Title : Acute pancreatitis in pregnancy -a rare case report
Sagarika N Swamy, Gauri A. Prabhu , Anita Dalal , Shridevi Metgud Department of
Obstetrics and Gynaecology, Department of General Surgery, KAHER's Jawaharlal Nehru
Medical College, Belagavi-590010 (Karnataka), India
Authors: Sagarika N. Swamy, Gauri A. Prabhu, Anita Dalal, Shridevi Metgud
Affiliation: Department of Obstetrics and Gynaecology, Department of General Surgery,
KAHER's Jawaharlal Nehru Medical College, Belagavi-590010, Karnataka, India
Abstract
Acute pancreatitis (AP) during pregnancy is a rare but severe condition characterized by the
premature activation of pancreatic enzymes, resulting in inflammation and potential systemic
effects. The incidence of AP has been rising in recent years due to lifestyle changes and
psychosocial factors. Understanding the pathophysiology, risk factors, and management
strategies for AP is vital to ensuring both maternal and fetal well-being. This report presents a
rare case of acute on chronic pancreatitis in a pregnant woman, who exhibited left loin pain
and vomiting. The patient was managed conservatively and responded well to treatment.
Introduction
Acute pancreatitis is marked by the sudden inflammation of the pancreas, resulting from the
premature activation of enzymes such as zymogen and trypsinogen. This condition can lead
to local pancreatic destruction, an inflammatory cascade, pancreatic necrosis, abscess
formation, systemic inflammatory response syndrome (SIRS), and multi-organ dysfunction
syndrome (MODS). The incidence of acute pancreatitis during pregnancy has increased over
the past few decades, attributed to factors such as sedentary lifestyles and dietary habits.
Hence, understanding the pathophysiology and risk factors associated with AP is critical for
proper diagnosis and management.
Case Report
A 30-year-old female (G2P1L1) at 34 weeks of gestation presented to the labor room with a
four-month history of left loin pain radiating towards the back, which had worsened over the
previous 15 days. Four months prior, she experienced similar episodes, leading to a diagnosis
of chronic pancreatitis following an abdominal ultrasound. The patient had received
Ayurvedic treatment at that time, which alleviated her symptoms.
The patient reported a single episode of non-projectile, yellowish vomiting eight days prior to
admission. Her obstetric history included one uneventful lower segment cesarean section due
to placenta previa. Upon admission, the patient was conscious and coherent, with a BMI of
20, pulse rate of 96 bpm, and blood pressure of 100/70. Physical examination revealed a
uniformly distended abdomen, tenderness in the left hypochondrium, but no signs of guarding
or rigidity.
Laboratory tests indicated normal values for complete blood count, liver and renal function
tests, serum electrolytes, lipid profile, blood sugar, and serum calcium. Notably, serum
amylase was elevated at 495 units/liter, and serum lipase was 789 units/liter. An abdominal
ultrasound confirmed a single live intrauterine fetus of 34 weeks and 6 days gestation, with a
dilated main pancreatic duct and an intraductal calculus suggestive of chronic pancreatitis.
The patient was treated conservatively with intravenous fluids, analgesics, antiemetics, and
pancreatic enzymes, while monitoring her blood glucose levels every six hours. After three
days of treatment, repeat blood tests showed normalization of laboratory values and a
decreasing trend in serum lipase and amylase. Given that the gravid uterus was exacerbating
symptoms, a decision was made to terminate the pregnancy after administering antenatal
steroids. On the fifth day, an elective lower segment cesarean section was performed,
resulting in the delivery of a healthy female child weighing 2.6 kg. The patient tolerated sips
of water on postoperative day one, and her pain and vomiting subsided, leading to discharge
on postoperative day eight.
Discussion
Managing acute pancreatitis in pregnant patients necessitates careful consideration of both
maternal and fetal safety. Common diagnostic imaging and medications can pose risks to the
fetus, requiring alternative management strategies.
Diagnosis Criteria
Diagnosis of acute pancreatitis typically requires two of the following three features:
1. Characteristic abdominal pain.
2. Serum lipase or amylase levels elevated to three times the normal upper limit.
3. Imaging findings consistent with acute pancreatitis (e.g., ultrasound, MRI, CT).
Epidemiology and Risk Factors
The frequency of acute pancreatitis in pregnant women ranges from 1 in 1,000 to 1 in 5,000
pregnancies. Common causes include:
Gallstones
Chronic alcohol use
Hypertriglyceridemia
Medications
Autoimmune conditions
Infections
Trauma
Genetic factors
Hypercalcemia
Pancreatic duct obstruction
Idiopathic factors
Clinical Manifestations and Laboratory Findings
Common symptoms include:
Abdominal pain (colicky or stabbing)
Gastrointestinal symptoms (nausea, vomiting, anorexia)
Systemic signs (low-grade fever, tachycardia)
Laboratory findings typically show elevated serum lipase and amylase, alongside
metabolic and hematological markers of inflammation.
Management Strategies
Management of acute pancreatitis focuses on relieving symptoms and addressing underlying
causes:
1. Initial Assessment and Monitoring: Hospitalization for moderate to severe cases
with continuous monitoring.
2. Supportive Care: IV fluids, pain management, and electrolyte correction.
3. Treating Underlying Causes: Addressing issues such as gallstones or
hypertriglyceridemia.
4. Management of Complications: Interventions for infected necrosis or symptomatic
pseudocysts.
5. Long-Term Management: Regular follow-up for chronic pancreatitis risk.
Complications
Maternal complications may include SIRS, acute respiratory distress syndrome, acute kidney
injury, and pancreatic necrosis. Fetal complications can involve preterm labor, intrauterine
growth restriction, and neonatal complications such as respiratory distress syndrome.
Conclusion
Acute pancreatitis during pregnancy poses significant challenges that require a
multidisciplinary approach to management. Early recognition, tailored treatment strategies,
and regular follow-up are crucial for optimizing outcomes for both mother and fetus.
Addressing long-term risks and complications is essential for effective recovery.
References
1. Hemant S, Agarwal P, Rajeswari KS. Acute Pancreatitis in Pregnancy: A 2-Year
Experience at a Tertiary Care Center. Published April 29, 2024.
2. Tchounwou PB, Mierzyński R, Poniedziałek-Czajkowska E, editors. Pancreatitis in
Pregnancy—Comprehensive Review. Received October 5, 2022; Accepted December
1, 2022.
3. Jameson JL, et al. Harrison's Principles of Internal Medicine. 20th ed. New York:
McGraw-Hill Education; 2018.
4. Tenner S, et al. ACG Clinical Guideline: Management of Acute Pancreatitis. Am J
Gastroenterol. 2013;108(9):1400-15.
5. Feldman M, et al. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th
ed. Philadelphia: Elsevier; 2020.
6. Khan F. Acute pancreatitis in pregnancy: a rare case report. Department of Obstetrics
and Gynaecology, St Joseph’s Hospital, Guntur, Andhra Pradesh, India. Received
October 27, 2023; Accepted January 4, 2024.
7. Banks PA, et al. Classification of acute pancreatitis—2012: revision of the Atlanta
classification and definitions by international consensus. Gut, 62(1), 102-111.
8. Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. NEJM, 375(20), 1972-1981.
9. Talukdar R, Vege SS. Recent developments in acute pancreatitis. Clin Gastroenterol
Hepatol, 16(6), 910-919.
10. Lankisch PG, et al. Acute pancreatitis. Lancet, 386(9988), 85-96.
