Post-cesarean pneumoperitoneum beyond expected revealing a sealed cecal perforation: a case report

Small volumes of intraperitoneal air can follow cesarean delivery, but persistence or progression beyond the immediate postoperative period is unusual and may indicate hollow-viscus injury.

A 30-year-old gravida 5, para 3, abortus 1 Palestinian female with prior right ovarian cystectomy underwent an uncomplicated elective lower-segment cesarean section and was discharged on postoperative day 2. She re-presented on postoperative day 4 with colicky abdominal pain, distension, and subjective fever. The examination showed tachycardia and a distended, tympanitic abdomen with a clean Pfannenstiel incision. The inflammatory markers and leukocyte count rose. Computed tomography demonstrated pneumoperitoneum greater than expected postoperatively with diffuse bowel dilatation and mild free fluid; repeat computed tomography on postoperative day 6 showed progression. Oral-contrast computed tomography showed no extravasation. Peritoneal aspiration yielded turbid fluid that cultured extended-spectrum β-lactamase-producing Escherichia coli. As the isolate demonstrated sensitivity to gentamicin, the empiric aminoglycoside was continued incombination with metronidazole. This regimen was maintained until surgery, as advised by the infectious diseases team. Given concern for occult perforation, exploratory laparotomy on postoperative day 10 revealed fibrinous peritonitis and an approximately 2-cm sealed cecal perforation with healthy margins. Primary repair with appendectomy and drainage was performed. Early postoperative recovery was stable.

Progressive post-cesarean pneumoperitoneum, even with a negative contrast study, should prompt a high index of suspicion for concealed bowel perforation. Correlating serial imaging with inflammatory markers and peritoneal fluid analysis can guide timely intervention. When identified early, and when intraoperative contamination is limited, bowel-preserving primary repair with drainage can achieve favorable maternal outcomes.