What is the recommended management of acute pancreatitis occurring in the postpartum period after a lower‑segment cesarean section?

Management of Acute Pancreatitis Post-LSCS

Manage post-cesarean acute pancreatitis with immediate aggressive fluid resuscitation using Ringer's lactate (20 ml/kg bolus, then 3 ml/kg/h), early enteral feeding within 24 hours, multimodal pain control with hydromorphone, and urgent ERCP within 24 hours if biliary obstruction or cholangitis is present, followed by same-admission cholecystectomy once inflammation subsides. 1, 2, 3

Initial Assessment and Diagnosis

• Confirm diagnosis with serum amylase ≥4 times normal or lipase >2 times upper limit of normal in the setting of upper abdominal pain post-LSCS 1
• Assess severity immediately using clinical signs, APACHE II score, and CRP to stratify into mild versus severe disease 1
• Determine etiology through liver function tests, serum calcium, triglyceride levels, and transabdominal ultrasound—biliary causes (gallstones/sludge) are the most common culprit in postpartum pancreatitis 4, 5
• Patients with organ failure or SIRS should be admitted to ICU or high-dependency unit 2, 3

Fluid Resuscitation Strategy

Initiate early aggressive fluid resuscitation with Ringer's lactate: 20 ml/kg bolus followed by 3 ml/kg/h continuous infusion, as this reduces persistent SIRS and hastens clinical improvement. 2, 3

• Ringer's lactate is superior to normal saline due to potential anti-inflammatory effects 1, 6
• Reassess hemodynamic status every 12 hours by monitoring hematocrit, BUN, creatinine, and lactate 2
• Target mean arterial pressure ≥65 mmHg and urine output >0.5 ml/kg/h 7
• Critical pitfall: Avoid fluid overload as it worsens respiratory status and outcomes—early aggressive hydration is most beneficial within the first 12-24 hours only 2, 3

Pain Management

• Implement multimodal pain control with hydromorphone as the preferred opioid over morphine in non-intubated patients 2
• Continue pain medication until symptoms fully resolve, typically 5-7 days 2
• Avoid NSAIDs completely if any evidence of acute kidney injury is present 2, 7

Nutritional Support

Start enteral feeding within 24 hours rather than keeping the patient nil per os, as early enteral nutrition prevents gut failure and infectious complications. 2, 3

• Nasogastric feeding is safe and effective in approximately 80% of cases 2
• In mild pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 3, 5
• Avoid parenteral nutrition unless enteral feeding is not tolerated 3, 5

Biliary Management (Critical in Post-LSCS Cases)

If biliary pancreatitis with concurrent acute cholangitis is present, perform ERCP within 24 hours of admission. 1, 3, 5

• The postpartum period increases risk of biliary sludge and gallstones, making this a common etiology 4
• ERCP is effective even in septic patients when biliary obstruction is the culprit 4
• For mild gallstone pancreatitis without cholangitis: Perform laparoscopic cholecystectomy during the same hospital admission, ideally within 2 weeks and no longer than 4 weeks to prevent recurrent pancreatitis 1
• Even if ERCP with sphincterotomy is performed, same-admission cholecystectomy is still advised as there remains increased risk for other biliary complications 1
• Timing consideration: In cases with peripancreatic fluid collections, defer cholecystectomy until collections resolve or stabilize and acute inflammation ceases 1

Antibiotic Management

Do NOT use prophylactic antibiotics, even in predicted severe or necrotizing pancreatitis. 2, 3

• Antibiotics should only be administered when specific infections occur: respiratory, urinary, biliary, or catheter-related 1, 2
• In infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, decreasing morbidity and mortality 3
• Procalcitonin may be used to limit unwarranted antibiotic use 6

Management of Complications

If infected pancreatic necrosis develops, use a step-up approach with percutaneous drainage as first-line treatment, which resolves infection in 25-60% of patients without surgery. 1, 7

• Postpone surgical interventions for more than 4 weeks after disease onset to reduce mortality 1
• Minimally invasive strategies (VARD, endoscopic necrosectomy) result in less new-onset organ failure but require more interventions compared to open surgery 1
• Critical pitfall: Do not debride or undertake early necrosectomy if forced to perform early laparotomy due to abdominal compartment syndrome 1

Ongoing Monitoring

• Perform daily reassessment of clinical, biochemical, radiological, and bacteriological findings 1
• Monitor for prolonged ileus, abdominal distension, persistent tenderness, and "failure to thrive" as adverse clinical features 1
• Increasing leucocyte count, deranged clotting, rising APACHE II score, and CRP indicate possible sepsis requiring urgent reassessment 1
• Reserve CECT or MRI for patients with unclear diagnosis or those who fail to improve clinically 3

Common Pitfalls to Avoid

• Do not over-resuscitate: Aggressive fluids beyond 12-24 hours may cause harm 2, 3
• Do not prescribe prophylactic antibiotics "just in case": This increases antibiotic resistance without benefit 2
• Do not delay cholecystectomy: Failure to perform same-admission cholecystectomy leads to 17-32% risk of recurrent biliary events 1
• Do not prescribe somatostatin analogues or other "pancreatic-specific" medications: No pharmacological treatment has proven effective 2
• Timing is crucial in postpartum patients: Delays in diagnosis and treatment can be fatal, especially when biliary obstruction is present 4