Duodenal ulcer perforation during the second stage of spontaneous vaginal delivery: a case report and literature review

Perforated peptic ulcer during pregnancy and puerperium is extremely rare and potentially fatal. Diagnosis is often delayed because atypical symptoms mask signs of peritonitis. Perforation may occur during the intrapartum period. However, no cases have previously been reported during spontaneous vaginal delivery. A 25-year-old primigravida at 37 + 4 weeks of gestation with no history of abdominal surgery and a two-year history of self-limiting epigastric burning suddenly developed severe epigastric pain while actively pushing during the second stage of labor. Although the vaginal delivery proceeded without complications, the localized pain progressed to generalized peritonitis over the hours. A contrast-enhanced CT scan revealed pneumoperitoneum. Exploratory laparotomy uncovered a defect in the anterior duodenum, which was repaired using a Graham omental patch. The patient’s recovery was uneventful; she was discharged on postoperative day 8 with a prescription for Helicobacter pylori eradication therapy, given the identified risk factor. To the best of our knowledge, based on a targeted (non-systematic) literature search, this case represents one of the few reported instances of duodenal ulcer perforation associated with spontaneous vaginal delivery, and, uniquely, one occurring during the active second stage itself. In light of a review of sixteen previously reported patients across thirteen publications, several of which overlap with a recent systematic review, it is important to note that peritoneal signs may be masked or attributed to labor. This underscores the need for a lower threshold for imaging in cases of disproportionate or persistent abdominal pain.