Acute pancreatitis during pregnancy is a rare condition, with an incidence that varies and is reported between 1/1,000 and 1/10,000. (12, 10, 9, 5, 3, 16) These variations can be attributed to different diagnostic criteria and geographical factors. (14) Furthermore, recent years have seen an increase in the frequency of acute pancreatitis during pregnancy, a phenomenon that can be attributed notably to the global rise in obesity incidence and poor dietary lifestyle habits. (13,14 )
Acute pancreatitis is more frequently described in the third trimester of pregnancy. Ramin et al. reported the prevalence of acute pancreatitis as 19% in the first trimester, 26% in the second, 53% in the third, and 2% postpartum. (16)
The most common etiology is gallstone disease, described in studies between 65% and 70%. Subsequently, alcohol abuse and hypertriglyceridemia (approximately 4-5%) are the next two most common causes. (3, 4, 5) Other rarer etiologies include hyperparathyroidism, pancreatic tumors, trauma, infectious agents (HIV), autoimmune, and hereditary causes. (14)
However, a retrospective analysis of 54 cases of acute gravid pancreatitis reports hypertriglyceridemia as the leading cause, with an incidence of 41% in a cohort of Chinese patients.(8)
Triglyceride levels physiologically increase during pregnancy under the influence of estrogen, peaking at 2 to 4 times the normal level in the third trimester. They usually remain below 2,8 mmol/L and rarely exceed 3,8 mmol/L. Lipids are essential for fetal development and organogenesis. (10) This physiological increase notably explains the higher incidence of acute pancreatitis in the third trimester.
When TG levels rise, they can become harmful to the pancreas. According to recent research, a widely reported threshold is 11,3 mmol/L, beyond which the risk of developing acute pancreatitis is high. (2 - 5, 7-9, 11-13)
To our knowledge, only two similar clinical cases to ours have been described. The teams observed lactescent blood appearances with TG levels at 95,4 and 127,7 mmol/L, and one of the two teams also reported that the laboratory initially could not perform the analyses due to technical issues. (1, 2) In our case, the patient had TG levels of 79,3 mmol/L upon admission, with a lactescent serum. Results were obtained from a second blood draw, as the first one was interpretable.
This illustrates, among other factors, the complexity of diagnosing acute pancreatitis during pregnancy. In the third trimester, when faced with acute upper abdominal pain, a differential diagnosis must be undertaken, and preeclampsia should be ruled out. In our case, MgSO4 treatment was initiated due to the clinical presentation before blood test results were available.
The diagnosis of acute pancreatitis is established according to the Atlanta classification criteria, which require the presence of at least 2 of the following 3 elements: clinical epigastric pain, suggestive imaging (CT scan, ultrasound, or MRI), and a lipase level exceeding 3 times the normal range. The diagnostic criteria are the same as outside of pregnancy. (7, 8, 10, 13, 11).
However, common symptoms of pancreatitis (nausea, vomiting, abdominal discomfort, etc.) are also frequently described during normal pregnancies. Clinical examination of the abdomen can be challenging due to the displacement of intra-abdominal organs by the uterus. Classic clinical manifestations of peritonitis may be attenuated in pregnant patients due to stretching and displacement of the anterior abdominal wall, thus moving away from the inflammatory area. (4)
Managing the differential diagnosis also proves to be a considerable challenge due to the number of potential pathologies. (6) However, acute pancreatitis (AP) represents a priority to be rapidly excluded, given its association with significant maternal and fetal mortality. Early detection and appropriate management of AP during pregnancy are essential to minimize risks.
Historically, maternal-fetal mortality reached 20 to 50%. However, more recent studies describe perinatal mortality rates between 0 and 18% and maternal mortality decreased to less than 1%. (16) The improvement in maternal mortality is attributed to more precise diagnoses through better complementary examinations (laboratory tests and imaging) and improved therapeutic management. Fetal outcomes have improved due to progress and development in neonatal intensive care. (3,7) However, fetal mortality related to pancreatitis remains significant, primarily due to an increased risk of prematurity and intrauterine fetal death.(5) A case of missed diagnosis, masked by suspicion of uterine rupture, has been reported, resulting in fetal demise. (6)
Cases of biliary pancreatitis are associated with better perinatal outcomes compared to non-biliary pancreatitis cases, which are associated with fetal mortality rates described up to 60%. (5,7) According to Tang et al., pancreatitis associated with HTG is more strongly linked to severe fetal distress syndrome compared to pancreatitis of other etiologies. This team describes a fetal loss rate of 20.4%, attributed to likely insufficient maternal-fetal monitoring. Furthermore, as the severity of pancreatitis increases, the incidence of DFS and fetal death also increases. (8)
Our case highlights the importance of maternal-fetal monitoring, as evidenced by the occurrence of unexpected severe fetal distress syndrome. We hypothesize that the continuous and rapid increase in triglycerides up to 40 times the normal level could have led to fetal hypoxia by disrupting placental exchanges, possibly due to increased blood viscosity, thereby compromising adequate fetal oxygenation and resulting in the occurrence of DFS.
There is no international consensus regarding the management of acute pancreatitis (AP) during pregnancy due to the rarity of the condition. Treatment of the acute phase remains the same as outside of pregnancy, depending on the etiology and is conservative in nature. Conservative management includes a low-fat diet, adequate hydration, and pain management. (1-5, 7, 9, 13, 14)
In cases of AP secondary to hypertriglyceridemia (HTG), heparin therapy and insulin therapy are therapeutic options. They increase lipoprotein lipase activity, promoting TG degradation. (8) For rapid TG reduction, plasmapheresis may be performed, although its optimal role is unclear and its use should be considered on a case-by-case basis. (10) Additionally, fetal extraction allows for rapid TG reduction and should be considered based on gestational age. (1)
Therapeutic management should be multidisciplinary and conducted in a specialized center. It is primarily determined by gestational age and disease severity, necessitating an individualized approach for each patient. Medical termination of pregnancy or delivery should be considered based on the severity of the condition. Vaginal delivery is preferred, as cesarean section exposes the patient to an increased risk of infection. (9)
The main management of HTG remains its prevention and screening. Currently, systematic screening for HTG through TG measurement during pregnancy is not recommended in Belgium. Some teams suggest TG measurement in the first and third trimesters. Patients with documented HTG should adjust their lifestyle by adopting a low-fat diet and engaging in regular physical activity. (10,15)
In conclusion, acute pancreatitis during pregnancy is a rare but potentially serious condition, with hypertriglyceridemia being among its most common etiologies. Prevention is key in its management. Early diagnosis of acute pancreatitis remains a challenging task. Close maternal-fetal monitoring is crucial for promptly detecting any potentially severe complications and implementing appropriate therapeutic measures to preserve the health and well-being of both the mother and the fetus. Given the higher risk of fetal mortality in cases of acute pancreatitis due to hypertriglyceridemia, expedited fetal extraction should be considered.