Acute pancreatitis in pregnancy

Introduction to pregnancy with acute pancreatitis Acute pancreatitis is an acute chemical inflammation caused by the activation of pancreatic digestive enzymes on the pancreatic tissue itself. It is not only a local inflammatory lesion of the pancreas, but also a systemic disease involving multiple organs. Acute pancreatitis during pregnancy. Less common, but it is very harmful to mother and child. With the improvement of people's living standards and changes in diet structure, the incidence of this disease has increased in recent years. Generally, women are more likely than men, often associated with gallstones, and can occur at any stage of pregnancy, with more late pregnancy and puerperium. Severe acute necrotizing pancreatitis is an acute onset and a serious condition, which is one of the most dangerous digestive complications that threaten the life of mother and baby. basic knowledge The proportion of illness: 0.005% Susceptible population: pregnant women Mode of infection: non-infectious Complications: abortion, premature delivery

Pregnancy with acute pancreatitis

Affected by endocrine hormones

Increased ability to absorb fat in the intestine leads to hyperlipidemia. After overeating, the high-fat, high-protein diet increases bile and pancreatic secretion, but mechanically compresses the bile duct and pancreatic duct due to the enlarged uterus (especially in late pregnancy). The bile and pancreatic juice are blocked, and can enter the pancreas along the pancreatic duct, thereby activating the trypsinogen into trypsin. Under the action of various causes, the pancreas is self-dissolving and the pancreas is autolyzed. The pressure is increased, the pancreatic tissue is congested, edema, and exudation.

Proliferation of placental lactogen in the body

The triglyceride in serum is degraded, releasing a large amount of free fatty acids, causing acute fat infiltration of pancreatic cells, and causing acute fat embolism of pancreatic arterioles and microcirculation, causing pancreatic necrosis.

Biliary disease

There are many causes of pregnancy complicated with acute pancreatitis. In recent years, studies have shown that biliary tract diseases are the most common, accounting for about 50%, of which cholelithiasis accounts for 67% to 100%. Other causes may be accompanied by hyperemesis and increased mechanical compression of the uterus. Increased pancreatic duct pressure, pre-eclampsia of pregnancy-induced hypertension syndrome, long-term paralysis of pancreatic vessels, infection, hypercalcemia induced by hyperparathyroidism, application of thiazide diuretics and tetracycline, alcoholism, etc. In addition to the effects of neuroendocrine during pregnancy, biliary smooth muscle relaxation, Oddis sphincter spasm, pancreatic juice back into the pancreatic duct, trypsin is activated, pancreatic juice secretion increases, pancreatic duct pressure increases, pancreatic tissue hemorrhage and edema, more likely to cause pancreatitis, Abnormal lipid metabolism during pregnancy, triglyceride increased, serum lipid particles embolized pancreatic blood vessels, can cause acute pancreatitis, causing adverse consequences.

Pathogenesis

Anatomical and physiological changes in the digestive system due to changes in endocrine in the body during pregnancy:

1. The gallbladder volume increases during pregnancy, the tension is weakened, the cholestasis is concentrated, the cholesterol concentration is increased, and the soluble change of bile salts becomes one of the risk factors for the formation of gallstones.

2. Hyperplasia of parathyroid cells during pregnancy, causing elevated levels of serum parathyroid hormone, causing hypercalcemia and stimulating trypsin secretion, activating trypsin and increasing the chance of forming pancreatic duct stones, while parathyroid hormone has a pancreatic Direct toxicity.

3. Due to the influence of uterus enlargement, the clinical manifestations are often atypical, the diagnosis is prone to delay, resulting in a rapid increase in the condition, prone to metabolic acidosis, severe complications such as shock and vital organ failure endanger the mother and child life.

Different degrees of edema, hemorrhage and necrosis are the basic pathological changes of acute pancreatitis. According to the severity of the disease, pancreatitis is divided into acute edematous pancreatitis and acute hemorrhagic necrotizing pancreatitis.

Pregnancy with acute pancreatitis prevention

Preventive measures include removing the cause and avoiding incentives, such as abstinence, overeating, and hyperlipidemia. Cholelithiasis plays an important role in the pathogenesis of acute pancreatitis. Therefore, patients with cholelithiasis with a history of acute pancreatitis should be treated. Elective cholecystectomy and common bile duct exploration.

Pregnancy with complications of acute pancreatitis Complications, abortion, premature delivery

The uterus of pregnancy is stimulated by pancreatic necrosis and inflammatory exudate, causing abortion caused by uterine contractions. Premature birth, pancreatic inflammation, necrotic tissue and digestive enzymes enter the body through blood circulation and lymphatic vessels, which can cause blood circulation disorder in the uterus placenta, resulting in serious fetal Hypoxia or stillbirth.

Pregnancy with acute pancreatitis symptoms Common symptoms Upper abdominal pain Blood pressure drop Abdominal pain Bloating high fever Astragalus shock Peritoneal effusion Peritonitis Nausea

Due to the degree of disease, clinical manifestations such as symptoms and signs are quite different.

Abdominal pain

The main clinical symptoms of this disease, severe abdominal pain, from the upper abdomen, can also focus on the right upper abdomen or left upper abdomen, radiating to the back; involving the whole pancreas is a belt-like radiation pain to the lower back, often 12 to 48h after a full meal Inter-onset, pain can be different, persistent, eating can be aggravated, edema-type abdominal pain can be relieved after a few days, hemorrhagic necrotic disease develops rapidly, abdominal pain lasts for a long time and can cause total abdominal pain.

2. nausea and vomiting

Often accompanied by abdominal pain, vomiting is severe and frequent, spit out the contents of the stomach and duodenum, occasionally with coffee-like content, abdominal pain after vomiting is not alleviated.

3. Bloating

The above abdomen is the main, early is reflex intestinal paralysis, severe inflammation is caused by inflammatory stimulation, abdominal distension is more obvious during abdominal fluid accumulation, bowel sounds are weakened or disappeared, defecation, exhaustion stops, and bloody or purulent ascites may occur.

4. Peritonitis signs

In edematous pancreatitis, tenderness is limited to the upper abdomen, often no obvious muscle tension, elevated uterine fundus during pregnancy, relatively deep pancreatic position, so that the signs of peritonitis appear late and often not obvious, hemorrhagic necrotic pancreatitis tenderness is obvious Muscle tone and rebound tenderness, a wide range and extended to the whole abdomen.

5. Other

Initially, there is moderate fever, about 38 °C, combined with cholangitis can have chills, high fever, pancreatic necrosis with infection is one of the main symptoms of high fever; biliary pancreatitis can be seen jaundice; patients with severe pancreatitis can appear pulse Speed, blood pressure drop, hypovolemia and even shock; with acute lung failure, there are shortness of breath, difficulty and cyanosis (ARDS), but also mental symptoms, gastrointestinal bleeding (hematemesis and blood in the stool), severe pancreatitis more water Electrolyte and acid-base balance disorder and multiple organ failure, DIC, a small number of critically ill patients with blue-purple spots on the left and umbilical skin (Grey-Turner sign and Cullen sign).

Examination of pregnancy with acute pancreatitis

Blood, urine amylase

The serum amylase value generally begins to increase from 2 to 6 hours after the onset, peaks at 12 to 24 hours, and begins to decrease after 48 to 72 hours, lasting for 3 to 5 days. The normal value of the Somogyi method is 40 to 180 U. If the increase is >500 U, there is an early diagnosis. Significance, urinary amylase is generally 2 to 12 hours later than blood amylase, and slowly decreases after 1 to 2 weeks. The normal value of Winslow method is 8 to 32 U, which is clinically valuable than 250 U.

2. Serum lipase

After the obstruction of the pancreatic duct, the serum lipase can be increased, generally starting at 72h after the disease, lasting 7 to 10 days, the normal value of the Tietz method is 0.1-1.0kU/L, and in acute pancreatitis, 90% of patients can exceed this Value, especially for patients with advanced critical illness, when the amylase is reduced due to pancreatic destruction, the continuous increase in serum lipase is diagnostic.

3. Other acute pancreatitis serum trypsin

Amylase/creatinine clearance, white blood cell count, hematocrit, blood glucose, blood lipids, bilirubin, alkaline phosphatase, etc. can be increased.

Imaging examination: B-ultrasound can show the increase of pancreas volume, uneven structure, blurred boundary, bleeding, necrosis, thick and strong echo and silent band around the pancreas, foreign literature reports, 70% of acute pancreatitis in pregnancy Ultrasound has abnormalities, of which 56% are caused by multiple gallstones, 7% are cholestasis, 5% can be thickened by gallbladder wall, CT is enlarged, pancreas is enlarged, body tail is dominant, and there is obvious density reduction zone, small omentum Area, mesenteric vascular root and left kidney have different degrees of infiltration, X-ray, magnetic resonance, pancreaticobiliary or pancreatic angiography can also assist diagnosis if necessary.

Diagnosis and differential diagnosis of pregnancy complicated with acute pancreatitis

diagnosis

Diagnosis of acute pancreatitis during pregnancy is the same as non-pregnancy. Patients with any upper abdominal pain during pregnancy should consider the possibility of acute pancreatitis. According to clinical symptoms and signs, combined with blood, urine amylase abnormalities and imaging examinations Diagnosis of the disease.

It should be emphasized that the diagnosis of acute pancreatitis during pregnancy is more difficult than during pregnancy. About 1/3 of the cases are diagnosed in time, while another 1/3 are often misdiagnosed as hyperemesis, perforation of peptic ulcer, cholecystitis, hepatitis, and intestine. Obstruction and pregnancy-induced hypertension, etc., must be carefully identified.

Differential diagnosis

Acute pancreatitis with acute gastroenteritis, upper gastrointestinal ulcer perforation, acute cholecystitis, biliary colic, acute intestinal obstruction, severe pregnancy-induced hypertension, mesenteric vascular embolism, etc. and pregnancy complications, pregnancy with pancreatitis due to pancreas The location is deep, and the inflammatory exudate stimulation often induces contractions, making abdominal pain and uterine contraction pain difficult to distinguish. Obstetricians should pay attention to the difference between premature birth and labor symptoms; when the pancreatic juice involves the peritoneum, the mesentery leads to localized or diffuse peritonitis. Muscle tension, tenderness, and shock symptoms appear, which must be differentiated from early exfoliation of the placenta.

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