Although The incidence of acute pancreatitis is increasing

Although acute pancreatitis is
an uncommon event during pregnancy, its incidence was reported to be
approximately 1 in 1000 to 1 in 10,000. (1– 3)
misdiagnosis or delayed management of such cases could be serious and lead to
high mortality.

There are many recorded
aetiologies, but commonest are the presence of biliary disease, congenital or
acquired hypertriglyceridemia. Rarely, acute pancreatitis is associated with
pre-eclampsia, eclampsia or HELLP syndrome. (4, 5)

Pancreatitis in pregnancy can
occur at any time, but more than 50% of cases are diagnosed during the third
trimester of pregnancy. The incidence of acute pancreatitis is increasing
proportionally with advanced gestational age, as well as, the presence
gallstones. (1)

There is no significant
difference regarding clinical presentations of acute pancreatitis in pregnant
and non-pregnant women. The common symptoms include anorexia, nausea, vomiting,
dyspepsia, abdominal pain and intolerance to fatty foods. The signs are mostly
low-grade fever and tachycardia. (6).

The diagnosis of acute
pancreatitis in pregnancy is so challenging. Based on integration between the
clinical manifestations, laboratory and radiological investigations. , the
diagnosis of acute pancreatitis can be made.

Treatment of acute
pancreatitis in pregnancy should be carried by a multidisciplinary team and
could be either conservative management or surgical intervention according to
the severity of presentation, the general condition of mother and the condition
of the fetus .

Acute pancreatitis
in pregnancy is rare and challenging to manage due to limited evidence.Theconnection
between acute pancreatitis and pregnancy is not well understood.  The definition of Acute pancreatitis in
pregnancy was defined according to the severity of symptoms as highlighted by
revision of the Atlanta classification(7) (table 1).

Acute pancreatitis
during pregnancy is a rare with a wide range in the incidence, ranging from
1:1000 to 1:10000 (1). Acute pancreatitis is not
frequent during the first and second trimester and represents about 12%, it is usually
occurring in the third trimester50% or earlypostpartum period 38%. (8)

This wide range of incidence
is based on the different susceptibility of each population on the etiological
and risk factors of acute pancreatitis.

Gallstones are the commonest
cause of acute pancreatitisduring pregnancy, accounting for more than 70% of
cases (1) and that is what we noticed in our
case even when Endoscopic retrograde cholangio-pancreatography (ERCP) was
performed and common bile duct stones were extracted.

 There are many other aetiologies and risk
factors leads to many complications as shown in table 2
(1, 9-12)



The pathophysiology of
pancreatitis in pregnancy is not completely understood but can be explained
during pregnancy by increased cholesterol secretion in the hepatic bile
especiallyduring thesecond and third trimester as compared to phospholipids
andbile acids leading to more saturated bile. Moreover, greater fasting and
postprandial gallbladder volumes as well as the reduced rate of emptying volume
can contribute to more bile concentration. Eventually, thebig residualvolume of
concentrated bile in the late gallbladder can lead tocrystals and gallstones. (1)

It is important to recognize that up to 10% of women can develop
gallbladder sludge or stones during pregnancy and that 4% of them maintain this
pathology to the postpartum period. (13)

On the other hand, McKay
et al found that there was no evidence of a specific link between pregnancy and
pancreatitis, but there was a marked association between pancreatitis and
gallstones. (14).

Another cause of
acute pancreatitis with pregnancy is hyperlipidemia and more specifically
hypertriglyceridemia. The trigger for acute pancreatitis is estimated at
approximately 1000 mg/dl of serum triglycerides. During the second and third
trimester of pregnancy, the serum levels of triglycerides and lipoproteins will
increase up to three-fold due to due to effect of estrogen(1).

However, it is rare
for triglycerides to reach the trigger levels except in cases of familial
hypertriglyceridemia or acute fatty liver (15).Its
pathophysiology is incompletely understood. Severity scoring and effective
management remain challenging (16).


The literature shows that gallstones
with alcohol abuse account for more than 80% of cases of acute pancreatitis.
Risk of acute pancreatitis from hypertriglyceridemia in pregnancy also seems to
be the highest in the third trimester and tends to be a more severe form of
pancreatitis than that due to gallstones. (11) .Diabetes mellitus mainly type 2 is associatedwith
2.8-fold higher risk (17).

Recurrence of pancreatitis can occur in up to two-thirds of patients,
and establishing the biliary origin of pancreatitis is important because
removal of gallstones is the definitive treatment(18, 19)

From our patient’s history, None of such risk factors were documented in
our case except pregnancy.In case of acute pancreatitis
in pregnancy, the most common clinical presentations are an abdominal pain
(89.47%) and vomiting (68.42%) (3). Pregnant
women with acute pancreatitis may present with anorexia and fever.Bowel sounds
are reduced due to a paralytic ileusand a positive Murphy’s sign may be
present. Associatedpulmonary findings are noticed  in 10% of patients(20)

There are many diagnostic
challenges and controversies regarding diagnosis and management of acute
pancreatitis associated withpregnancy. Most symptoms like nausea, vomiting,
abdominaldiscomfort, or pain, are frequently seen inpregnancy. Clinical
evaluation of acuteabdomen in pregnancy is confusing and difficult due tothe
anatomical displacement of abdominal organs by thegravid uterus.Some ofthe
hematological and biochemical ofacute pancreatitis are similar to normal
pregnancies value, so the diagnosis of acute pancreatic needs a deeper
investigations. An elevated serum amylase level has a diagnostic sensitivity of
81% and adding serum lipase increases the sensitivity of 94% (21).

More detailed clinical
and laboratory findingsare described in Table 3.(7,22).

Our patient presented with
nausea, vomiting and abdominal pain mainly in upper right hypochondrium,
radiating to the back. She noticed that urine is dark in color. No fever, no
diarrhea or constipation. No vaginal bleeding or discharge. She was afebrile
not jaundice. The abdomen is soft with tenderness in the epigastrium and right
upper quadrant.

The diagnosis of acute
pancreatitis in our case was determined by clinical finding, laboratory tests,
and ultrasound findings. Serum amylase, ALP, and AST were high, while WBC was


Before the 1970s the diagnosis
of acute pancreatitis in pregnancy was less because most of cases were
diagnosed during surgery or during autopsy (2,23).

An ultrasound scan is safe and
not expensive but it has low diagnostic value for acute pancreatitis. Another
imaging modality especiallyin cases of unclear ultrasound findings is magnetic
resonance cholangiopancreatography (MRCP) without contrast medium which has
over 90% sensitivity without hazards to mother and her fetus.  Use of endoscopic retrograde
cholangiopancreatography (ERCP) limited only to women who need therapeutic
procedures. MRCP has less sensitivity compared to Endoscopic ultrasound in the
visualization of choledocholithiasis(20, 24).

The diagnosis in this case
established after ultrasound shows multiple gallstone average wall thickness.
No surrounded free fluid. Dilated common bile duct. Conservative management
started in high dependency unit under the supervision of obstetricians, surgeons,
intensivist, and the dietician. Then after delivery ERCP done and common bile
duct stones extracted followed by laparoscopic cholecystectomy after 3 days
then patient improved.



The management of
acute pancreatitis in pregnancy is the same for non-pregnant women. The
management contains fluid resuscitation, oxygen, analgesics, and cessation of
oral feeding to prevent the autodigestion of pancreas (22).

In the literature,
conservative management is preferred for mild cases (25).

Some factors may
play a role in the management of acute pancreatitis in pregnancy, including  the gestational age of pregnancy, the presence
of common bile duct dilatation, a presence of cholangitis, and the severity of
acute pancreatitis(1).

The use of antibiotics is
controversial. The literature shows that antibiotic prophylaxis does not reduce
mortality or protect against infected necrosis and frequency of
surgicalintervention (26).

Indications for surgery in
pregnancy are severe symptoms, obstructive jaundice, acute cholecystitis
intractable to medical treatment, and peritonitis (1, 8).

During pregnancy,
mild acute pancreatitis is the most common form and has no organ failure or
other complications. While Severe acutepancreatitis is associated with
persistent organ failure. There are some local complicationsinclude
peripancreatic fluid collection and peripancreatic orpancreatic necrosis (7).So according to
that our case was a mild case and responded well to conservative management
during pregnancy.

Complications of
acute pancreatitis can affect both, the motherand  herfetus. The onset ofpancreatitis at the
first trimester is associated with more morbidity and mortality due to delay in
management. The complications can be fetal or maternal  either local or systemic complications, as
shown in table 4 (7,9,10,22,23,27,28)



Local complications
are divided into early and late complications. Early complications defined
ashomogenous fluid collections without a well-defined wall but confined fascial
planes, localized at the region of the pancreas, usually resolve without
intervention and most of themremain sterile.These fluid collections do not
require intervention. Late Local Complications is defined as pancreatic
pseudocyst characterized by the presenceof a well-defined wall which contains a
fluid collectionwith no solid material. It develops more than 4 weeksafter the
onset of interstitial oedematous pancreatitis.CT is the most used diagnostic
imaging method,in pregnant women might be enough the MRI or ultrasonographyjust
to confirm the absence of solid material(7).


The prognosis in case of mild
acute pancreatitis is good with no effect on mother or fetus(29).In 1973,
maternal mortality due to acute pancreatitis in pregnancy was 31%, but in 2009
it went down to 1%(30).The
maternal and fetal mortality become less nowadays due to improvement and
widespread of imaging techniques.

The perinatal mortality was
50% in 1973 but in a review in 2009, note even one perinatal death out of 73
patients with acute pancreatitis in pregnancy in the second and third trimester
and all 73 patients delivered term babies (23).Some
documented fetal risks from acute pancreatitis during pregnancy include
threatened preterm labour, prematurity, and in utero fetal death (8).




Early diagnosis of
acute pancreatitis in pregnancy and conservative management with careful
maternal and fetal monitoring is recommended and associated with good perinatal
outcome. Surgical intervention is limited for some indications after full counseling
by a multidisciplinary team. Due to the complexity of acute pancreatitis in
pregnancy, thescientific society and committee should focus on establishing
specificsuggestions and guidelines about the management of acute pancreatitis
in pregnancy rather than basing on expert opinion, case series and case