Pregnancy and Pancreatitis. Chronic Pancreatitis in Pregnancy

Acute pancreatitis in pregnant develops infrequently, proceeds severely and in 39 % of cases ends by death. Perinatal mortality at this disease reaches 39‰. Acute pancreatitis develops at any term of gestation, but more often in its second half; the maternal mortality from acute pancreatitis rises with increase in term of gestation.

Clinical picture. In 75 % of pregnant acute pancreatitis is clinically manifested by an acute excruciating pain in the upper part of the abdomen (epigastric area, left or right hypochondrium). Most often the pain is of a girdle character. Nausea, vomiting, collapse occur. At the beginning of disease the abdomen can remain soft, without any signs of peritoneum irritation; in future the phenomena of enteroparesis and intestinal obstruction become of most importance. More often than in non-pregnancy the painless forms of acute pankreatitis are observed. In this case the disease is manifested by shock and symptoms of affection of the central nervous sysem. A similar course of acute pancreatitis is an extremely unfavorable prognostic sign; a death rate in such cases makes up 83 %. At examination icteritiousness is sometimes revealed; the spontaneous petechias on the lateral surfaces of abdomen (Terner's symptom) or round the umbilicus can appear (Cullen's symptom). Fever occurs in half of patients.

In most cases of acute pancreatitis the level of amylase in blood rises in 8 hours after attack and reaches the peak in 24-36 hours. The content of amylase (diastase) in urine considerably increases; usually it rises in 24-48 hours after the onset of disease and remains increased for 10 days. The level of lipase increases a little bit later and remains increased longer than the level of amylase.

The estimation of calcium content in blood is of great diagnostic importance. The lowest levels of calcium at acute pancreatitis are observed between the 2nd and 4th day of disease. The decrease of calcium level in blood serum after the 2nd week of disease usually testifies to disease progress. In most women suffering from acute pancreatitis during pregnancy, leukocytosis and anaemia are marked.

Acute pancreatitis is accompanied by changes of glucose level in blood, often by hypo- and hyperglycemia. Hypoglycemia can be due to starvation or increased level of insulin. Hyperglicemia testifies to a severe course of disease, usually with lethal outcome. In 15-25 % of women diabetes mellitus develops after the attack of acute pancreatitis.

The treatment of acute pancreatitis consists in treatment of shock; the suppression of pancreatic function is achieved by nasogastric suction of gastric contents, exclusion of oral intake of preparations and foodstuffs (regimen of hunger and thirst), administration of anticholinergic drugs: atropine (1 ml of 0.1 % solution subcutaneously), platyphyllin (1 ml of 0.2 % solution subcutaneously), and also administration of enzymatic inhibitors — gordox, contrical, trasylol (at first 25,000-50,000 units intravenously, then 25,000-75,000 units intravenously droppingly in a 5 % glucose solution; the following days introduction of 50,000-25,000 units per day, reducing the dose in the process of improvement of clinical picture and laboratory results).

To decrease pain and spastic component, spasmolytic agents and anodynes are administered: no-spa (2-4 ml of a 2 % solution intramuscularly), papaverine hydrochloride (1-2 ml of a 1-2 % solution intramuscularly), analgin (1-2 ml of a 50 % solution intramuscularly), baralgin (5 ml intravenously or intramuscularly), novocaine (2-5 ml of a 0.25 % solution intravenously). To patients with pancreatonecrosis antibiotics are administered with the purpose of prevention of suppuration. To decrease a secretory pancreatic activity and remove edema of pancreas, diuretics should be administered (1-2 ml of a 1 % lasix solution intravenously).

Besides, at treatment of acute pancreatitis the electrolyte balance should be maintained, by introduction of large quantity of fluid (3-6 l) with electrolytes. On revealing hyperglycemia insulin should be administered.

If an adequate conservative therapy turns out to be ineffective, there are doubts as for the diagnosis, there is a rapidly increased abscess, acute occlusion of bile ducts with stone and development of icterus, a surgical intervention is indicated.

Effect of Acute Pancreatitis on Pregnancy. One of the most frequent and widespread complications in patients with acute pancreatitis is premature labor, the cases of intrauterine death of the fetus are not uncommon. The development of weak contractile activity of the uterus is possible in labor, as well as asphyxia of the intrauterine fetus. In postpartum period the development of puerperal infectious-inflammatory diseases is possible.

Management of Pregnancy in Patients with Acute Pancreatitis. There are no convincing proofs that arresting of pregnancy in the I trimester or initiation of premature birth in the second its half improves prognosis for mother. At development of acute pancreatitis during pregnancy an adequate therapy should be started as early as possible; if the treatment is ineffective, the question on abortion and subsequent surgical treatment should be solved quite individually. The choice of method of delivery in pregnant with acute pancreatitis presents great difficulty. Most often a woman has weakness of labor pains and prolongation of labor. Cesarean section is undesirable, because it has to be performed in conditions of infected abdominal cavity, therefore the extraperitoneal cesarean section can be a method of choice.

Chronic Pancreatitis in Pregnancy. Chronic pancreatitis develops after the previous acute pancreatitis or as a primary chronic disease. Exacerbation of chronic pancreatitis during pregnancy is encountered as rarely as acute pancreatis. The clinical picture of exacerbation of chronic pancreatitis during pregnancy is to a great extent similar to exacerbation in non-pregnancy. Pain of a cramping or permanent character is the main complaint. More often pain occurs in the upper part of abdomen or in the epigastric area and irradiates to the left shoulder, shoulder-blade, neck or to the left iliac bone, sometimes having a girdling character.

Pain is not connected to taking meals, however it can considerably increase after eating fat food. In the majority of patients there are dyspepsia complaints, such as nausea, vomiting, eructation, loss of appetite, abdominal swelling, sometimes salivation. The excretion of plentiful, porridge-like, grayish, fetid “fatty” faeces (pancreatic steatorrhea) caused by dysfunction of pancreas is a characteristic symptom.

Sometimes a slight icteritiousness of skin and eyes is observed. On abdominal palpation tenderness in the area of pancreas projection is marked.

Data of additional methods of examination are the same as in acute pancreatitis.

Treatment of exacerbation of chronic pancreatitis is based on the same principles as of acute pancreatitis. Diet therapy is the basic and most essential link of complex therapy of chronic form of disease. In the period of remission it is necessary to take food 4-5 times a day. Food should contain the excess amount of carbohydrates, water soluble vitamins, substances with lipotropic action, limited quantity of fats at normal or increased quantity of proteins. Cold drinks, cakes, pastry, beef tea or fish broth should be excluded.

At exacerbation of chronic pancreatitis during the first 3 days the fast and thirst regimen is administered. Subsequently a low-caloric diet is recommended, excluding fats, salt, nitrous extractive substances increasing a secretory activity of the stomach and causing intestinal bloating. Further a carbohydrate and protein diet is primarily administered. Of medicines spasmolytics and sedatives, antienzymic preparations are given.

In the period of remission of chronic pancreatitis pancreatin (1 g 3 times a day after meals) or preparations containing enzymes of stomach, pancreas and small intestine, such as holenzim, panzinorm, festal (1-2 pills 3 times a day after meals) should be administered.

Effect of Chronic Pancreatitis on Pregnancy. Pregnancy in 28 % of such patients is complicated by toxemia of early terms of pregnancy (nausea, vomiting), and quite often the vomiting proceeds for 16-17 weeks of pregnancy. Chronic pancreatitis does not produce essential effect on the course of second half of pregnancy and on delivery.

Effect of Pregnancy on the Course of Chronic Pancreatitis. Changes of hormonal status characteristic of pregnancy promote the development and exacerbation of pancreatitis. However, the most frequent reasons of development of pancreatitis during pregnancy are diseases of gallbladder, cholelithiasis (approximately in 55% of cases). Different infectious processes (acute pyelonephritis, thrombophlebitis), as well as overeating, alcoholism, application of anticoagulants are instrumental in development and exacerbation of pancreatitis in pregnancy.

Management of Pregnancy at Chronic Pancreatitis. At stable remission of chronic pancreatitis, in the absence of marked dysfunctions of pancreas and complications, such as diabetes mellitus, pregnancy in patients with chronic pancreatitis may be continued.

From the first weeks of pregnancy the woman with chronic pancreatitis should be under supervision of obstetrician-gynecologist and therapeutist in order at occurrence of first signs of exacerbation of disease the proper medicinal therapy was started.

At exacerbation of disease the obstetric management is the same as at acute pancreatitis.