Symptomatology
Acute pancreatitis in pregnancy presents in a similar way as during nonpregnant status. However, it is difficult to diagnose in pregnancy due to similarity to many acute abdominal illnesses. The signs and symptoms of gallbladder disease usually precede pancreatitis such as colicky abdominal pain radiating to right flank, scapula, and shoulder. It is rapid in onset with maximum intensity in 10–20 min. These are typical symptoms of gallbladder disease. Also, there can be anorexia, nausea, vomiting, dyspepsia, low-grade fever, and fatty food intolerance [1, 3].
Physical Examination
In moderate to severe disease, patient appears acutely ill lying with limbs flexed (fetal position). There might be fever, tachycardia, dyspnea, and low blood pressure due to loss of fluid in the third space. On abdominal examination, there might be tenderness guarding and rigidity and sluggish or absent bowel sounds. The altered acid-base balance can lead to fetal hypoxia. Severe and sustained hypoxemia can lead to fetal demise [3, 4].
Diagnosis of Acute Pancreatitis
AP is usually diagnosed by symptomatology, laboratory investigations, and imaging.
1.
Laboratory diagnosis:
(i)
Serum amylase and lipase (increased by threefold).
(ii)
S. amylase to s. creatinine clearance ratio may be helpful in pregnancy (ratio >5 % suggests acute pancreatitis) [7].
(iii)
2
Imaging techniques:
(i)
Abdominal ultrasound: It is safe in pregnancy and detects dilated pancreatic duct, pseudocysts, and focal accumulation more than 2–3 cm. It can also detect gallbladder stones, but insensitive for detection of stone or sludge in CBD.
(ii)
EUS (endoscopic ultrasound): It can detect stones in CBD even <2 mm or sludge. It has high positive predictive value. It can be done under mild sedation and is safe in pregnancy. EUS is appropriate prior to therapeutic ERCP.
(iii)
MRCP (magnetic resonance cholangiopancreatography): It can be used if USG is inconclusive. There is paucity of data regarding safety of MRCP in the first trimester.
(iv)
RCP (endoscopic retrograde cholangiopancreatography): It has lost its value because of risk of radiation. ERCP should only be used in selected cases of CBD stones or sludge. In cases of severe acute biliary pancreatitis, ERCP within 24 h is recommended to decompress CBD, removal of gallstones, and subsequent papillotomy. ERCP should be done by experienced endoscopist and radiologist with confirmed diagnosis. The fetus should be shielded all the time during procedure to minimize exposure [5].
Management
Management of AP depends on four questions:
(i)
Does the patient have AP (diagnosis)?
(ii)
If having AP, what is predicted severity?
(iii)
Is there biliary etiology?
(iv)
What is the trimester of pregnancy?
Conventional Treatment
Mainly, it includes fluid restoration, analgesics, antiemetics, monitoring of vital signs, and estimation of fetal heart rate. Oxygen is given whenever it is required.
Nutrition
Enteral nutrition by nasojejunal feeding is better than TPN (total parenteral nutrition) in patients with severe AP. Keeping patient nil by mouth might increase the risk of infection. Enteral nutrition is physiological, helps the gut flora maintain the gut mucosal immunity, and reduces translocation of bacteria, while simultaneously avoiding all the risks of TPN [5].
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