Perspectives in Medical Research

INTRODUCTION

Acute pancreatitis is an inflammatory disorder caused by premature activation of pancreatic digestive enzymes, leading to pancreatic autodigestion and systemic inflammatory response. During pregnancy, its reported incidence ranges from 1 in 1,000 to 1 in 5,000 pregnancies, making it an uncommon but clinically significant complication [1–3]. Most cases are attributed to gallstone disease or hypertriglyceridemia, while alcohol-related pancreatitis is less common in pregnant women ^[2, 4].

Although acute pancreatitis in pregnancy has been increasingly reported, acute exacerbation of underlying chronic pancreatitis remains rare, with limited published data guiding obstetric decision-making ^[4, 5]. Physiological changes of pregnancy, overlapping abdominal symptoms, and limitations on imaging modalities further complicate diagnosis and management [4–6]. We report a case of acute on chronic pancreatitis presenting in late pregnancy, emphasizing diagnostic considerations, multidisciplinary management, and rationale for planned early delivery.
 

CASE PRESENTATION

A 30-year-old woman, gravida 2 para 1 living 1, presented at 34 weeks and 4 days of gestation with left upper abdominal and loin pain radiating to the back. The pain had been intermittent for four months but had worsened significantly over the preceding 15 days. She reported one episode of non-projectile, yellowish vomiting eight days prior to admission. There was no history of fever, jaundice, urinary symptoms, or vaginal bleeding. Her obstetric history was notable for a previous lower-segment caesarean section performed for placenta previa, with an otherwise uncomplicated postoperative course. Four months before the current admission, she had been evaluated for similar abdominal pain and diagnosed with chronic pancreatitis on ultrasonography. She had received alternative ayurvedic treatment without subsequent gastroenterology follow-up.

On examination, the patient was conscious, oriented, and hemodynamically stable. Her body mass index was 20 kg/m², pulse rate 96 beats/min, blood pressure 100/70 mmHg, respiratory rate 16 breaths/min, and temperature was normal. Abdominal examination revealed a uniformly distended abdomen with a gravid uterus corresponding to 34 weeks. Tenderness was present in the epigastrium and left hypochondrium. Costovertebral angle tenderness was absent bilaterally. Bowel sounds were diminished but audible, and there were no signs of peritoneal irritation.

Laboratory investigations showed a normal hemogram (white blood cell count 7,200/µL; haemoglobin 11.4 g/dL; platelet count 2.4 × 10⁵/µL). Liver function tests were within normal limits (AST 28 IU/L, ALT 24 IU/L, alkaline phosphatase 65 IU/L, total bilirubin 0.6 mg/dL). Renal function tests were normal (serum creatinine 0.8 mg/dL, blood urea nitrogen 12 mg/dL). Serum electrolytes were within normal limits (sodium 138 mEq/L, potassium 4.2 mEq/L). Fasting blood glucose was 95 mg/dL, serum calcium 8.9 mg/dL, and lipid profile was normal (triglycerides 95 mg/dL).

Serum amylase was elevated to 495 U/L (reference range 25–125 U/L) and serum lipase to 789 U/L (reference range 13–60 U/L).

Obstetric ultrasonography revealed a single live intrauterine foetus at 34 weeks and 6 days with appropriate growth parameters (estimated fetal weight 2.1 kg), normal amniotic fluid volume, and no placental abnormalities. Abdominal ultrasonography demonstrated dilatation of the main pancreatic duct (approximately 6 mm), presence of an intraductal calculus, and mild pancreatic oedema without necrosis or peripancreatic collections, consistent with acute on chronic pancreatitis.
 

THERAPEUTIC INTERVENTION

The patient was admitted and managed conservatively with bowel rest, intravenous Ringer’s lactate at 125 mL/hour, paracetamol for analgesia with opioids for breakthrough pain, and metoclopramide for nausea. Pancreatic enzyme supplementation was initiated, and blood glucose levels were monitored every four hours. Continuous cardiotocographic monitoring was performed.

By the third hospital day, the patient showed partial clinical improvement. Repeat laboratory investigations demonstrated a decline in pancreatic enzyme levels, with serum amylase decreasing to 320 U/L and serum lipase to 450 U/L, while renal and electrolyte parameters remained stable. Despite improvement, abdominal pain persisted intermittently.
 

DECISION-MAKING AND FOLLOW-UP

Given incomplete symptom resolution, advanced gestational age, and concern that the gravid uterus was contributing to ongoing pancreatic irritation, a multidisciplinary team involving obstetrics, maternal–fetal medicine, gastroenterology, anesthesia, and neonatology reviewed the case. Considering fetal maturity and potential maternal risks of continued pregnancy, planned delivery was recommended after informed consent.

Two doses of intramuscular betamethasone (12 mg, 24 hours apart) were administered. An elective repeat caesarean section was performed at 34 weeks and 6 days under spinal anesthesia. Intraoperatively, the pancreas appeared mildly oedematous without evidence of necrosis or abscess. A live female infant weighing 2.6 kg was delivered with Apgar scores of 8 and 9 at one and five minutes, respectively.

Postoperative recovery was uneventful. Oral intake was gradually resumed, and abdominal pain resolved completely. The patient was discharged on postoperative day 8. At two-week follow-up, she was asymptomatic with normal serum amylase (78 U/L) and lipase (45 U/L). The neonate remained well and was discharged after routine observation.
 

DISCUSSION

This case illustrates acute exacerbation of chronic pancreatitis during late pregnancy, a scenario infrequently described in published literature. Most Indian and Asian series report acute pancreatitis during pregnancy without documented underlying chronic pancreatic disease ^[1, 7-10]. The presence of ductal dilatation and intraductal calculus on ultrasonography in our patient confirmed chronic pathology, distinguishing this case from typical acute presentations.

The clinical presentation and enzyme levels in our patient were comparable to reported Asian case series, where serum amylase and lipase values show wide variability and do not consistently correlate with disease severity ^[7-9, 11]. The favourable biochemical response within 72 hours suggested mild to moderate disease, supporting initial conservative management in line with guideline recommendations ^[5, 6].

The timing of delivery in pancreatitis complicating pregnancy remains individualized. While conservative management is preferred, several reports suggest that delivery in late gestation may facilitate maternal recovery when symptoms persist despite adequate therapy ^[8, 9, 12]. In our case, partial response, mechanical effects of advanced pregnancy, and fetal maturity justified planned caesarean delivery, resulting in excellent maternal and neonatal outcomes.

Long-term follow-up is essential in patients with chronic pancreatitis, given the risk of recurrence, pancreatic insufficiency, and future pregnancy complications. Early gastroenterology follow-up was therefore arranged for definitive evaluation and counselling.
 

CONCLUSION

This case demonstrates that acute exacerbation of chronic pancreatitis can occur in late pregnancy and may require individualized management. While conservative therapy remains the initial approach, planned delivery in selected advanced-gestation cases may facilitate maternal recovery with favourable neonatal outcome. Multidisciplinary involvement and close follow-up are essential.