Although acute pancreatitis isan uncommon event during pregnancy, its incidence was reported to beapproximately 1 in 1000 to 1 in 10,000. (1– 3)misdiagnosis or delayed management of such cases could be serious and lead tohigh mortality.

There are many recordedaetiologies, but commonest are the presence of biliary disease, congenital oracquired hypertriglyceridemia. Rarely, acute pancreatitis is associated withpre-eclampsia, eclampsia or HELLP syndrome. (4, 5)Pancreatitis in pregnancy canoccur at any time, but more than 50% of cases are diagnosed during the thirdtrimester of pregnancy. The incidence of acute pancreatitis is increasingproportionally with advanced gestational age, as well as, the presencegallstones. (1) There is no significantdifference regarding clinical presentations of acute pancreatitis in pregnantand non-pregnant women. The common symptoms include anorexia, nausea, vomiting,dyspepsia, abdominal pain and intolerance to fatty foods. The signs are mostlylow-grade fever and tachycardia. (6).

The diagnosis of acutepancreatitis in pregnancy is so challenging. Based on integration between theclinical manifestations, laboratory and radiological investigations. , thediagnosis of acute pancreatitis can be made. Treatment of acutepancreatitis in pregnancy should be carried by a multidisciplinary team andcould be either conservative management or surgical intervention according tothe severity of presentation, the general condition of mother and the conditionof the fetus .Acute pancreatitisin pregnancy is rare and challenging to manage due to limited evidence.

Theconnectionbetween acute pancreatitis and pregnancy is not well understood.  The definition of Acute pancreatitis inpregnancy was defined according to the severity of symptoms as highlighted byrevision of the Atlanta classification(7) (table 1).Acute pancreatitisduring pregnancy is a rare with a wide range in the incidence, ranging from1:1000 to 1:10000 (1).

Acute pancreatitis is notfrequent during the first and second trimester and represents about 12%, it is usuallyoccurring in the third trimester50% or earlypostpartum period 38%. (8)This wide range of incidenceis based on the different susceptibility of each population on the etiologicaland risk factors of acute pancreatitis.Gallstones are the commonestcause of acute pancreatitisduring pregnancy, accounting for more than 70% ofcases (1) and that is what we noticed in ourcase even when Endoscopic retrograde cholangio-pancreatography (ERCP) wasperformed and common bile duct stones were extracted.

 There are many other aetiologies and riskfactors leads to many complications as shown in table 2(1, 9-12)The pathophysiology ofpancreatitis in pregnancy is not completely understood but can be explainedduring pregnancy by increased cholesterol secretion in the hepatic bileespeciallyduring thesecond and third trimester as compared to phospholipidsandbile acids leading to more saturated bile. Moreover, greater fasting andpostprandial gallbladder volumes as well as the reduced rate of emptying volumecan contribute to more bile concentration. Eventually, thebig residualvolume ofconcentrated bile in the late gallbladder can lead tocrystals and gallstones. (1)It is important to recognize that up to 10% of women can developgallbladder sludge or stones during pregnancy and that 4% of them maintain thispathology to the postpartum period.

(13)On the other hand, McKayet al found that there was no evidence of a specific link between pregnancy andpancreatitis, but there was a marked association between pancreatitis andgallstones. (14).Another cause ofacute pancreatitis with pregnancy is hyperlipidemia and more specificallyhypertriglyceridemia. The trigger for acute pancreatitis is estimated atapproximately 1000 mg/dl of serum triglycerides. During the second and thirdtrimester of pregnancy, the serum levels of triglycerides and lipoproteins willincrease up to three-fold due to due to effect of estrogen(1). However, it is rarefor triglycerides to reach the trigger levels except in cases of familialhypertriglyceridemia or acute fatty liver (15).

Itspathophysiology is incompletely understood. Severity scoring and effectivemanagement remain challenging (16).The literature shows that gallstoneswith alcohol abuse account for more than 80% of cases of acute pancreatitis.Risk of acute pancreatitis from hypertriglyceridemia in pregnancy also seems tobe the highest in the third trimester and tends to be a more severe form ofpancreatitis than that due to gallstones. (11) .Diabetes mellitus mainly type 2 is associatedwith2.8-fold higher risk (17).

Recurrence of pancreatitis can occur in up to two-thirds of patients,and establishing the biliary origin of pancreatitis is important becauseremoval of gallstones is the definitive treatment(18, 19)From our patient’s history, None of such risk factors were documented inour case except pregnancy.In case of acute pancreatitisin pregnancy, the most common clinical presentations are an abdominal pain(89.47%) and vomiting (68.

42%) (3). Pregnantwomen with acute pancreatitis may present with anorexia and fever.Bowel soundsare reduced due to a paralytic ileusand a positive Murphy’s sign may bepresent.

Associatedpulmonary findings are noticed  in 10% of patients(20) There are many diagnosticchallenges and controversies regarding diagnosis and management of acutepancreatitis associated withpregnancy. Most symptoms like nausea, vomiting,abdominaldiscomfort, or pain, are frequently seen inpregnancy. Clinicalevaluation of acuteabdomen in pregnancy is confusing and difficult due totheanatomical displacement of abdominal organs by thegravid uterus.Some ofthehematological and biochemical ofacute pancreatitis are similar to normalpregnancies value, so the diagnosis of acute pancreatic needs a deeperinvestigations. An elevated serum amylase level has a diagnostic sensitivity of81% and adding serum lipase increases the sensitivity of 94% (21). More detailed clinicaland laboratory findingsare described in Table 3.(7,22).Our patient presented withnausea, vomiting and abdominal pain mainly in upper right hypochondrium,radiating to the back.

She noticed that urine is dark in color. No fever, nodiarrhea or constipation. No vaginal bleeding or discharge. She was afebrilenot jaundice.

The abdomen is soft with tenderness in the epigastrium and rightupper quadrant.The diagnosis of acutepancreatitis in our case was determined by clinical finding, laboratory tests,and ultrasound findings. Serum amylase, ALP, and AST were high, while WBC wasnormal.Before the 1970s the diagnosisof acute pancreatitis in pregnancy was less because most of cases werediagnosed during surgery or during autopsy (2,23).An ultrasound scan is safe andnot expensive but it has low diagnostic value for acute pancreatitis.

Anotherimaging modality especiallyin cases of unclear ultrasound findings is magneticresonance cholangiopancreatography (MRCP) without contrast medium which hasover 90% sensitivity without hazards to mother and her fetus.  Use of endoscopic retrogradecholangiopancreatography (ERCP) limited only to women who need therapeuticprocedures. MRCP has less sensitivity compared to Endoscopic ultrasound in thevisualization of choledocholithiasis(20, 24).The diagnosis in this caseestablished after ultrasound shows multiple gallstone average wall thickness.No surrounded free fluid. Dilated common bile duct. Conservative managementstarted in high dependency unit under the supervision of obstetricians, surgeons,intensivist, and the dietician.

Then after delivery ERCP done and common bileduct stones extracted followed by laparoscopic cholecystectomy after 3 daysthen patient improved.The management ofacute pancreatitis in pregnancy is the same for non-pregnant women. Themanagement contains fluid resuscitation, oxygen, analgesics, and cessation oforal feeding to prevent the autodigestion of pancreas (22).In the literature,conservative management is preferred for mild cases (25).

Some factors mayplay a role in the management of acute pancreatitis in pregnancy, including  the gestational age of pregnancy, the presenceof common bile duct dilatation, a presence of cholangitis, and the severity ofacute pancreatitis(1).The use of antibiotics iscontroversial. The literature shows that antibiotic prophylaxis does not reducemortality or protect against infected necrosis and frequency ofsurgicalintervention (26).Indications for surgery inpregnancy are severe symptoms, obstructive jaundice, acute cholecystitisintractable to medical treatment, and peritonitis (1, 8).During pregnancy,mild acute pancreatitis is the most common form and has no organ failure orother complications.

While Severe acutepancreatitis is associated withpersistent organ failure. There are some local complicationsincludeperipancreatic fluid collection and peripancreatic orpancreatic necrosis (7).So according tothat our case was a mild case and responded well to conservative managementduring pregnancy.Complications ofacute pancreatitis can affect both, the motherand  herfetus.

The onset ofpancreatitis at thefirst trimester is associated with more morbidity and mortality due to delay inmanagement. The complications can be fetal or maternal  either local or systemic complications, asshown in table 4 (7,9,10,22,23,27,28)Local complicationsare divided into early and late complications. Early complications definedas homogeneous fluid collections without a well-defined wall but confined fascialplanes, localized at the region of the pancreas, usually resolve withoutintervention and most of them remain sterile.These fluid collections do notrequire intervention. Late Local Complications is defined as pancreaticpseudocyst characterized by the presence of a well-defined wall which contains afluid collection with no solid material. It develops more than 4 weeks after theonset of interstitial oedematous pancreatitis.

CT is the most used diagnosticimaging method,in pregnant women might be enough the MRI or ultrasonography justto confirm the absence of solid material(7).The prognosis in case of mildacute pancreatitis is good with no effect on mother or fetus(29).In 1973,maternal mortality due to acute pancreatitis in pregnancy was 31%, but in 2009it went down to 1%(30).Thematernal and fetal mortality become less nowadays due to improvement andwidespread of imaging techniques.The perinatal mortality was50% in 1973 but in a review in 2009, note even one perinatal death out of 73patients with acute pancreatitis in pregnancy in the second and third trimesterand all 73 patients delivered term babies (23).Somedocumented fetal risks from acute pancreatitis during pregnancy includethreatened preterm labour, prematurity, and in utero fetal death (8).

 Early diagnosis ofacute pancreatitis in pregnancy and conservative management with carefulmaternal and fetal monitoring is recommended and associated with good perinataloutcome. Surgical intervention is limited for some indications after full counselingby a multidisciplinary team. Due to the complexity of acute pancreatitis inpregnancy, thescientific society and committee should focus on establishingspecificsuggestions and guidelines about the management of acute pancreatitisin pregnancy rather than basing on expert opinion, case series and casereports.

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