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Pancreatitis During Pregnancy

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Pancreatitis is inflammation of the pancreas. This is an organ located in the back of the upper abdomen, behind the stomach. The pancreas is both an endocrine gland that releases four different hormones into the blood and an exocrine gland that releases digestive enzymes and a base called bicarbonate (HCO3-) into the small intestine. The pancreas can become inflamed for a variety of reasons, including damage from certain drugs, but the most common causes are alcohol abuse and gallstones. Pancreatitis is rare during pregnancy, but when it does occur during pregnancy gallstones are usually the reason and usually the woman has had multiple pregnancies, since multiple pregnancies increase the chances of developing gallstone disease. Other factors increasing the risk of gallstones, and thus pancreatitis, are being overweight and especially obese, being above the age of forty, being native American, and simply being female.

A gallstone can obstruct the pancreatic duct, a tube that runs through the length of the pancreas and joins with the common bile duct. A gallstone also can obstruct the common bile duct, but in either case, pancreatic secretions, including digestive enzymes, backup within the pancreas. Consequently, the digestive enzymes partly digest pancreatic tissue itself, leading to inflammation. More often this causes acute pancreatitis, pancreatitis whose symptoms are severe with sudden onset, but it is also possible to have chronic pancreatitis, meaning pancreatitis that waxes and wanes over time. Like acute pancreatitis, chronic pancreatitis has multiple causes, including alcohol abuse. However, chronic pancreatitis can also develop as a result of multiple episodes of acute pancreatitis making the pancreatic tissue increasingly susceptible to inflammation. Chronic pancreatitis also can result from autoimmune disease, meaning that the immune system attacks one’s own body tissues.

Clues that you may be suffering from pancreatitis come from symptoms, notably pain just below the ribs, which typically radiates around your torso to the back, meaning in a belt-shaped pattern. The pain tends to worsen after a meal, because the meal stimulates secretion of pancreatic enzymes. To evaluate you for pancreatitis, doctors draw blood for various lab tests, such as a comprehensive metabolic panel (CMP), a complete blood count (CBC), and often liver function tests. Particularly important information comes from tests for levels of enzymes called lipase and amylase. These are pancreatic enzymes that leak into the blood when the pancreas is inflamed. A finding that lipase and amylase are elevated at least three times the upper limit of the normal range suggests acute pancreatitis. Of these two enzymes, lipase is more specific than amylase for pancreatitis, meaning that amylase is often elevated due to causes other than pancreatitis. These enzymes often are not so elevated in cases of chronic pancreatitis.

Doctors can obtain a clear diagnosis by way of one of two specialized imaging tests. One of the tests is called cholangiopancreatography (ERCP) and the other is called magnetic resonance cholangiopancreatography (MRCP). In addition to its diagnostic capability, ERCP offers the advantage of being able to treat some causes of pancreatitis, for instance through removal of a stone. However, ERCP also has disadvantages. For instance, it can actually cause an episode of acute pancreatitis, due to inadvertent injection of contrast dye into the pancreatic tissue itself. ERCP also exposes you and your fetus to some ionizing radiation, although the radiation dose is fairly low. In contrast, MRCP does not impart any ionizing radiation dose and its diagnostic capability is good and is constantly improving. However, MRCP cannot be used for any kind of treatment. In addition to these tests, you also may be evaluated with abdominal ultrasonography.

During the diagnostic workup, doctors will consider your age and various lab test results together as what doctors call the Ranson criteria. The Ranson criteria generate a score that is used to determine whether your pancreatitis is mild, requiring only supportive measures and monitoring, or if it is likely to be severe acute pancreatitis. In the latter case, you must be admitted into the intensive care unit and there could be particularly dangerous complications, notably the pancreas bleeding and becoming infected. This can lead to necrosis (death of tissue the organ), or to sepsis (infection throughout the body). Pancreatitis can cause digestive difficulty that can include diarrhea and lack of absorption of food and fat-soluble vitamins. This causes nutritional deficiencies and weight loss, which can be harmful to a pregnancy, preventing you from gaining needed weight. Pancreatitis, especially chronic pancreatitis, can also cause hormonal problems, such as type 1 diabetes, and various other complications in numerous organs. Depression also can develop in those with pancreatitis. Over time, chronic pancreatitis can lead to pancreatic cancer. As for direct effects on the fetus, acute pancreatitis can lead to preterm birth and prematurity as well as fetal death.

Acute pancreatitis with infection requires antibiotic treatment. Some of the antibiotics given to non-pregnant acute pancreatitis patients carry risks for the baby, but other antibiotics can be given safely during pregnancy. Other medical treatments typically given include supplemental digestive enzymes to replace enzymes that the pancreas is not producing, pain medication, insulin for diabetes, corticosteroids for autoimmune pancreatitis, and antidepressants, since depression often develops along with pancreatitis. Some of these medications entail pregnancy risks, but often there are choices within categories of drugs with options that are fairly pregnancy safe.

Mild cases of acute pancreatitis are treated with supportive measures. This means that you will be admitted to the hospital and given fluid hydration intravenously and nothing by mouth (no food). If you develop complications, you may need surgical intervention. Sometimes, chronic pancreatitis is treated with surgical procedures, such as a Whipple procedure in which the head of the pancreas is removed along with part of the small intestine, part of the common bile duct, the gallbladder, and sometimes part of the stomach. Women suffering from acute pancreatitis must avoid eating, which makes it very challenging to breastfeed. As for new mothers with chronic pancreatitis, the appropriateness of nursing depends on the particular underlying condition. However, chronic pancreatitis is extremely rare among new mothers, even more rare than acute pancreatitis.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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