What is the management of acute pancreatitis in pregnancy?

Management of Acute Pancreatitis in Pregnancy

Acute pancreatitis in pregnancy should be managed with early aggressive fluid resuscitation using Lactated Ringer's solution, early oral feeding within 24 hours, abdominal ultrasound to identify gallstones, and urgent ERCP within 24 hours if cholangitis is present, with all severe cases requiring ICU/HDU-level monitoring. 1

Initial Assessment and Diagnosis

Establish the diagnosis within 48 hours using clinical presentation, elevated pancreatic enzymes, and imaging. 1

• Perform abdominal ultrasonography immediately as the first-line imaging modality to evaluate for gallstones, which cause 65-100% of cases in pregnancy. 1, 2
• Use non-contrast MRCP for suspected choledocholithiasis rather than CT to avoid radiation exposure. 1
• Endoscopic ultrasound can be considered if MRCP cannot be performed, potentially avoiding the need for ERCP. 1
• Stratify severity within 48 hours to determine the appropriate level of care required. 1

Fluid Resuscitation and Hemodynamic Support

Initiate early aggressive fluid resuscitation with Lactated Ringer's solution: 20 ml/kg bolus followed by 3 ml/kg/hour continuous infusion. 3

• Reassess hemodynamic status every 12 hours by monitoring hematocrit, BUN, creatinine, and lactate. 3
• Avoid fluid overload as it worsens respiratory status and outcomes. 3
• For severe disease with persistent organ failure, establish central venous access for CVP monitoring, place urinary catheter and nasogastric tube. 4, 1
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature. 4, 1

Pain Management

Use multimodal pain control with hydromorphone (Dilaudid) as the preferred opioid in non-intubated patients. 3

• Completely avoid NSAIDs if any evidence of acute kidney injury is present. 3

Nutritional Support

Initiate early oral feeding within 24 hours rather than keeping the patient nil per os. 1, 3

• If oral feeding is not tolerated, enteral nutrition is strongly preferred over parenteral nutrition as it prevents gut failure and infectious complications. 1, 3
• Nasogastric feeding can be used safely and is effective in approximately 80% of cases. 4, 3

Management of Gallstone Pancreatitis

The approach depends on severity and presence of biliary obstruction or cholangitis:

Urgent ERCP (Within 24 Hours)

Perform urgent ERCP within 24 hours for patients with concomitant cholangitis (fever, rigors, positive blood cultures, deranged liver function tests). 4, 1

Early ERCP (Within 72 Hours)

• Perform early ERCP within 72 hours for patients with predicted or actual severe pancreatitis, jaundice, or dilated common bile duct. 4
• All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found. 4

Timing Considerations for ERCP in Pregnancy

• Ideally perform ERCP in the second trimester when possible with a multidisciplinary team including maternal-fetal medicine, neonatologist, obstetrician, anesthesiologist, and experienced endoscopist. 1
• Pregnant patients have higher risk for post-ERCP pancreatitis (12% vs 5% in non-pregnant patients). 1

Definitive Management

All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission unless a clear plan exists for treatment within two weeks. 4

• For first trimester: conservative treatment followed by laparoscopic cholecystectomy in second trimester. 2
• For second trimester: laparoscopic cholecystectomy during current admission. 2
• For third trimester: conservative treatment or ERCP with sphincterotomy, followed by laparoscopic cholecystectomy in early postpartum period. 2

Special Considerations for Third Trimester

Use left lateral or left pelvic tilt position to avoid compression of the inferior vena cava during procedures. 1

• Perform fetal monitoring before and after any procedures. 1

Antibiotic Management

Do not use prophylactic antibiotics routinely, even in predicted severe or necrotizing pancreatitis. 1, 3

• Administer antibiotics only for specific infections: respiratory, urinary, biliary, or catheter-related. 1, 3
• If antibiotics are used prophylactically (controversial), limit duration to maximum 14 days. 4
• Always perform ERCP under antibiotic cover. 4

ICU/HDU-Level Care

All patients with severe acute pancreatitis must be managed in ICU or HDU with full monitoring and systems support. 4, 1

Indications for ICU/HDU admission:

• Persistent organ failure despite adequate fluid resuscitation 1, 3
• Signs of sepsis 4
• Deterioration in clinical status 6-10 days after admission 4
• Greater than 30% pancreatic necrosis with persistent symptoms 4

Monitoring requirements:

• Continuous blood pressure, heart rate, oxygen saturation, respiratory rate, temperature, and fluid balance 3
• Regular arterial blood gas analysis to detect hypoxia and acidosis 4
• Swan-Ganz catheter if initial resuscitation fails or cardiocirculatory compromise exists 4

Management of Necrosis and Complications

Obtain dynamic CT scanning with non-ionic contrast within 3-10 days for patients with persistent organ failure, signs of sepsis, or clinical deterioration. 4

• Perform image-guided fine needle aspiration for patients with greater than 30% necrosis and persistent symptoms or clinical suspicion of sepsis. 4
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 4

Maternal and Fetal Outcomes

Fetal risks include threatened preterm labor, prematurity, and in utero fetal death, particularly with severe disease. 2

• With prompt hospitalization and supportive care, maternal and fetal morbidity and mortality are not prohibitive in most cases. 5
• Hypertriglyceridemia-induced pancreatitis has particularly poor outcomes when diagnosed in early pregnancy, with maternal mortality 7.5-9.0% and fetal mortality 10.0-17.5%. 6

Common Pitfalls to Avoid

• Do not delay ERCP in the presence of cholangitis - this is a true emergency requiring intervention within 24 hours. 1
• Do not use routine CT scanning unless there are specific clinical indications, to minimize fetal radiation exposure. 1
• Do not withhold nutrition - early feeding within 24 hours improves outcomes. 1, 3
• Do not position patients supine in third trimester during procedures - use left lateral tilt. 1
• Strict asepsis must be observed with all invasive monitoring equipment as these serve as sources of subsequent sepsis. 4