Perforated Duodenal Ulcer in the Immediate Postpartum Period: Diagnostic Pitfalls Following Caesarean Delivery

Postpartum abdominal pain is frequently encountered and is most often related to obstetric causes such as uterine involution, infection, or postoperative discomfort following cesarean delivery; however, more atypical etiologies can also occur. Perforated peptic ulcer disease in the immediate postpartum period is uncommon and may be overlooked, particularly when symptoms overlap with expected postoperative findings and recent surgical history. We report a woman in her early 30s who developed severe upper abdominal pain four days after a primary cesarean delivery performed for maternal exhaustion in the setting of intraamniotic infection. Her initial postoperative course was uncomplicated, and she was discharged on scheduled ibuprofen and acetaminophen for pain control. On presentation, she was tachycardic with elevated liver enzymes, raising concerns for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, biliary pathology, or postoperative infection. MRI and CT imaging demonstrated pneumoperitoneum and ascites, findings that were initially attributed to recent surgery. Due to persistent symptoms, a diagnostic laparoscopy was performed and revealed a 1.5 cm perforated duodenal ulcer with diffuse peritonitis. The ulcer was repaired with oversewing and a Graham patch, and the patient recovered following appropriate surgical and medical management; Helicobacter pylori testing prior to discharge was negative. This case highlights that a perforated peptic ulcer should remain in the differential diagnosis for postpartum patients presenting with persistent abdominal pain, even in the absence of classic risk factors, as recent cesarean delivery can complicate imaging interpretation and delay diagnosis, underscoring the importance of early multidisciplinary evaluation and prompt surgical intervention to reduce morbidity.