Journal of Perinatology (2014) 34, 87–94

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STATE-OF-THE-ART
Acute pancreatitis during pregnancy: a review
G Ducarme1, F Maire2,3, P Chatel4, D Luton4 and P Hammel2,3

This article aims to draw together recent thinking on pregnancy and acute pancreatitis (AP), with a particular emphasis on
pregnancy complications, birth outcomes and management of AP during pregnancy contingent on the etiology. AP during
pregnancy is a rare but severe disease with a high maternal–fetal mortality, which has recently decreased thanks to earlier
diagnosis and some maternal and neonatal intensive care improvement. AP usually occurs during the third trimester or the early
postpartum period. The most common causes of AP are gallstones (65 to 100%), alcohol abuse and hypertriglyceridemia. Although
the diagnostic criteria for AP are not specific for pregnant patients, Ranson and Balthazar criteria are used to evaluate the severity
and treat AP during pregnancy. The fetal risks from AP during pregnancy are threatened preterm labor, prematurity and in utero
fetal death. In cases of acute biliary pancreatitis during pregnancy, a consensual strategy could be adopted according to the
gestational age, and taking in consideration the high risk of recurrence of AP (70%) with conservative treatment and the specific
risks of each treatment. This could include: conservative treatment in first trimester and laparoscopic cholecystectomy in second
trimester. During the third trimester, conservative treatment or endoscopic retrograde cholangiopancreatography with biliary
endoscopic sphincterotomy, and laparoscopic cholecystectomy in early postpartum period are recommended. A multidisciplinary
approach, including gastroenterologists and obstetricians, seems to be the key in making the best choice for the management of
AP during pregnancy.

Journal of Perinatology (2014) 34, 87–94; doi:10.1038/jp.2013.161; published online 19 December 2013
Keywords: acute pancreatitis; management; pregnancy; review

INTRODUCTION time limit using ‘acute pancreatitis’, ‘pregnancy’, ‘surgery’ or

Acute pancreatitis (AP) during pregnancy is a rare disease with ‘management’ as keywords.
an estimated incidence rate of about 1 case per 1000 to 10 000
pregnancies.1–3 The diagnosis of AP is more frequent in
multiparous patients (75%).3,4 AP is rare during the first and DIAGNOSIS OF AP
second trimester of pregnancy (12%), it usually occurs during the The diagnostic criteria for AP are not specific for pregnant
third trimester (50%) or the early postpartum period (38%).3–5 patients. Some standards have been developed in non-pregnant
AP during pregnancy is a severe disease with a high maternal– patients and are often used as a guide to diagnose AP during
fetal mortality rate (37% and 60%, respectively) according to old pregnancy. The disease usually appears during the third trimester
published series of cases, but this has recently decreased thanks to or in the early postpartum period with the association of
earlier diagnosis and some maternal and neonatal intensive care symptoms like upper abdominal pain, nausea or vomiting,
improvement.6–8 Latest studies show rare maternal and fetal anorexia, fever and elevated serum amylase or lipase activities.4
mortalities, around 0 to 3%.1,5,9,10 The diagnosis of AP during pregnancy can be difficult. Pregnancy-
Causes of AP occurring during pregnancy can be different, as linked hematological and biochemical alterations may have an
they are in non-pregnant patients. However, the respective impact on the interpretation of the diagnostic tests (serum amylase
frequency of each cause is different (Table 1). The most common and lipase levels) and the assessment of the AP’s severity (physiologic
identified causes of AP in pregnancy are gallstones (65 to 100%), leukocytosis in pregnant women under 16 000 mm–3, alkaline
alcohol abuse (5 to 10%), idiopathic (15%) and familial hyper- phosphatase can reach to three times normal in normal pregnancy).
triglyceridemia-induced pancreatitis (5%).1,11 An increase in serum amylase and lipase activities should be taken
Given the current uncertainty regarding incidence, manage- into account during pregnancy, as in non-pregnant women, for the
ment and outcome of AP in pregnancy, it is important to establish diagnosis of AP.12 So, an elevated serum amylase and/or a lipase
accurate, generalizable information so that patients can be level higher than three times normal has a good positive predictive
counseled and treated appropriately. This article aims to draw value for the diagnosis of AP in pregnant women. The serum lipase
together recent thinking on AP during pregnancy, with a level has a better sensitivity (94% vs 83%) and specificity (96% vs
particular emphasis on pregnancy complications, birth outcomes 88%) than the serum amylase level to diagnose AP.13
and management of AP during pregnancy contingent on the As well as in non-pregnant patients with AP, the etiological
etiology. We have performed a Pubmed (Medline) search with no investigation based on the assessment data (personal and family
1
Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche sur Yon, France; 2Pôle des Maladies de l’Appareil Digestif, Service de Gastroentérologie-
Pancréatologie, Hôpital Beaujon, AP-HP, Clichy, France; 3Inserm U773-CRB3, Université Paris-Diderot, Clichy, France and 4Department of Obstetrics and Gynecology, Hôpital
Beaujon, AP-HP, Université Paris-Diderot, Clichy, France. Correspondence: Dr G Ducarme, Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000
La Roche sur Yon, France.
E-mail: g.ducarme@gmail.com
Received 24 May 2013; revised 21 October 2013; accepted 12 November 2013; published online 19 December 2013
 Acute pancreatitis during pregnancy
G Ducarme et al
88
Table 1. Causes of AP in pregnant women
Gallstones (65–100%)
Alcohol abuse (5–10%)
Familial hypertriglyceridemia-induced pancreatitis (5%)
Idiopathic (15%)
Drugs-induced AP (thiazide diuretics) (cases)
Pancreatitis associated with pregnancy-induced hypertension (cases)
Acute fatty liver of pregnancy associated with AP (cases)
Hyperparathyrodism (cases)
Gene mutations (cases)
Cationic trypsinogen (PRSS1)
CFTR
PSTI
PPARG
Abbreviations: AP, acute pancreatitis; CFTR, cystic fibrosis transmembrane
conductance regulator; PPARG, peroxisome proliferator-activated receptor
gamma; PSTI, pancreatic secretory trypsin inhibitor.
history, alcohol consumption and drugs), blood tests (white cell
count, liver enzyme concentrations guide to the presence of
cholelithiasis) and imaging is necessary to orientate, evaluate the
severity and treat AP during pregnancy.
Abdominal ultrasound is safe and it has higher sensitivity than
computerized tomography for detecting gallstones in cases of AP.
Magnetic resonance imaging (MRI) is an accurate technique for
detecting the cause of acute abdominal and pelvic pain during
pregnancy and should be considered for pancreas screening
during pregnancy after sonographically indeterminate findings.14
MRI can provide information on AP and its complications (edema,
pseudocysts or hemorrhagic pancreatitis), and it can also help to
determine whether the main pancreatic duct is clear or not when
persistent cholestasis occurs. MRI has also the advantage of not
causing any fetal toxicity even when gadolinium contrast media is
used, while iodinated contrast medium during computerized
tomography could induce fetal hypothyroidism.15–19 Overall,
both sensitivity and negative predictive value for the diagnosis
of choledocholithiasis are lower than those of endoscopic
ultrasonography. However, their non-invasive nature and the
absence of general anesthesia lead to prefer them as first choice
tests in pregnant patients.20
EVALUATION OF SEVERITY
Ranson and Balthazar criteria for the classification of AP’s severity
in non-pregnant patients have been developed (Table 2) and are
often used as a guide to evaluate the disease’s severity and treat it
during pregnancy.21 In addition to abdominal ultrasound, MRI has
shown to be as effective as computerized tomography for staging
AP using the Balthazar severity index.22 If there is no problem for
the differential diagnosis, it is strongly recommended to perform
an evaluation using imaging at least 48 h after the beginning of
pain (Figure 1), as too early staging may underestimate the
severity of an AP.13 In the literature, severe AP (scoreX3) during
pregnancy are mainly due to gallstone migration or to hyper-
glyceridemia.10,23
PRENATAL COMPLICATIONS
The fetal risks from AP during pregnancy are threatened preterm
labor, prematurity and in utero fetal death. Previously reported
high perinatal mortality rates secondary to AP are due to neonatal
deaths after preterm delivery. In recent series, perinatal mortality
rates were improved, mainly because 74% of the infants were
delivered in term.4 A large retrospective study including 101 cases
of pancreatitis (89 AP and 12 chronic pancreatitis) affecting
among 305 101 deliveries in 10 years showed no maternal death,
Journal of Perinatology (2014), 87 – 94
Table 2. Ranson’s criteria for prognosis of acute pancreatitis
Ranson’s criteria on admission:
Age 455 years
White blood cell count 416 000 cells mm–3
Blood glucose 411 mmol l–1
Serum AST 4250 IU l–1
Serum LDH 4350 IU l–1
Ranson’s criteria after 48 h of admission:
Hypocalcemia (serum calcium o2.0 mmol l–1)
Fall in hematocrit by 410%
Hypoxemia (PO2 o60 mm Hg)
Increase in BUN to 41.98 mmol l–1 after IV fluid hydration
Base deficit (negative base excess) 44 mmol l–1
Sequestration of fluids 46 l
Interpretation
If the score X3, severe pancreatitis likely
If the score o3, severe pancreatitis is unlikely
Or
Score 0–2: 2% mortality
Score 3–4: 15% mortality
Score 5–6: 40% mortality
Score 7–8: 100% mortality
Abbreviation: AST, aspartate aminotransferase; BUN, blood urea nitrogen;
IV, intravenous; LDH, lactate dehydrogenase.
and the perinatal mortality was 3.6%.1 Patients who developed AP
during the first trimester had the lowest percentage of term
pregnancy (60%) and the highest risks of fetal loss (20%) and
preterm delivery (16%).24 Sun et al.10 compared maternal–fetal risk
between 18 pregnancies complicated by severe AP and 51
pregnancies with mild AP. They concluded that miscarriages and
preterm infants contributed to fetal loss in the ‘mild’ group, while
fetal death and stillbirth contributed in the ‘severe’ group. Cases of
acute biliary pancreatitis were associated with better perinatal
outcomes than non-biliary causes.1
ACUTE BILIARY PANCREATITIS
Epidemiology
Elevated progesterone levels induce biliary hypotonia, increasing
the pressure of the sphincter of Oddi—which leads to bile stasis—
and the impregnation of estrogen changes the composition of
bile, which becomes more lithogenic.23 Therefore, the risk of
biliary sludge and stones increases throughout pregnancy. The
main independent risk factor for gallstones is pre-pregnancy
obesity.3,25 high-density lipoprotein cholesterol was also inversely
associated with incidental gallbladder lithiasis.25
The incidence of biliary manifestations during pregnancy (colic,
acute cholecystitis, cholangitis or biliary AP) is from 0.05 to 8%.
During pregnancy, cholelithiasis is the most common cause of AP
accounting for 65 to 100% of cases.4,23,26 In a prospective study of
over 3000 patients who had ultrasound examination throughout
the pregnancy, the authors showed a cumulative incidence of
sludge or gallstones in early postpartum in 10.2%, with biliary
sludge in 5.1%, stones in 2.8% and gallstones in patients with pre-
existing sludge in 2.3%.25 A symptomatic biliary complication
occurred in 1.2% of the pregnant women. The variability of the
reported incidence is related to a center effect and the sensitivity
of the techniques used for the lithiasis diagnosis (microlithiasis are
frequent during pregnancy and only endoscopic ultrasonography
has a high sensitivity for the diagnosis).
Treatments
The particularity of the acute biliary pancreatitis during preg-
nancy is its high recurrence rate, around 70% (90% during
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 Acute pancreatitis during pregnancy
G Ducarme et al
89

Figure 1. Non-enhanced abdominal magnetic resonance imaging (MRI) in a woman who presented an acute pancreatitis at 37 weeks
gestation. Non-enhanced abdominal MRI showing the extent of necrosis in contact with the tail of the pancreas, around the kidneys and in
the parietocolic folds (arrows, a, b), the gallbladder with no parietal thickening and no visible gallstone, and the diffuse enlargement of the
pancreas with heterogeneous attenuation of pancreatic parenchyma (arrows, c, d).

hospitalization) vs 20% to 30% in the general population.6,27,28
Management should consider both maternal and fetal risks conti-
ngent on the treatment: irradiation during endoscopic retrograde
cholangiopancreatography (ERCP) with biliary endoscopic sphinc-
terotomy, general anesthesia and laparoscopy.
Surgery? A review included 12 studies, concerning 113 patients
with confirmed gallstone-induced AP during pregnancy, compar-
ing conservative with surgical treatment.9 No maternal deaths
were reported in either group. Maternal morbidity, fetal morbidity
and mortality were low and not significantly different between the
two groups. However, in 12 reports about biliary pancreatitis, the
authors reported a trend toward higher rate of fetal mortality
(8.0% vs 2.6%, P ¼ 0.28) in the conservative group, suggesting the
need for earlier cholecystectomy (and biliary tract clearance when
necessary) during pregnancy.
Recently, Othman et al.29 published a retrospective study in a
tertiary-care referral hospital. A total of 112 patients who
had complications related to gallstones during pregnancy was
reported and classified into three groups: conservative treatment,
laparoscopic cholecystectomy and ERCP. The number of emer-
gency department visits, recurrent biliary symptoms and the
number of hospitalizations were significantly higher in the conser-
vative treatment group compared with the active intervention
group (cholecystectomy and/or ERCP). The authors concluded that
ERCP and laparoscopic cholecystectomy can be safe alternative
approaches during pregnancy.
Open cholecystectomy or laparoscopic cholecystectomy?. The
literature review identified 20 studies (197 patients) describing
laparoscopic cholecystectomy during pregnancy, excluding small
series of o5 patients.9 The procedure was performed more often
during the second trimester of pregnancy without any maternal
death.
Four retrospective studies have compared open cholecystec-
tomy vs laparoscopic cholecystectomy.30–33 These studies did
not show any significant difference in maternal and fetal
outcome. One fetal death occurred in the laparoscopic chole-
cystectomy group, compared with two in the open-surgery group
(P ¼ 0.41). There were 6 out of 89 (6.74%) preterm deliveries in the
laparoscopic cholecystectomy group compared with 2 out of 69
(2.90%) in the open-surgery group (P ¼ 0.27).9
No study has specifically evaluated the fetal risk associated
with intraoperative opacification of the biliary tract. This tech-
nique should be limited in case of suspected choledocholi-
thiasis, using a preoperative MRI or an intraoperative ultrasound
imaging.
In addition to the more commonly recognized benefits of
laparoscopy, comparing laparotomy (duration of postoperative
hospital stay, quicker return transit, lower risk of postoperative
venous thrombosis by early mobilization), there is a shorter
duration of sedation (responsible for fetal respiratory depression),
and a reduced incision size and uterine manipulation, which is the
most associated factor with a risk of preterm delivery. Precautions
are recommended to avoid high intraperitoneal pressures: to favor

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 Acute pancreatitis during pregnancy
G Ducarme et al
90
the left lateral decubitus position to minimize aorto-caval
compression; to avoid rapid changes in position; and to use
electrocoagulation with caution.9,34
Time for surgery?. Another important question is when the
best moment for surgery is if the situation allows elective
choice in pregnant woman. Laparoscopic cholecystectomy
appears to be a safe procedure during all trimesters but it is
best carried out during the second trimester because the fetus
has completed the organogenesis and the uterus is not too
large. Laparoscopic cholecystectomy should be proposed as
soon as the technical conditions for surgery are possible with-
out major maternal–fetal morbidity (that is, concomitant chole-
cystitis).35–37
Role of ERCP. ERCP has become an invaluable diagnostic and
therapeutic tool for biliary and pancreatic disorders. The indica-
tions for ERCP with biliary endoscopic sphincterotomy are
choledocholithiasis associated with AP, and prevention of
recurrence of AP during the third trimester of pregnancy. Many
studies have reported the results of ERCP during pregnancy and
all have shown the absence of serious complications for the
mother and the fetus.38–46 The risk of induced AP with ERCP is
around 5% without serious form if the procedure is done by an
experienced surgeon. The risk of fetal complications related to
ERCP has shown to be o5%.47
The main concern about performing ERCP during pregnancy
centers on radiation exposure to the fetus during fluoroscopy.
Therapeutic ERCP is associated with significantly higher radiation
exposure than diagnostic ERCP. Average effective dose
was 3.1 mSv for diagnostic and 12.4 mSv for therapeutic
ERCP.48,49 Published series on estimated dose exposure to
fetus during ERCP have ranged from 0.1 to 3 mSv, which is
significantly lower than the threshold dose required for fetal
malformation (5 mSv during pregnancy), otherwise known as the
deterministic effect.47,50 Studies concerning nonradiation ERCP
using wire-guided biliary cannulation and choledochoscopy have
been published and the authors have concluded that this
technique is a safe and effective treatment for symptomatic
choledocholithiasis during pregnancy.43,44 The fetal risks from
performing ERCP during pregnancy must therefore be weighed
against the risks to the fetus and the patient in the absence of
intervention.
Therapeutic strategy. No standardized guidelines have been
published concerning the most effective management of acute
biliary pancreatitis in pregnant women to reduce maternal and
neonatal mortality and morbidity.
A recent multimodal approach to acute biliary pancreatitis
during pregnancy has been published.51 The authors reported
seven pregnant women who were managed by using magnetic
resonance cholangiopancreatography, ERCP and sphincterotomy
followed by laparoscopic cholecystectomy. They concluded that
this active management of acute biliary pancreatitis provides
definite treatment and seems to put both mother and fetus at
lower risk than presumed.
Finally, according to the high risk of recurrence of AP (70%) with
conservative treatment and the specific risks of each treatment,
and although there are no randomized studies, consensual
strategy according to the gestational age could be adopted
(Table 3):
- First trimester: conservative treatment and laparoscopic chole-
cystectomy during second trimester.
- Second trimester: laparoscopic cholecystectomy.
- Third trimester: conservative treatment or ERCP with biliary
endoscopic sphincterotomy, and laparoscopic cholecystectomy
in the early postpartum period.
Journal of Perinatology (2014), 87 – 94
HYPERTRIGLYCERIDEMIA
Epidemiology
Hypertriglyceridemia in pregnant patients can occur on pre-
existing dyslipidemia, associated with others diseases (hyperten-
sion, diabetes and alcoholism), or without any predisposing factor.
Triglycerides concentration rises gradually, 2.5-fold over pre-
pregnancy levels, reaching a peak during the third trimester to
as high as almost twice the non-pregnant values. That’s why the
AP occurs more often during the third trimester of pregnancy.
Lipids decrease gradually during postpartum to regain pre-
pregnancy level in 6 weeks.52,53 These changes are related to an
increasing hepatic synthesis of very low-density lipoproteins and a
reduction in the activity of lipoprotein lipase in relation to the high
levels of estrogen.53 Factors favoring dyslipidemia disturbances
are excessive weight gain, diabetes, alcohol consumption, drugs
(steroids, diuretics and beta-blockers) and latent genetic
abnormalities (lipoprotein lipase, apoC2 or apoE). Experimental
models of isolated dog pancreas have shown direct toxicity of
triglycerides.54
Pregnancy, especially in the third trimester, can deregulate
controlled lipid levels in women with familial hypertriglyceridemia
and it may lead to AP and significant morbidity in both mother
and fetus. Familial severe hypertriglyceridemia (levels 410 g l–1) is
a known cause of AP during pregnancy. The incidence of familial
hypertriglyceridemia-induced pancreatitis is estimated at 1/25 000
pregnancies.55,56
Treatment
A history of familial hypertriglyceridemia requires bio-
logical monitoring for pregnancy-related hypertriglyceridemia in
those patients with a pre-pregnancy fasting triglyceride level
44 mmol l–1. A serum triglyceridemia level over 10 g l–1 is an
identifiable risk factor for complications.57,58 The mainstay
treatment, including dietary restriction of fat and lipid-lowering
agents when triglyceride level increases to 410 g l–1, effectively
prevents further episodes of hypertriglyceridemia-induced AP
during pregnancy.59
In the non-pregnant population, plasma exchange is proven to
be a safe and useful management method in cases of severe
hypertriglyceridemia where conventional drug treatment has
failed.60,61 It can quickly clear triglycerides from plasma, both
by lipid epuration and by compensation using fresh frozen
plasma and lipoprotein lipase adjunction.62 There are very few
data on the efficacy of plasma exchange in pregnant patients,
based on clinical cases or short series.52,56,63 A short series
reported a mean removal rate during a single plasma exchange
for triglyceride of around 66 and 83% after the second in 17 non-
pregnant patients with hypertriglyceridema-induced pancreatitis.62
Technical variants are numerous and involve centrifugation
or filtration supplemented or not by immunoadsorption
(Ac anti-apoB), precipitation (heparin-induced extracorporeal
low-density lipoprotein precipitation) or by adsorption on
dextran. They all share a high production cost and require high
technology.
Other treatment options including combined heparin and
insulin infusions have been described in the context of hyper-
triglyceridemia-induced AP.64–67 The clinical data of these
publications have shown pain relief and a reduction of triglyce-
rides below 10 g l–1 in 24 to 48 h. These results were comparable to
those obtained with plasma exchange.
In conclusion, no standardized guidelines have been published
concerning the most effective management of hypertriglyceride-
mia-induced AP during pregnancy. Therapy should include a
multidisciplinary team to address dietary fat restriction, appro-
priate nutritional supplements and possible medications when
needed. Therapeutic plasma exchange and/or other treat-
ment options including combined parenteral heparin and insulin
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Table 3. Algorithm of treatment in acute biliary pancreatitis in pregnant women
infusions in severe cases are effective approaches to treat
gestational hypertriglyceridemia-induced AP. Termination of
pregnancy (induction of labor or cesarean section) would be
discussed according to the term and the severity of the AP.
The early application of treatments in parturient women with
hypertriglyceridemia-induced AP may improve the clinical
course.57,58
ALCOHOL
Chronic alcoholic consumption is a rare cause of AP during
pregnancy, estimated at 5 to 10%. Alcohol and chronic alcoholic
pancreatitis before pregnancy were associated with increased
rates of recurrence of AP and preterm delivery (66.7% vs 18.6% in
case of simple gallstone pancreatitis).1,68
No standardized guidelines have been published concerning
the most effective management of chronic alcoholic pancreatitis
during pregnancy. Therapeutic strategy should include a multi-
disciplinary team to address appropriate nutritional supplements,
& 2014 Nature America, Inc.
Acute pancreatitis during pregnancy
G Ducarme et al
91
and possible medications when needed. Termination of preg-
nancy would be discussed according to the term and the severity
of the recurrence of AP. The early application of treatments in
parturient women with chronic alcoholic pancreatitis may improve
the clinical course.
DRUGS-INDUCED AP
As in non-pregnant patients, drug-induced AP may occur and it
should be systematically explored in the examination. In the litera-
ture, thiazide diuretics are the most common drugs implicated in
the occurrence of AP during pregnancy.69
PANCREATITIS ASSOCIATED WITH PREGNANCY-INDUCED
HYPERTENSION
Pancreatitis associated with pregnancy-induced hypertension
is exceptional. Severe preeclampsia may cause widespread
end-organ damage with abnormalities of the microcirculation
Journal of Perinatology (2014), 87 – 94
 Acute pancreatitis during pregnancy
G Ducarme et al
92
involving brain, liver, kidney and circulatory systems, and it may
affect the gastrointestinal system, resulting in a concomitant
pancreatic ischemia and severe necrotizing AP.70–72 Haukland
et al.73 showed in 13 patients with severe preeclampsia that mean
serum concentration of amylase was statistically significantly
higher than the corresponding mean serum concentrations in
30 normal pregnancies (1.6 vs 1.1 mmol l–1).
ACUTE FATTY LIVER OF PREGNANCY ASSOCIATED WITH AP
Acute fatty liver of pregnancy is a rare condition occurring in the
third trimester of pregnancy, characterized by nausea, vomiting,
abnormal and moderate hyperbilirubinemia. It may be compli-
cated by renal and acute liver failure, respiratory distress,
coagulopathy and rarely pancreatitis. Twelve cases of acute fatty
liver of pregnancy associated with AP have been reported with a
high maternal mortality rate (17%).74
GENETIC CAUSE
Very rare cases of gene mutations (cationic trypsinogen (PRSS1),
cystic fibrosis transmembrane conductance regulator, pancreatic
secretory trypsin inhibitor or peroxisome proliferator-activated
receptor gamma) have been reported in pregnant women
with AP.75–77
ADDITIONAL TREATMENT IN PREGNANT PATIENTS WITH AP
Management of AP in pregnant patients is often guided by
management of AP in non-pregnant patients: fasting, analgesics,
nutritional support and various complications.
A particular attention should be paid to the nutrition of
pregnant women with severe AP, based on the American Society
for Parenteral and Enteral Nutrition standards.78 Early enteral
nutrition for a very short period in a pregnant woman to
avoid denutrition has a significant impact because such therapy
modulates the stress response, promotes more rapid resolution of
the disease process, also decreases the risk of bacterial
translocation and infection of tissue necrosis, and results in
better outcome.79
In cases of pregnancy complicated by AP, the main risks of
maternal mortality are those usually associated with necrotizing
AP, necrosis infection and multi-organ failure. No prophylactic
antibiotic is recommended in agreement with the meta-analysis
comparing antibiotics with placebo, which concluded that
prophylactic intravenous antibiotics cannot reduce infected
pancreatic necrosis and mortality in patients with acute necrotiz-
ing pancreatitis.80
No standardized guidelines have been published concerning
the most effective way for delivery in women with AP during the
third trimester of pregnancy to reduce maternal and neonatal
mortality and morbidity. The decision depends on the gestational
age and the severity of AP. When vaginal delivery is possible, it is
preferable to limit the risk of superinfection necrosis associated
with laparotomy used for cesarean sections. A multidisciplinary
approach involving gastroenterologists, surgeons and obstetri-
cians is desirable.37,81
Pancreatic pseudocysts complicate 5% of the cases of
pancreatitis (fewer than 1 in 60 000 deliveries) and are most
frequently associated with alcoholic pancreatitis. The manage-
ment of this rare condition is not standardized. If a pseudocyst of
the pancreas is formed, the recommended management is
to observe asymptomatic pseudocysts and those present for
o6 weeks, as these have a 30% to 40% rate of spontaneous
resolution. Although in some cases laparoscopic or percutaneous
or endoscopic drainage of pseudocysts was performed ante-
partum, most patients were conservatively managed before
delivery.82–84
Journal of Perinatology (2014), 87 – 94
CONCLUSION
AP during pregnancy is a rare but severe disease. There is no
consensus in the literature regarding the management of AP
during pregnancy. Traditionally conservative, the treatment of
biliary lithiasis depends on the symptoms. A multidisciplinary
approach, including gastroenterology and obstetric care, seems to
be a key in making the best choice for management of AP during
pregnancy.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHOR CONTRIBUTIONS
GD, FM and PC were the main contributors to the conception, manuscript
design and preparation of the manuscript. DL and PH advised on the original
design and reviewed the manuscript.
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