Postpartum Typhoid Intestinal Perforation: A Case Report

Abdulwahab Oluwatomisin Lawal
http://orcid.org/0000-0003-3781-5169
MCON institute of medical research
Department of Surgery, University of Ilorin Teaching Hospital, Ilorin. Nigeria.

Dare Julius
Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin. Nigeria

Olabinjo Hafeezoh
Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin. Nigeria

Balogun Olayinka
Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin. Nigeria

Aremu Ishaq
Department of Surgery, University of Ilorin Teaching Hospital, Ilorin. Nigeria.

Adenuga Adedire
Department of Surgery, Cedarcrest Hospitals Abuja. Nigeria.

DOI: https://doi.org/10.55320/mjz.49.2.1135

Keywords: Typhoid fever, intestinal perforation, Pregnancy

Typhoid fever remains a highly contagious and multi-systemic infection caused by salmonellae typhi, and like other gastro-enteric infection, it poses a higher risk of morbidity and mortality during pregnancy as a result of the physiological changes associated with pregnancy as well as concerns of antibiotic safety in pregnancy. The occurrence of typhoid perforation in pregnancy may be easily confused for other causes of acute abdomen in pregnancy.

We report the presentation, management and outcome of a 25 year old postpartum woman who presented with typhoid intestinal perforation in a resource limited environment. She had an emergency exploratory laparotomy and was managed post operatively in the ICU but clinically deteriorated and subsequently died on the third post-operative day secondary to multiple organ failure from severe sepsis.

Typhoid perforation in pregnancy is a rare presentation, a high index of suspicion, and early intervention, would reduce the incidence of morbidity and mortality associated with this disease condition.

Typhoid fever is a potentially fatal and highly contagious, multi-systemic infection with salmonellae typhi: a human specific gram negative bacillus.^[1] It is mainly spread through the ingestion of food or water contaminated with the pathogen. Intravenous and trans-placental transmissions have also been documented^[2] .

The incubation period usually ranges between 7-14 days and an inoculum of about 1000 organisms or more is required for active infection to occur^[2] , however pregnant women may develop the disease earlier than 7 days with a lower bacterial load, due to reduced peristalsis, biliary stasis and the immunomodulation that occurs with pregnancy which is aimed at increasing the pregnant woman’s tolerance for the foetal graft.^{[3, 4]} Bowel perforation is a grave complication of typhoid enteritis and the management poses significant challenge to surgeons in developing countries owing to late presentation, lack of availability of appropriate diagnostic amenities and emergence of virulent strains of the causative organism.^{[5, 6]}

The diagnosis of typhoid fever is largely uncommon in pregnancy and more often late.^[3] This could be due to underdiagnosis as the condition may mimic common febrile illnesses such as malaria in pregnancy. Nausea and vomiting may be attributed to the pregnancy symptoms and the associated abdominal pain may be dismissed as labour pain at or near term7, in which the disease entity itself may be a precipitant to preterm labour.^[7]

The occurrence of typhoid perforation in pregnancy is also rare and may be easily confused for other causes of acute abdomen in pregnancy, such as degenerating uterine fibroids, ovarian accidents or acute appendicitis^[8]

Blood picture may not show leucocytosis due to pregnancy and malnutrition^[7] . In addition, radiographs and computed tomography are usually avoided in pregnancy due to fear of exposure of the unborn newborn to ionizing radiation^[7] . Many patients also present late as a result of multiple initial home care therapies, attribution of the pain to being normal for the pregnant status and delay in diagnosis at health centres. This results in presentation of such patient in a poor clinical state. All of these contribute to the poor prognosis associated with this disease condition.^[9]

A 25year old, P3⁺⁰ (3 alive) woman presenting 5 days postpartum following preterm vaginal delivery of a live male neonate at estimated gestational age of 34 weeks in a peripheral hospital. She presented with severe abdominal pain of eight days duration with associated high-grade fever. There was associated history of multiple episodes of bilious vomiting, abdominal distension and constipation, with reduction in urine output. She had gone into preterm labour 3 days after the onset of symptoms, and had since been managed at the peripheral hospital prior presentation to our facility. Baby was alive and well at the time of presentation.

Examination at presentation revealed an acutely ill looking woman, pale, febrile: 39.6°C, in respiratory distress, with a respiratory rate of 50 cycles per minute and a SPO2 of 97% in room air. Pulse rate was 128 beats per minute and blood pressure was of 90/70 mm/hg. Her abdomen was distended with generalised tenderness and guarding.

Complete blood count showed a packed cell volume of 32% and white blood cell count of 21x109 /L with 82% neutrophilia. Thick and thin films for malaria parasite were positive. She had elevated urea and creatinine of 17.7mmol/L and 139mmol/L respectively, but liver function parameters were essentially normal. Abdominal and chest radiograph showed free peritoneal air.

She was resuscitated with intravenous fluids, analgesics and antibiotics. She was placed on nasogastric tube and urethral catheter with hourly monitoring of urine output. She had an emergency laparotomy done with intraoperative finding of multiple (five) typhoid perforations at the terminal ileum with associated massive faecal soilage. She had resection of the diseased segment and a divided ileostomy done.

She was managed post operatively in the ICU but clinically deteriorated, developing severe sepsis with septic shock, and subsequently died on the third post-operative day secondary to multiple organ failure.

About 0.6-4.9% of enteric fever cases have been complicated by intestinal perforation.10 A higher rate of 10-33% have been reported in West Africa which has been linked to the high virulence of the salmonella typhi strains in West Africa and the heightened hypersensitivity reaction in the Peyer’s Patches of individuals in this subregion.^{[9, 10]}

Initial infection is characterised by malaise, vague abdominal pain, erythematous rash (rose spots), myalgia and rising fever.^{[2, 4]} In peripartum women, these symptoms may be initially mistaken for viral febrile illnesses; malaria fever, urinary tract infection, chorioamnionitis or puerperal sepsis.^[2] Failure to receive prompt treatment may result in altered sensorium, intestinal haemorrhage and bowel perforation^{[2, 9]} . This patient presented initially at a peripheral hospital where she was commenced on oral antibiotics for a probable bacterial infection.

Typhoid perforation is the most dangerous complication of typhoid enteritis as it is highly unpredictable and associated with high morbidity and mortality^[10] . Unresolved typhoid enteritis results in bacteraemia and settling of organisms in the bile from where they further migrate into the reticulo-endothelial system and multiply rapidly^{[3, 5]} A high proportion of the total bacterial load settles in the Payers patches of the terminal ileum in the second week of the infection resulting in hypertrophy, mesenteric adenitis and ulceration due to the recruitment of inflammatory cells of the mononuclear and lymphocytic cell^[9] . It is thought that perforation occur as a result of delayed hypersensitivity reaction elicited by the organism^[9] This may explain the occurrence of perforation in patients who are already on antibiotics specific for salmonella and in those who have had prior laparotomy and closure of perforation.^[8]

In pregnant patients, the gravid uterus usually separates the parietal peritoneum of the anterior abdominal wall from the content of the perforated bowel leading to a delay in eliciting the features of peritonitis (guarding, tenderness and rebound tenderness).^{[2, 10]} Also, the rapid progression of the disease in pregnancy to involve complications like confusion and typhoid psychosis may obscure intestinal perforation and are often accompanied by septic shock leading to death.^{[2, 9, 10]} Apart from the problem of delayed diagnosis, pregnant women with typhoid fever are at increased risk of foetal loss especially in the first and second trimester. The risk of preterm delivery is highest in the third trimester, as seen in this case. Therefore, fever in pregnancy should be investigated early and treated adequately. Also abdominal pain should not be dismissed simply as due to physiological and anatomical changes in pregnancy until after thorough evaluation.

The investigation of choice for patient with peritonitis is an abdominal CT^[8] . It is a very good imaging modality and readily shows pneumoperitoneum and presence of free intraperitoneal fluid. Due to the limitation in this environment which includes financial and logistic problems, the diagnosis of intestinal perforation was confirmed by the presence of pneumoperitoneum in the erect plain chest radiograph of the patient. Plain chest radiograph is cheap and a readily available, it does not require the use of contrast and it is a good alternative option for initial imaging^[3] . Abdominal ultrasound can detect free intraperitoneal fluid and can give reasonable information on the ovaries and the uterus to rule out differentials. It is however limited in the presence of gaseous distension of the bowel. The combination of chest radiograph and abdominal ultrasound is very helpful in our environmental setting^[8] . Also, ciprofloxacin: a cheap and essential antibiotic in the management of typhoid enteritis is considered unsafe in pregnancy^[3] .

Early diagnosis, prompt resuscitation, antibiotics therapy and early surgical intervention are central to reducing the morbidity and mortality associated with intestinal typhoid perforation^{[2, 3]} . Diagnosis in the index case was delayed as her symptoms started during pregnancy, masking the clinical features. Also her health care was largely out of pocket and significantly delayed due to financial constraint, which also led to a delay in surgical intervention and at the time of surgery there was massive intraperitoneal faecal spillage, all of which contributed to poor prognostic factors.

Surgical intervention involves resection and anastomosis with intestinal diversion via an ileostomy. This is followed by copious peritoneal lavage, closure and post-operative intensive care. The surgical options for typhoid perforation in pregnancy or puerperium are limited as these patients come in late, with poor haemodynamic status and poor circulatory reserves. This patient had an ileostomy done on account of multiple ileal perforations and presence of faecal peritonitis.

Typhoid enteritis and perforation are better prevented in the general population.^{[3, 4]} This can be achieved by enlightening the public on maintaining strict hygiene for food and water and via immunization campaigns^{[3, 4]} . Health care professionals should have a high index of suspicion for women living in a low-resource setting presenting with an acute abdomen. Radiological imaging and proper evaluation of these patients should be done and abdominal pain should not be ruled out solely because of the pregnant or recently delivered status of a woman.

This report describes the presentation, management and outcome of a 25 year old postpartum woman who presented with typhoid perforation in a resource limited environment. She had an emergency exploratory laparotomy and was managed post operatively in the ICU but clinically deteriorated and subsequently died on the third post-operative day secondary to multiple organ failure from severe sepsis.

Typhoid perforation in pregnancy or puerperium is a rare presentation, a high index of suspicion, early recognition, prompt resuscitation and swift surgical intervention, would reduce the incidence of morbidity and mortality associated with this disease condition.

1. Parry CM, Hien TT, Dougan G, White NJ, Farvar JJ. Typhoid Fever. New England Journal of Medicine . 2002;347(22):770–82.
2. Seoud M, Saade G, Uwaydah M, Azoury R. Typhoid fever in pregnancy. Obstetrics and Gynecolology. 1988;7(5):711–4.
3. Touchan F, Hall JD, Richard VL. Typhoid fever during pregnancy: case report and review. Obstetrics Medicine. 2009;2(4):161–3.
4. Crump JA. Progress in typhoid fever epidemiology. Clinical infectious disease 2019;68 (Suppl 1):S4–9.
5. Ukwenya AY, Ahmed A, Garba ES. Progress in the management of typhoid perforation. Annals of African Medicine. 2011;10(4):259–65.
6. Agboola JO, Olatoke SA, Adebisi RG. Pattern and presentation of acute abdomen in a Nigeria teaching Hospital. Nigerian Medical Journal. 2014;55(3):255–70.
7. Riggall F, Salkind G, Spizllacy W. Typhoid fever complicating pregnancy. Obstetrics and Gynecology. 1974;44(1):117–21.
8. Chuang MT, Chen TS. Bowel obstruction and perforation during pregnancy: Case report and literature review. Taiwanese Journal of Obstetrics and Gynecology. 2021 Sep 1;60(5):927-30.
9. Na’aya HU, Eni UE, Chama CM. Typhoid perforation in Maiduguri, Nigeria. Annals of African Medicine. 2004;3(2):69–72.
10. Chalya PL, Mabula JB, Koy M, Kataraihya JB, Jaka H, Mshana SE, Mirambo M, Mchembe, Giiti G, Gilyoma JM. Typhoid intestinal perforations at a university teaching hospital in northwestern Tanzania: A surgical experience of 104 cases in a resource-limited setting. World Journal of Emergancy Surgery. 2012;7(1):1–11.
11. Manikanta KS, Sharangouda Patil, Mir Hassan. A Clinical Study of Prognostic Factors in Typhoid Ileal Perforation: in a Tertiary Hospital. SSRG- International Journal of Medicine Science. 2016;3(5):1–10.

Medical Journal of Zambia, Vol 49, 2

The Medical Journal of Zambia, ISSN 0047-651X, is published by the Zambia Medical Association.
© This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.