Post-partum pancreatitis.PR Pai, HK Shah, AB Samsi
Dept. of General Surgery, Seth GS Medical College, Bombay, Maharashtra.
Acute pancreatitis in pregnancy and post-partum period, rarely encountered in surgical practice, can have a lethal effect on the mother and the foetus. We report here a case of a 35 year old tertigravida who presented with high grade fever, abdominal pain with distension, tachycardia and tachypnoea. Chest examination and X-rays were suggestive of pneumonia. The abdomen was tense and tender. Peristalsis was absent. Ultrasound revealed presence of fluid in the abdominal cavity which on paracentesis was found to contain Gram positive cocci. Fluid amylase levels were high. On exploratory laparotomy, haemorrhagic oedematous pancreatitis was noticed. The patient expired on the 2nd post operative day.
Keywords: Acute Disease, Adult, Case Report, Female, Gram-Positive Bacterial Infections, Gram-Positive Cocci, Human, Pancreatitis, diagnosis,microbiology,surgery,Puerperal Infection,
Pancreatitis related to pregnancy occurs either during pregnancy or within six weeks of delivery. Its variable presentations, ranging from benign to classic to catastrophic, make diagnosis possible only with a high index of suspicion. For a favourable outcome, correct and early treatment is essential. This entity, first described in 1818 by Schmitt in a 30-year-old multigravida, is usually associated with gall-stone disease.
A 35-year-old tertigravida, presented 9 days post delivery (FTND), with a 5 days history of high grade fever, productive cough, upper abdominal pain with distension, nausea and diarrhoea. There was no other positive history.
On admission, she was dehydrated, pale and had tachycardia (1 40/min), tachypnoea (40/min) and a BP of 100/70 mm of Hg. Chest examination revealed decreased air entry bilaterally with crepitiations. Abdominal examination revealed a tense tender abdomen with absence of peristaltic sounds. Per rectal and per vaginal examinations were normal.
Chest X-rays confirmed the presence of pneumonia. Abdominal X- rays showed only dilated bowel loops. An emergency ultrasound showed dilated bowel loops with tree gas under the diaphragm and the presence of free fluid. Other organs were normal. Abdominal paracentesis revealed non-foul smelling fluid which showed pus cells and Gram positive cocci. Serum arnylase was 55 SI units (normal upto 100 SI units), and fluid arnylase was 750 SI units.
A decision to explore the patient was taken in view of the sonographic findings and a positive abdominal paracentesis. The patient was explored under local anaesthesia. Exploratory findings included saponification of the greater omental fat, haemorrhagic, oedematous pancreas with minimal free fluid and dilated bowel loops. There was no evidence of pus or perforation.
The patient had a cardiac arrest during surgery, was intubated and resuscitated. She was maintained on a ventilator in the intensive care unit.
Post- operatively, the patient maintained vital parameters for 24 hours and succumbed on the 2nd post-operative day. The post- mortem findings showed an edematous, haemorrhagic pancreas with normal liver, gall bladder, spleen and uterus. In addition, renal calculus disease and bilateral bronchopneumonia existed.
A review of the literature by Langmade and Edmondson in 1951 mentions symptomatology of pancreatitis in pregnancy described by Schmitt in 1818 and Lawerence in 1838 and presents 53 cases of pancreatitis in pregnancy. Walker and Diddle found a varying incidence from 1 in 3799 cases to 1 in 11, 467 cases.
An attack of pancreatitis is seen more often in a primigravida in the third decade of life. Though reported commonly in the 16-29th week of pregnancy, an attack during puerperium has been seen to occur in 73% of cases. This phenomenon is attributed to the return to normal levels of serum amylase, which are lowered in early pregnancy.
Walker and Diddle divided aetiological factors into four categories as follows:
1. Mechanical: (a) reflux of GI contents, (b) obstruction -cholelithiasisl,,,, as a result of increased cholesterol in pregnancy and formation of cholesterol stones.
2. Endocrine or metabolic: Increased progesterone in pregnancy causes (a) increased pancreatic secretion with increased lipase and trypsin concentrations. This was compared to attacks of acute pancreatitis occurring after a large meal when pancreatic secretions are at a high level and (b) hypotonia in duct musculature and increased tone of Sphincter of Oddi More Details. This was correlated with the occurrence of pancreatitis in 5 out of 8 patients in the 6th to 29th week of pregnancy when progesterone levels are highest. All the three patients without cholelithiasis referred to previously in Joupilla et al study belonged in this group.
3. Inflammatory or immunological: as a result of immunologic interaction between mother and child.
4. Toxic reaction to medications: due to thiazides - the diuretic used in pregnancy induced hypertension.
The low amylase values seen in our case are probably because more than 72 hours had already elapsed since the onset of the disease. By this time, though serum levels may be low, fluid amylase values remain high which correlates well with the value of fluid amylase in our case. The treatment of pancreatitis in pregnancy should be conservative as far as possible with great attention being given to rest to pancreas, correction of fluid and electrolyte imbalance with adequate crystalloid and colloid administration and care of the micro-circulation. Surgical drainage plays a role in reducing the load of toxic materials by draining the peritoneal fluid. Joupilla et al have quoted a maternal mortality rate of 5 to 15%.
We wish to thank Dr (Mrs) PM Pai, the Dean, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, for allowing us to present the data.