1. What every clinician should know

Clinical features and incidence

Pancreatitis in pregnancy is very rare, affecting approximately 1-2/10,000 pregnancies. All patients have upper abdominal pain, primarily in the epigastrum. The pain may radiate around the back and cause band-like pain around the upper abdomen. The pain is classically at least partially relieved by leaning forward. It is commonly associated with fever, and postprandial nausea and vomiting.

Pancreatitis is most commonly associated with gallstone obstruction of the common bile duct in females of reproductive age. Other causes include alcoholism, hypertriglyceridemia, hereditary chronic pancreatitis, mumps infection or trauma.

2. Diagnosis and differential diagnosis

A. Establishing the diagnosis

The patient will often present with upper abdominal pain, nausea, vomiting and low grade fever. Severe cases can present with shock or coma. The epigastrum is typically tender to palpation, but there is no guarding or rebound unless perforation has occurred. In some cases there may be a palpable mass in the epigastrum related to a pancreatic pseudocyst. Laboratory evaluation rests primarily with serum amylase, which can be elevated many times above normal. It rises 6-12 hours after onset of symptoms and lasts for the duration of the attack.

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There is no benefit to serial monitoring of amylase as the degree of elevation does not correlate with severity or duration of the disease. Amylase is relatively sensitive for pancreatitis, but is not specific. A serum lipase also may be obtained, and this test also is sensitive but not specific for pancreatitis. The combination of amylase and lipase does not appear to improve diagnostic accuracy. These assays are useful in pregnancy as they are not affected by pregnancy. Trypsinogen activation peptide may be a useful marker for early identification of pancreatitis and is more specific than amylase or lipase. It has not been studied in pregnancy and its utility in this setting is not known.

Radiologic studies may include a plain abdominal film, CT or MRI of the abdomen, and ultrasound. The plain film may show mild disease or a “sentinel loop” of bowel in more severe cases. This imaging modality is not helpful in the second or third trimester. An MRI may be obtained, although preferably without gadollinium, which readily crosses the placenta and may concentrate in the amniotic fluid. An ultrasound also may be obtained but may be of limited value, particularly in the third trimester, or if there is a large amount of bowel gas that may obscure the image. It is useful to determine if there are stones present that may be obstructing the common bile duct. CT scan is the radiologic diagnostic test of choice, but another test may be selected in an effort to limit radiation exposure.

B. Differential diagnosis

The differential diagnostic in pregnancy is narrow but includes abruption, liver disease associated with pre-eclampsia or HELLP syndrome, and acute fatty liver of pregnancy. Non-obstetric causes may include gallbladder disease, inflammatory bowel disease, sickle cell crisis, thrombosis or perforated viscous, and bowel obstruction.

3. Management

Management of pancreatitis is conservative, with no oral intake and bowel rest, along with intravenous hydration. An ERCP may be considered in cases of obstruction due to a gallstone. Narcotics also may be required, but should not include morphine, due to the risk of spasm of the sphincter of Oddi.

4. Complications

Potential complications include pancreatic necrosis, internal bleeding into the retroperitoneum, and electrolyte abnormalities associated with prolonged nausea and vomiting. Shock is a late consequence of pancreatitis, and is more common with alcoholic pancreatitis with underlying liver disease.

5. Prognosis and outcome

Pregnancy outcomes are generally favorable, with a relatively low risk of preterm labor or delivery. Occasionally patients may develop generalized peritonitis which may increase these risks slightly. There are no known long-term adverse neonatal consequences associated with pancreatitis, in the absence of any other maternal co-morbidities.

If pancreatitis is associated with an underlying morbidity such as alcoholism, infection, or hypertriglyceridemia, then those morbidities should be addressed and treated as appropriate. If alcohol abuse is suspected, then the patient should be referred to a provider in obstetrics with knowledge of the risks of prenatal alcohol exposure and Fetal Alcohol Syndrome.

6. What is the evidence for specific management and treatment recommendations

Ramin, KD, Ramin, SM, Richey, SD, Cunningham, FG. “Acute pancreatitis in pregnancy”. Am J Obstet Gynecol. vol. 173. 1995. pp. 87

Creasey, Resnick, Iams, Lockwood, Moore. “Maternal-Fetal Medicine: Principles and practice”. Definitive textbook used in Obstetrics and the specialty of Maternal-Fetal Medicine.