Clinical characteristics of acute pancreatitis in pregnancy: experience based on 121 cases. Arch Gynecol Obstet. 2018;297:333-339. [PMID: 29164335 PMCID: PMC5778161 DOI: 10.1007/s00404-017-4558-7]

Psychological experience and coping strategies of pregnant women with acute pancreatitis: a qualitative descriptive study

BACKGROUND

To clarify the psychological experience and coping strategies in patients with acute pancreatitis in pregnancy (APIP) and propose interventional measures to improve pregnancy outcomes in these women. With an increasing trend of pregnant women in advanced ages and multiparous women, the incidence of APIP has significantly increased. Pregnancy accompanied by concurrent pancreatitis may subject these women to notable psychological stress, which is a factor that has been infrequently reported in previous studies.

METHODS

APIP patients were interviewed from December 2020 to June 2021. Data were collected through semi-structured interviews based on an outline, including six questions. The interviews were recorded and analyzed using qualitative content analysis until data saturation was reached.

RESULTS

Ten APIP patients were interviewed and four themes were identified, including excessive psychological burden, uncomfortable experience, urgent requirement for adequate medical resources, and importance of social support.

CONCLUSION

Patients with APIP suffer from significant psychological stress due to their medical conditions and management. They desired adequate medical resources and social support. The local health department, hospital administrators, and medical staff should understand the psychological requirements and provide adequate healthcare and education that are easily accessible to these APIP patients. In addition, family support should also be encouraged to promote APIP patients' recovery.

Acute Pancreatitis in Pregnancy and Puerperium: Assessing Maternal and Fetal Impact, Etiologies, and Clinical Outcomes at a Tertiary Care Hospital in Pakistan

Introduction The association of acute pancreatitis with adverse obstetric outcomes remains subject to great controversy. Outcomes are affected by the standard of care available, and hence, will be better in developed countries than in underdeveloped countries like Pakistan. Therefore, this study aimed to understand the clinical characteristics and treatment of acute pancreatitis in pregnancy (APIP) and its associated maternal and neonatal outcomes in a tertiary care hospital in Pakistan. Methodology A retrospective clinical analysis of APIP cases during pregnancy and the postpartum period was conducted at Aga Khan University Hospital (AKUH) in Karachi, Pakistan, from January 1, 2015, to December 31, 2021. Data were collected from the medical records of women diagnosed with APIP. Pregnant women with chronic and recurrent pancreatitis were excluded. We analyzed baseline demographics, obstetric outcomes, and neonatal outcomes for those who delivered at AKUH. These individuals were monitored in postnatal outpatient clinics to track changes in their initial symptoms. Data were analyzed using IBM SPSS version 25.0. Results A total of 32 patients with APIP were included. Among them, 13 (40.6%) were primigravida, and 21 (65.6%) were multigravida. The majority 22 (69%) presented in the third trimester. The most common etiology was gallstones 13 (40.6%), followed by idiopathic causes 12 (37.5%), and hypertriglyceridemia 2 (6.3%). The disease course remained mild in 24 (75%) of patients, moderate in 5 (15.6%), and severe in 3 (9.4%) according to The Atlanta Criteria. Conservative management was successful in 27 (84.4%), while 5 (15.6%) of patients required surgical intervention. Severe disease courses led to organ dysfunction and disseminated intravascular coagulation in 5 (15.6%), and maternal mortality in 3 (9.4%). Preeclampsia was the most common obstetric complication (6 (18.8%)), and 13 (40.6%) patient underwent an emergency cesarean section. In the mild group, one patient experienced miscarriage, and 14 (43.7%) patients preterm births, with 6 (18.8%) of these newborns requiring NICU admissions and 2 (6.3%) experiencing perinatal mortality. In the severe group, 2 (6.3%) had intrauterine fetal demise. Post-delivery, 12 (37.5%) were lost to follow-up. However, among the patients who followed up, 21 (62.5%) experienced an improvement in their general health condition. Conclusions Our study underscores the increased risk of preeclampsia and preterm births in women with APIP, emphasizing the need for heightened vigilance in disease progression and antenatal care.

Dyslipidemia management in women of reproductive potential: An Expert Clinical Consensus from the National Lipid Association

Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.

Assessment of early factors for identification or prediction severe acute pancreatitis in pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) is a rare and serious condition, and severe APIP (SAPIP) can lead to pancreatic necrosis, abscess, multiple organ dysfunction, and other adverse maternal and infant outcomes. Therefore, early identification or prediction of SAPIP is important.

AIM

To assess factors for early identification or prediction of SAPIP.

METHODS

The clinical data of patients with APIP were retrospectively analyzed. Patients were classified with mild acute pancreatitis or severe acute pancreatitis, and the clinical characteristics and laboratory biochemical indexes were compared between the two groups. Logical regression and receiver operating characteristic curve analyses were performed to assess the efficacy of the factors for identification or prediction of SAPIP.

RESULTS

A total of 45 APIP patients were enrolled. Compared with the mild acute pancreatitis group, the severe acute pancreatitis group had significantly increased (P < 0.01) heart rate (HR), hemoglobin, neutrophil ratio (NEUT%), and neutrophil-lymphocyte ratio (NLR), while lymphocytes were significantly decreased (P < 0.01). Logical regression analysis showed that HR, NEUT%, NLR, and lymphocyte count differed significantly (P < 0.01) between the groups. These may be factors for early identification or prediction of SAPIP. The area under the curve of HR, NEUT%, NLR, and lymphocyte count in the receiver operating characteristic curve analysis was 0.748, 0.732, 0.821, and 0.774, respectively. The combined analysis showed that the area under the curve, sensitivity, and specificity were 0.869, 90.5%, and 70.8%, respectively.

CONCLUSION

HR, NEUT%, NLR, and lymphocyte count can be used for early identification or prediction of SAPIP, and the combination of the four factors is expected to improve identification or prediction of SAPIP.

Clinical characteristics and pregnancy outcome analysis of 20 cases of acute pancreatitis during pregnancy

OBJECTIVE

This study investigated the clinical characteristics and pregnancy outcomes of acute pancreatitis during pregnancy (APIP).

METHODS

A retrospective analysis was conducted on 20 cases of APIP admitted to Hubei Maternal and Child Health Hospital from January 2017 to September 2021. The etiology, clinical manifestations, and perinatal outcomes of APIP were analyzed using descriptive statistical analysis of the collected data.

RESULTS

The incidence of APIP in our hospital was 20 (0.02%) cases, all of which occurred in the late stage of pregnancy. Hypertriglyceridemic acute pancreatitis (HTG-AP) was the primary cause of APIP in 10 (50.0%) patients. A total of 11 (55.0%), seven (35.0%) and two (10.0%) patients had mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), respectively. Pregnant women with HTG-AP had significantly elevated serum triglyceride levels, had higher prepregnancy body mass indices, were more prone to developing diabetes and were more likely to progress to SAP. With a multidisciplinary approach and individualized treatment plans, there were no maternal deaths, and fetal death only occurred in one (5.0%) case.

CONCLUSION

HTG-AP is prone to advancing to more severe states, and it is becoming more common every year. Therefore, blood lipid management during pregnancy should be emphasized. Pregnant women with digestive symptoms or severe hyperlipidaemia should be screened for APIP in a timely manner and receive clinical intervention to improve maternal and fetal outcomes during the perinatal period.

Acute Pancreatitis in Pregnancy: A Propensity Score Matching Analysis and Dynamic Nomogram for Risk Assessment

BACKGROUND

Acute pancreatitis is easily confused with abdominal pain symptoms, and it could lead to serious complications for pregnant women and fetus, the mortality was as high as 3.3% and 11.6-18.7%, respectively. However, there is still lack of sensitive laboratory markers for early diagnosis of APIP and authoritative guidelines to guide treatment.

OBJECTIVE

The purpose of this study was to explore the risk factors of acute pancreatitis in pregnancy, establish, and evaluate the dynamic prediction model of risk factors in acute pancreatitis in pregnancy patients.

STUDY DESIGN

Clinical data of APIP patients and non-pregnant acute pancreases patients who underwent regular antenatal check-ups during the same period were collected. The dataset after propensity matching was randomly divided into training set and verification set at a ratio of 7:3. The model was constructed using Logistic regression, least absolute shrinkage and selection operator regression, R language and other methods. The training set model was used to construct the diagnostic nomogram model and the validation set was used to validate the model. Finally, the accuracy and clinical practicability of the model were evaluated.

RESULTS

A total of 111 APIP were included. In all APIP patients, hyperlipidemic pancreatitis was the most important reason. The levels of serum amylase, creatinine, albumin, triglyceride, high-density lipoprotein cholesterol, and apolipoprotein A1 were significantly different between the two groups. The propensity matching method was used to match pregnant pancreatitis patients and pregnant non-pancreatic patients 1:1 according to age and gestational age, and the matching tolerance was 0.02. The multivariate logistic regression analysis of training set showed that diabetes, triglyceride, Body Mass Index, white blood cell, and C-reactive protein were identified and entered the dynamic nomogram. The area under the ROC curve of the training set was 0.942 and in validation set was 0.842. The calibration curve showed good predictive in training set, and the calibration performance in the validation set was acceptable. The calibration curve showed the consistency between the nomogram model and the actual probability.

CONCLUSION

The dynamic nomogram model we constructed to predict the risk factors of acute pancreatitis in pregnancy has high accuracy, discrimination, and clinical practicability.

A retrospective study of pregnant patients with acute pancreatitis

OBJECTIVE

Acute pancreatitis is a rare disease in pregnant patients. Although it may have serious maternal and fetal consequences, morbidity and mortality rates have decreased recently due to appropriate and rapid treatment with earlier diagnosis. The aim of this study was to evaluate pregnant patients diagnosed with acute pancreatitis.

METHODS

The study included pregnant patients diagnosed with acute pancreatitis who were admitted to Adana City Training and Research Hospital in Adana, Turkey, between January 2014 and January 2022. Patients' files were screened. Patients' demographics, acute pancreatitis etiology, severity, complications, and applied treatment, as well as maternal and fetal outcomes were evaluated.

RESULTS

The study included 65 pregnant patients with acute pancreatitis. The mean age was 26.6±5 (19-41) years. Acute pancreatitis was observed in the third trimester. The most common cause of acute pancreatitis was gallstones, and its severity was often mild. Only two patients required endoscopic retrograde cholangiopancreatography, and the remaining patients were treated medically. Maternal and infant death developed in a patient with necrotizing acute pancreatitis secondary to hyperlipidemia.

CONCLUSION

The most common etiology of acute pancreatitis in pregnancy was gallstones. Acute pancreatitis occurred in the third trimester. Most of the patients had mild acute pancreatitis. Maternal and fetal complications were rare. We think that the reasons for the low mortality rate were mild disease severity and biliary etiology, and most patients were in the third trimester, as well as early diagnosis and no delay in the intervention.

Pregnancy With Diabetic Ketoacidosis and Hypertriglyceridemia-Induced Acute Pancreatitis: The Enigmatic Triad

Acute pancreatitis in pregnancy is a rare condition. Acute pancreatitis due to hypertriglyceridemia in a case of diabetic ketoacidosis is also a very rare condition with a very high mortality rate. Here, we report a case of a 34-week pregnancy with pregnancy-induced hypertension, diabetic ketoacidosis, and hypertriglyceridemia-induced acute pancreatitis with underlying gallstone disease, which might have contributed to the etiology of pancreatitis. There is no report of such a case in the available literature. The patient underwent a lower segment cesarean section and was conservatively treated for all other comorbidities and had a successful outcome.

Case Report: Abruptio placentae and epileptic seizure after occurrence of perinatal hyperglycaemia in woman with gestational diabetes mellitus and hypertriglyceridemia-induced acute pancreatitis

Hypertriglyceridemia-induced acute pancreatitis seldom occurs in the second trimester of pregnancy with gestational diabetes mellitus. For these patients, the existing knowledge on concomitant hyperglycemia is not sufficient. We report a case of abruptio placentae and epileptic seizure following perinatal hyperglycaemia in woman with gestational diabetes mellitus and hypertriglyceridemia-induced acute pancreatitis. The occurrence of abruptio placentae and epileptic seizure may be associated with concomitant hyperglycemia, and the epileptic seizure was terminated after she underwent treatment with insulin. We should pay more attention to the adverse effects of perinatal hyperglycemia and continue to give appropriate insulin treatment even if patients have passed the acute phase of hypertriglyceridemia-induced acute pancreatitis.

The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review

Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.

Defined, low threshold for caesarean section and multidisciplinary team management improves fetal outcome from acute pancreatitis in pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) is associated with increased maternal and fetal mortality.

OBJECTIVES

We sought to determine whether a low threshold for cesarean section (C-section) in severe acute pancreatitis (SAP) or Predict SAP improves maternal and fetal outcomes in patients with APIP.

METHODS

We identified patients with APIP at a single institution from a prospective database and studied fetal and maternal health in APIP before (2005-2014) and after (2015-2019) introduction of multidisciplinary team management with a defined, lowered threshold for C-section. The primary end point was fetal mortality comprising abortion and perinatal death. Risk factors associated with fetal mortality were analyzed by univariable and multivariable logistic regression analysis.

RESULTS

A total of 165 patients with APIP were eligible for analysis. There was a highly significant increase in patients undergoing C-section from 37 (30.8%) of 120 during 2005-2014 to 27 (60%) of 45 in 2015-2019 (P = 0.001), with a highly significant fall in fetal mortality from 37 (30.8%) of 120 to 3 (6.7%) of 45 between the same periods (P = 0.001), when maternal mortality fell from 6 to zero (P = 0.19). Maternal early systemic inflammatory response syndrome (SIRS) (odds ratio [OR] 6.98, 95% confidence interval [CI] 1.53, 30.80, P = 0.01) and SAP (OR 3.64, 95%CI 1.25, 10.60, P = 0.02) were two independent risk factors associated with fetal mortality.

CONCLUSIONS

Multidisciplinary collaboration and a defined, low threshold for C-section improve fetal outcomes in patients with APIP.

Acute Pancreatitis (AP) in Pregnancy and Its Complications From an Anesthesia Perspective: A Case Report

Acute pancreatitis (AP) is a rare event in pregnancy that is characterized by a sudden and severe inflammation of the pancreas. The clinical manifestation of AP during pregnancy is highly variable ranging from a mild form to a severe and potentially life-threatening presentation. We share a case of a 29-year-old female (gravida II, para I) who presented in her 33rd gestational week. The patient complained of upper abdominal pain and nausea. Her previous history revealed that she had four episodes of vomiting (food-containing, non-projectile) at home. Her uterine tone was normal, and her cervix was closed. Her white blood cell count was 13,000/mm3, and her C-reactive protein (CRP) level was 65 mg/L. She underwent an emergency laparotomy due to suspected acute appendicitis; however, no peritonitis was found intraoperatively. Further blood tests showed high levels of triglyceride at 87.5 mmol/L. The electrophoretic pattern of lipoprotein was consistent with type V hyperlipoproteinemia. An abdominal computed tomography (CT) confirmed the diagnosis of acute pancreatitis. During follow-up after one month, the patient showed triglyceride levels at 4.75 mmol/L and cholesterol at 6.07 mmol/L. Acute pancreatitis due to hypertriglyceridemia is a rare finding; nonetheless, it should be considered as a potential etiology in pregnant patients with nonobstructive abdominal pain.

Early predictive value of scoring systems and routine laboratory tests in severity and prognosis of acute pancreatitis in pregnancy

Background

Currently, no guidelines specifically recommend scoring systems and biomarkers for early evaluation of the severity and prognosis of acute pancreatitis in pregnancy (APIP).

Objectives

This study aimed to explore the early predictive value of scoring systems and routine laboratory tests on APIP severity and maternofetal prognosis.

Design

This study retrospectively analyzed 62 APIP cases in a 6-year period.

Methods

The predictive value of scoring systems and routine laboratory tests that were collected 24 h and 48 h after admission, for APIP severity and fetal loss, were analyzed.

Results

To detect severe acute pancreatitis (SAP), a 24-h Bedside Index for severity in acute pancreatitis (BISAP) achieved a higher area under the curve (AUC) value of 0.910 than the Acute Physiology and Chronic Health Evaluation II (AUC = 0.898) and Ranson score (AUC = 0.880). The combination of BISAP, glucose, neutrophil-to-lymphocyte ratio (NLR), hematocrit (Hct), and serum creatinine (Scr) provided an AUC value of 0.984, which had greater predictive power than BISAP (p = 0.015). 24-h BISAP and Hct were independent risk factors for predicting SAP of APIP. The cutoff values of Hct and blood urea nitrogen (BUN) to predict SAP were 35.60% and 3.75 mmol/l in the APIP. Furthermore, 24-h BISAP had the highest predictive power (AUC = 0.958) for fetal loss.

Conclusion

BISAP is a convenient and reliable indicator for the early prediction of SAP and fetal loss in APIP. The combination of BISAP, glucose, NLR, Hct and Scr proved to be the optimal early markers for the prediction of SAP in APIP within 24 h after admission. In addition, Hct > 35.60% and BUN > 3.75 mmol/l may be suitable thresholds for predicting SAP in APIP.

A novel clinical prediction model of severity based on red cell distribution width, neutrophil-lymphocyte ratio and intra-abdominal pressure in acute pancreatitis in pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) with a high risk of death is extremely harmful to mother and fetus. There are few models specifically designed to assess the severity of APIP. Our study aimed to establish a clinical model for early prediction of severity of APIP.

METHODS

A retrospective study in a total of 188 patients with APIP was enrolled. The hematological indicators, IAP (intra-abdominal pressure) and clinical data were obtained for statistical analysis and prediction model construction.

RESULTS

According to univariate and multivariate logistic regression analysis, we found that red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR) and Intra-abdominal pressure (IAP) are prediction indexes of the severity in APIP (p-value < 0.05). Our novel clinical prediction model was created by based on the above three risk factors and showed superior predictive power in primary cohort (AUC = 0.895) and validation cohort (AUC = 0.863). A nomogram for severe acute pancreatitis in pregnancy (SAPIP) was created based on the three indicators. The nomogram was well-calibrated.

CONCLUSION

RDW, NLR and IAP were the independent risk factors of APIP. Our clinical prediction model of severity in APIP based on RDW, NLR and IAP with predictive evaluation is accurate and effective.

Pancreatitis in Pregnancy-Comprehensive Review

Acute and chronic pancreatitis, until recently observed incidentally in pregnancy, has occurred much more frequently in the last 2-3 decades. Particularly severe complications for the mother and fetus may be a consequence of acute pancreatitis. Therefore, it is important to know more about the diagnostic and therapeutic possibilities of pancreatic diseases in the course of pregnancy. Epidemiology, causes, clinical characteristics, differential diagnosis, and complex management are presented in this review. Particular emphasis is on the prevention of acute pancreatitis (AP) through the proper diagnosis and treatment of cholelithiasis and hypertriglyceridemia, both before and during pregnancy. The most up-to-date reports and management strategies are presented. This publication contributes to a wide group of scientists and practitioners better understanding the discussed issues, and indicates the directions of research for the future.

Impact of acute pancreatitis during pregnancy in Chinese women: a meta-analysis

A random-effects meta-analysis was performed in English and Chinese databases since its inception to August 2020 to assess the incidence, causes and severity of acute pancreatitis (AP) at various stages of pregnancy, maternal and foetal mortality. A total of 154 articles representing 4034 patients with AP during pregnancy in China were included for the analysis. The incidence of AP during pregnancy was 0.0469 (95% confidence interval [CI], 0.0349; 0.0627) in the first trimester, whereas it was 0.2518 (95% CI, 0.2210; 0.2854) and 0.6323 (95% CI, 0.5870; 0.6753) in the second and third trimester, respectively. The major causes of AP were hypertriglyceridaemia (0.351 [95% CI, 0.3202; 0.3834]) and biliary pancreatitis (0.424 [95% CI, 0.4094; 0.5002]). The severity of AP was mild in majority of the patients. The incidence of AP at maternal mortality was 0.0184 (95% CI, 0.0126; 0.0269) and foetal mortality was 0.1018 (95% CI, 0.0867; 0.1192). Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Foetal mortality requires further investigation. IMPACT STATEMENTWhat is already known on this subject? Acute pancreatitis (AP) in pregnant women is characterised by acute onset and delay in understanding the interaction of the metabolic changes with pancreatic pathophysiology, and thus becomes difficult to diagnose the disease and provide timely treatment to the patients. This poses a greater health risk among women and their foetus by increasing their chances of mortality.What the results of this study add? We performed an exhaustive, random-effects meta-analysis involving 154 articles representing 4034 patients to assess the incidence of AP at various stages of pregnancy, the causes of AP and the severity of AP during pregnancy, maternal and foetal mortality.What are the implications of these findings for clinical practice and/or further research? Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Although the rates of maternal mortality have decreased in the recent years, foetal mortality still remains high and requires further investigation.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

Progress in research of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare and severe complication of pregnancy, which is characterized by rapid onset, rapid progression, many complications, and high mortality. According to previous studies, the incidence of APIP is about 1/10000-1/1000 and increases with gestational age. Due to the differences in genetic background and dietary habits between Asian and European populations, the incidence of APIP in China is as high as 1.14‰-2.27‰, significantly higher than that in Western countries. The lack of specific clinical symptoms of APIP often leads to misdiagnosis or missed diagnosis, which greatly increases the difficulty of diagnosis and treatment. Despite the deepening of the research on APIP, its pathogenesis is still unclear. This paper will give a systematical review of APIP.

Acute Pancreatitis in Pregnancy: A Ten-Year Noninterventional, Retrospective Cohort Experience

Background

The study is aimed at evaluating the clinical attributes, types, and risk factors associated with poor outcomes in women with acute pancreatitis (AP) during pregnancy.

Methods

From 2011 to 2020, 45 antenatal mothers with AP were included in this noninterventional, retrospective study. The correlation between etiology of AP, its severity, biochemical parameters, length of stay, and treatment was analyzed. Based on the presence of organ failure and systemic complications, the severity of AP was classified according to the revised Atlantic criteria.

Results

In total, 19 (42.2%), 15 (33.3%), and 11 (24.2%) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. The major cause of AP in these patients was hypertriglyceridemia (26.6%), while only 2 (4.44%) suffered from biliary pancreatitis. The median length of stay at hospital was significantly longer in patients with SAP (P = 0.034), and these patients had significantly higher triglycerides and total cholesterol levels when compared to MAP and MSAP. It was observed that levels of liver function enzymes such as alanine aminotransferase serum levels and aspartate aminotransferase serum levels were significantly higher in patients who stayed in hospital for >13 days. The presence of hypertriglyceridemia significantly increased the duration of stay (>13 days, P = 0.04) and induced SAP (P = 0.001). Majority of patients with SAP received blood purification than those with MAP and MSAP (P < 0.001).

Conclusion

Hypertriglyceridemia was associated with AP during pregnancy in our study. Early diagnosis of AP and assessment of its severity are very important for the general management of this disease.

Acute pancreatitis in pregnancy: a 10-year, multi-center, retrospective study in Beijing

OBJECTIVE

Acute pancreatitis in pregnancy (APIP) is a rare and serious complication during pregnancy. It has acute onset and is difficult to diagnose and treat. The aim of the present study was to describe the etiology, clinical manifestations, and maternofetal outcomes of APIP.

METHODS

We retrospectively reviewed 32 pregnant women who were treated at three tertiary care hospitals in Beijing, China. The correlation between the causes of APIP, severity, laboratory indices, and outcomes was analyzed.

RESULTS

The most common causes of APIP were hypertriglyceridemia (56.2%,18/32) and gallstones (28.1%, 9/32). Hypertriglyceridemia-induced APIP was associated with a higher rate of severe acute pancreatitis (P = 0.025). Serum level of triglycerides showed a positive correlation with the severity of APIP (P = 0.039). The most frequent presentation of APIP was abdominal pain (93.7%, 30/32). There were no maternal or fetal deaths in our study. Apgar scores at 1 min, 5 min, and 10 min of the premature neonates was correlated with the severity of APIP of the mother (P = 0.022; 0.002; 0.002).

CONCLUSION

High level of triglycerides may serve as a useful marker of the severity of APIP. The severity of APIP was associated with higher risk of neonate asphyxia. Appropriate timing of termination of pregnancy is a key imperative for APIP patients.

Chronic Pancreatitis in Females is Not Associated With Adverse Pregnancy Outcomes: A Retrospective Analysis

BACKGROUND

The effects of chronic pancreatitis (CP) on pregnancy and vice versa have not been studied well. We aimed to study the impact of CP on pregnancy-related outcomes and the effect of pregnancy on clinical profile of CP.

STUDY AND GOALS

We did a retrospective analysis of all female patients of CP of child-bearing age (above 18 y). The pregnancy-related outcomes of patients with CP were compared with the age-matched 115 controls from the low-risk pregnancy group identified using a simplified antepartum high-risk pregnancy scoring form. The clinical course of CP during pregnancy was compared with the pre-pregnancy course.

RESULTS

Among the 338 eligible patients, 46 patients were included after exclusions. All these 46 patients had at least 1 conception and 41 had at least 1 completed pregnancy with a total of 117 conceptions and 96 completed pregnancies. The pregnancy-related outcomes in patients with CP like abortions (21.7% vs. 11.3%;P=0.087), preterm deliveries (14.6% vs. 10.4%;P=0.47), antepartum course (82.7% vs. 82.6%;P=0.58), stillbirths (4.9% vs. 4.3%;P=0.88), cesarean section (36.6% vs. 34%;P=0.849) were comparable with controls. There was overall improvement in the severity and frequency of pain during pregnancy as compared with the pre-pregnancy symptoms (P=0.001).

CONCLUSION

CP is not associated with adverse pregnancy outcomes. Also, there is trend toward improvement in the clinical symptoms because of CP during the pregnancy.

Development and validation of a prediction model for moderately severe and severe acute pancreatitis in pregnancy

BACKGROUND

The severity of acute pancreatitis in pregnancy (APIP) is correlated with higher risks of maternal and fetal death.

AIM

To develop a nomogram that could predict moderately severe and severe acute pancreatitis in pregnancy (MSIP).

METHODS

Patients with APIP admitted to West China Hospital between January 2012 and December 2018 were included in this study. They were divided into mild acute pancreatitis in pregnancy (MAIP) and MSIP. Characteristic parameters and laboratory results were collected. The training set and test set were randomly divided at a ratio of 7:3. Least absolute shrinkage and selection operator regression was used to select potential prognostic factors. A nomogram was developed by logistic regression. A random forest model was used to validate the stability of the prediction factors. Receiver operating characteristic curves and calibration curves were used to evaluate the model’s predictive performance.

RESULTS

A total of 190 patients were included in this study. A total of 134 patients (70.5%) and 56 patients (29.5%) were classified as having MAIP and MSIP, respectively. Four independent predictors (lactate dehydrogenase, triglyceride, cholesterol, and albumin levels) were identified for MSIP. A nomogram prediction model based on these factors was established. The model had areas under the curve of 0.865 and 0.853 in the training and validation sets, respectively. The calibration curves showed that the nomogram has a good consistency.

CONCLUSION

A nomogram including lactate dehydrogenase, triglyceride, cholesterol, and albumin levels as independent predictors was built with good performance for MSIP prediction.

Acute pancreatitis in pregnancy and its impact on the maternal and foetal outcomes: A systematic review

BACKGROUND

The prevalence of AP in pregnancy (APIP) is uncertain with varying reports of its impact on maternal and foetal outcomes.

OBJECTIVES

This study was aimed to find the prevalence of APIP and its effect on the maternal and foetal outcomes.

SEARCH STRATEGY

Electronic databases were searched upto 31.05.2020 for the appropriate studies.

SELECTION CRITERIA

Prospective, retrospective observational studies or case series evaluating APIP in terms of maternal and foetal outcomes were included.

DATA COLLECTION AND ANALYSIS

Data on the prevalence of APIP, etiology, maternal mortality rates and foetal outcomes were collated. Due to high heterogeneity among the studies, the data has been represented as a systematic review.

RESULTS

A total of 16 studies with 8466 pregnant patients were included in the systematic review. The overall prevalence of APIP ranged from 0.225/1000 pregnancies to 2.237/1000 pregnancies. Gallstone disease was the most common cause ranging from 14.29 to 96.3%, with eastern studies reporting more cases of hypertriglyceridemia as etiology. Mild pancreatitis was noted in 33.33-100% of cases with milder disease among western studies. APIP incidence was higher during 3rd trimester (27.27%-95.24%). Maternal mortality ranged from 0 to 12.12/100 pregnancies. Foetal loss ranged from 0 to 23.08%, with adverse foetal outcomes ranging from 0 to 57.41%. Neonatal mortality ranged from 0 to 75.5/1000 neonatal live birth.

CONCLUSION

APIP is usually mild, but its incidence increases with gestational age. Maternal outcome is usually good but adverse foetal outcome is high in APIP (PROSPERO No.: CRD42020194313).

Perinatal outcomes in pregnancies complicated by acute pancreatitis

OBJECTIVES

Acute pancreatitis is a rare condition that can be associated with significant complications. The objective of this study is to evaluate the maternal and newborn outcomes associated with acute pancreatitis in pregnancy.

METHODS

A retrospective cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from the United States was performed. All pregnant patients with acute pancreatitis were identified using International Classification of Disease-9 coding from 1999 to 2015. The effect of acute pancreatitis on maternal and neonatal outcomes in pregnancy was evaluated using multivariate logistic regression, while adjusting for baseline maternal characteristics.

RESULTS

From 1999 to 2015, there were a total of 13,815,919 women who gave birth. There were a total of 14,258 admissions of women diagnosed with acute pancreatitis, including 1,756 who delivered during their admission and 12,502 women who were admitted in the antepartum period and did not deliver during the same admission. Acute pancreatitis was associated with increased risk of prematurity, OR 3.78 (95% CI 3.38-4.22), preeclampsia, 3.81(3.33-4.36), postpartum hemorrhage, 1.90(1.55-2.33), maternal death, 9.15(6.05-13.85), and fetal demise, 2.60(1.86-3.62) among women diagnosed with acute pancreatitis. Among women with acute pancreatitis, delivery was associated with increased risk of requiring transfusions, 6.06(4.87-7.54), developing venous thromboembolisms, 2.77(1.83-4.18), acute respiratory failure, 3.66(2.73-4.91), and disseminated intravascular coagulation, 8.12(4.12-16.03).

CONCLUSIONS

Acute pancreatitis in pregnancy is associated with severe complications, such as maternal and fetal death. Understanding the risk factors that may lead to these complications can help prevent or minimize them through close fetal and maternal monitoring.

Nomogram for Predicting Persistent Organ Failure With Acute Pancreatitis in Pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) with persistent organ failure (POF) poses a high risk of death for mother and fetus. This study sought to create a nomogram model for early prediction of POF with APIP patients.

METHODS

We conducted a cross-sectional study on APIP patients with organ failure (OF) between January 2012 and March 2021. 131 patients were collected. Their clinical courses and pregnancy outcomes were obtained. Risk factors for POF were identified by univariate and multivariate logistic regression analysis. Prediction models with POF were built and nomogram was plotted. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots.

RESULTS

Hypertriglyceridemia was the most common etiology in this group of APIP patients, which accounted for 50% of transient organ failure (TOF) and 72.3% of POF. All in-hospital maternal death was in the POF group (P<0.05), which also had a significantly higher perinatal mortality rate than the TOF group (P<0.05). Univariate and multivariate logistic regression analysis determined that lactate dehydrogenase, triglycerides, serum creatinine, and procalcitonin were independent risk factors for predicting POF in APIP. A nomogram for POF was created by using the four indicators. The area under the curve was 0.875 (95%CI: 0.80-0.95). The nomogram had a bootstrapped-concordance index of 0.85 and was well-calibrated.

CONCLUSIONS

Hypertriglyceridemia was the leading cause of organ failure-related APIP. Lactate dehydrogenase, triglycerides, serum creatinine, and procalcitonin were the independent risk factors of POF in APIP. Our nomogram model showed an effective prediction of POF with the four indicators in APIP patients.

The Effect of Admission Serum Triglyceride Level on the Prediction of Severity of Acute Pancreatitis in Pregnancy

Purpose

Previous studies indicated that the serum triglyceride level in patients with acute pancreatitis positively correlated with the severity of the disease among the general population. Despite the physiological hypertriglyceridemia in pregnant women, there are no reports on the relationship between serum triglyceride level and the severity of acute pancreatitis in pregnant (APIP) women. This study explores the relationship between serum triglyceride levels and the severity of APIP.

Patients and Methods

Clinical information of APIP patients admitted to the Shengjing Affiliated Hospital of China Medical University was gathered from January 2012 to December 2020 to conduct retrospective research. The participating patients were divided into mild, moderately severe, and severe acute pancreatitis. The clinical outcomes of patients with different serum triglyceride levels (0–2.3 mmol/L, 2.23–5.65 mmol/L, 5.65–11.2 mmol/l, ≥11.2 mmol/L) were analyzed by performing ordinal logistic regression analysis. Receiver operating curve analysis was used to calculate the threshold value of serum triglyceride concentration that can effectively predict the occurrence of severe acute pancreatitis (SAP).

Results

Hypertriglyceridemic acute pancreatitis (HTG-AP) occurred in 47% of APIP patients within the group, with a high prevalence among the Han population. In the present study, the serum triglyceride concentration correlated positively with the severity of APIP (r=0.403, P < 0.05). The adjusted logistic model demonstrated that relative to nominal triglyceride levels, the OR value of SAP were 1.036 (95% CI: 0.401–2.677), 3.429 (95% CI: 1.269–9265), 8.329 (95% CI: 3.713–18.682) with triglyceride at the level of 2.23–5.65 mmol/L, 5.65–11.2 mmol/l and ≥11.2 mmol/L. In APIP patients, a triglyceride concentration of 10.7mmol/L or more upon admission was a predictive value for the occurrence of SAP, with a sensitivity of 0.72 and a specificity of 0.65, AUC: 0.708 (95% CI: 0.620–0.796).

Conclusion

As the serum triglyceride level upon admission increased, the frequency of local and systemic complications increased significantly.

Management of gallstone-induced severe acute cholecystitis and pancreatitis in the second trimester of pregnancy during covid-19 pandemic: A case report

Introduction

Gallstone-induced severe acute cholecystitis with acute pancreatitis during pregnancy can be life-threatening both for the mother and fetus. Surgical approach is recommended in this complicated disease to prevent morbidity and mortality. During COVID-19 pandemic, additional precautions are needed when dealing with abdominal complaints.

Presentation of case

We present a 37-year-old female patient, pregnant at 22 weeks gestational age, who complained of fever, diffuse abdominal pain, and shortness of breath. Laboratory examination results revealed anemia, leukocytosis and an increase in amylase level. SARS-CoV-2 antibody is non-reactive. Imaging strongly suggested cholelithiasis and cholecystitis. The patient was given antibiotics for three days but there was no significant improvement. Open cholecystectomy with subcostal (Kocher) incision was performed. Patient was released from the hospital without post-operative complications.

Discussion

Treatment of gallstone induced severe acute cholecystitis with acute pancreatitis during pregnancy is challenging with the surgical complications. In the second and third trimester of pregnancy, it is more difficult to perform laparoscopic cholecystectomy because of the size of uterus. Laparoscopic procedure is also not recommended in early Covid-19 pandemic period. Therefore, open cholecystectomy with Kocher incision becomes the surgery of choice to avoid preterm birth.

Conclusions

Based on our case, open cholecystectomy with Kocher incision is a safe and effective procedure for pregnant patients with cholelithiasis, cholecystitis, and pancreatitis.

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Gallstone induced acute severe cholecystitis and acute pancreatitis during pregnancy is a complicated disease.

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Cholecystitis and pancreatitis have been reported for producing similar symptoms to COVID-19 disease.

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This Case requiring immediate surgical management, advanced gestational age surgery may become a challenge.

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Open cholecystectomy with Kocher incision is a safe and effective for pregnancy with acute abdominal case.

Hypertriglyceridemic pancreatitis

Hypertriglyceridemic acute pancreatitis is an emerging issue in gastroenterology, frequently underdiagnosed in clinical practice. Despite the rarity of the disease, hypertriglyceridemia should be considered as a leading cause of acute pancreatitis, especially in defined subsets of patients. Primary and secondary forms of hypertriglyceridemia need to be considered and excluded during the diagnostic work-up of all patients with acute pancreatitis. An accurate diagnosis is crucial to establish an appropriate treatment and to reduce the risk of recurrences. The aim of the present article is to briefly review epidemiology, etiology, diagnosis and therapy of hypertriglyceridemic acute pancreatitis, based on a clinical and practical point of view.

The changes of triacylglycerol and inflammatory factors during dialysis treatment of hypertriglyceridemia during pregnancy and analysis of nursing countermeasure

OBJECTIVE

To investigate the changes of triacylglycerol and inflammatory factors after hypertriglyceridemia acute pancreatitis (HTG-AP) dialysis during pregnancy and to analyze the nursing strategies.

METHODS

50 patients treated with HTG-AP dialysis in our hospital from February 2017 to June 2019 were selected. The patient's vital signs, triglyceride (TG), total cholesterol (TC), TG and TC decline rates before treatment, 1, 3, and 5 days after treatment and inflammatory factors [tumor necrosis factor-α (TNF-α), Interleukin-1β (IL-1β), Interleukin-6 (IL-6), Interleukin-10 (IL-10) level changes] were measured, as well as the acute physiological and chronic health evaluation II (APACHEII), multiple organ dysfunction syndromes (MODS), systemic inflammatory response syndrome (SIRS) and maternal treatment outcomes.

RESULTS

There was no significant change in body temperature before and after treatment (P>0.05); The heart rate, WBC, CRP before and after treatment were statistically different (P<0.05); Compared with before treatment, serum levels of TG and TC significantly decreased after treatment, and the rate of decrease was significantly increased (P<0.05); Compared with before treatment, the levels of inflammatory factors (TNF-α, IL-1β, IL-6, IL-10) gradually decreased after treatment, and the serum levels of patient's TNF-α, IL-1β, IL-6, IL-10 after 5 days of treatment were more significant (P<0.05); Compared with before treatment, APACHEll, MODS and SIRS scores significantly decreased after treatment, and APACHEll, MODS and SIRS scores were better after 5 days of treatment (P<0.05); The mortality rate during treatment was 2.00%; the complication rate was 32.00%, including 5 cases of acute respiratory distress syndrome, 4 cases of pleural effusion, 4 cases of lung infection, 2 cases of acute renal insufficiency and 1 case of shock.

CONCLUSION

Dialysis treatment can promote the recovery of HTG-AP patients promptly, improve triglycerides, and reduce inflammation. After the targeted nursing intervention, the treatment efficacy significantly improved.

Pancreatic Disorders of Pregnancy

The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.

Familial Chylomicronemia Syndrome-Induced Acute Necrotizing Pancreatitis during Pregnancy

Acute pancreatitis is a rare condition in pregnancy, associated with a high mortality rate. Hypertriglyceridemia represents its second most common cause. We present the case of a 38-year-old woman in the 24^th week of gestation with a history of hypertriglyceridemia and recurrent episodes of pancreatitis. She was admitted to our hospital with acute pancreatitis due to severe hypertriglyceridemia. She was stabilized and treated with fibrates. Despite her favorable clinical course, she developed a second episode of acute pancreatitis complicated by multi-organ dysfunction and pancreatic necrosis, requiring a necrosectomy. The pregnancy was ended by cesarean section, after which three plasmapheresis sessions were performed. She is currently asymptomatic with stable triglyceride levels. Acute pancreatitis due to hypertriglyceridemia represents a diagnostic and therapeutic challenge in pregnant women, associated with serious maternal and fetal complications. When primary hypertriglyceridemia is suspected, such as familial chylomicronemia syndrome, the most important objective is preventing the onset of pancreatitis.

Risk Factors for Fetal Death and Maternal AP Severity in Acute Pancreatitis in Pregnancy

Background: Acute pancreatitis in pregnancy is a rare but highly life-threatening gestational and perinatal disease. Objective: This study aimed to identify the risk factors for fetal death and acute pancreatitis severity. Methods: This retrospective cohort study enrolled patients with acute pancreatitis in pregnancy in our center from January 1, 2012, to August 1, 2020, and classified them according to two clinical endpoints, fetal outcome and disease severity. The groups were examined and compared according to gestational week, etiology, gravidity and parity, complications in pre- and post-delivery, and medical history. Logistic regression analysis was performed to identify the independent risk factors for fetal death and acute pancreatitis severity. Results: Of the 90 enrolled patients, 28 (31.1%) had fetal death and 43 (47.8%) had severe acute pancreatitis. Logistic regression analysis showed that pre-delivery acute respiratory distress syndrome (OR, 5.8; 95% CI, 1.5-22.4; p = 0.010) and gestational week (OR, 0.9; 95% CI, 0.8-1.0; p = 0.011) were risk factors for fetal death. Gestation week (OR, 1.2; 95% CI, 1.1-1.3; p = 0.003) and fetal intrauterine death (OR, 5.9; 95% CI, 1.8-19.4; p = 0.003) were risk factors for severe acute pancreatitis. Conclusions: Pre-delivery acute respiratory distress syndrome and gestational week were independent risk factors for fetal death. Fetal intrauterine death and gestational week were independent risk factors for severe acute pancreatitis.

Bochdalek hernia masquerading as severe acute pancreatitis during the third trimester of pregnancy: A case report

BACKGROUND

The occurrence of a diaphragmatic hernia during the third trimester of pregnancy is rare; to our knowledge, there has only been a single case report related to congenital Bochdalek hernia complicated with mild acute pancreatitis during pregnancy. Nonspecific symptoms and lack of experience due to its rarity make the diagnosis of this condition very challenging. We report a case of diaphragmatic hernia accompanied by mild acute pancreatitis in the third trimester of pregnancy, which was misdiagnosed as severe acute pancreatitis.

CASE SUMMARY

A 19-year-old woman presented at gestation of 31⁺² weeks with continuous distension pain for 3 d in the left lumbar region of no obvious cause. Ultrasonographic findings of left ureterectasis, with nonspecific lumbago and abdominal pain, led to the misdiagnosis of renal colic. Increased serum amylase and/or lipase levels indicated acute pancreatitis. Following the treatment of pancreatitis, her condition deteriorated. The patient was finally diagnosed with a diaphragmatic hernia complicated with mild acute pancreatitis on magnetic resonance imaging at our hospital. Caesarean section was performed at gestation of 31⁺⁶ weeks, followed by hernia repair, and the pancreatitis was treated sequentially. The patient was discharged in good condition 20 d after the surgery.

CONCLUSION

In this case, surgical treatment was not the same as that for non-pregnant diaphragmatic hernia repair. It is important to first perform a cesarean section before commencing the therapy.

The early predictive value of routine laboratory tests on the severity of acute pancreatitis patients in pregnancy: a retrospective study

Acute pancreatitis in pregnancy (APIP) varies in severity from a self-limiting mild condition to a severe life-threatening condition, and its severity is significantly correlated with higher risks of maternal and foetal death. This study evaluated the early predictive value of routine laboratory tests on the severity of APIP patients. We enrolled 100 patients with APIP in West China Hospital. Initial routine laboratory tests, including the biochemistry and hematologic tests were collected within 48 hours after the onset of APIP. For predicting SAP in AP, LDH had the highest specificity of 0.879. RDW was a suitable predictive marker as it had the sensitivity of 0.882. Lower levels of triglycerides (<4.72 mmol/L) predicted mild AP of APIP, with an area under the curve (AUC) of 0.724, and a negative predictive value of 0.80. Furthermore, a risk score was calculated based on white blood cells, neutrophils, RDW, LMR and LDH, as an independent marker (adjusted odds ratio = 3.013, 95% CI 1.893 to 4.797, P < 0.001), with the highest AUC of 0.906, a sensitivity of 0.875 and a specificity of 0.828. In conclusion, the risk score we recommended was the powerful marker to aid in the early prediction of the severity of APIP patients.

Identification and functional characterization of a novel heterozygous missense variant in the LPL associated with recurrent hypertriglyceridemia-induced acute pancreatitis in pregnancy

Background

Acute pancreatitis in pregnancy (APIP) is a life‐threatening disease for both mother and fetus. To date, only three patients with recurrent hypertriglyceridemia‐induced APIP (HTG‐APIP) have been reported to carry rare variants in the lipoprotein lipase (LPL) gene, which encodes the key enzyme responsible for triglyceride (TG) metabolism. Coincidently, all three patients harbored LPL variants on both alleles and presented with complete or severe LPL deficiency.

Methods

The entire coding regions and splice junctions of LPL and four other TG metabolism genes (APOC2, APOA5, GPIHBP1, and LMF1) were analyzed by Sanger sequencing in a Han Chinese patient who had experienced two episodes of HTG‐APIP. The impact of a novel LPL missense variant on LPL protein expression and activity was analyzed by transient expression in HEK293T cells.

Results

A novel heterozygous LPL missense variant, p.His210Leu (c.629A > T), was identified in our patient. This variant did not affect protein synthesis but significantly impaired LPL secretion and completely abolished the enzymatic activity of the mutant protein.

Conclusion

This report describes the first identification and functional characterization of a heterozygous variant in the LPL that predisposed to recurrent HTG‐APIP. Our findings confirm a major genetic contribution to the etiology of individual predisposition to HTG‐APIP.

Hypertriglyceridemia triggered acute pancreatitis in pregnancy - diagnostic approach, management and follow-up care

Acute pancreatitis is a pregnancy complication potentially lethal for both the mother and fetus, occurring most frequently in the third trimester or early postpartum. Hypertriglyceridemia may be the cause of important disease in pregnant patients. Patients with triglyceride levels exceeding 1000 mg/dL are at increased risk of developing severe pancreatitis. Diagnostic criteria and management protocols are not specific for pancreatitis complicating pregnancy. Other causes of acute abdominal pain must be considered in the differential diagnosis. Decision-making in the obstetric context is challenging and bears potential legal implications. Pre-pregnancy preventive measures and prenatal antilipemic treatment are mandatory in high risk patients.

Inhibition of macrophage migration inhibitory factor attenuates inflammation and fetal kidney injury in a rat model of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a severe disease during pregnancy that mostly occurs during the third trimester. It can lead to additional complications including preterm delivery and high fetal mortality. In this study, we investigated the protective effects of (S, R)-3-(4-hydroxyphenyl)-4, 5dihydro-5-isoxazole acetic methyl ester (ISO-1), an inhibitor of macrophage migration inhibitory factor (MIF), on fetal kidney injury associated with the maternal acute necrotizing pancreatitis (ANP) and its potential mechanisms in a rat model. The APIP rat model was induced by retrograde infusion of sodium taurocholate saline solution into biliopancreatic duct. ISO-1 was given by intraperitoneally injection 30 min before the model was induced. The levels of maternal serum amylase, lipase, tumor necrosis factor-α (TNF-α) and interleukins (IL)-1β were measured. Maternal pancreas and fetal kidney injury were evaluated, and the expressions of MIF, phospho-p38MAPK (p-p38), nuclear factor-κB (NF-κB), TNF-α, IL-1β in fetal kidneys were detected. The results showed that fetal rats exhibited obvious acute kidney injury during APIP, and pregnant rats pretreated with ISO-1 notably attenuated the lesions. ISO-1 also significantly reduced the expression of MIF and the activations of p38MAPK, NF-κB, as well as the levels of TNF-α and IL-1β. These results indicated that ISO-1 could attenuate fetal kidney injury in pregnant rats with ANP by inhibiting MIF mediated p38MAPK/NF-κB signal pathways to reduce inflammatory response.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM

To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.

METHODS

Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.

RESULTS

Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.

CONCLUSION

This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

Abruptio Placentae Caused by Hypertriglyceridemia-Induced Acute Pancreatitis during Pregnancy: Case Report and Literature Review

BACKGROUND

Hormonal effects during pregnancy can compromise otherwise controlled lipid levels in women with hypertriglyceridemia and predispose to pancreatitis leading to increased morbidity for mother and fetus. Elevation of triglyceride levels is a risk factor for development of pancreatitis if it exceeds 1000 mg/dL. Pancreatitis should be considered in emergency cases of abdominal pain and uterine contractions in Emergency Department at any stage of pregnancy. We report a case of abruptio placentae caused by hypertriglyceridemia-induced acute pancreatitis. Also, literature review of cases of acute pancreatitis induced by hypertriglycaemia in pregnancy has been made.

CASE

A 22-year-old woman presented to our Emergency Department, at 35 weeks of gestation, for acute onset of abdominal pain and uterine contractions. Blood tests showed a high rate of triglyceride. The patient was diagnosed with abruptio placentae caused by hypertriglyceridemia-induced acute pancreatitis. Immediate cesarean section was performed and it was observed that blood sample revealed a milky turbid serum. Insulin, heparin, and supportive treatment were started. She was discharged on the 10th day.

CONCLUSION

Consequently, patients with known hypertriglyceridemia or family history should be followed up more closely because any delay can cause disastrous conclusions for mother and fetus. Acute pancreatitis should be considered in pregnant women who have sudden onset, severe, persistent epigastric pain and who have a risk factor for acute pancreatitis.

Neutrophil-lymphocyte ratio, gamma-glutamyl transpeptidase, lipase, high-density lipoprotein as a panel of factors to predict acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare but dangerous complication. APIP has common symptoms with acute abdomen. Assessment of an acute abdomen is more complicated during pregnancy because the gravid uterus could mask most of symptomatic signs. It has been a challenge to diagnose APIP by physical examination or diagnostic imaging. Case studies on APIP are also limited for analysis on the risk factors associated with the disease. This retrospective study evaluated a series of risk factors from a relatively substantial number of APIP cases to determine early predictors or prognosis markers for APIP.Fifty-nine APIP patients together with 179 random normal pregnant women in Shengjing Affiliated Hospital of China Medical University were included for this retrospective study. Medical parameters of blood test in biochemistry and hematology were compared between 2 groups using t test. Multivariate logistic regression analysis was performed to investigate the relationship between various factors and APIP using Statistical Applied Software (SAS student version).Compared with normal pregnant women, APIP patients have elevated values in alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen, creatinine, C-reactive protein, direct bilirubin, fibrin degradation products, gamma-glutamyl transpeptidase (GGT), glucose, lipase, pH and decreased values in albumin, fibrinogen, high-density lipoprotein (HDL), hemoglobin, low-density lipoprotein cholesterol (LDL-D), and total proteins from their blood tests. In addition, APIP patients have decreased numbers in red cells but increased numbers in white blood cells and increased ratio of neutrophil/lymphocyte (N/L). Among these factors, N/LR, GGT, lipase, and HDL are significantly associated with APIP. This study suggests that the combination of those factors serve as a panel of indicators for early-onset prognosis of APIP.GGT, lipase, HDL, and N/LR can serve as a panel of factors to predict APIP. More case studies are important to further evaluate the predicting power of this panel factors in APIP.