European Journal of Obstetrics & Gynecology and Reproductive Biology
ReviewAcute pancreatitis in pregnancy: an overview
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.
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