Review
Acute pancreatitis in pregnancy: an overview

https://doi.org/10.1016/j.ejogrb.2011.07.037Get rights and content

Abstract

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

Introduction

The incidence of acute pancreatitis in pregnancy varies in different studies. In Midwestern USA the incidence of acute pancreatitis was 1 in 3021 pregnancies [1]. In a study of a hospital in Texas USA 43 out of 147,197 pregnant women had acute pancreatitis (incidence 1 in 3333) [2]. A lower incidence of 1 in 4449 was reported by Hernandez et al. [3] and an even lower incidence of 1 in 10,000 live births was found in a retrospective study in Pennsylvania, USA [4]. Incidence of acute pancreatitis in pregnancy is probably similar to non-pregnant population (about 1 in 2500 adults in USA) [5]. The difference in the reported incidence is attributed to age, habits and genetic variation [6].

Acute pancreatitis is a rare complication in pregnancy. However, it is associated with maternal and perinatal mortality and should always be considered in the differential diagnosis of upper quadrant abdominal pain with/without vomiting and nausea. This is especially relevant in the 3rd trimester when the incidence is higher [1]. Over the past decades the mortality rate for both the woman and the fetus was high, reaching 37% and 11–37%, respectively. Recent studies showed that maternal mortality declined to <1% and the perinatal mortality 0–18%. The main cause of perinatal mortality is preterm delivery, a complication of acute pancreatitis and its decline can be attributed to the improved management in specialized neonatal intensive care units [2]. The low incidence of maternal mortality is due to the improvement in laboratory tests and imaging techniques leading to early diagnosis [2].

Section snippets

Pathogenesis

The most common causes of acute pancreatitis in pregnancy are: gallstones (66%), alcohol abuse (12%), idiopathic (17%), hyperlipidemia (4%), and less commonly hyperparathyroidism, trauma, medication and fatty liver of pregnancy [1]. Pancreas divisum and sphincter of Oddi dysfunction may also cause acute pancreatitis in non-pregnant population [6], [7]. It should be noted that the percentage of idiopathic pancreatitis is declining as knowledge of genetic etiologies and predispositions to

Gallstones

It remains unclear whether high parity is a risk factor for gallstones [20], [21], [22], [23], [24], [25]. In contrast, pre-pregnancy body mass index (BMI) is a strong predictor of incident gallbladder disease [26], [27]. Obesity (BMI  30 kg/m2) is associated with increased incidence of new gallbladder disease [26]. Interestingly, weight gain during pregnancy is inversely associated with risk of incident gallbladder disease.

Insulin resistance is another condition associated with obesity and is

Symptoms, presentation and investigations

The symptoms of acute pancreatitis in pregnancy are non-specific; the predominant symptom is upper abdominal pain which is usually midepigastric and could radiate to the back in about 40% of the cases [2]. Pain is commonly accompanied by midepigastric tenderness, nausea and vomiting [47], [48]. Fever may also be present [48]. The duration of symptoms may vary from 1 day up to 3 weeks. In severe cases sinus tachycardia, hyperventilation and smell of acetone of the breath can also be present [49]

Complications

In the non-pregnant patient, acute pancreatitis can be mild with local inflammation or severe with local or systemic complications. The mild form usually resolves without complications. Only 10% of acute pancreatitis are severe and are complicated with pancreatic necrosis and peripancreatic tissue necrosis and could progress to multiple organ failure due to infection of the necrotic tissue [65]. Severe acute pancreatitis is associated with increased mortality.

Recurrent pancreatitis, pancreatic

Conservative management

Intravenous fluid therapy is required and supplemented with nutritional therapy. Enteral nutrition is the preferable route of nutrition in predicted severe acute pancreatitis [74] during pregnancy [3]. Furthermore, naso-jejunal enteral nutrition has lower incidence of infectious morbidity compared with parenteral nutrition [75]. Low-fat semi-elemental enteral nutrition is useful in acute pancreatitis in pregnancy regardless of the etiology [66].

The incidence of catheter-related complications

Conclusions

Recent advances in diagnosis and treatment of acute pancreatitis in pregnancy have led to a decrease in maternal and fetal mortality. The commonest causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. Recent studies have substantially improved our understanding of acute pancreatitis in pregnancy, and we look forward to further advances.

References (102)

  • I. Bartha et al.

    Acute hypertriglyceridemic pancreatitis during pregnancy due to homozygous lipoprotein lipase gene mutation

    Clin Chim Acta

    (2009)
  • S.H. McGladdery et al.

    Lipoprotein lipase and apoE polymorphisms: relationship to hypertriglyceridemia during pregnancy

    J Lipid Res

    (2001)
  • B. Lindkvist et al.

    A prospective cohort study of smoking in acute pancreatitis

    Pancreatology

    (2008)
  • A. Kennedy

    Assessment of acute abdominal pain in the pregnant patient

    Semin Ultrasound CT MR

    (2000)
  • F. Roumieu et al.

    Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences

    Eur J Obstet Gynecol Reprod Biol

    (2008)
  • G. Vijayaraghavan et al.

    Imaging of acute abdomen and pelvis: common acute pathologies

    Semin Roentgenol

    (2009)
  • V. de Ledinghen et al.

    Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study

    Gastrointest Endosc

    (1999)
  • M.S. Petrov

    Gestational pancreatitis: when does etiology matter?

    Am J Obstet Gynecol

    (2009)
  • A. Blum et al.

    Gallstones in pregnancy and their complications: postpartum acute pancreatitis and acute peritonitis

    Eur J Intern Med

    (2005)
  • S.J. Tang et al.

    Acute pancreatitis during pregnancy

    Clin Gastroenterol Hepatol

    (2010)
  • M.G. Besselink et al.

    Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial

    Lancet

    (2008)
  • C. Nelson-Piercy et al.

    Severe hypertriglyceridemia complicating pregnancy, management by dietary intervention and omega-3 fatty acid supplementation

    Nutrition

    (2009)
  • U. Mahadevan et al.

    American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

    Gastroenterology

    (2006)
  • K.K. Kao et al.

    The biochemical basis for the anti-inflammatory and cytoprotective actions of ethyl pyruvate and related compounds

    Biochem Pharmacol

    (2010)
  • R.S. Date et al.

    A review of the management of gallstone disease and its complications in pregnancy

    Am J Surg

    (2008)
  • T.H. Baron et al.

    Pregnancy and radiation exposure during therapeutic ERCP: time to put the baby to bed?

    Gastrointest Endosc

    (2009)
  • C.J. Glueck et al.

    Treatment of severe familial hypertriglyceridemia during pregnancy with very-low-fat diet and n-3 fatty acids

    Nutrition

    (1996)
  • J.J. Eddy et al.

    Pancreatitis in pregnancy

    Obstet Gynecol

    (2008)
  • R.S. Legro et al.

    First-trimester pancreatitis. Maternal and neonatal outcome

    J Reprod Med

    (1995)
  • S.A. Khan et al.

    Controversies in the etiologies of acute pancreatitis

    J Pancreas

    (2010)
  • A. Kingsnorth et al.

    Acute pancreatitis

    BMJ

    (2006)
  • G.J. Wang et al.

    Acute pancreatitis: etiology and common pathogenesis

    World J Gastroenterol

    (2009)
  • F.F. Bolukbas et al.

    Risk factors associated with gallstone and biliary sludge formation during pregnancy

    J Gastroenterol Hepatol

    (2006)
  • D.Z. Braverman et al.

    Effects of pregnancy and contraceptive steroids on gallbladder function

    N Engl J Med

    (1980)
  • D.H. Van Thiel et al.

    Pregnancy-associated sex steroids and their effects on the liver

    Semin Liver Dis

    (1987)
  • A. Vonlaufen et al.

    Molecular mechanisms of pancreatitis: current opinion

    J Gastroenterol Hepatol

    (2008)
  • M.R. Warth et al.

    Lipid metabolism in pregnancy. II. Altered lipid composition in intermediage, very low, low and high-density lipoprotein fractions

    J Clin Endocrinol Metab

    (1975)
  • P. Saharia et al.

    Acute pancreatitis with hyperlipidemia: studies with an isolated perfused canine pancreas

    Surgery

    (1977)
  • E. Herrera

    Lipid metabolism in pregnancy and its consequences in the fetus and newborn

    Endocrine

    (2002)
  • B.C. Koo et al.

    Imaging acute pancreatitis

    Br J Radiol

    (2010)
  • L. Basso et al.

    A study of cholelithiasis during pregnancy and its relationship with age, parity, menarche, breast-feeding, dysmenorrhea, oral contraception and a maternal history of cholelithiasis

    Surg Gynecol Obstet

    (1992)
  • C. Thijs et al.

    Pregnancy and gallstone disease: an empiric demonstration of the importance of specification of risk periods

    Am J Epidemiol

    (1991)
  • G. Andreotti et al.

    Reproductive factors and risks of biliary tract cancers and stones: a population-based study in Shanghai, China

    Br J Cancer

    (2010)
  • K.M. Maclure et al.

    Weight, diet, and the risk of symptomatic gallstones in middle-aged women

    N Engl J Med

    (1989)
  • F. Angelico et al.

    The epidemiology of cholelithiasis in Italy: prevalence and incidence data

    Epidemiol Prev

    (1991)
  • L. Barbara et al.

    A population study on the prevalence of gallstone disease: the Sirmione Study

    Hepatology

    (1987)
  • C.W. Ko et al.

    Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy

    Hepatology

    (2005)
  • D. Katsika et al.

    Body mass index, alcohol, tobacco and symptomatic gallstone disease: a Swedish twin study

    J Intern Med

    (2007)
  • L. Gautron et al.

    Sixteen years and counting: an update on leptin in energy balance

    J Clin Invest

    (2011)
  • L. Hardie et al.

    Circulating leptin in women: a longitudinal study in the menstrual cycle and during pregnancy

    Clin Endocrinol (Oxf)

    (1997)
  • Cited by (78)

    • Hyperlipidemia and risk for preclampsia

      2022, Journal of Clinical Lipidology
      Citation Excerpt :

      The degree of LDL elevation in pregnant women with FH is more than normal controls. Despite high circulating levels of atherogenic lipoproteins in FH patients, data from several studies do not support an association between maternal LDL levels and maternal or perinatal outcomes, including PreE, preterm delivery, or low birth weight babies.31 Despite these favorable findings on perinatal outcomes, the impact of pregnancy on statin interruption in homozygous FH, may affect long-term maternal CV outcomes.

    • Cholesterol and early development

      2022, Cholesterol: From Chemistry and Biophysics to the Clinic
    • Sex Differences in the Exocrine Pancreas and Associated Diseases

      2021, Cellular and Molecular Gastroenterology and Hepatology
      Citation Excerpt :

      This phenomenon is hypothesized to be due to increased fat accumulation and breakdown during pregnancy. Although levels of triglycerides often do not reach >300 mg/dL or levels commonly associated with hypertriglyceridemic pancreatitis, women with preexisting lipid metabolism abnormalities are at increased risk of developing AP.134 Though mucinous cystic neoplasms are commonly premalignant, pregnant women with pancreatic cystic lesions commonly present with malignant lesions that are hormone responsive and may enlarge during pregnancy.135,136

    • Dyslipemias and pregnancy, an update

      2021, Clinica e Investigacion en Arteriosclerosis
    View all citing articles on Scopus
    View full text