|Year : 2015 | Volume
| Issue : 2 | Page : 164-166
Perforated duodenal ulcer in the third trimester of pregnancy
Fasika Amdeslasie1, Yibrah Berhe2, Tewelde T Gebremariam3
1 Department of Surgery, Institute of Biomedical Sciences, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
2 Department of Obstetrics and Gynecology, School of Medicine, Institute of Biomedical Sciences, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
3 Department of Medical Microbiology and Immunology, Institute of Biomedical Sciences, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
|Date of Web Publication||6-May-2015|
Tewelde T Gebremariam
P. O. Box: 1168, Mekelle
Source of Support: None, Conflict of Interest: None
Perforated duodenal ulcer during pregnancy is rare. We report a case of 20-year-old woman who developed perforated duodenal ulcer in the third trimester of pregnancy. Surgical repair was performed with good outcome.
ملخص البحث :
تندر حدوث مضاعفات قرحة الأثنى عشر كالثقب في جداره أثناء الحمل. يعرض الباحثون حالة لسيدة في العشرين من العمر حدث لها ثقب بقرحة الأثنى عشر في الثلث الأخير من الحمل وقد تم معالجتها جراحيًا بنجاح.
Keywords: Perforated peptic ulcer disease, pregnancy, third trimester
|How to cite this article:|
Amdeslasie F, Berhe Y, Gebremariam TT. Perforated duodenal ulcer in the third trimester of pregnancy. Saudi J Med Med Sci 2015;3:164-6
|How to cite this URL:|
Amdeslasie F, Berhe Y, Gebremariam TT. Perforated duodenal ulcer in the third trimester of pregnancy. Saudi J Med Med Sci [serial online] 2015 [cited 2023 Jan 28];3:164-6. Available from: https://www.sjmms.net/text.asp?2015/3/2/164/156435
| Introduction|| |
The risk of developing peptic ulcer disease (PUD) during pregnancy is rare. , Pregnancy creates several difficulties in the diagnosis and management of peptic ulcers. Nevertheless, prompt diagnosis and timely management of PUD in pregnancy are essential as complications can result in quite significant morbidity or even mortality for the patient.  We present a case of perforated duodenal ulcer in the third trimester.
| Case report|| |
The case we present here is about a 20-year-old woman in 28 th week of her first pregnancy. She presented with 1-day history of supra-umbilical pain, abdominal distension and repeat vomiting of coffee ground nature. She also had chronic epigastric discomfort for which she sought no medical advice. The rest of her medical history, including the antenatal care was unremarkable.
The objective findings at presentation were poor general condition, hypothermia (35.4°C) with blood pressure (BP) 80/60 mmHg, pulse rate 114/min; respiratory rate 28/min. Abdominal examination showed grossly distended soft, moves with respiration tenderness. There was mild abdominal pain with no rebound with a uterus size of 30-week on examination. Clinically patient had ascites with no hepatomegaly or splenomegaly. Bowel sounds were sluggish. Digital rectal examination showed normal colored stools on examining finger no palpable mass. She had normal anal sphincter tone. Fetus had a longitudinal lie and was engaged but no fetal heart beat was appreciated. Vaginal examination revealed closed cervix (3 cm and unaffected with unfavorable Bishop Score) with an assessment of third trimester intrauterine fetal death (IUFD), small bowel obstruction versus perforated viscus. She was admitted to surgical ward and she was investigated. Her laboratory profile revealed white blood cell (WBC) 10600/mm 3 (lymphocytes 18%, neutrophils 70.3%, eosinophils 2.4%, basophils = 0.3%, and monocytes = 8.1%), platelet count 80,000/mm 3 , hemoglobin 4 mg/dL, serum electrolytes: Na = 149.6 mmol/L, K = 4.30 mmol/L, and Cl = 121.1 mmol/L, urinalysis: Urine WBC/high powered field (HPF) = 0, red blood cell/HPF = 10-15 and many bacteria and pseudo hyphae, blood chemistry: Creatinine = 3.1 mg/dL, serum glutamic-pyruvic transaminase = 55 U/L, serum glutamic oxaloacetic transaminase = 91 U/L, and urea = 177 mg/dL.
Plain abdominal X-ray did not show any remarkable finding. She was resuscitated with crystalloids, catheterized, nasogastric tube was inserted and a decision to perform an exploratory laparotomy was made. The findings were 2 L of gastrointestinal (GI) content and 1 cm anterior wall perforation at the first part of duodenum. The peritoneal collection was aspirated and omental patch was done, abdominal cavity was thoroughly lavaged with normal saline and drainage was inserted. Postoperatively, the patient was continued on intravenous antibiotics. After the operation, her BP was continuously in the hypertensive range. The systolic was 150-160 mmHg and the diastolic was 100-160 mmHg. She was again investigated after surgery and her laboratory profile revealed platelet count of 96,000/mm 3 , urea 177 mg/dL and creatinine 3.1 mg/dL.
With the diagnosis of primigravid, IUFD and severe preeclampsia, the patient was started on magnesium sulfate and anti-hypertensives, and after stabilization she was induced with oxytocin and delivered vaginally a 1.9 kg dead male neonate. After delivery her BP, laboratory results (platelet count and renal function) normalized, and her general condition improved. She was discharged with omeprazole. On subsequent follow-up, she had regained full functionality and had no complaints.
| Discussion|| |
Peptic ulcer disease during pregnancy is a rare occurrence ,,, ranging from 1 to 6 in every 23,000 pregnancies. ,, when it occurs survival of both mother and child is unusual. 
The secretion of gastric acid varies inversely with the concentration of the gonadotrophic hormone. Furthermore, due to the effect of estrogen, increased levels of diamine oxidase (histaminase) is seen during pregnancy. This enzyme breaks down the histamine that is responsible for the release of hydrochloric acid from the parietal cells in the stomach. Other plausible factors are nutritious diet, rest, avoidance of smoking, alcohol and use of antacids.  PUD can get complicated when it presents with hemorrhage, perforation or stricture formation. 
The symptoms of PUD are mimicked by other common GI problems in pregnancy. Cardinal symptoms of PUD are pain, nausea, and vomiting. The pain is often epigastric and worse at night. In the presence of a gravid uterus, it can be quite difficult for patients to localize the pain. In our patient, pain was initially localized to the lower abdomen. Unlike Reflux disease the pain is not exacerbated by recumbency or associated with regurgitation. Although nausea and vomiting occurs in 50-80% of normal pregnancies, it is uncommon for these symptoms to persist beyond 20-week gestation. Nausea and vomiting of pregnancy is classically most intense in the morning whilst PUD symptoms are worse nocturnally and postprandially during the day. PUD symptoms also get worse with increasing gestation and are therefore usually most severe in the third trimester. Occasionally, PUD may present with hematemesis. Uncomplicated PUD produces minimal physical signs. When complicated physical signs are often present; abdominal tenderness, rebound tenderness, and fecal occult blood may be present. ,
Management should always be multidisciplinary involving obstetricians, gastroenterologists, and surgeons. Baseline investigations should include full blood count, serum urea and electrolytes, liver function tests, and serum amylase. Abdominal ultrasound evaluation is useful to exclude cholelithiases and gall stone pancreatitis. Although abdominal X-rays are generally contraindicated in pregnancy, they must be performed when there is suspicion of GI perforation to assess the presence of pneumo-peritoneum. The maternal and fetal benefits of prompt diagnosis and treatment far outweigh any fetal risks of teratogenicity or childhood cancer. 
For patients who have mild symptoms of PUD, lifestyle changes (avoidance of fatty foods, caffeine, cigarette smoking, alcohol, and nonsteroidal anti-inflammatory drugs) or medications such as antacids or Histamine receptor antagonists, for example, ranitidine can be used. Surgery becomes mandatory when perforation is suspected. Early surgery improves maternal and fetal prognosis. Fluid resuscitation and correction of electrolyte imbalance should be instituted before surgery. Surgery for duodenal perforation usually involves a Graham patch closure.
Postoperative antibiotics should be continued for at least a week. Medical treatment for PUD must be started and continued until patient is seen at the follow-up clinic. Our patient was started on omeprazole. These agents are highly effective in treatment of duodenal ulcers and can be used once patient has delivered. Their safety in pregnancy is however currently unproven because of scant clinical data. Clear follow-up instructions must be given before discharge.
| Conclusion|| |
Perforated duodenal ulcer in pregnancy occurs rarely. This case, is hence reported to draw the attention to its occurrence which may lead to maternal death. The treating doctor should be vigilant to pick it up early in the course of management.
| References|| |
Ito F, Maruyama S, Fujimoto Y, Yamashita K. A case of perforated duodenal ulcer developed during early pregnancy. Adv Obstet Gynecol 2011;63:488-92.
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.
Cappell MS. Gastric and duodenal ulcers during pregnancy. Gastroenterol Clin North Am 2003;32:263-308.
Nazir S, Chung M, Malhotra V, Asarian A, Papas P, Vinces F. Peptic ulcer disease and duodenal perforation in a puerperium female: A case report and literature review. New York, Brooklyn: Lutheran Medical Center. Available from:http://www.sages.org/meetings/annual-meeting/abstracts-archive/peptic-ulcer-disease-and-duodenal-perforation-in-a-puerperium-female-a-case-report-and-liter. Accessed February 28/2014.
Ranganna H, Nalini KS, Biliangadi HN. Duodenal perforation in a lady with twin gestation and severe preeclampsia. J Case Rep 2013;3:349-52.
Paul M, Tew WL, Holliday RL. Perforated peptic ulcer in pregnancy with survival of mother and child: Case report and review of the literature. Can J Surg 1976;19:427-9.
Nigam A, Jain S, Lal P. Twisted ovarian fibroma mimicking as an ectopic pregnancy. J Case Rep 2013;3:64-7.
Frise CJ, Nelson-Piercy C. Peptic ulcer disease in pregnancy. J Obstet Gynaecol 2012;32:804.