Chandrakala Magudapathi Consultant and Director Genesis Royal Infirmary, Director Genesis Foundation, COGS, FOGSI secretary 2013 and 14, MC Member 2015–2019, IMA Managing committee and Women’s wing 2014–2017, NABH assessor, Reviewer of JOGI, RCOG 2014, IUJA, Poster Presentation at RCOG 2017, RCOG 2014, Paper on Induction of labour— Reappraisal of protocol at 21st World Congress, COGI China 2015, Faculty AICOG, Dakshin, YUVA FOGSI. Panelist and speaker on Quality healthcare IMA district and Zonal meet. Best paper and poster awards in YUVA FOGSI and AICOG. Publications (1) Vesicocervical fistula: secondary to intrauterine device (Lippes loop) erosion, International Urogynecology Journal, ISSN 0937-3462, I, DOI 1.1007/s00192-015-2667-z. (2) Glanzmann’s Thrombasthenia Complicating Pregnancy, The Journal of Obstetrics and Gynaecology of India, https ://doi.org/10.1007/s1322 4-012-0319-5, April 2013. (3) A rare case of Polyhydramnios-Neonatal Bartter syndrome Journal of Perinatology, Vol 14, No 1, April–June 2013. (4) Osseous metaplasia of the Endometrium: A rare entity The Journal of Obstetrics and Gynaecology of India, https ://doi.org/10.1007/s1322 4-014-0589-1 July 2014. (5) Uterus Didelphys with Longitudinal Vaginal Septum: Normal Delivery Magudapathi C. J Clin Case Rep 2:194. https ://doi. org/10.4172/2165-7920.10001 94 August 27, 2012. (6) Krukenberg Tumour in Pregnancy Magudapathi, C., Nithya, J., Mohanraj, R. et al. Indian J Gynecol Oncolog (2017) 15: 66. https ://doi.org/10.1007/s4094 4-017-0161-x. (7) Angiosarcoma of Breast in pregnancy Magudapathi, C., Garreepally, H., Pichamuthu, A. et al. Indian J Gynecol Oncolog (2018) 16:59. https ://doi.org/10.1007/s4094 4-018-0231-8.
BackgroundTo study the course of pancreatitis in pregnant women and demonstrate that early diagnosis and conservative management leads to good maternal and perinatal outcome.
Methods:This article is a retrospective case series study. Six patients with acute pancreatitis during pregnancy were seen in a tertiary referral based obstetric practice at our department in the last 5 years. One of them had gallstones, one hyperlipidemia, one Diabetes and one miliary tuberculosis on ATT . Conservative treatment was instituted for pancreatitis. All of them were followed at least six weeks post-partum.
Results:There was no maternal mortality and perinatal mortality. Acute pancreatitis occurred in both primipara and multipara patients. Preterm labor was a complication in most of our cases complicated by acute pancreatitis. Most patients experienced relief from the pancreatitis soon after delivery. One patient underwent cesarean section due to fetal distress all the other 5 patients had vaginal delivery. One patient had Pseudopancreatic cyst and had a morbid postpartum period.
Conclusion:Pancreatitis is a rare event in pregnancy, approximately 3 in 10,000 pregnancies. It is most often acute and related to gallstones but nonbiliary causes should be sought because they are associated with worse outcomes. Although acute pancreatitis is a rare complication of pregnancy with 50% maternal and 70 % perinatal mortality early and appropriate treatment is of utmost importance to improve the outcome.
Pancreatitis is rare in pregnancy with an incidence of 1 in 10,000 approximately. Late diagnosis and delay in treatment results in worst pregnancy outcomes. It presents mostly in second or third trimester. Commonest presentation is biliary disease and rarely hypertriglyceridemia or preeclampsia. There is no significant association between pancreatitis and pregnancy, but there is association with gallstones. Conservative management and early delivery seems to improve maternal and perinatal outcome. It is a spectrum of mild to severe disease with necrosis, causing abscesses, pseudocyst and multi-organ dysfunction.
This study is a retrospective case series of six cases from over a period of 5 years from 2009 to 2013 at GKNM Hospital, Coimbatore, India. All pregnant women who were diagnosed as pancreatitis were included in the study. Diagnosis was based on clinical, laboratory and imaging criteria. Diagnosis was by levels of amylase, lipase and ultrasound. Prognostic scoring was by (BISAP) bedside index for severity in acute pancreatitis. Results were expressed as mean and average.
Among six patients, average age was 27.5 years (25–30 years), and mean body mass index was 22.8 (15–33). Most of them belonged to middle class socioeconomic status (Table 1). Two of them were chronic with acute presentation and four were acute. Five cases were diagnosed between 18 and 30 weeks, and one was diagnosed on first postnatal day. The commonest clinical symptom at presentation was epigastric pain, vomiting and abdominal distension (Table 2). Biliary sludge or calculi were the etiology in four cases, and two were secondary to hypertriglyceridemia. Diagnosis was based on amylase and lipase levels. Only one patient who was diagnosed late had pseudo-pancreatic cyst and underwent cesarean delivery due to abruption and had a morbid postnatal period including laparotomy drainage (Table 3). All the rest had good maternal outcome. All the offsprings including three preterm deliveries who were followed up to 2 years had a good outcome (Table 4). Recurrence was a common finding in the chronic cases.
Commonest causes of pancreatitis are alcohol,
gallstones and hyperlipidemia. Rarely pancreatitis occurs due to
anatomic or functional disorders, trauma, penetrating ulcers, drugs,
infections, infestations, pregnancy, hypercalcemia, anorexia or bulimia
and autoimmunity.
The hallmark symptom of acute pancreatitis is
the acute onset of persistent upper abdominal pain, usually with nausea
and vomiting. Pain is present at the epigastric and periumbilical
regions. Patients are usually restless and bend forward (in the
knee-chest position) in an effort to relieve the pain because supine
position may exacerbate the intensity of symptoms. Physical examination
findings are variable but may include fever, hypotension, severe
abdominal tenderness, guarding, respiratory distress and abdominal
distention. Clinical features (abdominal pain and vomiting) with
elevated pancreatic enzymes are the cornerstones of diagnosis [1].
Amylase
provides acceptable accuracy of diagnosis, but lipase is preferred due
to longer persistence after an attack and pancreas being its only source
has superior sensitivity and specificity. Amylase-to-creatinine
clearance ratio may be helpful in pregnancy; ratio greater than 5%
suggests pancreatitis as per newer studies.
Abdominal ultrasound
has only 20–25% visualization of pancreas. It is valuable in diagnosing
gallstones, CBD gallstones and other differentials and complications.
Endoscopic ultrasound (EUS) has better diagnostic ability if common bile
duct stone is suspected.
Computed tomography is rarely needed for diagnosis and provides good evidence for absence of pancreatitis and prediction of severity. There is risk of CT radiation exposure to the fetus, but has to be performed when benefits out-weigh the risk. Magnetic resonance cholangiopancreatography (MRCP) is indicated in pregnancy if other non-ionizing forms of diagnostic imaging studies are inconclusive or to avoid radiation exposure.
Endoscopic retrograde cholangiopancreatography (ERCP) should be only as a therapeutic option in selected cases with confirmed bile duct stones. In severe acute biliary pancreatitis (SABP) with or without cholangitis, early ERCP, preferably within 24 h, is recommended.
Liver function test ALT > 150 U/L suggests gallstone pancreatitis and fulminant disease. Renal function test for severity includes serum electrolytes, BUN, creatinine, glucose. Lipid profile, cholesterol and triglycerides are checked to identify causes. Complete blood count and C-reactive protein are tested if suspicious of infection. Research tests like immunoglobulin, interleukins may be considered [2].
Prognostic scorings like APACHE, Ransons, CTSI and Imrie scoring predict poor clinical outcomes. The easiest prognostic scoring is the bedside index for severity in acute pancreatitis (BISAP) which includes BUN > 25 mg/d L, impaired mental status (disorientation, lethargy, somnolence, coma or stupor) ≥ 2 SIRS criteria, age > 60, pleural effusion. Score 0 < 1% risk of mortality, score ≤ 2, 1.9% mortality risk, and score > 3, 22% mortality risk.
Management is mainly supportive involving early and prompt fluid management for volume status to maintain electrolyte, acid base balance and oxygen supplementation to maintain saturation. Restrict oral intake until the gut motility returns. Enteral nutrition is good when the gut motility is present. Total parenteral nutrition can be used in pregnancy. Pain is managed with narcotics. The above mentioned treatment was given in all our cases.
Medical management includes prophylactic broad spectrum antibiotics in severe pancreatitis to prevent infective necrosis. Acid suppressants were administered to neutralize the gut. Octreotide was used transiently for anti-inflammatory and cytoprotective effect on pancreas. Antibiotics and octreotide were administered in all six women. Hypertriglyceridemia medications are not recommended during pregnancy hence were not administered [3].
Surgical management was indicated only in obstructive jaundice, acute cholecystitis intractable to medical treatment, peritonitis and pseudo-pancreatic cyst. Laparoscopic or open cholecystectomy, percutaneous aspiration or ERCP was rarely performed.
Maternal complications are IDDM, pseudocyst, pancreatic necrosis, pancreatic abscess, peritonitis, pleural effusion, lung collapse, increased ICU admission, adult respiratory distress disseminated intravascular coagulation, acute renal failure, multi-organ dysfunction, shock and recurrence [4]. Pancreatic pseudocyst needed drainage in one woman in our study. Fetal complications include preterm, IUGR and stillbirths.
Conflict of interest There are no potential conflicts of interest.
Human and Animal Rights No experimental study was done. Retrospective analyses of the cases was performed and observations charted.
Informed consent Informed consent was obtained prior to the study, and patient identity was not disclosed.
