Acute pancreatitis with eclampsia-preeclampsia syndrome and poor maternal outcome: two case reports and review of literature

An Unusual Cause of Pancreatitis: Eclampsia

Pancreatitis in pregnancy is not a common entity and has only been described with dysfunction of the biliary tract. Pregnancy in itself has not been described as a cause of pancreatitis, as is evidenced by the normal serum amylase and lipase values during the course of normal gestational periods. Pregnancy is known to be associated with hepatic dysfunction in the second or third trimesters, which can sometimes involve the pancreas but has not been documented to cause isolated involvement of the pancreas. This gives us reason to believe that pregnancy-induced hypertension complicated with eclampsia is a rare but sinister and important differential in the peripartum period. Here is a case of a 25-year-old primigravida who presented to the hospital with eclampsia and developed pancreatitis on her second postoperative day in the hospital with no antecedent history of biliary disease, dyslipidemia, or alcohol consumption.

Do Case Reports and Case Series Generate Clinical Discoveries About Preeclampsia? A Systematic Review

Background

Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known.

Objective

To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia.

Methods

A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.

Results

We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme.

Conclusion

Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.

miR-24-3p regulation of retinol binding protein 4 in trophoblast biofunction and preeclampsia

Preeclampsia (PE) is a pregnancy-related disease and is the leading cause of overall maternal mortality and morbidity. Our previous studies have shown that the serum and placental levels of retinol-binding protein 4 (RBP4) in PE are reduced. Our previous bioinformatics analysis predicted that RBP4 is a target of the microRNA miRNA-24-3p. In this study, our database analysis also indicated that RBP4 is a miR-24-3p target. Compared with that of the normal placenta, the expression level of RBP4 in human PE placenta was significantly reduced, and miR-24-3p was highly expressed. In HTR-8/SVneo cells, transfection of exogenous miR-24-3p reduced RBP4 expression. A dual-luciferase reporter assay validated RBP4 as a direct target of miR-24-3p, indicating that it directly binds to the 3'-untranslated region of RBP4. This binding was reversed by a mutation in the microRNA-binding site. Transwell invasion experiments and CCK8 assay showed that inhibitory effect of miR-24-3p reduced RBP4 mediated HTR-8/SVneo cell invasion and proliferation. These data provide a new overarching perspective on the physiological role played by miR-24-3p in regulating RBP4 during trophoblast dysfunction and PE development.

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.

Preeclampsia and the Risk of Pancreatitis: A Nationwide, Population-Based Cohort Study

Background

Preeclampsia is a multiple organ dysfunction during pregnancy, including hepatic, renal, and neurological dysfunction, and is defined as hypertension and proteinuria occurring after 20 weeks of pregnancy. Clinical features seen in preeclampsia are due to relatively poorly perfused placenta and maternal endothelial dysfunction. Some studies have found that preeclampsia may cause acute pancreatitis due to microvascular abnormalities and visceral ischemia. This retrospective cohort study used the Taiwanese National Health Insurance Research Databases (NHIRD) to study the relationship between preeclampsia and the risk of pancreatitis.

Methods

In total, 606,538 pregnant women were selected from the NHIRD between January 1, 1998 and December 31, 2010. They were divided into a preeclampsia cohort (n = 485,211) and a nonpreeclampsia cohort (n = 121,327). After adjusting for comorbidities that may induce pancreatitis, we analyzed and compared the incidence of pancreatitis in the two cohorts.

Results

The overall incidence of pancreatitis in the preeclampsia cohort was significantly higher than that in the control cohort (4.29 vs. 2.33 per 10,000 person-years). The adjusted HR of developing pancreatitis increased 1.68-fold (95% CI: 1.19-2.36) in the preeclampsia cohort. In addition, pregnant women with preeclampsia without comorbidities had a significantly high risk of pancreatitis (aHR = 1.83, 95% CI 1.27-2.63). The combined effect of preeclampsia and alcohol-related diseases resulted in the highest risk of pancreatitis (aHR = 43.4, 95% CI: 6.06-311.3).

Conclusion

Compared with patients without preeclampsia, the risk of pancreatitis in patients with preeclampsia is significantly increased after adjusting for demographics and comorbidities. The risk of pancreatitis is greatly increased when preeclampsia is accompanied by alcohol-related diseases, hepatitis C, gallstones, diabetes, or age of 26–35 years. Early identification and effective control of preeclampsia and the associated comorbidities can reduce the risk of pancreatitis and the associated morbidity and mortality.

Non-gallstone acute pancreatitis and pre-eclampsia: A case report

Acute pancreatitis is rare but well documented in pregnancy and most cases are attributable to biliary disease. We present a case of acute non-gallstone pancreatitis in a patient with acute and severe pre-eclampsia.

A 39-year-old primigravida woman at 33 + 4 weeks' dichorionic diamniotic gestation presented with severe bilateral lower-limb oedema and underwent an emergency caesarean section due to the development of acute severe pre-eclampsia. Postpartum, the woman developed out-of-proportion generalised upper abdominal tenderness with worsening liver function and markedly raised lipase and amylase levels. Imaging confirmed oedema and inflammatory changes in keeping with acute non-gallstone pancreatitis. The patient improved with conservative management and was eventually discharged home on day 13 postpartum.

The development of abdominal pain out of proportion to expected clinical progression should prompt the physician to consider other causes, including acute pancreatitis, in order to provide effective and timely clinical care. The clinical presentation of this woman suggests that pre-eclampsia may be associated with the development of acute pancreatitis. Further prospective study would be needed to establish any association.

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Out-of-proportion abdominal pain after caesarean section warrants further review.

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Microvascular abnormalities associated with pre-eclampsia may affect pancreatic blood flow.

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Pre-eclampsia should be considered as a cause of acute pancreatitis.

Characteristics and outcome of severe preeclampsia/eclampsia concurrent with or complicated by acute pancreatitis: a report of five cases and literature review

OBJECTIVE

The objective of this study is to determine the rate of acute pancreatitis in preeclampsia/eclampsia patients and describe the clinical manifestations, treatment characteristics and outcome of five cases of severe preeclampsia concurrent with or complicated by acute pancreatitis.

METHODS

The clinical data of pregnant women with preexisting or gestational hypertension who sought medical care between January 2002 and December 2015 at the Pregnant Women Critical Care Unit of Chaoyang Hospital, Capital Medical University, Beijing, China were retrieved. The rate of acute pancreatitis in preeclampsia/eclampsia patients was calculated and patients with preeclampsia/eclampsia and acute pancreatitis were included for further analysis.

RESULTS

Totally 1703 pregnant women who received medical care at our institution during the review period were diagnosed with hypertension. Four hundred and seven (23.9%) of them had severe preeclampsia. Five (1.2%, 5/407) women with severe preeclampsia developed acute pancreatitis. Their median age was 32 (range 25-35) years and the median duration of gestation was 32 (range 28-40) weeks. Mild acute pancreatitis occurred in three cases, and moderately severe and severe acute pancreatitis in one case each. Four patients underwent cesarean resection and one patient underwent vaginal delivery. Conservative therapy was undertaken. No patient received surgical intervention and cure was achieved in all patients.

CONCLUSION

Acute pancreatitis may complicate severe preeclampsia/eclampsia or may be concurrent with severe preeclampsia/eclampsia, complicating and compromising the management of preeclampsia/eclampsia. Physicians should be alert for the presence of acute pancreatitis as prompt diagnosis and treatment, rapid termination of pregnancy and subsequent conservative management of pancreatitis could lead to a general favorable outcome.