Acute pancreatitis is the inflammation of the pancreas, a gland that produces digestive enzymes and hormones. While rare during gestation, occurring in approximately 1 in 1,000 to 1 in 10,000 pregnancies, it represents a serious maternal complication. The physiological and hormonal shifts during pregnancy increase a woman’s susceptibility. Given that it involves both the mother and the developing fetus, prompt recognition and specialized management are necessary for a favorable outcome.
Primary Causes Linked to Pregnancy
While alcohol consumption and gallstones are primary causes in the general population, the causes shift significantly during pregnancy. For pregnant women, the most frequent cause is gallstone disease, accounting for more than 70% of cases.
The dramatic increase in estrogen and progesterone hormones during gestation plays a role in this increased risk. Estrogen causes the liver to produce bile saturated with more cholesterol, making the bile thicker and more prone to forming stones. Progesterone relaxes smooth muscles throughout the body, including the gallbladder. This relaxation reduces the gallbladder’s ability to contract and empty efficiently, leading to bile stasis and the formation of biliary sludge and stones.
Another significant cause is severe hypertriglyceridemia, or extremely high levels of triglycerides in the blood. Pregnancy naturally causes a two- to four-fold increase in triglyceride levels, peaking in the third trimester, but these levels rarely exceed 300 mg/dL. Pancreatitis is typically triggered only when the serum triglyceride concentration rises above 1,000 mg/dL. This usually occurs in women with a pre-existing underlying lipid disorder exacerbated by hormonal changes. Other less frequent causes include certain medications, trauma, and hyperparathyroidism, but gallstones and hypertriglyceridemia are the dominant factors.
Recognizing the Symptoms and Diagnostic Steps
The clinical presentation of acute pancreatitis centers on severe, persistent abdominal pain, typically felt in the upper-middle abdomen and often radiating straight through to the back. This pain is accompanied by nausea and repeated vomiting that does not bring relief, along with a potential low-grade fever and a rapid heart rate. These symptoms can sometimes be difficult to distinguish from common pregnancy discomforts, such as severe heartburn or early labor contractions, which can delay diagnosis.
Diagnosis requires meeting at least two of three criteria: the characteristic abdominal pain, elevated levels of specific pancreatic enzymes, and evidence of the condition on imaging. Blood tests measure serum amylase and lipase; a level at least three times the upper limit of normal strongly suggests pancreatitis. Lipase is considered the more accurate marker because its levels remain elevated for a longer period.
Imaging is necessary to confirm the diagnosis and identify the cause while minimizing risk to the fetus. Transabdominal ultrasound is the preferred initial imaging technique because it poses no radiation risk and is highly effective at identifying gallstones or biliary sludge. CT scans are generally avoided due to radiation exposure. Magnetic resonance imaging (MRI) provides detailed images of the pancreas and bile ducts without radiation, but it is reserved for complex cases where the diagnosis or cause remains unclear after ultrasound.
Managing Acute Pancreatitis While Pregnant
Initial treatment focuses on supportive care, similar to management in non-pregnant patients. Aggressive intravenous fluid resuscitation is paramount to prevent dehydration and maintain adequate blood flow to both the mother and the placenta. Patients are kept NPO (nil per os, or nothing by mouth) to fully rest the pancreas and halt the production of digestive enzymes.
Effective pain management is a central component of care, utilizing medications known to be safe during pregnancy. If the inability to eat extends beyond a few days, nutritional support may be initiated to ensure the mother and fetus receive necessary nutrients. Antibiotics are not routinely given unless there is suspicion of an infected pancreatic necrosis or another infectious complication.
Interventions are tailored to the underlying cause once confirmed. If the cause is gallstone-related, Endoscopic Retrograde Cholangiopancreatography (ERCP) may be necessary to remove a stone blocking the bile duct. ERCP is performed with minimal radiation exposure to protect the fetus, and it is reserved for cases involving cholangitis or severe bile duct obstruction. If gallbladder removal (cholecystectomy) is required to prevent recurrence, it is optimally performed laparoscopically during the second trimester, as this is the safest period for fetal development. When hypertriglyceridemia is the cause, treatment involves strict dietary fat restriction and, in severe cases, specialized lipid-lowering treatments to rapidly reduce triglyceride levels below the dangerous threshold.
Maternal and Fetal Outcomes
Acute pancreatitis carries a higher risk of adverse outcomes for both the mother and the fetus compared to non-pregnant patients. For the mother, the condition can progress to a severe form, leading to systemic complications such as acute kidney injury, respiratory failure, and sepsis. Pancreatitis in pregnancy is also associated with an increased risk of developing preeclampsia, a serious hypertensive disorder of pregnancy.
While contemporary management has improved the prognosis, the maternal mortality rate associated with acute pancreatitis during pregnancy is estimated to be around 2.8%. For the fetus, the inflammatory response and systemic illness in the mother increase the risks of complications. These fetal complications include intrauterine fetal death, preterm labor, and the delivery of a small-for-gestational-age infant.
The pooled fetal mortality rate is approximately 12.3%, although this rate is significantly higher if the condition occurs during the first trimester. Prompt and specialized management of the mother’s condition is the best way to mitigate these risks and improve the overall fetal outcome. Mild cases that are managed quickly often result in good fetal outcomes, but any delay in diagnosis or treatment can rapidly worsen the prognosis.