Acute pancreatitis in pregnancy: an overview

Management of Severe Hypertriglyceridemia in Pregnancy With Niacin: Reevaluating Safety and Therapeutic Benefits

Background: Severe hypertriglyceridemia (triglycerides (TGs) >1000 mg/dL, >11.3 mmol/L) is a rare but potentially morbid condition in pregnancy. Physiological changes in pregnancy may unmask or exacerbate an underlying defect in TG metabolism. When conventional therapies are ineffective in controlling TG levels, a personalized management approach is needed. We present a case of severe hypertriglyceridemic pancreatitis successfully managed with niacin, a treatment that has seen limited use in pregnancy due to the paucity of available data. Case Presentation: A 29-year-old pregnant woman with a history of cholecystectomy and a prepregnancy BMI of 30.6 kg/m2 presented at 12 weeks' gestation with acute pancreatitis and severe hypertriglyceridemia (6900 mg/dL, 77.9 mmol/L). After initial management with intravenous (IV) fluids, insulin infusion, and a low-fat diet, her TG levels improved. However, she was readmitted at 23 weeks' gestation with recurrent hypertriglyceridemia (2872 mg/dL, 32.4 mmol/L), requiring a more aggressive insulin regimen. Despite various interventions, including omega-3 fatty acids (O3FAs), fenofibrate, and central venous catheter insulin infusion, her TG levels remained elevated, necessitating early delivery at 34 weeks' gestation. Her postpartum recovery included continued TG management with fenofibrate and O3FAs. Four years later, during a second pregnancy, she presented with similar hypertriglyceridemia, managed with diet, metformin, fenofibrate, and insulin. Due to persistent hypertriglyceridemia (>3000 mg/dL, 33.9 mmol/L), niacin was added as an additional therapy and titrated to 2000 mg/day, which successfully sustained TG levels below 1000 mg/dL (11.3 mmol/L) through the remainder of her pregnancy. She delivered her second child via cesarean section at 35 weeks' gestation due to preeclampsia. Both children had developmental issues, with her first child diagnosed with attention-deficient hyperactivity disorder (ADHD) and her second child with autism spectrum disorder and motor delays. The patient was encouraged to remain on long-term management for her metabolic condition. Conclusions: Managing severe hypertriglyceridemia during pregnancy is challenging due to uncertainties about treatment efficacy and safety. Timely reduction of maternal TGs is essential to prevent complications and requires adjustments throughout pregnancy. This case demonstrates the effectiveness and safety of niacin, often underutilized due to perceived side effects, in managing severe hypertriglyceridemia in pregnancy when other treatments were inadequate.

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.

Fibrates and risk of congenital malformations: a nationwide cohort study in South Korea

PURPOSE

To examine the association between maternal prescriptions for fibrates and congenital malformations in live births.

METHODS

Nationwide retrospective cohort study was conducted using the data sourced from the Korean National Health Insurance database. A cohort of 756,877 completed pregnancies linked to live-born infants in 215,600 women with dyslipidemia between 2012 and 2021. The study compared data on congenital anomalies between pregnancies who were exposed to fibrates and those who were not exposed to fibrates in the first trimester. Odds ratios (OR) were calculated by a multivariable analyses using logistic regression models to adjust for potential confounders.

RESULTS

260 pregnancies (0.12%) were exposed to fibrates during the first trimester. The prevalence of malformations in exposed offspirng was 10.77%, not significantly different compared with 9.68% in offspring of women who were not prescribed fibrates during pregnancy in patients with dyslipidemia (OR 1.13; 95% CI 0.75-1.70).

CONCLUSION

This study implies that the use of fibrates during pregnancy may be safe, as it did not show any association with congenital anomalies. However, caution is warranted due to an elevated risk associated with prolonged exposure.

Characteristics, Physiopathology and Management of Dyslipidemias in Pregnancy: A Narrative Review

Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD). During pregnancy, physiological changes elevate cholesterol and triglyceride levels to support fetal development, which can exacerbate pre-existing conditions and lead to complications such as pre-eclampsia, gestational diabetes, and increased ASCVD risk for both mother and child. Effective management strategies are necessary, especially for pregnant women with inherited forms of dyslipidemia (i.e., familial hypertriglyceridemia, hyperchylomicronemia), where personalized dietary adjustments are crucial for successful pregnancy outcomes. Pharmacological interventions and lipoprotein apheresis may be necessary for severe cases, though their use is often limited by factors such as cost, availability, and potential fetal risks. Despite the promise of advanced therapies, their widespread application remains constrained by limited studies and high costs. Thus, a personalized, multidisciplinary approach is essential for optimizing outcomes. This review provides a comprehensive overview of current strategies and evidence-based practices for managing dyslipidemia during pregnancy, emphasizing the balance of maternal and fetal health. Additionally, it discusses the physiological changes in lipid metabolism during pregnancy and their implications, particularly for women with inherited forms of dyslipidemia.

Acute Biliary Pancreatitis in the First Trimester of Pregnancy Without Abdominal Pain, Associated With Vomiting: A Rare Atypical Clinical Case Report and a Mini-Review of the Literature

Acute pancreatitis is rare during pregnancy, with gallstone formation being the primary risk factor. This case report involves a 37-year-old pregnant woman, gravida 4, para 3, who presented to the Emergency Department of the General Hospital of Trikala at 13 weeks gestation, with vomiting for approximately 12 hours and no abdominal pain. A clinical examination by a surgical team, along with a history of cholelithiasis and supporting laboratory and ultrasound findings, led to the diagnosis of acute pancreatitis. The patient was carefully monitored and received immediate supportive treatment, including antibiotics. After a gradual improvement in clinical and laboratory findings, she was discharged on the sixth day of hospitalization, with the decision to postpone the cholecystectomy until after delivery, if possible. At 39 weeks of pregnancy, she delivered vaginally. One month later, she underwent a scheduled laparoscopic cholecystectomy. This case report describes a rare and atypical case of mild acute biliary pancreatitis in the first trimester of pregnancy, highlighting the management of the disease in pregnant women, which may vary depending on the severity of symptoms, potential complications, and gestational age.

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.

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.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

A novel homozygous nonsense variant of LMF1 in pregnancy-induced hypertriglyceridemia with acute pancreatitis

Hypertriglyceridemia (HTG)-induced pancreatitis during pregnancy could lead to maternal and fetal death. However, its genetic bases are not fully understood, and its treatment strategies are yet to be established. Here we report a case with a novel homozygous nonsense variant of LMF1 in pregnancy-associated HTG with acute pancreatitis. Our patient had childhood-onset severe HTG that had been well-controlled by dietary management in the non-pregnant period with plasma triglyceride (TG) levels at around 200 mg/dL. Milky plasma was noted at the first-trimester pregnancy checkup, followed by a severe increase in plasma TG (10,500 mg/dL) that resulted in pancreatitis in the last trimester. The implementation of strict dietary fat restriction (less than 4 grams per day) reduced plasma TG levels and led to successful delivery. Exome sequencing revealed a novel homozygous nonsense variant in LMF1 (c.697C>T, p.Arg233Ter). The activities of lipoprotein lipase (LPL) and hepatic lipase in post-heparin plasma were not abolished but reduced. The use of pemafibrate decreased plasma TG levels with a concomitant increase in LPL activity. HTG in childhood or early pregnancy is commonly assumed to be polygenic in origin but should be regarded as a feature suggestive of monogenic hyperchylomicronemia. Adequate TG monitoring and dietary fat restriction should be implemented to prevent potentially lethal events of pancreatitis.

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.

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.

Hypertriglyceridemia-induced pancreatitis after egg retrieval for in vitro fertilization and fenofibrate cessation

A 36-year-old woman with prior hypertriglyceridemia-induced pancreatitis presented with a recurrence of pancreatitis after beginning in vitro fertilization (IVF). Her primary care physician had discontinued fenofibrate due to concerns for teratogenicity. This case illustrates the importance of fibrate therapy for high-risk women undergoing IVF, despite limited evidence regarding its teratogenicity.

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.

Acute Pancreatitis During and After Pregnancy: Incidence, Risk Factors, and Prognosis

BACKGROUND

Acute pancreatitis may complicate pregnancy and both are associated with gallstones, but its incidence is not well known.

AIMS

To validate hospital discharge records in diagnosing acute pancreatitis and gallstones and to evaluate acute pancreatitis incidence in non pregnant, pregnant and after delivery using hospital discharge records METHODS: We identified all hospital discharge records of hospitalized Sicilian women of childbearing age (2011-2016). We determined agreement between 300 hospital discharge records and hospital records in diagnosing acute pancreatitis and gallstones. Acute pancreatitis incidence, prognosis, and their relationship with age and gallstones were calculated in the three groups using hospital discharge records.

RESULTS

There was 92% and 88% agreement in diagnosing acute pancreatitis and gallstones between hospital discharge and hospital records. In non pregnant, 1,564 of 7,236,863 women-years (21.61/100,000 person-years) developed acute pancreatitis. During pregnancy, 34 of 226,492 women-years developed acute pancreatitis (20.02/100,000 person-years). Postpartum acute pancreatitis incidence was higher than non pregnant, only in the first 2 years with the peak in the first semester (95.4/100,000 person-years). The increased incidence of postpartum acute pancreatitis was associated with gallstones in youngest women (gallstones acute pancreatitis in women below 20 years old versus non pregnant: rate ratios 16.61; 95% CI 8.40-32.87).

CONCLUSIONS

Agreement in acute pancreatitis and gallstones diagnosis between hospital discharge and hospital records was accurate. Acute pancreatitis incidence was increased only in the first 2 years after delivery in young women with gallstones.

Insulin can be used to treat severe hypertriglyceridaemia in pregnant women without diabetes

Severe hypertriglyceridaemia can lead to acute pancreatitis, which is associated with maternal and perinatal mortality when it occurs in pregnancy. Rapid reduction of triglyceride levels is a primary goal in the management of severe hypertriglyceridaemia, however, there are limited safe option for treatment in pregnancy. We present a case of a woman without diabetes presenting with severe hypertriglyceridaemia in late gestation who was safely and successfully treated with insulin and review the literature surrounding the management of this important condition.

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.

Current Diagnosis and Management of Primary Chylomicronemia

Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.

PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes ( LPL , LMF1 , GPIHBP1 , APOC2 , and APOA5 ). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).

The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive.

The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life.

Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease.

Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.

Sex Differences in the Exocrine Pancreas and Associated Diseases

Differences in pancreatic anatomy, size, and function exist in men and women. The anatomical differences could contribute to the increase in complications associated with pancreatic surgery in women. Although diagnostic criteria for pancreatitis are the same in men and women, major sex differences in etiology are reported. Alcohol and tobacco predominate in men, whereas idiopathic and obstructive etiologies predominate in women. Circulating levels of estrogens, progesterone, and androgens contribute significantly to overall health outcomes; premenopausal women have lower prevalence of cardiovascular and pancreatic diseases suggesting protective effects of estrogens, whereas androgens promote growth of normal and cancerous cells. Sex chromosomes and gonadal and nongonadal hormones together determine an individual's sex, which is distinct from gender or gender identity. Human pancreatic disease etiology, outcomes, and sex-specific mechanisms are largely unknown. In rodents of both sexes, glucocorticoids and estrogens from the adrenal glands influence pancreatic secretion and acinar cell zymogen granule numbers. Lack of corticotropin-releasing factor receptor 2 function, a G protein-coupled receptor whose expression is regulated by both estrogens and glucocorticoids, causes sex-specific changes in pancreatic histopathology, zymogen granule numbers, and endoplasmic reticulum ultrastructure changes in acute pancreatitis model. Here, we review existing literature on sex differences in the normal exocrine pancreas and mechanisms that operate at homeostasis and diseased states in both sexes. Finally, we review pregnancy-related pancreatic diseases and discuss the effects of sex differences on proposed treatments in pancreatic disease.

Dyslipemias and pregnancy, an update

During pregnancy there is a physiological increase in total cholesterol (TC) and triglycerides (TG) plasma concentrations, due to increased insulin resistance, oestrogens, progesterone, and placental lactogen, although their reference values are not exactly known, TG levels can increase up to 300mg/dL, and TC can go as high as 350mg/dL. When the cholesterol concentration exceeds the 95^th percentile (familial hypercholesterolaemia (FH) and transient maternal hypercholesterolaemia), there is a predisposition to oxidative stress in foetal vessels, exposing the newborn to a greater fatty streaks formation and a higher risk of atherosclerosis. However, the current treatment of pregnant women with hyperlipidaemia consists of a diet and suspension of lipid-lowering drugs. The most prevalent maternal hypertriglyceridaemia (HTG) is due to secondary causes, like diabetes, obesity, drugs, etc. The case of severe HTG due to genetic causes is less prevalent, and can be a higher risk of maternal-foetal complications, such as, acute pancreatitis (AP), pre-eclampsia, preterm labour, and gestational diabetes. Severe HTG-AP is a rare but potentially lethal pregnancy complication, for the mother and the foetus, usually occurs during the third trimester or in the immediate postpartum period, and there are no specific protocols for its diagnosis and treatment. In conclusion, it is crucial that dyslipidaemia during pregnancy must be carefully evaluated, not just because of the acute complications, but also because of the future cardiovascular morbidity and mortality of the newborn child. That is why the establishment of consensus protocols or guidelines is essential for its management.

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.

Severe gestational hypertriglyceridemia: a rare but serious situation

The severe hypertriglyceridemia during pregnancy is a rare condition. It is a problem for diagnostic, prognostic and therapeutic. This dyslipidemia benefit from specific and effective treatments, but it is still poorly codified. Dietary is still the essential therapeutic, but fetal extraction should also be considered if the gestational age permits. Post-partum monitoring is required but etiologic thorough is not recommended if the triglycerides rate normalizes. The major complication of hypertriglyceridemia should be actively sought because of important maternal mortality rate.

Familial hypertriglyceridaemia and type 2 diabetes in pregnancy: prevention of acute pancreatitis with diet control and omega-3 fatty acids

Acute pancreatitis in pregnancy is rare and can be caused by hypertriglyceridaemia. The management of hypertriglyceridaemia in pregnancy is complex and challenging as many lipid-lowering medications have been found to be unsafe in pregnancy. Patients who present with hypertriglyceridaemia commonly have multiple risk factors such as, diabetes, alcohol excess and hypothyroidism which pose a greater challenge to the management of these patients. We present a case of a 31-year-old woman presenting with familial hypertriglyceridaemia and type 2 diabetes mellitus in her third pregnancy. She had an uneventful pregnancy with the use of omega-3 fatty acids nutritional support, low-fat diet and tight glucose control with insulin and metformin.

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.

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

BACKGROUND & AIMS

The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies.

METHODS

The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included.

RESULTS

Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis.

CONCLUSION

The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Serum thyroid hormones levels are significantly decreased in pregnant rats with acute pancreatitis

Acute pancreatitis in pregnancy (APIP), which was thought to be a rare but severe disease, with a high perinatal mortality among maternal-fetuses. Our research aimed to study and assess thyroid injury in a rat model of APIP and its possible mechanisms. The APIP model was established by retrograde injection with sodium taurocholate. Sham-operated (SO) and APIP groups were performed at 3 time-points. Histological changes in the maternal thyroid and pancreas were assessed. The activities of serum amylase, lipase and levels of FT3, FT4, MDA, TNF-α and IL-1β were detected in maternal rats, and the expression of MIF, ICAM-1 and CD68 in the maternal thyroids were determined. In this study, maternal thyroid injury as well as pancreas injury occurred in a time-dependent manner. The activities of serum amylase, lipase and levels of MDA, TNF-α and IL-1β were markedly increased in acute pancreatitis rats, the levels of serum FT3 and FT4 were obviously decreased in APIP groups, and the expressions of MIF, ICAM-1 and CD68 were significantly increased in the thyroid of the APIP group. Ultrastructural thyroid injuries were observed in the APIP group. Our research suggests that thyroid injury is involved in the rat experimental model of APIP. The degree of thyroid dysfunction is associated with APIP, which may affect the prognosis of acute pancreatitis.

Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.

Management of Gallstone-Induced Acute Pancreatitis in Pregnancy: A Tertiary-Center Experience

Objectives:

Gallbladder stones are the most frequently reported etiology of acute pancreatitis in pregnancy and are often diagnosed in the third trimester. This condition is associated with both mother and infant morbidity and mortality, and its treatment remains controversial.

Methods:

Relevant patient data between September 2010 and April 2017 from the Kanuni Sultan Suleyman Training and Research Hospital were analyzed regarding etiology (of gallstone pancreatitis), trimester of pregnancy, diagnostic tools, pancreatitis stage, clinical status, medical treatment, surgical interventions, and pregnancy status.

Results:

We included 68 patients recorded with acute pancreatitis due to biliary gallstones. Pancreatitis symptoms developed in most (n=38) (55.8%) patients during the third trimester. Of 24 patients who had their first episode of pancreatitis in the first trimester of pregnancy, 12 (50%) were readmitted due to recurrence. Seven (11.3%) patients whose Ranson scale score was 3 underwent computed tomography evaluation. The number of patients with acute cholecystitis with pancreatitis was 5 (7.3%), whereas the number of patients with choledocholithiasis was 4 (5.8%). Sphincterotomy with endoscopic retrograde cholangiopancreatography was performed in 2 (2.9%) patients. Laparoscopic cholecystectomy was performed in 9 (13.2%) patients during pregnancy. No fetal and maternal morbidity and mortality was found in all periods.

Conclusion:

Developments in supportive care, wide-spread use of imaging methods, and a multidisciplinary approach with better antenatal care of pregnant patients with acute pancreatitis can help prevent fetal and maternal morbidity and mortality in such cases. Early laparoscopic cholecystectomy should be considered especially in pregnant patients with acute pancreatitis due to gallstones in the first trimester.

Acute starvation ketoacidosis in pregnancy with severe hypertriglyceridemia: A case report

RATIONALE

Pregnant women are more prone to ketosis due to the relative insulin resistance, accelerated lipolysis and increased free fatty acids.

PATIENT CONCERNS

We report a pregnant woman with hyperlipidemia, who experienced severe metabolic acidosis after a short period of starvation.

DIAGNOSES

Based on her clinical symptoms, exclusion diagnosis and therapeutic diagnosis, her condition was diagnosed as starvation ketoacidosis.

INTERVENTIONS

An emergency caesarean section under general anesthesia was implemented 2 hours after her admission. The metabolic acidosis was treated with fluid resuscitation using compound sodium lactate, bicarbonate, and 5% dextrose together with insulin 6U.

OUTCOMES

Both mother and baby were discharged clinically well.

LESSONS

Starvation ketoacidosis may happen in special patient who was in pregnancy and with severe hypertriglyceridemia, after just one day fasting and vomiting.

[Influence of acute pancreatitis in pregnancy on pregnancy outcomes and neonates]

OBJECTIVE

To study the influence of acute pancreatitis in pregnancy (APIP) on pregnancy outcomes and neonates.

METHODS

A retrospective analysis was performed for 33 APIP patients and 31 neonates born alive.

RESULTS

Of the 33 APIP patients, 26 (79%) developed APIP in the late pregnancy. Fourteen (45%) patients had hyperlipidemic APIP, 13 (42%) had biliary APIP, and 4 (13%) had other types of APIP. According to the severity, 22 (67%) were mild APIP, 5 (15%) were moderate APIP, and 6 were severe APIP. None of the 33 APIP patients died. Among the 20 patients with term delivery, 11 underwent termination of pregnancy; among the 10 patients with preterm delivery, 9 underwent termination of pregnancy; two patients experienced intrauterine fetal death, and one experienced abortion during the second trimester. Among the 31 neonates born alive (two of them were twins), 1 (3%) died, 12 (39%) experienced neonatal hyperbilirubinemia, 8 (26%) had neonatal hypoglycemia, 6 (19%) had neonatal respiratory distress syndrome, 5 (16%) experienced infectious diseases, and 2 (6%) experienced intracranial hemorrhage. The hyperlipidemic APIP group had a higher percentage of patients undergoing termination of pregnancy than the biliary APIP and other types of APIP groups (P&lt;0.05). The incidence rate of preterm infants in the moderate APIP was higher than in the mild and severe APIP groups (P&lt;0.05). The mean birth weights of neonates were the lowest in the moderate APIP group. The incidence rates of neonatal respiratory distress syndrome, intracranial hemorrhage, and infectious disease were the lowest in the mild APIP group (P&lt;0.05).

CONCLUSIONS

APIP can lead to adverse pregnancy outcomes and neonatal diseases, which are associated with the severity of pancreatitis.

Impact of cigarette smoking on recurrence of hyperlipidemic acute pancreatitis

AIM

To investigate the impact of cigarette smoking on the recurrence rate and recurrence-free survival in patients with hyperlipidemic acute pancreatitis (HLAP).

METHODS

A total of 863 patients were admitted to our hospital for acute pancreatitis (AP) from January 2013 to March 2016, of whom 88 diagnosed with HLAP were enrolled in this retrospective study. Demographic data, medical history, previous episodes of pancreatitis, consumption of alcohol and cigarettes, as well as biochemical and hematological data were carefully recorded for univariate and multivariate analyses. During follow-up, the information on current smoking status and recurrent AP was gathered. Recurrence-free survival (RFS) was calculated using the Kaplan-Meier method, and the differences between groups were compared using the log-rank test.

RESULTS

No significant differences were observed between the three groups in age or medical history of hyperlipidemia, fatty liver, diabetes mellitus, hypertension, or AP. The current smokers had a remarkably higher recurrence rate and a greater incidence of repeated episodes of AP (50.0% and 77.8%, respectively) than non-smokers (9.8% and 39.0%), and these two percentages were reduced to 9.1% and 36.4% for patients who gave up smoking. The median follow-up time was 13.5 mo and HLAP recurred after hospital discharge in 23 (26.1%) patients. Multivariate analysis identified current smoking (HR = 6.3, P = 0.020) as an independent risk factor contributing to HLAP recurrence. Current smokers had significantly worse RFS than non-smokers (23 mo vs 42 mo), but no significant difference was documented between ex-smokers (34 mo) and non-smokers. The RFS was not significantly different between light and heavy smokers.

CONCLUSION

Smoking is associated with worse RFS and an increased rate of HLAP recurrence. Continued smoking correlates with a compromised survival and smoking cessation should be recommended.

Hypercalcemia-Induced Pancreatitis in Pregnancy Following Calcium Carbonate Ingestion

BACKGROUND

Calcium carbonate is often used to relieve Gastroesophageal Reflux Disease (GERD) in pregnant patients. This report describes a potentially serious complication.

CASE

A pregnant female presented at 34 weeks gestation with abdominal pain, nausea, and vomiting. Home medications included an unquantifiable amount of calcium carbonate 500 mg due to constant consumption for GERD. Laboratory findings included elevated calcium, amylase, lipase, and triglyceride level. Pancreatitis was diagnosed and abdominal ultrasound excluded gallstones. Despite hydration, lipase rose and emergency cesarean section was performed. Hypercalcemia was managed by intravenous fluid administration. After delivery, pancreatitis resolved.

CONCLUSION

Pancreatitis developed in pregnant patient with hypercalcemia due to excessive calcium carbonate ingestion and resolved after delivery of the fetus, fluid resuscitation, and return of calcium level to normal.

Clinical characteristics of acute pancreatitis in pregnancy: experience based on 121 cases

Purpose

Acute pancreatitis in pregnancy (APIP) is a rare condition; however, it markedly affects maternal and fetal health. This study aimed to describe the types, clinical characteristics, mortality, and the safety and necessity of gestation termination of acute pancreatitis in pregnancy (APIP).

Methods

We retrospectively reviewed 121 APIP cases in the Gastroenterology Department of The First Affiliated Hospital of Nanchang University. APIP diagnosis were based on 2012 Atlanta Criteria. The correlation between APIP types, severity, biochemical parameters and mortality was analyzed.

Results

The most common symptoms for APIP were abdominal pain (86.8%) and vomiting (73.6%). The most common causes for APIP were gallstone (36.4%) and hypertriglyceridemia (32.2%) and hypertriglyceridemic APIP was correlated with a higher rate for local complication (P = 0.012). Serum calcium level was negatively correlated with the severity of APIP (P < 0.01). The overall maternal and fetal mortality rate were 3.3% (4/121) and 11.6% (14/121), respectively. The severity of APIP was significantly correlated with higher risks for maternal and fetal death (P < 0.01). 72.7% of moderate-to-severe APIP patients underwent Cesarean section to terminate gestation safely.

Conclusion

The most common causes of APIP were gallstone and hypertriglyceridemia. Lower level of serum calcium could be used as an indicator for the severity of the APIP. The severity of APIP was associated with higher risk for neonate asphyxia, and maternal and fetal death.

Fatal Abdominal Compartment Syndrome Due to Severe Triglyceride-Induced Pancreatitis in Early Pregnancy

Serum levels of maternal lipids rise physiologically in normal pregnancy, and women with underlying hypertriglyceridemia may experience dramatic elevations which place them at risk for pancreatitis. We describe the case of a woman with severe familial hypertriglyceridemia and prior pancreatitis who discontinued her lipid-lowering therapy early in pregnancy. She promptly developed severe abdominal pain and was hospitalized with acute pancreatitis during the late first trimester. Despite aggressive medical treatment and critical care monitoring, she developed abdominal compartment syndrome (ACS) with associated acute renal failure, which progressed to cardiorespiratory failure and was ultimately fatal. ACS is an alarming complication of acute pancreatitis that has been poorly studied in pregnancy.

A preliminary study on fetal lung injury in a rat model of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP), which was thought to be rare, is becoming more frequent. In addition, high perinatal mortality among fetuses has been reported. Our research aimed to investigate and assess fetal lung injury in a rat model of APIP and its possible mechanisms. The APIP model was induced by sodium taurocholate in Sprague-Dawley rats during the third trimester. Sham-operated (SO) rats in late gestation were used as controls, and dynamic observation and detection in the SO and acute pancreatitis (AP) groups were performed at 3 time-points. Histological changes in the fetal lungs, as well as the maternal pancreas and placenta were assessed. The levels of serum amylase, lipase, TNF-α and IL-1β were detected in maternal rats, and the expression of surfactant proteins A, B, C and D as well as their mRNA were determined. In this study, fetal lung injury as well as maternal pancreas and placenta injuries occurred in a time-dependent manner. The levels of serum amylase, lipase and TNF-α were markedly increased in maternal rats, and the levels of surfactant proteins A, B, C and D in fetal lungs were significantly decreased in the fetal lungs of the AP group. Ultrastructure injuries and the dysregulated synthesis and secretion of pulmonary surfactant proteins were observed in the AP group. Our research suggests that fetal lung injury is involved in the rat model of APIP and that the dysregulated synthesis and secretion of pulmonary surfactant proteins play a critical role in fetal lung injury during APIP.

A Case of Idiopathic Severe Acute Pancreatitis following Cesarean Section Delivery

Acute pancreatitis rarely occurs in the postpartum period. Furthermore, there are very few reports of it after cesarean section delivery. A 35-year-old woman presented with dyspnea and abdominal distension on the third day after cesarean section delivery. Under a suspicion of acute pancreatitis, she was initially managed with conservative treatment. However, she developed intra-abdominal fluid collections and gastric bleeding, which were managed with percutaneous drainage, endoscopic hemostasis, and angiographic embolization. She was discharged with good clinical recovery. Postpartum pancreatitis, especially after cesarean section, is rare; however, its management is not different from that for usual pancreatitis.

Mitogen-Activated Protein Kinases Are Activated in Placental Injury in Rat Model of Acute Pancreatitis in Pregnancy

OBJECTIVES

To establish a rat model of acute pancreatitis in pregnancy (APIP) and evaluate its general presentations, assess placental injury, and discuss possible mechanisms.

METHODS

The APIP rat model was induced by sodium taurocholate in Sprague-Dawley rats of later gestation. Normal and sham-operated (SO) rats in later gestation were set as controls, 3 time points were set in SO and APIP groups to determine optimal modeling time. Histological changes of pancreas and placenta were assessed. Placental injury was determined by immunohistochemistry stain of caspase-3. Serum levels of amylase, lipase, and Ca; proinflammatory cytokines as tumor necrosis factor-α, interleukin-1β (IL-1β), IL-6, and anti-inflammatory cytokine IL-10 by enzyme-linked immunosorbent assay; mitogen-activated protein kinases and their phosphorylated forms by Western blotting.

RESULTS

Pancreatic necrotizing and placental injury occurred in time-dependent patterns. Serum levels of amylase and lipase significantly increased but Ca decreased; tumor necrosis factor-α, IL-1β, IL-6, and IL-10 were all increased in the APIP group; c-Jun N-terminal kinase, p38, and ERK1/2 were activated but with different distributing patterns in the placenta.

CONCLUSIONS

Placental injury is involved in the rat model of APIP, and a modeling time of 6 hours is optimal and conducive to further studies; c-Jun N-terminal kinase and p38 may play important roles in placental injury during APIP.

Presentation and management of acute hypertriglyceridemic pancreatitis in pregnancy: A case report

Pancreatitis related to hypertriglyceridemia can occasionally occur during pregnancy, particularly if there are underlying genetic abnormalities in lipid metabolism. We report the case of a 27-year-old female with hypertriglyceridemic pancreatitis in pregnancy that was treated initially with lipid lowering medications, followed by plasma exchange for persistently elevated triglyceride levels. Despite multiple interventions, she developed recurrent pancreatitis and simultaneously had a preterm birth. In this case report, we highlight the various therapies and the use of plasmapharesis in secondary prevention of hypertriglyceridemic pancreatitis in pregnancy.

Severe dyslipidemia in pregnancy: The role of therapeutic apheresis

During pregnancy physiological changes occur in the lipid metabolism due to changing hormonal conditions: the LDL cholesterol (LDL-C), triglycerides (TG) and lipoprotein(a) [Lp(a)] increase throughout pregnancy. Common lipoprotein disorders are associated in pregnancy with two major clinical disorders: severe hypertriglyceridemia (SHTG) is a potent risk factor for development of acute pancreatitis and elevated cholesterol due to greater concentrations of LDL and remnant lipoproteins and reduced levels of HDL promote atherosclerosis. The combination of homozygous Familial Hypercholesterolemia (HoFH) and pregnancy can be a fatal condition. Therapeutic plasma exchange (TPE) may be used for an urgent need of a fast and effective lowering of TG levels in order to prevent a severe pancreatitis episode or hypertriglyceridemia-induced complications during pregnancy. LDL apheresis can decrease LDL-C and prevent complications and can be considered in the treatment of pregnancies complicated by high LDL-C. These conditions are configured in patients with HeFH who were taking statins before pregnancy (selected cases), patients already receiving apheresis before pregnancy suffering from HoFH, patients suffering from hypertriglyceridemia due to familial hyperlipoproteinemia types I and V, and cases of hypertriglyceridemia secondary to diabetes.