Postpartum pneumoperitoneum without any visceral perforation: a case report and literature review

Introduction and Importance: Spontaneous postpartum pneumoperitoneum (SPPP) is extraordinarily uncommon; fewer than ten cases are documented but radiographically it imitates visceral perforation, the archetypal surgical catastrophe. Prompt recognition averts unwarranted laparotomy and preserves maternal health. Case Presentation: A 24‑year‑old G4P3 delivered vaginally with a fourth‑degree perineal tear. Twenty‑four hours later she developed mild abdominal discomfort and transient tachycardia. CT showed discrete subdiaphragmatic free air; repeat CT with rectal contrast and cystography confirmed pneumoperitoneum without leak. Her abdomen remained soft and non‑tender, and vital signs normalized. Under multidisciplinary observation she received intravenous fluids, analgesia, ceftriaxone and metronidazole; symptoms resolved and day 3 imaging was unchanged. She was discharged fully recovered on postpartum day 5. Clinical Discussion: Air probably traversed the transiently patent cervix, uterus, and fallopian tubes, a route amplified by deep perineal trauma and operative manipulation. A focused literature review (pre-specified databases and criteria) supports three hallmarks of benign SPPP onset within 72 h postpartum, absence of peritonitis, and rapid response to conservative care and highlights an incidentally detected asymptomatic postpartum case, suggesting under-recognition of subclinical presentations. Our report is the first to describe SPPP in a patient with both grade IV tear and previous cesarean section, broadening the clinical spectrum. Conclusion: Heightened awareness of SPPP allows judicious observation, prevents unnecessary surgery, and optimizes postpartum recovery.