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Perforated peptic ulcer in pregnancy and puerperium: A systematic review
Goran Augustin1, Jure Krstulović2,3, Ante Tavra3
1Department of Surgery, University Hospital Centre Zagreb, Zagreb 10000, Croatia. augustin.goran@gmail.com.
Background:
Peptic ulcer disease (PUD) during pregnancy is extremely rare. Perforated peptic ulcer (PPU) during pregnancy has high maternal and fetal mortality. Symptoms attributed to pregnancy and other diagnoses make the diagnosis of preoperative PPU during pregnancy and puerperium challenging.
Aim:
To identify predictive factors for early diagnosis and treatment, and the association between the diagnosis and maternal/neonatal outcomes.
Methods:
We searched PubMed, PubMed Central, and Google Scholar. Articles were analyzed following preferred reporting items for systematic reviews and meta-analysis. The search items included: 'ulcer', 'PUD', 'pregnancy', 'puerperium', 'postpartum', 'gravid', 'labor', 'perforated ulcer', 'stomach ulcer', 'duodenal ulcer', 'peptic ulcer'. Additional studies were extracted by reviewing reference lists of retrieved studies. We included all available full-text cases and case series. Demographic, clinical, obstetric, diagnostic and treatment parameters, and outcomes were collected.
Results:
Forty-three cases were collected. The mean maternal age was 30.9 years; 36.6% were multiparous, and 63.4% were nulliparous or primiparous, with multiparas being older than primiparas. Peptic ulcer perforated in 44.2% of postpartum and 55.8% of antepartum patients. Antepartum PPU incidence increased with advancing gestation 2.3% in the first, 7% in the second, and 46.5% in the third trimester. The most common clinical findings were abdominal tenderness (72.1%), rigidity (34.9%), and distension (48.8%). Duodenal ulcer predominated (76.7%). In 79.5%, the time from delivery to surgery or vice versa was > 24 hours. The maternal mortality during the third trimester and postpartum was 10% and 31.6%, respectively. The trimester of presentation did not influence maternal mortality. The fetal mortality was 34.8%, with all deaths in gestational weeks 24-32.
Conclusion:
Almost all patients with PPU in pregnancy or puerperium presented during the third trimester or the first 8 days postpartum. Early intervention reduced fetal mortality but without influence on maternal mortality. Maternal mortality did not depend on the use of X-ray imaging, perforation location, delivery type, trimester of presentation, and maternal age. Explorative laparoscopy was never performed during pregnancy, only postpartum.
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