This is a case of a pregnant lady at 8 weeks of gestation, who presented with acute abdomen. She was initially diagnosed with ruptured ectopic pregnancy and ruptured corpus luteal cyst as the differential diagnosis. However she then, was finally diagnosed as acute hemorrhagic pancreatitis with spontaneous complete miscarriage. This is followed by review of literature on this topic. Acute pancreatitis in pregnancy is not uncommon. The emphasis on high index of suspicion of acute pancreatitis in women who presented with acute abdomen in pregnancy is highlighted. Early diagnosis and good supportive care by multidisciplinary team are crucial to ensure good maternal and fetal outcomes.
Acute pancreatitis in pregnancy is not an uncommon problem. The annual incidence of acute pancreatitis in general population is 5 to 80 per 100,000. However in pregnancy, it varies and is approximately 1 in 1000 to 1 in 10,000 [
Acute pancreatitis in pregnancy, as the name suggests, presents as an acute abdomen and can have a lethal effect on both the mother and the fetus. The high perinatal mortality and maternal mortality due to this condition have come down greatly due to the widespread use of ultrasound, Magnetic Resonance Imaging (MRI), and endoscopy as well as laparoscopy with multidisciplinary involvement in managing the condition.
We are reporting a case of acute pancreatitis in the first trimester of pregnancy which we initially diagnosed as ruptured ectopic pregnancy with a differential diagnosis of ruptured corpus luteal cyst. The final diagnosis was acute hemorrhagic pancreatitis with missed miscarriage.
A 25-year-old gravida 4 para 3 at 8-week gestation presented to the emergency department with sudden onset of generalised abdominal pain and vomiting. There was no per vaginal bleeding, hematemesis, diarrhea or constipation, syncopal attack, or fever. She did not have any medical illness except for gastritis which occurred intermittently but was treated effectively with antacids and H2 antagonists by her family doctor.
On admission, she was conscious and in pain. She was normotensive and afebrile. There was tachycardia with pulse rate of 118 bpm. She had mild pallor but no jaundice. There was tenderness at the lower half of the abdomen with rebound tenderness but no guarding. No other significant findings were noted on physical examination.
Ultrasound examination showed a doubtful, very small intrauterine gestational sac with no fetal echo or yolk sac. There was significant amount of free fluids in the pelvic cavity; however, no adnexal mass was seen. A provisional diagnosis of ruptured ectopic pregnancy was made with ruptured corpus luteal cyst as the differential diagnosis. An emergency laparotomy was done and, intraoperatively, there was about 500 mL serosanguinous fluid in the peritoneal cavity and presence of ruptured corpus luteal cyst without any active bleeding.
Postoperatively, she was initially stable. However there were persistent abdominal pain and tachycardia of 130–150 bpm four hours after the laparotomy. Further investigations were done to look for other causes of her illness. Hemoglobin was still within normal range, from 16.6 to 15.5 g/dL (reference range: 12–15 g/dL), white cell count was raised at 19.7 × 109/L (reference range: 4.0–11.0 × 109/L), platelet count was normal (205 × 109/L reference range: 110–450 × 109/L), and hematocrit was normal (39.2% reference range: 37–47%). However, serum amylase, urine diastase, and lactate dehydrogenase were all raised. Serum amylase was 1273 U/L (reference range: 25–125), urine diastase was 3054 U/L (reference range: 1–17), and lactate dehydrogenase was 827 U/L (reference range: 125–220 U/L). Corrected calcium was 2.16 mmol/L (reference range: 2.1–2.55 mmol/L), and random blood sugar was 12.4 mmol/L (6.7–11.1 mmol/L). Serum albumin was low at 24 g/L (reference range: 35–50 g/L); bilirubin was raised at 46.8
Ultrasound of the abdomen showed bulky pancreas with peripancreatic fluid suggestive of acute pancreatitis (see Figure
A bulky and inhomogeneous pancreas with presence of peripancreatic fluid in keeping with acute pancreatitis.
Despite hydration and supportive management, tachycardia persisted and subsequently she developed Adult Respiratory Distress Syndrome (ARDS). Chest radiograph showed bilateral lower lobe haziness. She then required ventilation with CPAP and was nursed in ICU. Surgical team decided to perform a diagnostic laparoscopy to rule out any concomitant perforated gastric ulcer or perforated bowel. Intraoperatively, there was hemorrhagic fluid about 500 cc with saponification seen on the omentum with inflammation seen around the retroperitoneum region seen. The whole length of the bowel was normal. Peritoneal washout was done. Thus a diagnosis of acute hemorrhagic pancreatitis was made.
She was managed by a multidisciplinary team involving the intensivist, surgeon, gynaecologist, dietitian, and physiotherapist. She required assisted ventilation for five days. Her blood pressure remained stable without any inotrope. She was given intravenous morphine as painkiller. Reassessed after 48 hours later, the Modified Glasgow Score was 2. She also developed ileus, which required Ryle’s tube and subsequently endoscopic nasoenteral tube (ENET) before it resolved. Postpyloric enteral feeding was commenced initially. Intravenous pantoprazole was also given. Intravenous Tazocin was given for 14 days.
Her general wellbeing and the blood test parameters improved remarkably. She was asymptomatic and the last blood test results prior to discharge were as follows: serum amylase dropped to 147 U/L (reference range: 25–125), serum LDH was 557 U/L (125–220 U/L), serum albumin was 37 g/L (35–50 g/L), and random blood sugar was normal.
She had complete miscarriage after a week of admission.
After 16 days staying in the hospital, she was well and was discharged home with further follow-up with the surgical team.
Acute pancreatitis (AP) in pregnancy is most often associated with gallstone disease or hypertriglyceridemia [
Acute pancreatitis in pregnancy is more difficult to diagnose in first trimester as compared to third trimester. The most common clinical presentations were abdominal pain (89.47%) and vomiting (68.42%) [
In evaluating pregnant patients with acute pancreatitis, it is suggested for four important questions to be answered, which are as follows. (1) Does this patient have acute pancreatitis (establishing the diagnosis and ruling out other causes)? (2) If it is acute pancreatitis what is the predicted severity (whether it is mild AP (MAP) or severe AP (SAP))? (3) Is there biliary aetiology? (4) What is the trimester of pregnancy? This last question will determine choice of imaging and mode of therapy [
Diagnosis of acute pancreatitis in this lady was established mainly by clinical presentation, blood markers, and ultrasound findings. The unresolved pain despite the initial intraoperative finding just showed a nonbleeding ruptured corpus luteal cyst which suggests there must be other causes of her abdominal pain. Serum amylase and/or lipase are useful blood marker in diagnosing acute pancreatitis. In this lady her serum amylase was very high which is adequate to establish the diagnosis, further being supported with the ultrasound findings later. Typically serum amylase concentration greater than three times normal is seen at presentation, which peaks in the first 24 h and falls to baseline in 3–5 days. In contrast, serum lipase concentrations are elevated for up to two weeks, making it a more sensitive and specific diagnostic test. However literature suggested that both enzyme concentrations were similar in nonpregnant and pregnant women and increase in either would be suggestive of acute pancreatitis in pregnancy [
Mild acute pancreatitis (MAP), which is the most common form, has no organ failure or local or systemic complications and resolves in the first week. Severe acute pancreatitis (SAP) is defined by persistent organ failure, that is, organ failure for more than 48 hours. Local complications include peripancreatic fluid collection and peripancreatic or pancreatic necrosis [
We diagnosed the disease as severe acute pancreatitis (SAP) after the ultrasound clearly showed peripancreatic fluid and managed the patient in intensive care unit with the help of surgeons, intensivist, obstetricians, and the dietician. Ultrasound scan is safe and relatively inexpensive but it has low diagnostic value for acute pancreatitis. Another alternative imaging in cases of indeterminate ultrasound findings is magnetic resonance cholangiopancreatography (MRCP) without contrast medium which has over 90% sensitivity without exposing the mother and fetus to ionizing radiation. MRCP also limited the use of endoscopic retrograde cholangiopancreatography (ERCP) only to women who need therapeutic procedures. Endoscopic ultrasound has higher sensitivity than MRCP in visualization of choledocholithiasis and micro stones but it requires sedation [
The initial management of acute pancreatitis in pregnancy does not vary from nonpregnant state. It consists of fluid restoration, oxygen, analgesics, and cessation of oral feeding to suppress exocrine function of pancreas, thereby preventing autodigestion of pancreas [
In mild acute pancreatitis (MAP), nutritional support is not needed because the clinical course is usually uncomplicated and low fat diet can be started within 3–5 days [
Though we have used antibiotics in this patient, prophylactic use of antibiotics in acute pancreatitis is controversial [
Prognosis for mild acute pancreatitis (MAP) is excellent with no adverse effects on the fetus or mother. In 1973, maternal mortality due to acute pancreatitis in pregnancy was 31% [
Management of severe acute pancreatitis (SAP) occurring in first trimester carries a better prognosis for mother but it is associated with increased fetal loss of about 20% [
The paradoxical trend in acute pancreatitis in pregnancy is the increase in the number of patients diagnosed but overall decline in perinatal and maternal morbidity and mortality associated with it. Increase in incidence can be attributed to various factors such as better diagnostic facilities, greater awareness of the disease, and increase in incidence of obesity all over the world. The advent of rapid assay methods for amylase, better supportive care of pancreatitis, newer therapeutic measures for gallstone pancreatitis, and overall improvement in antenatal care have definitely contributed to better maternal and fetal outcomes.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Special thanks are due to Department of Obstetrics and Gynaecology, Department of Surgery, and Department of Anaesthesiology, Sungai Buloh Hospital, Selangor, Malaysia.