Persistent Postpartum Fever May be a Symptom of Gastric Cancer

A 39-year-old primigravida was admitted at 31 weeks gestation for suspected preterm labor. 

The lady had a history of polycystic ovarian syndrome (PCOS) and autonomic ataxia. Her family history included hepatitis B, prostate cancer, hypertension in her paternal side, and thyroid cancer in her mother.

The patient conceived after ovulation induction with clomiphene citrate and human menopausal gonadotrophin and had dichorionic diamniotic twins. She had ovarian hyperstimulation syndrome, which improved with treatment, and she received regular pregnancy checkups. She experienced hyperemesis at 15 weeks and gastric compression and vomiting at 26 and 31 weeks, which did not worsen. 

At 31 weeks and five days, she was admitted for threatened preterm labor. At 32 weeks and one day, she developed a fever and tested positive for influenza A – treated with oseltamivir. 

At 32 weeks and five days, an emergency cesarean section was performed due to premature rupture of membranes. Postoperatively, she had no complications and was discharged on postpartum day six.

On postpartum day seven, she developed a fever, back pain, and abdominal pain and was admitted on postpartum day 10. Physical examination showed normal blood pressure and heart rate but a fluctuating fever and upper respiratory symptoms. Abdominal examination and transvaginal ultrasound revealed ascites but no signs of uterine infection. Suspected pyelonephritis was evaluated with an abdominal ultrasound, which showed a small liver mass. Blood tests showed mildly elevated WBC and CRP. She tested positive for influenza A again and was treated with zanamivir inhalation therapy.

Persistent fever postpartum day 18 despite zanamivir therapy led to further investigations. Repeat ultrasound showed ascites and several cystic liver lesions. Contrast-enhanced CT identified multiple tumors in the liver, enlarged lymph nodes, splenomegaly, ascites, and gastric wall thickening. Elevated CEA and CA19-9 levels and upper gastrointestinal endoscopy indicated Borrmann type 4 gastric cancer, confirmed as stage IV adenocarcinoma.

Chemotherapy was commenced on postpartum day 29 with various drug combinations, but the disease progressed, and she passed away 10 months after diagnosis. 

Pregnancy-associated gastric cancer is rare and often misdiagnosed due to symptom overlap with pregnancy. Persistent gastrointestinal symptoms or unexplained fever should prompt endoscopic evaluation. In this case, thorough ultrasound examinations led to the diagnosis of gastric cancer – highlighting the importance of detailed imaging in such cases.

Source: Sato T, Kawamura H, Haba G, et al. Cureus. 2024 May;16(5).