Tuesday, November 14, 2006

Pregnancy and Pancreatitis

Pregancy and Pancreatitis:

The incidence of pancreatitis ranges from 1 in 1,066 live births to 1 in 3,333 pregnancies. The most common predisposing cause of pancreatic symptoms during pregnancy is cholelithiasis (i.e., gallstones that block the pancreatic duct). A second common scenario noted in pregnancy is hypertriglyceride-induced pancreatitis. This results from the increased estrogen effect of pregnancy and the familial tendency for some women toward high triglyceride levels. Drugs, specifically tetracycline and thiazides (not commonly used in pregnancy), as well as increased alcohol consumption, can also cause pancreatitis. Recently, pancreatitis has been linked to more than 800 mutations of the cystic fibrosis transmembrane conductance regular gene. Pancreatitis can be seen throughout pregnancy and when noted, is most likely to be secondary to cholelithiasis.

  • Signs and symptoms of acute pancreatitis:

.............1. usually include mid epigastric pain,

.............2. left upper quadrant pain radiating to the left flank,

.............3. anorexia,

.............4. nausea,

.............5. vomiting,

.............6. decreased bowel sounds,

.............7. low-grade fever, and

.............8. associated pulmonary findings 10% of the time (unknown cause). A pulse oximeter reading should be obtained. Pulmonary signs often include hypoxemia, which can lead to full-blown adult respiratory distress syndrome. Other symptoms may include nausea, vomiting, jaundice, abdominal tenderness, muscle rigidity, and hypocalcemia.

  • The most common misdiagnosis of pancreatitis in the first trimester is hyperemesis. Given this constellation of symptoms, it is critical to distinguish between hyperemesis gravidarum and pancreatitis when evaluating a woman in the first trimester of pregnancy. In women presenting with severe nausea and vomiting in the first trimester, consider obtaining amylase, lipase levels, and liver function tests, which when elevated are diagnostic for pancreatitis. In one study of 25 cases of pancreatitis, 11 cases were diagnosed in the first trimester.
  • Pancreatitis in pregnancy had been associated in the past with a high maternal death rate and fetal loss rate. However, more recent studies have found that these rates are declining due to earlier diagnosis and greater treatment options, which have improved management of pancreatic symptoms that can cause preterm labor. The relapse rate for gallstone-related pancreatitis is higher than for other causes—up to 70% with conservative treatment only.
  • Hyperlipidemia during pregnancy is the second most common cause of pancreatitis. Lipids and lipoprotein levels increase during pregnancy, as do triglyceride levels, which increase threefold peaking in the third trimester. An increase in cholesterol of 25% to 50% occurs primarily as a result of higher blood levels of estrogen.[34]. The level of triglycerides required to induce acute pancreatitis is between 750 and 1,000 mg/dL.[35] The total serum triglyceride level during pregnancy is usually less than 300 mg/dL. After delivery, triglyceride levels usually fall. Fifty percent of women with pancreatitis develop hypocalcemia secondary to diminished calcium in pregnancy, which worsens with pancreatitis.
  • Imaging of the pancreas can be performed by using ultrasound and computed tomography. Ultrasound is the imaging technique of choice for pregnant women because it can distinguish a normal appearing pancreas from one that is enlarged, and it can also identify gallstones.
  • Diagnostic blood tests include serum amylase and lipase, as well as triglyceride levels, calcium levels, and a complete blood count. Amylase levels in pregnancy range from 10 to 130 in some labs to 30 to 110 in others or even up to 150 to 160. These values vary depending on each laboratory, and the provider should consult their own laboratory norms. Lipase, another enzyme produced by the pancreas, has norms ranging from 4 to 57 and from 23 to 208 (these also vary depending on laboratory). Amylase levels can also rise with cholecystitis, bowel obstruction, and ruptured ectopic, as well as other conditions. In one study, an elevated amylase level had a diagnostic sensitivity of 81%, and adding lipase increased the sensitivity to 94%. In another study, the mean amylase levels in a selected group of persons presenting with pancreatitis was 1,400 IU/L. Amylase levels do not correlate with disease severity. Elevated serum lipase levels remain elevated longer than amylase following an episode of pancreatitis.
  • Ranson developed criteria for classification of severity of acute pancreatitis based on non-pregnant persons. One set of criteria is used at the time of admission and another after the initial 48 hours. In persons with fewer than three prognostic signs, the risk of death or major complications is small. These criteria are often used as a guide when treating gravid women with pancreatitis as well.
  • Conservative medical management of pancreatitis includes:
  • .............1. intravenous fluids, nasogastric suctioning, total parenteral nutrition, use of analgesics and antispasmodics, fat restriction with total parenteral nutrition, and antibiotics. Lipoprotein apheresis and plasmapheresis are therapies known to lower serum triglyceride levels.

    .............2. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy are techniques used to treat gallstone-related pancreatitis. Again, fluoroscopy time during pregnancy is limited or omitted. Fetal shielding can be used in which a lead apron is placed over the maternal abdomen, and fluoroscopy is limited to less than one minute. Increased serum amylase levels are often elevated transiently following this procedure.

    .............3. A number of studies and case reports document the use of endoscopic retrograde cholangiopancreatography in pregnancy. Jamidar et al. details 23 pregnant women with pancreatic-biliary disease, treated at several different medical centers, who underwent diagnostic and therapeutic endoscopic retrograde cholangiopancreatography. Prophylactic antibiotics were administered, and the abdomen was shielded with a lead apron. Fluoroscopy time was kept under 1 minute. Common bile stones were found in 14 of the 23 women. There was one spontaneous abortion in the second trimester, occurring 3 months after endoscopic retrograde cholangiopancreatography and a spontaneous abortion after a third stent replacement occurred in another woman. Second trimester is thought to be the ideal time for endoscopic retrograde cholangiopancreatography to avoid any possible teratogenic effects of radiation.

    Barthel et al. present three case reports using endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Their limited experience and outcomes in these three women noted only one postprocedure episode of pancreatitis lasting 48 hours. Nesbitt et al. has also documented three cases. All three pregnant women experienced rapid resolution of symptoms and successful pregnancy outcomes.

    Key Points in Triage for Pancreatitis
    ...1. Most cases of pancreatitis in pregnancy are gallstone-related.
    ...2. Serum amylase, lipase levels, and triglyceride levels (especially if no gallstones present) are diagnostic for pancreatitis.
    ...3. Ranson's criteria are used to judge severity and recovery progress in pregnant women.
    ...4. Pulmonary findings are present 10% of the time.
    ...5. Fiberoptic interventional techniques have altered clinical care.

    GALLSTONES and pancreatitis in pregnancy

    Pregnancy is associated with increased risk of gallstone formation. Gallstones are an important cause of pancreatitis in pregnancy. Cholecystectomy is the second most common nonobstetric surgical procedure in pregnancy after appendectomy.

    • Incidence: Thirty-one percent of women develop sludge during pregnancy, and 2% develop new gallstones. Risk is highest in the second or third trimester and postpartum.
    • Pathogenesis: The exact mechanism is not known. Possible factors are increased lithogenicity of bile, increased stasis of bile, and decreased gall bladder emptying.
    • Clinical features:
      ......1. Right upper quadrant pain Epigastric pain
      ....22. Fever
      ......3. Vomiting
      ......4. Jaundice
      ......5. Tenderness in right upper quadrant - May be difficult to elicit because of an enlarged uterus
      ......6. Pancreatitis

    Treatment: Severe biliary colic can be managed conservatively with:

    • hydration,
    • narcotics,
    • antibiotics, and
    • dietary modifications.
    • Endoscopic retrograde cholangiopancreatography may be needed in cases of cholangitis, biliary obstruction, or pancreatitis.
    • Cholecystectomy is indicated in the presence of persistent or recurrent symptoms, significant nutritional compromise, and weight loss. This is required in fewer than 0.1% of cases. The second trimester is the best period for surgery.

    Diabetes mellitus is a chronic disease in which the body is unable to metabolize sugar properly, usually due to the pancreas' inability to produce enough insulin. The result is elevated levels of sugar in the blood and urine. Type 2 diabetes, the most common form, usually occurs later in adulthood and can often be controlled by diet alone or by oral medication. Type 1 diabetes, which often begins in childhood, is less common and more severe, requiring close monitoring of the diet and insulin injections to control blood sugar. Serious disease of the kidneys, eyes, heart, and blood vessels is more common with Type 1 diabetes, particularly when the disorder is not kept under complete control.

    • During pregnancy, the placenta produces several hormones that counteract the effects of insulin. The body must therefore produce more insulin -- as much as 30 percent more -- to do the required job. Under normal circumstances, the pancreas is easily able to keep up. In some women who are destined to become diabetic later in life, however, their bodies cannot meet the increased requirements of pregnancy, and they develop diabetes during pregnancy. Called gestational diabetes, this common disorder occurs in 1-3 percent of all pregnancies. These women are usually treated by diet and are monitored more carefully toward the end of pregnancy. Their outlook for having a healthy baby is excellent. After delivery, blood-sugar levels usually return to normal, but these women are at increased risk of developing diabetes later in life.
    • In women who are already diabetic, the control of blood sugar is made more difficult, because of the placental hormones and the nutritional needs of the fetus. Doctors once believed the conditions of women with kidney or eye disease as a result of diabetes worsened when they became pregnant. Now, the medical evidence suggests that pregnancy does not appear to have any long-term impact on such complications. In the rare woman who has heart disease associated with diabetes, the risk to her is so great that pregnancy is usually contraindicated.
    • You should be aware that birth defects are more common in diabetic pregnancies. In mild diabetics, the increased blood-sugar level crosses the placenta and raises the blood-sugar and insulin levels in the fetus, sometimes leading to very large babies. With large infants, the risk of trauma during birth is increased, as is the possible need for cesarean section. Blood- sugar problems can also occur in the infants shortly after birth. For example, their pancreas may overreact and produce more insulin than necessary, causing low blood-sugar levels. In more severe diabetics, damage to blood vessels can lead to inadequate placental function, resulting in poor fetal growth and stillbirth.
    • Despite the risks, the outlook is encouraging. With the current level of understanding and medical management, many of the risks and complications of diabetes can be greatly reduced, making preconception evaluation and counseling extremely important. Most of the birth defects associated with diabetes -- typically involving the heart and the spinal canal -- happen in the first five to eight weeks of fetal development. There is reliable evidence that careful control of blood sugar before conceiving and during the early weeks of pregnancy can greatly reduce, but not eliminate, the risk of birth defects. Taking prenatal vitamins with folic acid before conception may also help. Much more careful control than usual of diet and blood sugar throughout the pregnancy -- checking glucose levels several times daily to ensure a normal level -- helps reduce the risk of birth defects, large infants, and metabolic problems after birth.
    • Careful monitoring of the fetus with non-stress tests and ultrasound may also be necessary, and early delivery by induction or cesarean section is sometimes required. Identification and early treatment of infections is also important, since diabetics are more susceptible. Urinary tract infections, for example, may be a possible cause of premature labor. A general medical examination that includes the eyes, kidney, heart, and blood pressure is often necessary to evaluate your current condition, assess risks, and plan for your pregnancy. Pregnancy in a diabetic is considered high risk and may require limitation of activity and possibly ceasing work and being hospitalized.
    • The management of a diabetic pregnancy is clearly a team effort that involves the patient, the obstetrician or perinatologist, and the internist or endocrinologist. The team may also include a nutritionist, ophthalmologist (eye specialist), nephrologist (kidney specialist), cardiologist (heart specialist), or neonatologist (newborn specialist). As always, a healthy life-style, including achieving proper weight, following a nutritious diet, exercising, and avoiding alcohol and tobacco will help to give you the healthiest pregnancy possible.

    Safety of ERCP during pregnancy.
    Am J Gastroenterol. 2003; 98(2):308-11 (ISSN: 0002-9270)
    Tham TC; Vandervoort J; Wong RC; Montes H; Roston AD; Slivka A; Ferrari AP; Lichtenstein DR; Van Dam J; Nawfel RD; Soetikno R; Carr-Locke DLDivision of Gastroenterology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

    • OBJECTIVES: There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy.
    • METHODS: We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential.
    • RESULTS: The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose. CONCLUSIONS: ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

    Pregnancy and Childbirth

    Blame that Morning Sickness on Your Ancient Ancestors

    By: Karen Barrow

    Medically Reviewed On: September 01, 2006

    Despite its name, morning sickness—nausea and vomiting that is often one of the first symptoms of pregnancy—can happen at any time of the day. Up to 90 percent of pregnant women experience this less-than-pleasant side effect, yet scientists are only beginning to understand why running to the bathroom and saltines are a rite-of-passage for moms-to-be.

    Now, new research has shed some light onto morning sickness, and its roots lie in evolution.

    Researchers from the University of Liverpool suggest that morning sickness may have developed over time to protect pregnant women from potentially dangerous food or from eating too much unhealthy food.

    To test the theory, Dr. Craig Roberts and colleagues looked at the rates of morning sickness in different regions of the world and the typical diet of the population in that region. Ultimately, not only was "high overall food intake correlated with pregnancy sickness, but also the amount of certain types of food predicted the incidence of pregnancy sickness," he said.

    In other words, it's not just the amount of food you eat, but the type of food that seems to influence the degree of your morning sickness.

    To further look at this phenomenon, Roberts then compared only those women from Europe and North America and pinpointed the types of foods that seem to trigger the symptoms of morning sickness: sugars, alcohol and meat. Additionally, women who ate high amounts of cereal-based products tended to have lower-than-average rates of nausea and vomiting during pregnancy.

    The researchers theorize that women's bodies have slowly developed an aversion to sugar, alcohol and meat because all of these foods contain high levels of toxins that could be potentially dangerous to a mother and her child. Cereals, on the other hand, tend to contain a very low level of toxins, so they could possibly be safer for a woman to eat. Remember, however, that these toxins may not pose the same hazard now that they did in the days of ancient man.

    "While there may be no particular harm in eating, say, meat, now that we have refrigeration and 'best before' dates," said Roberts,"our bodies may be pre-programmed by evolution to avoid these particular foodstuffs in the first trimester."

    If there is a particular food that seems to make your morning sickness that much worse, it may be acceptable to avoid it, but be sure to consult with your doctor before changing your diet. That way, you can be sure that you and your baby are still getting all of the vitamins and nutrients you need.


    Article - Eating for Two: Before, During and After a Pregnancy
    Article - Ensuring Your Baby's Health: Pregnancy Screening Tests

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