Pancreatitis in pregnancy is an acute or chronic destruction of the pancreas that has arisen or worsened during gestation. It is manifested by shingling pain in the epigastrium and left hypochondrium, nausea, vomiting, flatulence, decreased appetite, diarrhea, sometimes hyperthermia and multiple organ disorders. It is diagnosed on the basis of data on the level of pancreatic enzymes in the blood and urine, ultrasound results. Anti-enzyme drugs, analgesics, gastric secretion blockers, infusion agents, enzymes are used for treatment. According to the indications, sanitizing and draining operations, resection of the organ are carried out.
Various forms of pancreatitis are detected in 0.02-0.1% of pregnant women, while in 88% of patients the pathological process is acute. The disease is detected in more than half of cases of emergency surgical pathology during pregnancy. Acute pancreatitis is more often affected by primiparous patients, a relapse of the chronic form is usually observed with repeated gestations. Although the disorder can develop at any time, in 52% of cases the disease occurs in the third trimester. The relevance of timely diagnosis of pancreatitis is associated with a significant increase in the risk of maternal and perinatal mortality with late detection of acute forms of the disease and incorrectly selected treatment tactics.
According to studies in the field of gastroenterology conducted in the 70s of the twentieth century, the etiology of pancreatitis during gestation is the same as in non-pregnant patients (with the exception of specific damage to the gland in HELLP syndrome). The provoking factors of the disease are disorders of bile secretion and lipid metabolism, the use of hepatotoxic and pancreatoxic substances (alcohol, thiazide diuretics, metronidazole, sulfasalazine, corticosteroids), nutritional errors (a diet with a large amount of fatty, fried, spicy foods), smoking, cytomegalovirus infection, worm infestations (opisthorchiasis, ascariasis), autoimmune processes, genetic predisposition.
A certain role in the development of the disease is played by abnormalities of the pancreatic gland, increased pressure in the abdominal cavity, duodenal hypertension, gastrointestinal diseases (dysfunction of the Oddi sphincter, peptic ulcer of the stomach, duodenum, bacterial overgrowth syndrome in the small intestine). Abdominal injuries, abdominal surgical interventions, and endoscopic manipulations can trigger autopsy of pancreatic tissue. In pregnant women, some of these factors are leading in connection with the physiological restructuring of the body. The causes of the acute process are:
- Bile secretion disorder. Acute biliary-dependent inflammation is detected in 65-66% of patients. It is usually formed due to stagnation of the secretion due to blocking of the Oddi sphincter and pancreatic duct by small bile concretions in cholelithiasis, which arose, manifested or worsened during gestation. Additional factors are changes in bile viscosity, intestinal and gallbladder motility disorders, biliary dyskinesia, cholestasis of pregnant women caused by hormonal restructuring.
- Hyperlipidemia and hypertriglyceridemia. Under the influence of estrogens, the concentration of cholesterol, triglycerides, and lipids in the blood serum of pregnant women increases physiologically. In patients suffering from metabolic syndrome, obesity, congenital disorders of fat metabolism (I, IV, V types of congenital hyperlipidemia according to Frederikson), the triglyceride content exceeds 600-750 mg / dl — the level at which, as a result of vascular microembolism by fat particles and fatty infiltration of acinar cells, destruction of pancreatic tissue begins.
- Hyperparathyroidism. Hyperparathyroidism is observed in 0.15-1.4% of patients. Violation of the secretion of parathyroid hormone is associated with pregnancy-specific changes in the metabolism of calcium, actively consumed by the growing fetus. An increase in the concentration of PTH is accompanied by an increase in pancreatic secretion, increased absorption of calcium in the intestine and its leaching from the bones, followed by deposition in parenchymal organs. Obturation of the pancreatic ducts with calcinates disrupts the outflow of pancreatic juice, which causes tissue destruction.
- Preeclampsia. Complex endothelial dysfunction, characteristic of preeclampsia, provokes hemostasis disorders at the procoagulant, anticoagulant, vascular-platelet levels, which is manifested by chronic DIC syndrome and systemic microcirculatory disorders in various organs. Multi-focal tissue hypoxia and pancreatic tissue ischemia lead to irreversible changes in the parenchyma of the organ. The situation is aggravated by the redistribution of blood in the vascular bed with its shunting through the placenta.
In 12.3% of pregnant women, acute pancreatitis is caused by the pancreotoxic effect of free bile acids, the content of which increases with the abuse of alcoholic beverages in combination with smoking. In some cases, the causes of sudden pancreatic inflammation during gestation remain unidentified, the disease is considered idiopathic.
Pathology recurs during pregnancy in a third of patients suffering from chronic pancreatitis. The reasons for the deterioration of the condition are changes in eating habits, decreased motor activity, slowing of gastrointestinal motility caused by the action of sex hormones, emotional worries about the outcome of gestation and childbirth. Often the exacerbation coincides with early toxicosis or disguises itself as it. Chronic pancreatitis can also occur during gestation as a result of the transformation of unrecognized acute inflammation, which in 60% of cases is not diagnosed in a timely manner.
A key link in the development of pancreatitis in pregnancy is the deterioration of the outflow of pancreatic secretions due to partial or complete obstruction of the ducts, followed by damage to their walls and intra—organ activation of enzymes. Under the influence of lipase and trypsin, the parenchyma of the organ is self-digested. Sometimes tissue destruction is provoked by thrombotic, ischemic, inflammatory processes, direct toxic effects on secretory cells. With prolonged subclinical influence of damaging factors, pancreatitis is chronicled, in response to the destruction of the parenchyma, connective tissue grows reactively, which leads to wrinkling, scarring, sclerosing of the organ with a violation of its excretory and endocrine functions.
The systematization of pancreatitis in pregnancy corresponds to the generally accepted classification of the disease. The most significant for the choice of tactics of pregnancy management is the allocation of acute and chronic variants of inflammation. More often, pregnant women are diagnosed with acute pancreatitis, which requires urgent therapy to prevent serious extragenital and obstetric complications. Taking into account the clinical picture and morphological changes, specialists distinguish 4 phases of active pancreatic inflammation: enzymatic (from 3 to 5 days), reactive (from 4-6 days to 14 days), sequestration (up to six months), outcome (from 6 months onwards). The process can occur in a milder edematous (interstitial) variant and severe destructive with limited or widespread fatty, hemorrhagic or mixed organ damage.
Chronic pancreatitis is detected in 12% of pregnant women, and in 1/3 of cases it is the result of a transferred but undiagnosed acute variant of pathology. The disease occurs in latent (pain-free), chronic recurrent, painful, pseudotumor, sclerosing forms. To plan a pregnancy in a patient with chronic pancreatitis, it is important to take into account the stage of the disease. There are the following stages of the disease:
- Initial. Exacerbations occur no more than once a year, the pain is easily relieved by medications. In the inter-approach period, clinical manifestations, changes in tests, ultrasound results are minimal or absent. An uncomplicated course of pregnancy is possible with appropriate correction of diet and lifestyle.
- Medium-heavy. There are up to 4 exacerbations of the disease per year. In the projection of the pancreatic gland, pulling pains and discomfort are constantly felt. Dyspeptic disorders occur, indicating a violation of the secretory function of the organ. Morphological changes are detected on ultrasound. There is a high probability of complications of gestation.
- Severe (terminal, cachectic). The disease worsens more than 4 times a year. Pain syndrome is constantly expressed. Both secretory and endocrine functions of the organ are disrupted, gross digestive disorders and signs of diabetes mellitus are noted. Related bodies are involved in the process. Normal development of pregnancy is impossible.
Clinical manifestations of pathology depend on the characteristics of the course and variant. Acute pancreatitis often occurs suddenly in the II-III trimesters in the form of increasing constant or cramping pains in the epigastrium or subcostal region. The intensity of pain can be so pronounced that a woman has a vascular collapse or pain shock with loss of consciousness, depression of cardiovascular activity. Nausea, vomiting, bloating, abdominal wall tension, hyperthermia are possible. Almost half of the patients have icteric sclera and skin. During pregnancy, severe pain-free forms with shock, headaches, confused consciousness, and other neurological symptoms occur more often than outside the gestational period.
Relapse of chronic pancreatitis is usually observed in the 1st trimester, accompanied by severe nausea, vomiting, which are regarded by the patient and the obstetrician-gynecologist as signs of early toxicosis. The persistence of clinical symptoms of dyspepsia longer than the 12th week of pregnancy often indicates damage to the pancreas. In the classic course of chronic pancreatitis, pain syndrome becomes the leading sign. Pressing or aching pain can bother a woman constantly or occur after eating fatty, fried food. Sometimes it manifests itself paroxysmally.
The localization of pain corresponds to the site of organ damage: with the destruction of the gland head, pain is felt in the epigastrium on the right, body — on the left, tail — in the left hypochondrium. A characteristic sign of pancreatitis is shingling painful sensations that spread from under the xiphoid process along the left costal arch to the spine. Pain can give the left shoulder, shoulder blade, iliac region, less often — in the precardial zone. In violation of enzyme secretion, dyspepsia is expressed, aversion to fat is noted, poor appetite, increased saliva secretion, belching, bloating, diarrhea with copious mushy stools having a characteristic greasy sheen. A pregnant woman gains weight more slowly.
In the past, acute destructive inflammation of the pancreatic gland was considered one of the most serious gastroenterological diseases with a high maternal mortality rate reaching 37-38%. Perinatal fetal death was observed in 11-37% of pregnancies with pancreatitis. Thanks to the introduction of modern diagnostic and therapeutic methods, these indicators have now been reduced to 0.1-0.97% and 0.5-18%, respectively. In 5.4% of cases, inflammatory destruction recurs during the same gestation period, in 6.6% — within three months after delivery, in 22-30% the pathological process becomes chronic.
Although with acute inflammation of the pancreas, the fetus usually does not experience direct damaging effects, the prognosis of pregnancy worsens. 20% of patients who had the disease had spontaneous miscarriages, 16% had premature births. The main complication in the 3rd trimester is DIC syndrome. The most serious extragenital disorders are infection of inflamed tissues, the formation of retroperitoneal phlegmon, the development of enzymatic peritonitis, erosive bleeding and pseudocysts, pancreatogenic and infectious-toxic shock.
In 28% of pregnant women with chronic forms of the disease, severe early toxicosis is observed, lasting up to 16-17 weeks. In the second half of the gestational period, chronic inflammatory destruction of the pancreatic gland does not significantly worsen the obstetric prognosis. The long-term consequences of chronic pancreatitis that occurred during pregnancy are morphological changes in the organ with the formation of pseudocysts and cysts, abscess formation, pancreolytiasis, the development of severe insulin-dependent diabetes, stenosis of the pancreatic duct and the large duodenal papilla due to scar-inflammatory processes, malignancy.
According to the observations of specialists in the field of obstetrics, pancreatitis in pregnancy is often diagnosed untimely or not recognized at all. This is due to erased symptoms with local destruction of pancreatic tissue or chronic course of the process. To confirm the diagnosis, the following methods of examinations are recommended for women with suspected pancreatitis:
- Analysis of the content of pancreatic enzymes. When organ cells are damaged in the blood, the activity of lipase, general and pancreatic amylase increases. The concentration of alpha-amylase in urine increases. For acute and aggravated chronic pancreatitis, an increase in the level of serum elastase-1 is characteristic.
- Ultrasound of the pancreas. The presence of an active process, according to pancreatic sonography, is indicated by an increase in the size of the organ, a decrease in echogenicity due to tissue edema, heterogeneity of the morphological structure, more pronounced in the chronic variant of pancreatitis. When the head is affected, the pancreatic duct may expand.
- A general blood test. The changes are more indicative in the acute process: there is a high leukocytosis with neutrophilosis, a shift of the leukocyte formula to the left, a significant increase in ESR, an increase in hematocrit. In chronic pancreatitis, these indicators increase slightly and are less informative.
- Biochemical blood testing. Damage to the insulin apparatus of the pancreatic gland with active destruction of the organ is manifested by a decrease in glucose tolerance, and in more severe cases — hyperglycemia. For pancreatitis, a decrease in the calcium content in the blood, hypoproteinemia, dysproteinemia is typical.
To identify the insufficiency of the external secretory function, a coprological study is additionally prescribed. These coprograms confirm a decrease in the digesting capacity of duodenal juice. Radiological methods (duodenography in hypotension) are rarely used because of the possible damaging effects on the fetus. Pancreatitis is differentiated with preeclampsia, premature detachment of the normally located placenta, HELLP syndrome, gestational cholestasis, acute fatty liver of pregnant women, appendicitis, cholecystitis, intestinal obstruction, cholelithiasis, pancreatic cancer, paranephritis, pyelonephritis, hepatic colic in nephrolithiasis, cystic fibrosis, coronary heart disease. In addition to the gastroenterologist, the patient is advised by a therapist, abdominal surgeon, hepatologist, urologist, cardiologist, endocrinologist, oncologist.
Developing obstetric tactics, they take into account the peculiarities of the course of the disease in a particular patient. Women with persistent remission, preserved secretion in the absence of complications (pancreatogenic diabetes, etc.) are recommended dynamic monitoring, periodic examinations by a gastroenterologist, correction of the diet with a restriction of the amount of spicy, fatty, fried, complete abstinence from alcohol. When prescribing medications for the treatment of concomitant disorders, it is necessary to take into account their possible pancreotoxic effect. Acute pancreatitis, which developed before the 12th week of pregnancy, is an indication for its termination, and with a gestational term of 36 weeks and beyond — for early delivery.
A patient with pancreatitis in pregnancy is hospitalized in a surgical hospital. The main therapeutic tasks are relief of pain, inflammation, restoration of secretory functions of the organ, removal of intoxication, prevention of possible complications. An important stage of treatment is to ensure the functional rest of the damaged gland: to suppress the secretion of pancreatic juice for 3-7 days (taking into account the severity of inflammation), a regime of hunger and thirst with parenteral nutritional support is observed, the contents of the stomach are sucked through a nasogastric probe every 4-6 hours, local hypothermia of the epigastric region is provided. The scheme of drug therapy includes:
- Blockers of gastric secretion. The drugs consolidate the effect of the created functional rest of the pancreas. A decrease in the volume of gastric juice secreted is accompanied by a decrease in the activity of pancreatic secretion, which makes it possible to localize damage and prevent further autolysis of the organ.
- Anti-enzyme agents. Antiproteolytic drugs allow inactivating pancreatic enzymes that destroy the gland tissue. They are more effective when the process is active. In chronic variants of the disease, drugs with a metabolic effect that selectively inhibit trypsin are preferred.
- Analgesics. To eliminate the pain syndrome, nonsteroidal anti-inflammatory drugs, antispasmodics are prescribed. In more complex cases, glucocorticosteroids are used. With intense pain and signs of pancreatogenic shock, it is possible to perform epidural anesthesia with mepivacaine and buprenorphine.
- Detoxification drugs. Since active pancreatitis is accompanied by massive destruction of tissues, pregnant women may develop a pronounced intoxication syndrome. Infusion therapy with drip administration of crystalloid and colloidal solutions is used to remove toxic metabolites.
To prevent infection of necrosis foci, preventive administration of antibiotics that do not have contraindications for use during pregnancy is possible. In severe cases of pancreatitis in pregnancy, according to indications, the volume of circulating blood is replenished, disorders of water-electrolyte metabolism are corrected under the control of diuresis, antiplatelet agents are used. After the active process is stopped, in the presence of functional insufficiency of the organ, substitution therapy with poly-enzyme preparations is carried out.
To prevent infectious complications, the patient is recommended natural childbirth with adequate anesthesia (usually epidural anesthesia). Due to the significant risk of infection, cesarean section is performed in exceptional cases according to obstetric indications. With the ineffectiveness of conservative therapy, the increase in destruction of the gland, the spread of the inflammatory process to the retroperitoneal tissue and peritoneum, sanitizing and draining interventions, pancreatoduodenal resection are indicated. Usually, in the 3rd trimester before abdominal surgery, pregnancy is completed with surgical delivery, which allows saving the life of the child.
Prognosis and prevention
The outcome of pancreatitis in pregnancy depends on the stage of the disease. With sustained remission, the prognosis is favorable. Frequent exacerbations, high activity of the process increase the risk of complications. Patients with an established diagnosis should take into account the recommendations of a gastroenterologist when planning pregnancy. For preventive purposes, women with gastrointestinal diseases, hyperlipidemia are recommended early registration in a women’s clinic, a diet with a limited content of animal fats, refusal of nicotine and alcohol. If necessary, medication correction of serum lipoprotein levels is performed.