Acute pancreatitis and pregnancy: a 10-year single center experience

Evolving trends in interventions and outcomes for acute biliary pancreatitis during pregnancy: A two-decade analysis

BACKGROUND/OBJECTIVES

Cholelithiasis is the most common cause of acute pancreatitis in pregnancy. We analyzed trends in acute biliary pancreatitis (ABP) among pregnant women over the past two decades to evaluate changes in outcomes, including the incidence of severe acute pancreatitis, mortality rates, and hospital length of stay.

METHODS

Using the National Inpatient Sample, we identified adult women of childbearing age (age 18-50 years) with hospitalization for ABP from 2002 to 2020. Trends were analyzed using Cochran-Armitage and F-tests. Multivariable binary logistic regression was used to evaluate the outcome of severe acute pancreatitis (SAP).

RESULTS

45,064 pregnant and 212,009 non-pregnant women were hospitalized for ABP (2002-2020), with a significant increase in ABP during pregnancy (14.1 %→17.8 %; p < 0.001). Trend analyses in the pregnant cohort revealed increasing age (mean 27  →  28.1 years; p < 0.001), Class-III obesity (0.7 %→7.8 %; p < 0.001), comorbidities (Elixhauser index ≥3) (2.9 %→11.2 %; p < 0.001), and SAP (2.2 %→5.0 %; p < 0.001). Mortality remained very low (<0.01 %). Performance of ERCP (22.2 %→26.5 %; p < 0.001) and cholecystectomy (41.0 %→54.1 %; p < 0.001) increased while duration of hospitalization decreased (Mean 4.9  →  3.6 days; p < 0.001). Multivariable analysis revealed that the development of SAP was associated with Black race (OR 1.70, 95 % CI: 1.10-2.63) and comorbidities (OR 5.10, 95 % CI 3.64-7.14).

CONCLUSIONS

Pregnant women represent a significant portion of hospitalized ABP cases, paralleling increases in age, comorbidities, and obesity rates. Racial disparities are linked to higher odds of SAP, though comorbidities have a dominant effect. There has been an increase in guideline-recommended procedures (ERCP and cholecystectomy); however, further research is needed to address the implementation gap, considering the increased complexity of pregnant women with ABP.

Acute Pancreatitis in Pregnancy and Puerperium: Assessing Maternal and Fetal Impact, Etiologies, and Clinical Outcomes at a Tertiary Care Hospital in Pakistan

Introduction The association of acute pancreatitis with adverse obstetric outcomes remains subject to great controversy. Outcomes are affected by the standard of care available, and hence, will be better in developed countries than in underdeveloped countries like Pakistan. Therefore, this study aimed to understand the clinical characteristics and treatment of acute pancreatitis in pregnancy (APIP) and its associated maternal and neonatal outcomes in a tertiary care hospital in Pakistan. Methodology A retrospective clinical analysis of APIP cases during pregnancy and the postpartum period was conducted at Aga Khan University Hospital (AKUH) in Karachi, Pakistan, from January 1, 2015, to December 31, 2021. Data were collected from the medical records of women diagnosed with APIP. Pregnant women with chronic and recurrent pancreatitis were excluded. We analyzed baseline demographics, obstetric outcomes, and neonatal outcomes for those who delivered at AKUH. These individuals were monitored in postnatal outpatient clinics to track changes in their initial symptoms. Data were analyzed using IBM SPSS version 25.0. Results A total of 32 patients with APIP were included. Among them, 13 (40.6%) were primigravida, and 21 (65.6%) were multigravida. The majority 22 (69%) presented in the third trimester. The most common etiology was gallstones 13 (40.6%), followed by idiopathic causes 12 (37.5%), and hypertriglyceridemia 2 (6.3%). The disease course remained mild in 24 (75%) of patients, moderate in 5 (15.6%), and severe in 3 (9.4%) according to The Atlanta Criteria. Conservative management was successful in 27 (84.4%), while 5 (15.6%) of patients required surgical intervention. Severe disease courses led to organ dysfunction and disseminated intravascular coagulation in 5 (15.6%), and maternal mortality in 3 (9.4%). Preeclampsia was the most common obstetric complication (6 (18.8%)), and 13 (40.6%) patient underwent an emergency cesarean section. In the mild group, one patient experienced miscarriage, and 14 (43.7%) patients preterm births, with 6 (18.8%) of these newborns requiring NICU admissions and 2 (6.3%) experiencing perinatal mortality. In the severe group, 2 (6.3%) had intrauterine fetal demise. Post-delivery, 12 (37.5%) were lost to follow-up. However, among the patients who followed up, 21 (62.5%) experienced an improvement in their general health condition. Conclusions Our study underscores the increased risk of preeclampsia and preterm births in women with APIP, emphasizing the need for heightened vigilance in disease progression and antenatal care.

Non-pancreatic hyperlipasemia: A puzzling clinical entity

BACKGROUND

Increased lipase level is a serological hallmark of the diagnosis of acute pancreatitis (AP) but can be detected in various other diseases associated with lipase leakage due to inflammation of organs surrounding the pancreas or reduced renal clearance and/or hepatic metabolism. This non-pancreatic hyperlipasemia (NPHL) is puzzling for attending physicians during the diagnostic procedure for AP. It would be clinically beneficial to identify the clinical and laboratory variables that hinder the accuracy of lipase diagnosis with the aim of improve it. A more precise description of the NPHL condition could potentially provide prognostic factors for adverse outcomes which is currently lacking.

AIM

To perform a detailed clinical and laboratory characterization of NPHL in a large prospective patient cohort with an assessment of parameters determining disease outcomes.

METHODS

A Hungarian patient cohort with serum lipase levels at least three times higher than the upper limit of normal (ULN) was prospectively evaluated over 31 months. Patients were identified using daily electronic laboratory reports developed to support an ongoing observational, multicenter, prospective cohort study called the EASY trial (ISRCTN10525246) to establish a simple, easy, and accurate clinical scoring system for early prognostication of AP. Diagnosis of NPHL was established based on ≥ 3 × ULN serum lipase level in the absence of abdominal pain or abdominal imaging results characteristic of pancreatitis.

RESULTS

A total of 808 patients [male, n = 420 (52%); median age (IQR): 65 (51-75) years] were diagnosed with ≥ 3 × ULN serum lipase levels. A total of 392 patients had AP, whereas 401 had NPHL with more than 20 different etiologies. Sepsis and acute kidney injury (AKI) were the most prevalent etiologies of NPHL (27.7% and 33.2%, respectively). The best discriminative cut-off value for lipase was ≥ 666 U/L (sensitivity, 71.4%; specificity, 88.8%). The presence of AKI or sepsis negatively affected the diagnostic performance of lipase. NPHL was associated with a higher in-hospital mortality than AP (22.4% vs 5.1%, P < 0.001). In multivariate binary logistic regression, not lipase but increased amylase level (> 244 U/L) and neutrophil-to-lymphocyte ratio (NLR) (> 10.37, OR: 3.71, 95%CI: 2.006-6.863, P < 0.001), decreased albumin level, age, and presence of sepsis were independent risk factors for in-hospital mortality in NPHL.

CONCLUSION

NPHL is a common cause of lipase elevation and is associated with high mortality rates. Increased NLR value was associated with the highest mortality risk. The presence of sepsis/AKI significantly deteriorates the serological differentiation of AP from NPHL.

Expert consensus on multidisciplinary approach to the diagnosis and treatment of primary hyperparathyroidism in pregnancy in China

Primary hyperparathyroidism in pregnancy is a rare disease that can have detrimental effects on both maternal and fetal/neonatal outcomes. The physiological changes that occur during pregnancy can complicate the diagnosis, imaging examinations, and treatment of this disorder. To enhance our understanding and management of primary hyperparathyroidism in pregnancy, experts from various fields, including endocrinology, obstetrics, surgery, ultrasonography, nuclear medicine, pediatrics, nephrology, and general practice in China, collaborated to develop a consensus addressing the critical aspects of the diagnosis and treatment of primary hyperparathyroidism in pregnancy with a multidisciplinary team approach. This consensus provides valuable guidance for healthcare professionals in managing this condition, ultimately improving outcomes for both mothers and their babies.

Diagnosis and Management of Acute Pancreatitis in Pregnancy

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.

Impact of acute pancreatitis during pregnancy in Chinese women: a meta-analysis

A random-effects meta-analysis was performed in English and Chinese databases since its inception to August 2020 to assess the incidence, causes and severity of acute pancreatitis (AP) at various stages of pregnancy, maternal and foetal mortality. A total of 154 articles representing 4034 patients with AP during pregnancy in China were included for the analysis. The incidence of AP during pregnancy was 0.0469 (95% confidence interval [CI], 0.0349; 0.0627) in the first trimester, whereas it was 0.2518 (95% CI, 0.2210; 0.2854) and 0.6323 (95% CI, 0.5870; 0.6753) in the second and third trimester, respectively. The major causes of AP were hypertriglyceridaemia (0.351 [95% CI, 0.3202; 0.3834]) and biliary pancreatitis (0.424 [95% CI, 0.4094; 0.5002]). The severity of AP was mild in majority of the patients. The incidence of AP at maternal mortality was 0.0184 (95% CI, 0.0126; 0.0269) and foetal mortality was 0.1018 (95% CI, 0.0867; 0.1192). Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Foetal mortality requires further investigation. IMPACT STATEMENTWhat is already known on this subject? Acute pancreatitis (AP) in pregnant women is characterised by acute onset and delay in understanding the interaction of the metabolic changes with pancreatic pathophysiology, and thus becomes difficult to diagnose the disease and provide timely treatment to the patients. This poses a greater health risk among women and their foetus by increasing their chances of mortality.What the results of this study add? We performed an exhaustive, random-effects meta-analysis involving 154 articles representing 4034 patients to assess the incidence of AP at various stages of pregnancy, the causes of AP and the severity of AP during pregnancy, maternal and foetal mortality.What are the implications of these findings for clinical practice and/or further research? Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Although the rates of maternal mortality have decreased in the recent years, foetal mortality still remains high and requires further investigation.

Epidural Analgesia for Pain Management in Acute Pancreatitis during Pregnancy and Its Effect on Maternal and Fetal Outcome

Background

Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes.

Methods

This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital.

Results

A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients.

Conclusion

AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

Acute Pancreatitis in Pregnancy: A Ten-Year Noninterventional, Retrospective Cohort Experience

Background

The study is aimed at evaluating the clinical attributes, types, and risk factors associated with poor outcomes in women with acute pancreatitis (AP) during pregnancy.

Methods

From 2011 to 2020, 45 antenatal mothers with AP were included in this noninterventional, retrospective study. The correlation between etiology of AP, its severity, biochemical parameters, length of stay, and treatment was analyzed. Based on the presence of organ failure and systemic complications, the severity of AP was classified according to the revised Atlantic criteria.

Results

In total, 19 (42.2%), 15 (33.3%), and 11 (24.2%) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. The major cause of AP in these patients was hypertriglyceridemia (26.6%), while only 2 (4.44%) suffered from biliary pancreatitis. The median length of stay at hospital was significantly longer in patients with SAP (P = 0.034), and these patients had significantly higher triglycerides and total cholesterol levels when compared to MAP and MSAP. It was observed that levels of liver function enzymes such as alanine aminotransferase serum levels and aspartate aminotransferase serum levels were significantly higher in patients who stayed in hospital for >13 days. The presence of hypertriglyceridemia significantly increased the duration of stay (>13 days, P = 0.04) and induced SAP (P = 0.001). Majority of patients with SAP received blood purification than those with MAP and MSAP (P < 0.001).

Conclusion

Hypertriglyceridemia was associated with AP during pregnancy in our study. Early diagnosis of AP and assessment of its severity are very important for the general management of this disease.

Acute pancreatitis in pregnancy: a 10-year, multi-center, retrospective study in Beijing

OBJECTIVE

Acute pancreatitis in pregnancy (APIP) is a rare and serious complication during pregnancy. It has acute onset and is difficult to diagnose and treat. The aim of the present study was to describe the etiology, clinical manifestations, and maternofetal outcomes of APIP.

METHODS

We retrospectively reviewed 32 pregnant women who were treated at three tertiary care hospitals in Beijing, China. The correlation between the causes of APIP, severity, laboratory indices, and outcomes was analyzed.

RESULTS

The most common causes of APIP were hypertriglyceridemia (56.2%,18/32) and gallstones (28.1%, 9/32). Hypertriglyceridemia-induced APIP was associated with a higher rate of severe acute pancreatitis (P = 0.025). Serum level of triglycerides showed a positive correlation with the severity of APIP (P = 0.039). The most frequent presentation of APIP was abdominal pain (93.7%, 30/32). There were no maternal or fetal deaths in our study. Apgar scores at 1 min, 5 min, and 10 min of the premature neonates was correlated with the severity of APIP of the mother (P = 0.022; 0.002; 0.002).

CONCLUSION

High level of triglycerides may serve as a useful marker of the severity of APIP. The severity of APIP was associated with higher risk of neonate asphyxia. Appropriate timing of termination of pregnancy is a key imperative for APIP patients.

Chronic Pancreatitis in Females is Not Associated With Adverse Pregnancy Outcomes: A Retrospective Analysis

BACKGROUND

The effects of chronic pancreatitis (CP) on pregnancy and vice versa have not been studied well. We aimed to study the impact of CP on pregnancy-related outcomes and the effect of pregnancy on clinical profile of CP.

STUDY AND GOALS

We did a retrospective analysis of all female patients of CP of child-bearing age (above 18 y). The pregnancy-related outcomes of patients with CP were compared with the age-matched 115 controls from the low-risk pregnancy group identified using a simplified antepartum high-risk pregnancy scoring form. The clinical course of CP during pregnancy was compared with the pre-pregnancy course.

RESULTS

Among the 338 eligible patients, 46 patients were included after exclusions. All these 46 patients had at least 1 conception and 41 had at least 1 completed pregnancy with a total of 117 conceptions and 96 completed pregnancies. The pregnancy-related outcomes in patients with CP like abortions (21.7% vs. 11.3%;P=0.087), preterm deliveries (14.6% vs. 10.4%;P=0.47), antepartum course (82.7% vs. 82.6%;P=0.58), stillbirths (4.9% vs. 4.3%;P=0.88), cesarean section (36.6% vs. 34%;P=0.849) were comparable with controls. There was overall improvement in the severity and frequency of pain during pregnancy as compared with the pre-pregnancy symptoms (P=0.001).

CONCLUSION

CP is not associated with adverse pregnancy outcomes. Also, there is trend toward improvement in the clinical symptoms because of CP during the pregnancy.

Acute pancreatitis in pregnancy and its impact on the maternal and foetal outcomes: A systematic review

BACKGROUND

The prevalence of AP in pregnancy (APIP) is uncertain with varying reports of its impact on maternal and foetal outcomes.

OBJECTIVES

This study was aimed to find the prevalence of APIP and its effect on the maternal and foetal outcomes.

SEARCH STRATEGY

Electronic databases were searched upto 31.05.2020 for the appropriate studies.

SELECTION CRITERIA

Prospective, retrospective observational studies or case series evaluating APIP in terms of maternal and foetal outcomes were included.

DATA COLLECTION AND ANALYSIS

Data on the prevalence of APIP, etiology, maternal mortality rates and foetal outcomes were collated. Due to high heterogeneity among the studies, the data has been represented as a systematic review.

RESULTS

A total of 16 studies with 8466 pregnant patients were included in the systematic review. The overall prevalence of APIP ranged from 0.225/1000 pregnancies to 2.237/1000 pregnancies. Gallstone disease was the most common cause ranging from 14.29 to 96.3%, with eastern studies reporting more cases of hypertriglyceridemia as etiology. Mild pancreatitis was noted in 33.33-100% of cases with milder disease among western studies. APIP incidence was higher during 3rd trimester (27.27%-95.24%). Maternal mortality ranged from 0 to 12.12/100 pregnancies. Foetal loss ranged from 0 to 23.08%, with adverse foetal outcomes ranging from 0 to 57.41%. Neonatal mortality ranged from 0 to 75.5/1000 neonatal live birth.

CONCLUSION

APIP is usually mild, but its incidence increases with gestational age. Maternal outcome is usually good but adverse foetal outcome is high in APIP (PROSPERO No.: CRD42020194313).

Survival of a case of pre-eclampsia complicated with acute fatty liver of pregnancy and acute pancreatitis

Acute fatty liver of pregnancy (AFLP) and acute pancreatitis are peculiar complications of pregnancy. When acute pancreatitis occurs co-incidentally with acute fatty liver of pregnancy, mortality is high. Here, we report a case of a 22-year-old lady in her 36th week of gestation, who presented with pre-eclampsia, acute fatty liver of pregnancy and acute pancreatitis. She fulfilled six Swansea criteria for diagnosis of AFLP, and the diagnosis of acute pancreatitis was based on clinical suspicion, elevated pancreatic enzymes and the sonographic appearance of a swollen pancreatic head.

Pancreatic Disorders of Pregnancy

The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.

Clinical Course of Chronic Pancreatitis During Pregnancy and its Effect on Maternal and Fetal Outcomes

INTRODUCTION

There are limited data on the effect of chronic pancreatitis (CP) on pregnancy outcomes and vice versa. Our aim was to evaluate the clinical trajectory of CP during pregnancy and its effect on pregnancy outcomes.

METHODS

All female patients of child-bearing age (≥15 years) diagnosed with CP were studied from January 2004 to July 2019. The change in frequency of painful episodes was assessed before, during, and after pregnancy. Maternal and fetal outcomes were compared between pregnant women (early onset) and women presenting with CP after completion of all pregnancies (late onset).

RESULTS

Of 187 women with CP, pregnancy outcomes and clinical course were assessed in 99 patients. The frequency of painful exacerbations was significantly lower during pregnancy compared with prepregnancy and postpregnancy periods (P < 0.001). The median pain score decreased significantly to 0 (0-2) during pregnancy from 3 (0-6) before conception and increased to 4 (0-8) after pregnancy (P = 0.002). Women with early onset CP (n = 57) had their first child later and had fewer pregnancies compared with those with late onset CP (n = 42). There was no difference in maternal outcomes such as gestational diabetes, hypertension, and preterm delivery, and fetal outcomes such as abortion, low birth weight, and still birth between the groups. There was no reported congenital anomaly.

DISCUSSION

Younger patients with CP had later and fewer pregnancies, but there was no increased risk of adverse maternal and fetal outcomes. The clinical course of CP was usually benign during pregnancy with decreased frequency and severity of pain.

Sex-Related Differences of Acute and Chronic Pancreatitis in Adults

The incidence of acute and chronic pancreatitis is increasing in the United States. Rates of acute pancreatitis (AP) are similar in both sexes, but chronic pancreatitis (CP) is more common in males. When stratified by etiology, women have higher rates of gallstone AP, while men have higher rates of alcohol- and tobacco-related AP and CP, hypercalcemic AP, hypertriglyceridemic AP, malignancy-related AP, and type 1 autoimmune pancreatitis (AIP). No significant sex-related differences have been reported in medication-induced AP or type 2 AIP. Whether post-endoscopic retrograde cholangiopancreatography pancreatitis is sex-associated remains controversial. Animal models have demonstrated sex-related differences in the rates of induction and severity of AP, CP, and AIP. Animal and human studies have suggested that a combination of risk factor profiles, as well as genes, may be responsible for the observed differences. More investigation into the sex-related differences of AP and CP is desired in order to improve clinical management by developing effective prevention strategies, diagnostics, and therapeutics.

Risk Factors for Fetal Death and Maternal AP Severity in Acute Pancreatitis in Pregnancy

Background: Acute pancreatitis in pregnancy is a rare but highly life-threatening gestational and perinatal disease. Objective: This study aimed to identify the risk factors for fetal death and acute pancreatitis severity. Methods: This retrospective cohort study enrolled patients with acute pancreatitis in pregnancy in our center from January 1, 2012, to August 1, 2020, and classified them according to two clinical endpoints, fetal outcome and disease severity. The groups were examined and compared according to gestational week, etiology, gravidity and parity, complications in pre- and post-delivery, and medical history. Logistic regression analysis was performed to identify the independent risk factors for fetal death and acute pancreatitis severity. Results: Of the 90 enrolled patients, 28 (31.1%) had fetal death and 43 (47.8%) had severe acute pancreatitis. Logistic regression analysis showed that pre-delivery acute respiratory distress syndrome (OR, 5.8; 95% CI, 1.5-22.4; p = 0.010) and gestational week (OR, 0.9; 95% CI, 0.8-1.0; p = 0.011) were risk factors for fetal death. Gestation week (OR, 1.2; 95% CI, 1.1-1.3; p = 0.003) and fetal intrauterine death (OR, 5.9; 95% CI, 1.8-19.4; p = 0.003) were risk factors for severe acute pancreatitis. Conclusions: Pre-delivery acute respiratory distress syndrome and gestational week were independent risk factors for fetal death. Fetal intrauterine death and gestational week were independent risk factors for severe acute pancreatitis.

Considering delay of cholecystectomy in the third trimester of pregnancy

INTRODUCTION

Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal-fetal outcomes of antepartum versus postpartum cholecystectomy in New York State.

METHODS

Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise.

RESULTS

Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26-1.66], p < 0.0001) and greater incidence of preterm delivery (OR 2.54, 95% CI [1.37-4.43], p = 0.0019). Cholecystectomy timing was not independently associated with differences in composite maternal outcome (p = 0.1480), BDI (p = 0.2578), 30-day NPND readmission (p = 0.7579), any complications (p = 0.2506), and fetal demise (2.44% versus 0.44%, p = 0.0545). Subgroup analysis revealed no differences in any of the seven outcomes.

CONCLUSIONS

New York Statewide data suggest that although laparoscopic cholecystectomy is safe in pregnancy, delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery.

The early predictive value of routine laboratory tests on the severity of acute pancreatitis patients in pregnancy: a retrospective study

Acute pancreatitis in pregnancy (APIP) varies in severity from a self-limiting mild condition to a severe life-threatening condition, and its severity is significantly correlated with higher risks of maternal and foetal death. This study evaluated the early predictive value of routine laboratory tests on the severity of APIP patients. We enrolled 100 patients with APIP in West China Hospital. Initial routine laboratory tests, including the biochemistry and hematologic tests were collected within 48 hours after the onset of APIP. For predicting SAP in AP, LDH had the highest specificity of 0.879. RDW was a suitable predictive marker as it had the sensitivity of 0.882. Lower levels of triglycerides (<4.72 mmol/L) predicted mild AP of APIP, with an area under the curve (AUC) of 0.724, and a negative predictive value of 0.80. Furthermore, a risk score was calculated based on white blood cells, neutrophils, RDW, LMR and LDH, as an independent marker (adjusted odds ratio = 3.013, 95% CI 1.893 to 4.797, P < 0.001), with the highest AUC of 0.906, a sensitivity of 0.875 and a specificity of 0.828. In conclusion, the risk score we recommended was the powerful marker to aid in the early prediction of the severity of APIP patients.

Predicting fetal loss in severe acute pancreatitis during pregnancy: a 5-year single-tertiary-center retrospective analysis

OBJECTIVE

To determine the factors that predict fetal loss in patients with severe acute pancreatitis.

METHODS

A total of 96,132 cases including 215 patients with acute pancreatitis were evaluated, and 83 cases with severe acute pancreatitis were included in the study. Clinical data and maternal complications were analyzed.

RESULTS

The incidence of acute pancreatitis during pregnancy was 2.24%, of which 38.6%had severe acute pancreatitis. The maternal mortality and fetal mortality were 3.6% and 32.5%, respectively. Hypertriglyceridemia (HTG) was the most common cause of severe acute pancreatitis during pregnancy and, along with delayed diagnosis, was related to fetal loss. The incidence of maternal complications including multiple organ failure (MOF), gestation diabetes mellitus, and preeclampsia was higher in pregnancies with fetal loss compared with those without fetal loss. In multivariable analysis, the independent predictors associated with fetal loss were gestational age (odds ratio [OR],0.183; 95% confidence interval [CI],0.049-0.677; P = 0.0112), HTG (OR,3.477; 95% CI, 2.152-6.674; P = 0.028), time from onset to diagnosis (OR,2.311; 95% CI,1.958-2.967;P = 0.032), MOF (OR,6.579; 95% CI,2.225-9.873; P = 0.039), gestational diabetes mellitus (OR,5.854; 95% CI,3.043-8.661; P = 0.024), and preeclampsia (OR,6.351; 95% CI,3.667-8.965; P = 0.013). A prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.909.

CONCLUSION

Severe acute pancreatitis during pregnancy leads to a high rate of fetal mortality. Gestational trimester, delayed diagnosis, HTG, MOF, gestational diabetes mellitus, and preeclampsia are predictors of fetal loss. Therefore, close monitoring is essential for pregnancies complicated with HTG, diabetes mellitus, and hypertension.

Peripartum Severe Acute Pancreatitis with Rare Complications: Case Report and Review of Literature

Peripartum pancreatitis is a rare clinical condition that occurs usually in the third trimester of pregnancy. Pancreatitis is usually secondary to gallstones, and it can lead to life-threatening and rare complications. We report a case of necrotizing postpartum pancreatitis that developed abdominal compartment syndrome (ACS) in early course, posterior reversible encephalopathy syndrome (PRES), and splanchnic and extrasplanchnic thrombosis later on. Case. 31-year-old female, one week after delivery, presented to the emergency department with abdominal pain, nausea and vomiting, tenderness in the epigastrium, and raised pancreatic enzymes. Ultrasound (USG) showed bulky pancreas with gallstones. She was diagnosed as having acute biliary pancreatitis and started to be hydrated and was supplemented with analgesia. Her condition deteriorated on the 2nd day, and she was shifted to the surgical intensive care unit (SICU) where she developed abdominal compartment syndrome (ACS), respiratory distress, and acute kidney injury, requiring endotracheal intubation and ventilation. Computerized tomography (CT) showed pancreatic necrosis with multiple fluid collections and significant left-sided pleural effusion. Percutaneous drainage of pleural effusion was done, and she was stabilized to be weaned off from mechanical ventilation. On day 15, she underwent USG-guided drainage of the pancreatic collection and ERCP (endoscopic retrograde cholangiopancreatography) on day 19. Post-ERCP, she had tonic colonic convulsions which were treated with benzodiazepines and phenytoin. It was diagnosed by imaging studies as posterior reversible encephalopathy syndrome (PRES). Her abdomen was still distended and tender; CT showed a significant pseudocyst with splanchnic and extrasplanchnic thrombosis. She had laparotomy, gastrocystostomy, and cholecystectomy on day 28th. She made uncomplicated recovery and discharged in good health. Conclusion. Peripartum pancreatitis can be complicated by ACS, PRES, and splanchnic and extrasplanchnic thrombosis.

Hypertriglyceridemia triggered acute pancreatitis in pregnancy - diagnostic approach, management and follow-up care

Acute pancreatitis is a pregnancy complication potentially lethal for both the mother and fetus, occurring most frequently in the third trimester or early postpartum. Hypertriglyceridemia may be the cause of important disease in pregnant patients. Patients with triglyceride levels exceeding 1000 mg/dL are at increased risk of developing severe pancreatitis. Diagnostic criteria and management protocols are not specific for pancreatitis complicating pregnancy. Other causes of acute abdominal pain must be considered in the differential diagnosis. Decision-making in the obstetric context is challenging and bears potential legal implications. Pre-pregnancy preventive measures and prenatal antilipemic treatment are mandatory in high risk patients.

Familial hypertriglyceridaemia and type 2 diabetes in pregnancy: prevention of acute pancreatitis with diet control and omega-3 fatty acids

Acute pancreatitis in pregnancy is rare and can be caused by hypertriglyceridaemia. The management of hypertriglyceridaemia in pregnancy is complex and challenging as many lipid-lowering medications have been found to be unsafe in pregnancy. Patients who present with hypertriglyceridaemia commonly have multiple risk factors such as, diabetes, alcohol excess and hypothyroidism which pose a greater challenge to the management of these patients. We present a case of a 31-year-old woman presenting with familial hypertriglyceridaemia and type 2 diabetes mellitus in her third pregnancy. She had an uneventful pregnancy with the use of omega-3 fatty acids nutritional support, low-fat diet and tight glucose control with insulin and metformin.

SB203580 attenuates acute lung injury and inflammation in rats with acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) can lead to multiple maternal and fetal organ injury and mitogen-activated protein kinase (MAPK) signaling pathway may be involved in it; however, whether APIP can result in acute lung injury and P38MAPK signaling pathway is involved in the pathogenesis has not been elucidated. The present study was undertaken to investigate the participation of P38MAPK signaling pathway and the protective effect of SB203580, an inhibitor of P38MAPK on acute lung injury induced by APIP. Twenty-four late-gestation SD rats were randomly assigned to four groups: Sham operation (SO) group, SB302580 (SB) group, APIP group, and SB + APIP group. All the rats were killed 6 h after modeling. The severity of pancreatitis was evaluated by serum amylase (AMY) and lipase (LIPA) and histopathological changes. Histological assessment of the lung and inflammatory cell infiltration was performed by H&E and immunofluorescence assay. The lung wet/dry (W/D) weight ratio was determined, and the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6 were detected by enzyme-linked immunosorbent assay (ELISA). Western blot analysis was used to detect the protein expression of phosphorylated and total P38, tumor necrosis factor (TNF)-α, and intercellular adhesion molecules 1 (ICAM-1) in lung tissues. Obvious pathological changes existed in pancreas and lung after the induction of APIP, and their pathological scores were significantly higher than that of control group. The results showed that the phosphorylation of P38MAPK was elevated in the lung of APIP rats. Compared with APIP group, the intervention of SB203580 alleviated the pathological injury of the pancreas and lungs, decreased serum AMY and LIPA, attenuated the secretion of TNF-α, IL-1β, and IL-6 in lung, reduced the inflammatory cells' infiltration and lung W/D ratio and inhibited the activation of P38MAPK signaling pathway. These results suggest that APIP can lead to acute lung injury and inflammation and SB203580 can inhibit the lung injury by inhibiting the P38MAPK signaling pathway and blocking the inflammatory responses.

Management of Gallstone-Induced Acute Pancreatitis in Pregnancy: A Tertiary-Center Experience

Objectives:

Gallbladder stones are the most frequently reported etiology of acute pancreatitis in pregnancy and are often diagnosed in the third trimester. This condition is associated with both mother and infant morbidity and mortality, and its treatment remains controversial.

Methods:

Relevant patient data between September 2010 and April 2017 from the Kanuni Sultan Suleyman Training and Research Hospital were analyzed regarding etiology (of gallstone pancreatitis), trimester of pregnancy, diagnostic tools, pancreatitis stage, clinical status, medical treatment, surgical interventions, and pregnancy status.

Results:

We included 68 patients recorded with acute pancreatitis due to biliary gallstones. Pancreatitis symptoms developed in most (n=38) (55.8%) patients during the third trimester. Of 24 patients who had their first episode of pancreatitis in the first trimester of pregnancy, 12 (50%) were readmitted due to recurrence. Seven (11.3%) patients whose Ranson scale score was 3 underwent computed tomography evaluation. The number of patients with acute cholecystitis with pancreatitis was 5 (7.3%), whereas the number of patients with choledocholithiasis was 4 (5.8%). Sphincterotomy with endoscopic retrograde cholangiopancreatography was performed in 2 (2.9%) patients. Laparoscopic cholecystectomy was performed in 9 (13.2%) patients during pregnancy. No fetal and maternal morbidity and mortality was found in all periods.

Conclusion:

Developments in supportive care, wide-spread use of imaging methods, and a multidisciplinary approach with better antenatal care of pregnant patients with acute pancreatitis can help prevent fetal and maternal morbidity and mortality in such cases. Early laparoscopic cholecystectomy should be considered especially in pregnant patients with acute pancreatitis due to gallstones in the first trimester.

[Influence of acute pancreatitis in pregnancy on pregnancy outcomes and neonates]

OBJECTIVE

To study the influence of acute pancreatitis in pregnancy (APIP) on pregnancy outcomes and neonates.

METHODS

A retrospective analysis was performed for 33 APIP patients and 31 neonates born alive.

RESULTS

Of the 33 APIP patients, 26 (79%) developed APIP in the late pregnancy. Fourteen (45%) patients had hyperlipidemic APIP, 13 (42%) had biliary APIP, and 4 (13%) had other types of APIP. According to the severity, 22 (67%) were mild APIP, 5 (15%) were moderate APIP, and 6 were severe APIP. None of the 33 APIP patients died. Among the 20 patients with term delivery, 11 underwent termination of pregnancy; among the 10 patients with preterm delivery, 9 underwent termination of pregnancy; two patients experienced intrauterine fetal death, and one experienced abortion during the second trimester. Among the 31 neonates born alive (two of them were twins), 1 (3%) died, 12 (39%) experienced neonatal hyperbilirubinemia, 8 (26%) had neonatal hypoglycemia, 6 (19%) had neonatal respiratory distress syndrome, 5 (16%) experienced infectious diseases, and 2 (6%) experienced intracranial hemorrhage. The hyperlipidemic APIP group had a higher percentage of patients undergoing termination of pregnancy than the biliary APIP and other types of APIP groups (P<0.05). The incidence rate of preterm infants in the moderate APIP was higher than in the mild and severe APIP groups (P<0.05). The mean birth weights of neonates were the lowest in the moderate APIP group. The incidence rates of neonatal respiratory distress syndrome, intracranial hemorrhage, and infectious disease were the lowest in the mild APIP group (P<0.05).

CONCLUSIONS

APIP can lead to adverse pregnancy outcomes and neonatal diseases, which are associated with the severity of pancreatitis.

Macrophage migration inhibitory factor antagonist (S,R)3‑(4‑hydroxyphenyl)‑4,5‑dihydro‑5‑isoxazole acetic acid methyl ester attenuates inflammation and lung injury in rats with acute pancreatitis in pregnancy

Macrophage migration inhibitory factor (MIF) is an inflammatory cytokine involved in many acute and chronic inflammatory diseases. However, its role in acute lung injury associated with acute pancreatitis in pregnancy (APIP) has not yet been elucidated. The present study was undertaken to clarify the effect and potential mechanism of MIF antagonist (S,R)3‑(4‑hydroxyphenyl)‑4,5‑dihydro‑5‑isoxazole acetic acid methyl ester (ISO‑1) in the development of acute lung injury in rats with APIP. Eighteen late‑gestation SD rats were randomly assigned to three groups: Sham operation (SO) group, APIP group, and ISO‑1 group. All the rats were sacrificed 6 h after modeling. The severity of pancreatitis was evaluated by serum amylase (AMY), lipase (LIPA), tumor necrosis factor (TNF)‑α, interleukin (IL)‑1β and IL‑6 and assessing the histopathological score. Lung injury was determined by performing histology and inflammatory cell infiltration investigations. Western blot analysis was used to detect the protein expression of MIF, phosphorylated and total P38 and nuclear factor‑κB (NF‑κB) protein in lungs. The results showed that MIF was upregulated in the lung of APIP rats. Compared with APIP group, the intervention of ISO‑1 alleviated the pathological injury of the pancreas and lungs, decreased serum AMY and LIPA, attenuated serum concentrations of TNF‑α, IL‑1β, and IL‑6, reduced the number of MPO‑positive cells in the lung and inhibited the activation of P38MAPK and NF‑κB. These results suggest that MIF is activated in lung injury induced by APIP. Furhtermore, the present findings indicate that the MIF antagonist ISO‑1 has a protective effect on lung injury and inflammation, which may be associated with deactivating the P38MAPK and NF‑κB signaling pathway.

Fetal liver injury ameliorated by migration inhibitory factor inhibition in a rat model of acute pancreatitis in pregnancy

AIM

This study was designed to investigate and assess fetal liver injury in a rat model of acute pancreatitis in pregnancy (APIP) as well as its possible mechanisms and potential therapeutic targets.

METHODS

The APIP model was induced by sodium taurocholate in Sprague-Dawley rats during the third trimester. ISO-1, a macrophage migration inhibitory factor (MIF) antagonist, was given before the induction of APIP. In addition, sham-operated rats at later gestation were set as controls. Histological changes in the fetal liver and maternal pancreas were assessed. Amylase and lipase activity as well as the levels of tumor necrosis factor (TNF)-α and interleukin (IL)-1β were examined. The expression of MIF in fetal liver was determined by immunochemistry and the expression of NF-κB, IκBα, high mobility group box-1 protein (HMGB1), TNF-α, and IL-1β in fetal liver was determined by Western blot analysis. Ultrastructures of hepatic cells in fetal rats were observed under transmission electron microscopy.

RESULTS

ISO-1 ameliorated the following: (i) pathological injuries in maternal pancreas and fetal liver; (ii) levels of TNF-α and IL-1β in maternal serum; and (iii) levels of MIF, myeloperoxidase, NF-κB, HMGB1, TNF-α, and IL-1β in fetal liver.

CONCLUSION

Pathological damage and an inflammatory response in fetal liver were induced by APIP, and MIF inhibition ameliorated fetal liver injury by inhibiting the inflammatory cascade.

Clinical characteristics of acute pancreatitis in pregnancy: experience based on 121 cases

Purpose

Acute pancreatitis in pregnancy (APIP) is a rare condition; however, it markedly affects maternal and fetal health. This study aimed to describe the types, clinical characteristics, mortality, and the safety and necessity of gestation termination of acute pancreatitis in pregnancy (APIP).

Methods

We retrospectively reviewed 121 APIP cases in the Gastroenterology Department of The First Affiliated Hospital of Nanchang University. APIP diagnosis were based on 2012 Atlanta Criteria. The correlation between APIP types, severity, biochemical parameters and mortality was analyzed.

Results

The most common symptoms for APIP were abdominal pain (86.8%) and vomiting (73.6%). The most common causes for APIP were gallstone (36.4%) and hypertriglyceridemia (32.2%) and hypertriglyceridemic APIP was correlated with a higher rate for local complication (P = 0.012). Serum calcium level was negatively correlated with the severity of APIP (P < 0.01). The overall maternal and fetal mortality rate were 3.3% (4/121) and 11.6% (14/121), respectively. The severity of APIP was significantly correlated with higher risks for maternal and fetal death (P < 0.01). 72.7% of moderate-to-severe APIP patients underwent Cesarean section to terminate gestation safely.

Conclusion

The most common causes of APIP were gallstone and hypertriglyceridemia. Lower level of serum calcium could be used as an indicator for the severity of the APIP. The severity of APIP was associated with higher risk for neonate asphyxia, and maternal and fetal death.

Emergency general surgery in pregnancy

It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.

A preliminary study on fetal lung injury in a rat model of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP), which was thought to be rare, is becoming more frequent. In addition, high perinatal mortality among fetuses has been reported. Our research aimed to investigate and assess fetal lung injury in a rat model of APIP and its possible mechanisms. The APIP model was induced by sodium taurocholate in Sprague-Dawley rats during the third trimester. Sham-operated (SO) rats in late gestation were used as controls, and dynamic observation and detection in the SO and acute pancreatitis (AP) groups were performed at 3 time-points. Histological changes in the fetal lungs, as well as the maternal pancreas and placenta were assessed. The levels of serum amylase, lipase, TNF-α and IL-1β were detected in maternal rats, and the expression of surfactant proteins A, B, C and D as well as their mRNA were determined. In this study, fetal lung injury as well as maternal pancreas and placenta injuries occurred in a time-dependent manner. The levels of serum amylase, lipase and TNF-α were markedly increased in maternal rats, and the levels of surfactant proteins A, B, C and D in fetal lungs were significantly decreased in the fetal lungs of the AP group. Ultrastructure injuries and the dysregulated synthesis and secretion of pulmonary surfactant proteins were observed in the AP group. Our research suggests that fetal lung injury is involved in the rat model of APIP and that the dysregulated synthesis and secretion of pulmonary surfactant proteins play a critical role in fetal lung injury during APIP.

A Case of Idiopathic Severe Acute Pancreatitis following Cesarean Section Delivery

Acute pancreatitis rarely occurs in the postpartum period. Furthermore, there are very few reports of it after cesarean section delivery. A 35-year-old woman presented with dyspnea and abdominal distension on the third day after cesarean section delivery. Under a suspicion of acute pancreatitis, she was initially managed with conservative treatment. However, she developed intra-abdominal fluid collections and gastric bleeding, which were managed with percutaneous drainage, endoscopic hemostasis, and angiographic embolization. She was discharged with good clinical recovery. Postpartum pancreatitis, especially after cesarean section, is rare; however, its management is not different from that for usual pancreatitis.

Pancreatitis in pregnancy: etiology, diagnosis, treatment, and outcomes

BACKGROUND

Acute pancreatitis in pregnancy is a rare and dangerous disease. This study aimed to examine the etiology, treatment, and outcomes of pancreatitis in pregnancy.

METHOD

A total of 25 pregnant patients diagnosed with pancreatitis during the period of 1994 and 2014 was analyzed retrospectively.

RESULTS

The pregnant patients were diagnosed with pancreatitis during a period of 21 years. Most (60%) of the patients were diagnosed with pancreatitis in the third trimester. The mean age of the patients at presentation was 25.7 years, with a mean gestational age of 24.4 weeks. Abdominal pain occurred in most patients and vomiting in one patient was associated hyperemesis gravidarum. The common cause of the disease was gallstone-related (56%), followed by alcohol-related (16%), post-ERCP (4%), hereditary (4%) and undetermined conditions (20%). The level of triglycerides was minimally high in three patients. ERCP and wire-guided sphincterotomy were performed in 6 (43%) of 14 patients with gallstone-related pancreatitis and elevated liver enzymes with no complications. Most (84%) of the patients underwent a full-term, vaginal delivery. There was no difference in either maternal or fetal outcomes after ERCP.

CONCLUSIONS

Acute pancreatitis is rare in pregnancy, occurring most commonly in the third trimester, and gallstones are the most common cause. When laparoscopic cholecystectomy is not feasible and a common bile duct stone is highly suspected on imaging, endoscopic sphincterotomy or stenting may help to prevent recurrence and postpone cholecystectomy until after delivery.

Mitogen-Activated Protein Kinases Are Activated in Placental Injury in Rat Model of Acute Pancreatitis in Pregnancy

OBJECTIVES

To establish a rat model of acute pancreatitis in pregnancy (APIP) and evaluate its general presentations, assess placental injury, and discuss possible mechanisms.

METHODS

The APIP rat model was induced by sodium taurocholate in Sprague-Dawley rats of later gestation. Normal and sham-operated (SO) rats in later gestation were set as controls, 3 time points were set in SO and APIP groups to determine optimal modeling time. Histological changes of pancreas and placenta were assessed. Placental injury was determined by immunohistochemistry stain of caspase-3. Serum levels of amylase, lipase, and Ca; proinflammatory cytokines as tumor necrosis factor-α, interleukin-1β (IL-1β), IL-6, and anti-inflammatory cytokine IL-10 by enzyme-linked immunosorbent assay; mitogen-activated protein kinases and their phosphorylated forms by Western blotting.

RESULTS

Pancreatic necrotizing and placental injury occurred in time-dependent patterns. Serum levels of amylase and lipase significantly increased but Ca decreased; tumor necrosis factor-α, IL-1β, IL-6, and IL-10 were all increased in the APIP group; c-Jun N-terminal kinase, p38, and ERK1/2 were activated but with different distributing patterns in the placenta.

CONCLUSIONS

Placental injury is involved in the rat model of APIP, and a modeling time of 6 hours is optimal and conducive to further studies; c-Jun N-terminal kinase and p38 may play important roles in placental injury during APIP.

Management of a Septic Open Abdomen Patient with Spontaneous Jejunal Perforation after Emergent C/S with Confounding Factor of Mild Acute Pancreatitis

Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient.

Maternal and fetal outcomes of pancreatitis in pregnancy

OBJECTIVE

This study examined maternal and neonatal outcomes that are associated with pancreatitis in pregnancy, in particular preeclampsia.

STUDY DESIGN

We conducted a retrospective cohort study of all singleton nonanomalous pregnancies in California from 2005-2008 with an identification of all cases of pancreatitis. Outcomes of interest included preeclampsia, intrauterine fetal death, preterm delivery, and neonatal or infant death. Univariate and multivariable analyses were then conducted to examine the association of pancreatitis in pregnancy and maternal characteristics and fetal outcomes.

RESULTS

Our cohort of 2,039,870 pregnant women included 342 women (0.017%) with pancreatitis. Pancreatitis in pregnancy was not associated significantly with neonatal or infant death. When assessing fetal outcomes, pancreatitis was associated with preterm delivery, small for gestational age, jaundice, respiratory distress syndrome, and intrauterine fetal death (P < .001). Of note, pregnancy-associated pancreatitis was found to be associated with preeclampsia and severe preeclampsia in both univariate (P < .001) and multivariate analysis after we controlled for potential confounders (odds ratio, 4.21 [95% confidence interval, 2.99-5.93]; odds ratio, 7.85 [95% confidence interval, 5.03-12.24], respectively).

CONCLUSION

We found that pancreatitis in pregnancy was associated with several adverse maternal outcomes; in particular, a strong association existed with preeclampsia, which has its own implications and complications surrounding pregnancy management. Pancreatitis in pregnancy was also associated with increased risk for preterm delivery but not neonatal or infant death, which is consistent with the literature.

Alcoholic Pancreatitis Masquerading as Preeclampsia

BACKGROUND

Coexisting medical complications in pregnancy can present in a fashion similar to preeclampsia and can be challenging to differentiate.

CASE

We present a patient who, at 27 3/7 weeks of gestation, fulfilled diagnostic criteria for severe preeclampsia, including hypertension, proteinuria, headache, abnormal serum creatinine levels, thrombocytopenia, and liver function abnormalities, but who nevertheless did not have preeclampsia. Instead, she was diagnosed with alcoholic pancreatitis based on a history of heavy alcohol use and elevated amylase and lipase. Abnormal laboratory values resolved with supportive therapy, and she continued to term without subsequent recurrence of proteinuria or hypertension.

CONCLUSION

Alcoholic pancreatitis can be mistaken for preeclampsia.

A 23-year, single-center, retrospective analysis of 36 cases of acute pancreatitis in pregnancy

OBJECTIVE

To assess the incidence, causes, clinical characteristics, and outcomes of cases of acute pancreatitis in pregnancy (APIP).

METHODS

A retrospective review was conducted of the medical records of pregnant women who were diagnosed with APIP at any point during pregnancy, labor, or the puerperium and attended Beijing Chaoyang Hospital, China, between January 1, 1991, and March 31, 2014.

RESULTS

Among 34 292 pregnant women admitted to the center during the study period, 36 patients were diagnosed with APIP. The condition developed during the second (9 [25%] cases) and third (22 [61%]) trimesters. The underlying cause was hypertriglyceridemia for 14 (39%) patients and biliary diseases for 7 (19%). Severe acute pancreatitis was significantly more common among patients with hypertriglyceridemia (11/14 [79%]) than among those without hypertriglyceridemia (6/22 [27%]; P=0.006). Additionally, complications were recorded for more patients with hypertriglyceridemia (11 [79%]) than those without hypertriglyceridemia (4 [18%]; P<0.001). Delayed diagnosis was more common among patients with severe acute pancreatitis (8/17 [47%]) than among those with mild acute pancreatitis (3/19 [16%]; P=0.039). No maternal deaths and only two perinatal deaths were recorded.

CONCLUSION

The overall incidence of APIP was low; however, hypertriglyceridemia was associated with poor outcomes. Early diagnosis and prompt treatment should be implemented to improve maternal and fetal prognosis and decrease mortality.

Acute pancreatitis secondary to primary hyperparathyroidism in a postpartum patient: a case report and literature review

OBJECTIVE

Primary hyperparathyroidism (PHPT) is a rare clinical entity in reproductive women. Unusual hypercalcemia causing pancreatitis in the peripartum period carries significant morbidity to both the fetus and the mother.

CASE REPORT

A 38-year-old woman developed a morbid course of intractable intra-abdominal abscess by pancreatitis, hydronephrosis by renal lithiasis, and unusual neurological presentations soon after delivery. Serial serum calcium level and imaging studies lead to the final diagnosis of PHPT due to a parathyroid adenoma. Data on 14 patients who suffered from pancreatitis due to hyperparathyroidism were collected from a MEDLINE search. The reasons for delayed diagnosis and literature review of acute pancreatitis in PHPT are discussed.

CONCLUSION

Hypercalcemia can be masked during pregnancy and in severe pancreatitis, as was detected in about half of the case series. Clinicians should have a high level of suspicion of parathyroid adenoma in cases with a profound pancreatitis. Timely diagnosis and early therapeutic intervention are important to resolve complications and improve the outcomes of mothers and fetuses.

A Case of Idiopathic Acute Pancreatitis in the First Trimester of Pregnancy

Acute pancreatitis is rare in pregnancy, with an estimated incidence of approximately 1 in 1000 to 1 in 10,000 pregnancies. Acute pancreatitis in pregnancy usually occurs in the third trimester. Here, we report a case of acute pancreatitis in the first trimester. A 36-year-old primigravida at 11 weeks of gestation complained of severe lower abdominal pain. The pain gradually worsened and migrated toward the epigastric region. She had no history of chronic alcoholism. Blood investigations showed elevated level of C-reactive protein (9.58 mg/dL), pancreatic amylase (170 IU/L), and lipase (332 IU/L). There was no gallstone and no abnormality in the pancreatic and biliary ducts on ultrasonography. Antinuclear antibody and IgG4 were negative and no evidence of hyperlipidemia or diabetes was found. There was also no evidence of viral infection. On the third day of hospitalization, she was diagnosed with severe acute pancreatitis on magnetic resonance imaging. Medical interventions were initiated with nafamostat mesilate and ulinastatin, and parenteral nutrition was administered through a central venous catheter. On the eighth day of hospitalization, her condition gradually improved with a decreased level of pancreatic amylase and the pain subsided. After conservative management, she did not have any recurrence during her pregnancy.