What are the implications of pancreatitis in pregnancy?

From the Guidelines

Pancreatitis during pregnancy requires prompt diagnosis and careful management to protect both mother and fetus, with treatment involving hospitalization, intravenous fluids, pain control, and bowel rest, as well as consideration of ERCP and cholecystectomy in certain cases. The management of pancreatitis in pregnancy is crucial to prevent complications and ensure the best possible outcomes for both the mother and the fetus. According to the most recent guidelines, ERCP should be performed during the second trimester if possible, as it reduces the odds of early readmission by 60% 1.

Key Considerations

• Hospitalization with intravenous fluids, typically lactated Ringer's solution at 250-500 mL/hour initially, is essential for managing pancreatitis in pregnancy.
• Pain control with medications safe in pregnancy, such as acetaminophen or low-dose opioids like morphine, is crucial.
• Bowel rest and early reintroduction of nutrition, starting with clear liquids and advancing to a low-fat diet as tolerated, are important aspects of management.
• Gallstone pancreatitis, the most common cause during pregnancy, may require ERCP with sphincterotomy for bile duct stones.
• Close monitoring of maternal vital signs, fetal heart rate, and laboratory values, including amylase, lipase, liver enzymes, and electrolytes, is essential.

ERCP and Cholecystectomy

• ERCP during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis, ideally during the second trimester 1.
• Cholecystectomy should be considered during the second trimester for gallstone pancreatitis to prevent recurrence, but may be deferred until after delivery depending on clinical circumstances and gestational age.
• A multidisciplinary team, including an obstetrician, perinatologist or MFM, radiation safety officer, obstetrical anesthesiologist, and endoscopist with experience performing ERCP, should be involved in the decision-making process for ERCP and cholecystectomy during pregnancy 1.

Fetal Radiation Exposure

• Minimizing fetal radiation exposure is crucial during ERCP, and measures such as using a modern fluoroscopy unit with collimation ability, pulsed fluoroscopy, and low radiation dose protocols can help reduce exposure 1.
• The fetal teratogenic threshold dose is considered to be 50 mGy, and detrimental outcomes are usually seen with a dose >100 mGy 1.

Maternal and Fetal Outcomes

• Maternal and fetal outcomes are generally good with appropriate management of pancreatitis in pregnancy, though there is an increased risk of preterm labor.
• Severe cases of pancreatitis may require intensive care, and close monitoring of maternal and fetal health is essential to prevent complications.

From the Research

Implications of Pancreatitis in Pregnancy

• Pancreatitis in pregnancy is a rare but severe disease with high maternal-fetal mortality, although mortality rates have decreased due to earlier diagnosis and improved maternal and neonatal intensive care 2.
• The most common causes of pancreatitis in pregnancy are gallstones, alcohol abuse, and hypertriglyceridemia, with gallstones being the most common cause, accounting for 65-100% of cases 2, 3.
• The fetal risks associated with pancreatitis in pregnancy include threatened preterm labor, prematurity, and in utero fetal death 2, 4.

Diagnostic and Therapeutic Considerations

• The diagnostic criteria for pancreatitis are not specific for pregnant patients, but Ranson and Balthazar criteria are used to evaluate the severity and treat pancreatitis during pregnancy 2.
• A multidisciplinary approach, including gastroenterologists and obstetricians, is recommended for the management of pancreatitis during pregnancy 2, 3.
• Management strategies may include conservative treatment, laparoscopic cholecystectomy, and endoscopic retrograde cholangiopancreatography with biliary endoscopic sphincterotomy, depending on the gestational age and the specific risks of each treatment 2.

Clinical Manifestation and Outcomes

• Clinical features of pancreatitis in pregnancy include severe epigastric pain, nausea, vomiting, anorexia, and fever, with blood investigations showing an elevated white cell count and increased liver enzyme concentrations 3, 4.
• Maternal and fetal outcomes can be favorable with early diagnosis and conservative comprehensive treatment, although preterm labor and fetal loss can occur 4, 5.
• Surgical intervention may be necessary in some cases, and the second trimester is considered the safest time for surgery 3.