Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

DOI: https://doi.org/10.46296/yc.v10i19.0958

CORIOAMNIONITIS Y TUBERCULOSIS PERITONEAL EN EL EMBARAZO:

DIAGNÓSTICO INESPERADO Y DESENLACE OBSTÉTRICO ADVERSO.

REPORTE DE CASO

CHORIOAMNIONITIS AND PERITONEAL TUBERCULOSIS IN

PREGNANCY: AN UNEXPECTED DIAGNOSIS AND ADVERSE OBSTETRIC

OUTCOME—A CASE REPORT

1

Martinez-Soto Jessenia Elizabeth ; Salinas-Rocano Diana Jacqueline ;

Poma-Ramon Luis Alejandro ¹

1

Physician, University of Cuenca. Cuenca, Ecuador.

Resumen

Antecedentes: La infección intraamniótica es una causa importante de morbilidad materna y

desenlaces perinatales adversos. La tuberculosis durante el embarazo, en particular sus formas

extrapulmonares, puede manifestarse con síntomas inespecíficos y retrasar el diagnóstico. La

coexistencia de infección intraamniótica y tuberculosis peritoneal es excepcional y plantea un

reto diagnóstico cuando la fiebre persiste pese al tratamiento antimicrobiano y al control del foco

obstétrico. Presentación del caso: Una gestante con edad gestacional estimada de 21,8 semanas

ingresó por fiebre, dolor abdominal tipo contracción, sangrado vaginal y pérdida de líquido

amniótico. Presentaba taquicardia materna, temperatura de 38,6 °C, leucocitosis con neutrofilia

y rotura prolongada de membranas. La amniocentesis obtuvo líquido turbio y amarillento, con

marcada respuesta neutrofílica, glucosa no detectable y abundantes cocos grampositivos,

hallazgos compatibles con infección intraamniótica. Ante hallazgos ecográficos fetales

preocupantes y la persistencia de la infección, se indicó la interrupción médica del embarazo,

que culminó con la expulsión de un feto masculino de aproximadamente 370 g, sin signos vitales.

Posteriormente persistieron la fiebre elevada, la leucocitosis y el dolor abdominal intenso. La

laparotomía exploratoria evidenció engrosamiento peritoneal, múltiples lesiones blanquecino-

amarillentas, adherencias fibroadhesivas y líquido libre de aspecto purulento. La biopsia

peritoneal mostró inflamación granulomatosa necrosante con células gigantes tipo Langhans, y

el cultivo del líquido peritoneal aisló Mycobacterium tuberculosis, lo que confirmó el diagnóstico

de tuberculosis peritoneal. Conclusión: La persistencia de fiebre tras el tratamiento de una

aparente infección obstétrica debe motivar una reevaluación diagnóstica. La tuberculosis

peritoneal puede coexistir con una infección intraamniótica y simular o prolongar un cuadro de

sepsis obstétrica. Debido a que no se documentó M. tuberculosis en la placenta, las membranas

ni el líquido amniótico, no puede establecerse una relación causal directa entre la tuberculosis y

la corioamnionitis en esta paciente.

Palabras claves: corioamnionitis; infección intraamniótica; tuberculosis peritoneal; embarazo;

rotura prematura pretérmino de membranas; Mycobacterium tuberculosis.

Abstract

Background: Intra-amniotic infection is an important cause of maternal morbidity and adverse

perinatal outcomes. Tuberculosis during pregnancy, particularly extrapulmonary disease, may

have nonspecific manifestations and consequently be diagnosed late. The coexistence of intra-

amniotic infection and peritoneal tuberculosis is rare and poses a diagnostic challenge when fever

persists despite antimicrobial therapy and obstetric source control. Case presentation: A pregnant

patient at an estimated gestational age of 21.8 weeks was admitted with fever, contraction-like

abdominal pain, vaginal bleeding, and leakage of amniotic fluid. Maternal tachycardia, a

temperature of 38.6 °C, neutrophilic leukocytosis, and prolonged rupture of membranes were

documented. Amniocentesis yielded turbid, yellow fluid with a marked neutrophilic response,

undetectable glucose, and abundant gram-positive cocci, supporting the diagnosis of intra-

amniotic infection. Because of concerning fetal ultrasonographic findings and ongoing infection,

Información del manuscrito:

Fecha de recepción: 16 de abril de 2026.

Fecha de aceptación: 18 de junio de 2026.

Fecha de publicación: 10 de julio de 2026.

6

66

Martinez-Soto et al. (2026)

the pregnancy was terminated for medical indications, resulting in delivery of a male fetus

weighing approximately 370 g, with no signs of life. High-grade fever, leukocytosis, and severe

abdominal pain persisted thereafter. Exploratory laparotomy revealed diffuse peritoneal

thickening, multiple whitish-yellow lesions, extensive fibroadhesive changes, and free

intraperitoneal fluid with a purulent appearance. Peritoneal biopsy demonstrated necrotizing

granulomatous inflammation with Langhans-type giant cells, and peritoneal-fluid culture grew

Mycobacterium tuberculosis, confirming peritoneal tuberculosis. Conclusion: Persistent fever

after treatment of an apparent obstetric infection should prompt diagnostic reassessment.

Peritoneal tuberculosis may coexist with intra-amniotic infection and mimic or prolong obstetric

sepsis. Because M. tuberculosis was not documented in the placenta, membranes, or amniotic

fluid, a direct causal relationship between tuberculosis and chorioamnionitis cannot be

established in this patient.

Keywords: chorioamnionitis; intra-amniotic infection; peritoneal tuberculosis; pregnancy; preterm

prelabor rupture of membranes; Mycobacterium tuberculosis.

histopathology do not always

1

. Introduction

coincide.

Contemporary

emphasize

Tuberculosis (TB) remains a leading

cause of death from a single

infectious agent. The World Health

Organization estimated 10.7 million

incident TB cases and 1.23 million

TB-related deaths in 2024, including

recommendations

integrating maternal fever and

associated clinical findings with

microbiologic

or

inflammatory

evidence, particularly in cases

involving preterm prelabor rupture of

membranes and preterm birth [3,4].

3

.7 million cases among women [1].

Diagnosis during pregnancy may be

particularly challenging because

constitutional manifestations such as

fatigue, weight changes, dyspnea,

and sweating can overlap with

physiologic changes of gestation,

while extrapulmonary disease may

occur without respiratory symptoms

that would otherwise raise clinical

suspicion [2].

Peritoneal TB is an uncommon form

of extrapulmonary tuberculosis that

may present with persistent fever,

abdominal pain, ascites, peritoneal

thickening, or adhesions. These

findings overlap with those of several

surgical, infectious, gynecologic, and

obstetric conditions [5]. During

pregnancy, placental TB, intrauterine

infection caused by M. tuberculosis,

and acute membranitis have been

described. However, establishing

that clinical chorioamnionitis is

directly caused by M. tuberculosis

requires organism-specific evidence

Intra-amniotic infection, historically

referred to in clinical practice as

chorioamnionitis, encompasses a

spectrum in which clinical findings,

amniotic-fluid

results,

and

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

from the placenta, membranes,

amniotic fluid, or fetal tissues [6-8].

documented fever above 38.5 °C and

intermittent contraction-like

abdominal pain. She had self-

administered an anti-inflammatory

medication but could not recall the

active ingredient. She additionally

described leakage of clear, non-

We report the case of a patient in the

second trimester of pregnancy who

was initially managed for intra-

amniotic infection in the setting of

prolonged rupture.

Persistent fever followed by signs of

peritoneal irritation prompted

membrane

malodorous

vaginal

fluid;

a

crystallization test was positive for

amniotic fluid, prompting referral to a

hospital.

exploratory laparotomy and led to the

unexpected diagnosis of peritoneal

TB. This report identifies clinical

findings that should trigger diagnostic

On admission, moderate-intensity

contractions and leakage of clear

fluid persisted. No relevant medical,

allergy, or surgical history was

documented in the available clinical

record. Vital signs were as follows:

heart rate, 118 beats/min; blood

pressure, 110/70 mmHg; respiratory

rate, 19 breaths/min; oxygen

saturation, 94% on room air; and

axillary temperature, 38.6 °C. The

patient was alert and oriented.

reassessment

examines the

and

critically

but

possible,

unproven, association between the

two infectious processes.

2

. Case Presentation

A pregnant patient at an estimated

gestational age of 21.8 weeks by last

menstrual period presented with

contraction-like abdominal pain of

approximately three hours' duration.

The pain was initially mild and later

became moderate in intensity, and it

was accompanied by a moderate

Cardiopulmonary examination was

unremarkable. The abdomen was

enlarged by the gravid uterus, with a

uterine fundal height of 21 cm. Fetal

heart rate was 140 beats/min, and

uterine activity consisted of two

contractions within 10 minutes, each

lasting 15-20 seconds. The cervix

was posterior and closed, without

amount

of

bright-red

vaginal

bleeding. A previous ultrasound

examination had reportedly shown

complete placenta previa. The

patient also reported seven days of

6

68

Martinez-Soto et al. (2026)

effacement. Vaginal bleeding and

leakage of clear fluid were observed.

The clinical record documented

membrane rupture approximately six

days before examination.

amniotic fluid index of 12.6 cm, an

anterior placenta, breech

presentation, and male fetal sex. No

fetal movements were observed. The

institutional description of an anterior

placenta differed from the prior

Initial Diagnostic Assessment

external

ultrasound

report

of

complete placenta previa. Because

the complete earlier study was

unavailable, this discrepancy could

not be resolved retrospectively.

Complete blood count showed a

leukocyte count of 12.3 × 10³/µL, a

neutrophil count of 10.2 × 10³/µL

(85.6%), hemoglobin of 10.2 g/dL,

hematocrit of 29.7%, and a platelet

count of 232 × 10³/µL. C-reactive

protein was 10 mg/L. Initial

examination of the amniotic fluid

revealed abundant inflammatory

cells, bacteria (2+), and some gram-

positive cocci in pairs. Subsequent

amniocentesis yielded turbid, yellow

Therapeutic

Intervention

and

Obstetric Outcome

During hospitalization, febrile peaks

above 38 °C persisted. Intravenous

paracetamol, isotonic saline, and

broad-spectrum

therapy were administered. The

available record identifies

antimicrobial

fluid with

a

predominance of

polymorphonuclear cells (93%),

undetectable glucose, and abundant

leukocytes and gram-positive cocci

on Gram stain. Together with

ceftriaxone 1 g intravenously every

12 hours and documents a second

antimicrobial agent administered at

900 mg intravenously every 8 hours,

but does not identify that agent.

maternal

fever,

tachycardia,

prolonged rupture of membranes,

and uterine symptoms, these

findings supported the diagnosis of

intra-amniotic infection.

Given

the

concerning

findings

fetal

and

ultrasonographic

ongoing infection, the treating team

decided to terminate the pregnancy

for

medical

indications.

The

Institutional

obstetric

procedure resulted in delivery of a

male fetus weighing approximately

ultrasonography estimated a fetal

weight of 342 g and documented a

fetal heart rate of 150 beats/min, an

3

70 g, with no signs of life.

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

Despite termination of the pregnancy

and antimicrobial therapy, the febrile

Granulomatous tissue adherent to

the parietal peritoneum was sampled

for histopathologic examination, and

the peritoneal fluid was submitted for

culture.

syndrome

Approximately 10 days later,

temperatures above 38.9 °C

persisted, with a leukocyte count of

5.4 10³/µL and marked

neutrophilia. The patient developed

severe hypogastric pain on

did

not

resolve.

Histopathologic examination showed

granulomatous inflammation with

central necrosis, epithelioid cells,

lymphocytes, and Langhans-type

giant cells. Culture of the peritoneal

1

×

superficial and deep palpation, signs

of peritoneal irritation, and a visual

analog pain score of 9/10. This

fluid

grew

Mycobacterium

concordance

necrotizing

tuberculosis.

between

The

the

clinical

evolution

prompted

reassessment of the initial diagnosis

and investigation for an uncontrolled

intra-abdominal focus.

granulomatous morphology and

microbiologic

established

peritoneal

confirmation

the

diagnosis

of

Unexpected

Diagnosis

of

tuberculosis.

The

Peritoneal Tuberculosis

available source material did not

document molecular drug-resistance

testing, examination of the placenta

or membranes for M. tuberculosis,

TB-specific fetal evaluation, the

Exploratory

laparotomy

was

performed. Intraoperatively, diffuse

peritoneal thickening, multiple

whitish-yellow lesions involving the

visceral surfaces, extensive

subsequent

antituberculous

regimen, or maternal follow-up; these

data were therefore neither inferred

nor reconstructed.

fibroadhesive changes, and free

intraperitoneal fluid with a purulent

appearance

were

identified.

Clinical Timeline

Clinical time point

Key findings and decisions

~

7 days before admission

Fever >38.5 °C, contraction-like pain, and leakage of clear fluid.

Vaginal bleeding, fluid leakage, temperature 38.6 °C, heart rate

Admission, ~21.8 weeks

118/min, membranes ruptured for several days, cervix closed.

6

70

Martinez-Soto et al. (2026)

Clinical time point

Key findings and decisions

Leukocytosis/neutrophilia;

inflammatory

amniotic

fluid.

Initial evaluation

Amniocentesis: turbid fluid, 93% polymorphonuclear cells,

undetectable glucose, and abundant gram-positive cocci.

Antipyretics, hydration, and broad-spectrum antibiotics.

Ultrasound showed abnormal fetal findings and absence of fetal

movements.

During hospitalization

Obstetric outcome

Medically indicated pregnancy termination; male fetus without

signs of life, approximately 370 g.

Persistent fever >38.9 °C, leukocytosis/neutrophilia, severe

hypogastric pain, and signs of peritoneal irritation.

~

10 days later

Thickened peritoneum, diffuse whitish-yellow lesions,

Laparotomy

fibroadhesive changes, and free fluid with a purulent

appearance.

Biopsy with necrotizing granulomas and Langhans-type giant

cells; peritoneal-fluid culture positive for M. tuberculosis.

Etiologic confirmation

Surgical and Histopathologic Findings

Figure 1. Intraoperative findings during exploratory laparotomy. The peritoneal surfaces show

diffuse inflammatory changes, whitish-yellow lesions, and an adhesive pattern. The image is

reproduced from the original clinical material without diagnostic markings or other alterations.

6

71

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

Figure 2. Micrograph of peritoneal tissue. Histopathologic examination showed granulomatous

inflammation with central necrosis, epithelioid cells, lymphocytes, and Langhans-type giant cells,

findings suggestive of a tuberculous etiology. Magnification was not documented in the source

record.

from the American College of

3

. Discussion

Obstetricians and Gynecologists and

1

. From the Initial Obstetric

recent

microbiologic

integrating

reviews

clinical

Diagnosis to the Need for

Reassessment

emphasize

suspicion with amniotic-fluid data

when available, because fever alone

identifies neither the underlying

The initial diagnostic framework was

clinically consistent with intra-

amniotic infection in a pregnancy at a

etiology

nor

the

affected

compartment [3,4].

previable

gestational

age

complicated by prolonged rupture of

membranes. Maternal fever of 38.6

The critical issue in this case was

therefore not the plausibility of the

initial diagnosis, but its inability to

explain the entire subsequent clinical

course. After pregnancy termination

and broad-spectrum antimicrobial

therapy, persistent high-grade fever,

increasing leukocytosis, and the

development of abdominal pain with

°

C accompanied by tachycardia,

uterine symptoms, and fluid leakage

required immediate evaluation.

Amniocentesis

evidence

provided

direct

of

intra-amniotic

inflammation: turbid fluid, neutrophil

predominance, undetectable

glucose, and abundant gram-positive

cocci. Current recommendations

signs

of

peritoneal

irritation

suggested an additional disease

6

72

Martinez-Soto et al. (2026)

process or an uncontrolled focus.

Continuing to attribute the entire

course to chorioamnionitis alone

would have reflected diagnostic

anchoring. The change in clinical

trajectory appropriately prompted

reassessment of the differential

diagnosis and surgical exploration.

macroscopic appearance is not

pathognomonic and may mimic

carcinomatosis,

inflammatory

disease, fungal infection, or other

granulomatous peritonitides. The

diagnostic strength of this case lies in

the concordance between pathology

and

microbiology:

necrotizing

granulomas with Langhans-type

giant cells supported a mycobacterial

etiology, while culture of the

2

. Peritoneal Tuberculosis: Why It

May Be Missed During Pregnancy

peritoneal fluid

tuberculosis.

confirmed

M.

Peritoneal TB is an extrapulmonary

form of tuberculosis characterized by

nonspecific manifestations. Fever,

abdominal pain, anorexia, weight

In patients with ascites, ascitic-fluid

adenosine deaminase may support

suspicion of peritoneal TB. An

updated meta-analysis reported

pooled sensitivity and specificity

estimates of approximately 0.90 and

loss,

ascites,

and

peritoneal

thickening may evolve subacutely

and be mistaken for inflammatory or

infectious processes of another

etiology. During pregnancy, this

diagnostic difficulty is amplified

because constitutional symptoms

may overlap with physiologic

0

.94, respectively, although the

overall certainty of evidence was

very low [9]. Molecular assays such

as Xpert MTB/RIF may provide rapid

changes

of

gestation,

and

confirmation

and

an

initial

extrapulmonary disease may occur

without prominent cough or other

respiratory manifestations [2,5].

assessment of resistance, but their

sensitivity for abdominal TB is

limited, and a negative result does

not

exclude

disease

[5,10].

Laparotomy in this patient revealed a

Therefore, when the peritoneum is

accessible, tissue acquisition for

pattern

highly

TB:

suggestive

of

abdominal

a

thickened

histopathology,

culture,

and

peritoneum, whitish-yellow lesions,

fibroadhesive changes, and free

peritoneal fluid. Nevertheless, the

molecular testing represents a high-

value diagnostic strategy.

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

3

. Can Tuberculosis Explain the

polymerase chain reaction, or

staining for M. tuberculosis was

available from the amniotic fluid,

placenta, membranes, or fetal

tissues, and placental histopathology

was not documented. Thus, the most

rigorous interpretation is that two

processes were demonstrated—

Chorioamnionitis?

The literature demonstrates that M.

tuberculosis can involve the placenta

and, in rare cases, cause intrauterine

infection with acute inflammation of

the membranes. Taweevisit et al.

described intrauterine tuberculosis

intra-amniotic

infection

and

presenting

as

acute

peritoneal TB—with a potential

pathophysiologic relationship that

cannot be proven retrospectively.

Direct tuberculous causation of

chorioamnionitis therefore remains

chorioamnionitis, while more recent

pathologic series have documented

acute fetal membranitis, placental

necrosis, and M. tuberculosis

positivity by staining and molecular

methods [6,7]. A particularly relevant

report published online in 2025

described placental TB secondary to

unconfirmed

specific

by

compartment-

or

microbiologic

histopathologic evidence.

tuberculous

peritonitis,

with

4. Maternal-Fetal Implications

molecular confirmation in obstetric

tissues and fluids [8]. These

observations make it biologically

Tuberculosis during pregnancy is

associated with a higher risk of

maternal

complications, particularly when

diagnosis is delayed or

and

perinatal

plausible

extrapulmonary TB could contribute

to placental inflammation or

intrauterine infection.

that

maternal

extrapulmonary or disseminated

disease is present. Contemporary

reviews describe associations with

preterm birth, fetal growth restriction,

low birth weight, pregnancy loss, and

maternal morbidity [2,11]. In a series

of 19 placentas affected by TB,

Biologic plausibility, however, does

not establish causality in the present

case. The amniotic fluid contained

abundant gram-positive cocci,

whereas M. tuberculosis was

confirmed

in

the

No

peritoneal

culture,

seven in

pregnancies

ended

compartment.

intrauterine fetal death; prematurity

6

74

Martinez-Soto et al. (2026)

and cases of congenital TB were also

likelihood

of

demonstrating

documented

neonates [7].

among

surviving

gestational involvement by M.

tuberculosis [7]. In the present case,

the absence of these specimens

limits the ability to distinguish

concomitant ascending bacterial

chorioamnionitis from tuberculous

intrauterine infection.

In this patient, the adverse obstetric

outcome occurred in the setting of

prolonged

objectively

membrane

rupture,

intra-

documented

amniotic infection, and previously

unrecognized peritoneal TB. The

relative contribution of each process

to the fetal outcome cannot be

quantified. Intra-amniotic infection

alone can trigger a fetal inflammatory

response and is associated with fetal

deterioration, preterm birth, and

perinatal mortality; active maternal

TB may also increase obstetric risk

The clinical course also illustrates the

value of maintaining a low threshold

for investigating extrapulmonary TB

in patients with persistent fever,

abdominal pain, and an evolution not

fully explained by the initial

diagnosis, particularly in settings

where TB remains epidemiologically

relevant.

Current

guidelines

[

2,4]. The coexistence of both

recommend rapid microbiologic and

molecular testing whenever possible

and sampling of the affected site;

culture remains important for

confirmation and drug-susceptibility

testing [12,13].

conditions increased the clinical

complexity but does not justify

unsupported causal attribution.

5

. What Would Have Strengthened

Etiologic Attribution?

6

. Treatment and Pregnancy:

When maternal TB is suspected in a

Scope of the Available Information

similar

obstetric

presentation,

examination of the placenta and

membranes—and, when clinically

indicated and feasible, amniotic fluid

or fetal samples—may be decisive.

Combining histopathology, acid-fast

bacillus staining, culture, and

molecular assays increases the

Active TB during pregnancy requires

treatment and therapy should not be

postponed once the diagnosis is

established; the maternal and fetal

risks of untreated disease outweigh

those associated with recommended

first-line regimens when used in

6

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Chorioamnionitis and peritoneal tuberculosis in pregnancy: An unexpected diagnosis and adverse obstetric outcome—A case

report.

accordance

with

international

scenarios, failure to improve as

expected should prompt active

investigation for extrapulmonary TB.

When tuberculous involvement of

guidance [13,14]. However, the

available record does not document

the

antituberculous

regimen

administered after confirmation, the

drug-susceptibility profile of the

isolate, or the subsequent maternal

outcome. For methodological rigor,

pregnancy

is

suspected,

the

placenta, membranes, and relevant

obstetric specimens should be

examined using histopathology,

culture, and molecular methods.

these

elements were

neither

reconstructed nor assumed in this

manuscript.

Declarations

Informed consent for publication:

Written

informed

consent

for

4

. Conclusions

publication of the case and

accompanying images was obtained

and is retained by the authors.

This case demonstrates that a well-

supported initial obstetric diagnosis

should not preclude reconsideration

when the clinical pattern changes.

Conflicts of interest: The authors

declare no conflicts of interest.

Intra-amniotic

infection

was

supported by maternal fever,

prolonged rupture of membranes,

and markedly inflammatory amniotic

fluid containing abundant gram-

positive cocci. Persistent fever and

subsequent signs of peritoneal

irritation revealed a second process:

Data availability: The clinical data

underlying this report are restricted

because of patient confidentiality and

may be handled only in accordance

with institutional policies and the

consent obtained.

peritoneal

TB

confirmed

by

a

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