partum uterus.

Figure 3: The suction canula in the duodenum demonstrating the perforation.

Discussion

Peptic ulcer perforation disease is rare in post-partum period. Literature search suggests less than 50 cases published in English language.1,6,7 Though the true Incidence of PUD in post-partum may be more common than reported due attribution of common PUD symptoms to those of which are experienced during post-partum,3 mortality and morbidity rates are universally high.1,5–7 Common risk factors still apply to the post-partum mothers including Helicobactor pylori infection, use of non-steroidal anti inflammatory medication (NSAID), alcohol consumption and smoking.3 In this case, apart from the stress of childbirth, only post-partum use of NSAID was noted.

There are a number of unproven hypotheses for lowered incidence of peptic ulcer in pregnancy, namely related with high oestrogen concentration and increased plasma histaminase secreted from placenta.4 These effects will be lacking in the post-partum period.

Post-partum abdominal laxity is known to mask the classical sign of peritonism. The immediate post-partum period can also distract from traditional symptoms and signs. However, perforated peptic ulcer is associated with high maternal mortality and morbidity. Prompt surgical intervention is necessary to limit morbidity.5,6The case report highlights need of prompt and targeted imaging when necessary and multi-disciplinary team approach. In this case, the mother underwent surgery within two hours of CT scans, emphasising the above learning points.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Angelo Di Bartolo, House Officer, Mid Central District Health Board, Palmerston North; Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North; Rose Mitchell, Trainee Intern, Mid Central District Health Board, Palmerston North.

Acknowledgements

Correspondence

Dr Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North.

Correspondence Email

sikhar.sircar@midcentraldhb.govt.nz

Competing Interests

Nil.

1. Baird R. Peptic ulceration in pregnancy: report of a case with perforation. Can Med Assoc J. 1966 Apr 16; 94(16):861–862.

2. Sandweiss DJ, et al. Deaths from perforation and hemorrhage of gastroduodenal ulcer during pregnancy and puerperium. American Journal of Obstetrics and Gynaecology. January 01, 1943; volume 45, issue 1: p 131–136,

3. Nelson-Piercy C, Frise C. Peptic Ulcer in pregnancy. OBSTETRIC CASE REPORTS. Page 804 | Published online: 17 Oct 2012.

4. Cappell MS. Gastric and duodenal ulcers during pregnancy. Gastroenterology Clinics of North America. 2003; 32(1):263–308.

5. Dua S, Morrison C, Farrant J, Rolles K. Postpartum pneumoperitoneum: an important clinical lesson BMJ Case Rep. Published online Dec 3. 2012;

6. Engemise S, Oshowo A, Kyei-Mensah A. Perforated duodenal ulcer in the puerperium. Arch Gynecol Obstet. 2009; 279:407–410.

7. Essilfie P, Hussain M, Bolaji I. Perforated duodenal ulcer in pregnancy-a rare cause of acute abdominal pain in pregnancy: a case report and literature review. Case Rep Obstet Gynecol. 2011; 2011:263016. Epub 2011 Jul 18.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

This case highlights the diagnostic conundrum when women present with non-specific symptoms for a surgical acute abdomen in post-partum period.

Case report

A 31-year-old mother (KS) was booked under the midwives. Her pregnancy was low risk and she had a normal delivery. However, a post-partum haemorrhage followed and she was conservatively managed with syntometrine and syntocinon infusion. Bleeding settled and her vital signs were normal.

KS was on regular analgesics and normal diet by day 1. However, she made limited progress with pubic symphisis pain and was unable to be discharged even by day 3.

By day 4, KS developed a gradual onset of right upper quadrant pain. Her abdomen was soft on palpation. Blood results were unremarkable. Ten hours later, midwifery team sought further medical review. KS started complaining of vomiting and worsening pain. Bloods suggests stable haemoglobin, rising white cell count (11.5/L), normal Neutrophil and serum lactate. CRP was 17. Abdomen was felt to be tender but not peritonitic. Thirty minutes later, KS started bilious vomiting.

Her care was discussed with obstetric consultant on call and an urgent CT scan was arranged. Working diagnosis was of probable endometritis. CT finding is as below.

The general surgical team was immediately consulted. KS was taken to theatre for a diagnostic laparoscopy. Intraoperative finding revealed a perforated anterior duodenal ulcer with bilious and fibrin material within the abdomen. Repair was done through a small midline laparotomy with transverse closure of the defect with omental patch over the duodenum.

Figure 1: Axial CT scan suggested duodenal perforation with trans-luminal air and localised fat stranding in front of duodenum.

Figure 2: Coronal: Trans-luminal gas identified. Note post-partum uterus.

Figure 3: The suction canula in the duodenum demonstrating the perforation.

Discussion

Peptic ulcer perforation disease is rare in post-partum period. Literature search suggests less than 50 cases published in English language.1,6,7 Though the true Incidence of PUD in post-partum may be more common than reported due attribution of common PUD symptoms to those of which are experienced during post-partum,3 mortality and morbidity rates are universally high.1,5–7 Common risk factors still apply to the post-partum mothers including Helicobactor pylori infection, use of non-steroidal anti inflammatory medication (NSAID), alcohol consumption and smoking.3 In this case, apart from the stress of childbirth, only post-partum use of NSAID was noted.

There are a number of unproven hypotheses for lowered incidence of peptic ulcer in pregnancy, namely related with high oestrogen concentration and increased plasma histaminase secreted from placenta.4 These effects will be lacking in the post-partum period.

Post-partum abdominal laxity is known to mask the classical sign of peritonism. The immediate post-partum period can also distract from traditional symptoms and signs. However, perforated peptic ulcer is associated with high maternal mortality and morbidity. Prompt surgical intervention is necessary to limit morbidity.5,6The case report highlights need of prompt and targeted imaging when necessary and multi-disciplinary team approach. In this case, the mother underwent surgery within two hours of CT scans, emphasising the above learning points.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Angelo Di Bartolo, House Officer, Mid Central District Health Board, Palmerston North; Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North; Rose Mitchell, Trainee Intern, Mid Central District Health Board, Palmerston North.

Acknowledgements

Correspondence

Dr Sikhar Sircar, Senior Medical Officer, Mid Central District Health Board, Palmerston North.

Correspondence Email

sikhar.sircar@midcentraldhb.govt.nz

Competing Interests

Nil.

1. Baird R. Peptic ulceration in pregnancy: report of a case with perforation. Can Med Assoc J. 1966 Apr 16; 94(16):861–862.

2. Sandweiss DJ, et al. Deaths from perforation and hemorrhage of gastroduodenal ulcer during pregnancy and puerperium. American Journal of Obstetrics and Gynaecology. January 01, 1943; volume 45, issue 1: p 131–136,

3. Nelson-Piercy C, Frise C. Peptic Ulcer in pregnancy. OBSTETRIC CASE REPORTS. Page 804 | Published online: 17 Oct 2012.

4. Cappell MS. Gastric and duodenal ulcers during pregnancy. Gastroenterology Clinics of North America. 2003; 32(1):263–308.

5. Dua S, Morrison C, Farrant J, Rolles K. Postpartum pneumoperitoneum: an important clinical lesson BMJ Case Rep. Published online Dec 3. 2012;

6. Engemise S, Oshowo A, Kyei-Mensah A. Perforated duodenal ulcer in the puerperium. Arch Gynecol Obstet. 2009; 279:407–410.

7. Essilfie P, Hussain M, Bolaji I. Perforated duodenal ulcer in pregnancy-a rare cause of acute abdominal pain in pregnancy: a case report and literature review. Case Rep Obstet Gynecol. 2011; 2011:263016. Epub 2011 Jul 18.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE