Maternal and fetal death associated with acute pancreatitis during pregnancy: A case report

Abstract

BACKGROUND

Acute pancreatitis in pregnancy is a rare but serious condition that can lead to high maternal mortality and fetal loss. Instances of pregnancy complicated by severe acute pancreatitis, particularly with subsequent respiratory and cardiac arrest, are rarely reported.

CASE SUMMARY

We present the case of a 35-year-old woman, at 36 + 5 weeks of gestation, who presented with paroxysmal epigastric pain accompanied by low back pain, nausea, and vomiting. According to the clinical symptoms, B-ultrasound imaging and biochemical indicators, the patient was diagnosed with acute pancreatitis and initially managed conservatively. However, 3 hours after admission, the patient experienced respiratory and cardiac arrest, and the fetus died. In this case, the adverse outcomes occurred due to the lack of aggressive fluid resuscitation and an active surgical intervention.

CONCLUSION

Implementing aggressive fluid resuscitation to sustain tissue perfusion, alongside the proactive evaluation of pharmacological agents that suppress gastric acid secretion and inhibit pancreatic enzyme activity, may be beneficial in mitigating the risk of a severely adverse prognosis. Effective management of acute pancreatitis during pregnancy requires careful timing of surgical intervention, a thorough evaluation of the risks and benefits regarding the continuation or termination of pregnancy, and a focus on safeguarding both maternal and fetal health.

Key Words: Severe acute pancreatitis; Pregnancy; Cardiac arrest; Fetal death; Case report

Core Tip: Acute pancreatitis during pregnancy is an infrequent occurrence that can be linked to significant maternal and fetal mortality. The incidence of pregnancy complicated by severe acute pancreatitis accompanied by respiratory and cardiac arrest is particularly rare. This case report aims to examine the complex decision-making process involved in evaluating surgical interventions and determining the continuation or termination of pregnancy, with an emphasis on safeguarding the health of both the mother and fetus. Proactive and intensive management is crucial to prevent potentially catastrophic outcomes.

INTRODUCTION

Severe acute pancreatitis is a serious and complex condition characterized by rapid progression, numerous complications, and a high mortality rate, which ranges from 20% to 50%[1]. Pregnancy-associated acute pancreatitis has an incidence rate of 22.7%[2]. Acute severe pancreatitis during pregnancy, especially when complicated by respiratory arrest, is a rare occurrence. Furthermore, placental prolactin, produced by syncytiotrophoblasts, exerts a significant lipolytic effect, releasing large amounts of free fatty acids from triglycerides. These fatty acids can cause acute fatty infiltration of pancreatic cells and acute fatty embolization of the small pancreatic arteries and microcirculation, thereby exacerbating the severity of acute pancreatitis during pregnancy[3]. Acute pancreatitis in pregnancy is not limited to localized pancreatic inflammation but is often associated with organ dysfunction, including respiratory and cardiac failure. Early mortality is typically a result of multiple organ failure[4]. This article presents a case of maternal and fetal death due to acute pancreatitis in the third trimester and discusses its etiology, diagnosis, treatment, and prognosis.

CASE PRESENTATION

Chief complaints

A 35-year-old female at 36 weeks and 5 days of gestation presented with paroxysmal upper abdominal pain, occurring 4 hours postprandially, along with nausea and vomiting of gastric contents.

History of present illness

The patient had no significant medical history.

Physical examination

Her vital signs upon admission were as follows: Temperature 36.6 °C, heart rate 142 beats per minute (bpm), respiratory rate 20 breaths per minute, and blood pressure 88/50 mmHg. The patient’s height was 155 cm, and her weight was 71 kg. Obstetric examination revealed a uterine height of 31 cm, an abdominal circumference of 102 cm, and a fetal heart rate of 112 bpm, with irregular, weak uterine contractions. Cervical dilation was noted at 1 cm, with the fetal presentation at -3 station and intact fetal membranes.

Laboratory examinations

Relevant biochemical indicators are presented in Table 1.

Table 1 Biochemical indicators.

Item	Result	Unit	Reference range
Total bilirubin	4.8	umol/L	0-20.5
Direct bilirubin	1.3	umol/L	0-6.8
Indirect bilirubin	3.5	μmol/L	0-17.0
Total protein	65.2	g/L	62.0-80.0
Albumin	37.0	g/L	35.0-55.0
Globulin	28.2	g/L	20.0-45.0
Albumin/globulin ratio	1.31		1.00-2.50
Alanine aminotransferase	19	U/L	0-31
Aspartate aminotransferase	26	U/L	0-31
Alkaline phosphatase	203↑	U/L	45-150
Gamma-glutamyl transferase	9	U/L	7-32
Prealbumin	240.0	mg/L	200.0-400.0
Total bile acids	3.4	umol/L	0-12.0
Choline esterase	6579	U/L	4000-12600
Potassium	4.39	mmol/L	3.50-5.30
Sodium	139.3	mmol/L	135.0-148.0
Chloride	106.5	mmol/L	96.0-108.0
Calcium	2.41	mmol/L	2.10-2.60
Urea	5.69	mmol/L	1.708.30
Creatinine	103.0	umol/L	17.7-107.0
Serum amylase	87↑	U/L	0-82
Pancreatic amylase	54↑	U/L	0-53
Lipase	93↑	U/L	6-51
Glucose	15.09↑	mmol/L	3.80-6.10
Creatine kinase	326↑	U/L	0-200
Creatine kinase-MB	32↑	U/L	0-24
Lactate dehydrogenase	241	U/L	155-300

Imaging examinations

Obstetric color Doppler ultrasound revealed a single live fetus in a cephalic presentation, specifically in the occipital right anterior position. The biparietal diameter was approximately 9.0 cm, and the abdominal circumference measured 34.2 cm. A potential nuchal cord was suspected.

B-ultrasound imaging showed enlargement of the maternal pancreatic body, with changes in parenchymal echogenicity and peritoneal effusion. Irregular hypoechoic fluid collections were identified in the perihepatic region, hepatorenal space, and lower abdominal intestinal space, with the maximum fluid level measuring approximately 5.3 cm.

MULTIDISCIPLINARY EXPERT CONSULTATION

Acute pancreatitis was considered by hepatobiliary surgeons and sonographers.

FINAL DIAGNOSIS

The diagnostic considerations included: (1) Intrauterine live fetus with a threatened preterm birth at 36 weeks and 5 days of gestation; (2) Suspected acute pancreatitis during pregnancy; (3) Pregnancy potentially complicated by acute gastroenteritis; and (4) Pregnancy with concurrent obesity.

TREATMENT

Upon admission, the patient was placed on fasting and gastrointestinal decompression. The patient was advised to refrain from oral intake and received treatment with ceftazidime for infection control and phloroglucinol for spasmolytic relief.

Two hours following the initial assessment, the patient developed orthopnea and was unable to assume a supine position, although her upper abdominal pain had slightly improved. Electrocardiogram monitoring revealed the following vital signs: Body temperature 36.6 °C, heart rate 142 bpm minute, respiratory rate 23 breaths per minute, blood pressure 107/73 mmHg, and oxygen saturation at 97%.

Three hours later, the patient reported increased abdominal pain, with a temperature of 36.6 °C, a pulse of 142 bpm, a respiratory rate of 20 breaths per minute, and a blood pressure of 100/60 mmHg. Tenderness was noted in the upper abdomen and subxiphoid area, with regular contractions and a fetal heart rate of 108 bpm. The cervix was 2 cm dilated, with the fetal presentation at position -3, and the membranes were intact. The patient was assessed as being in premature labor and was moved to the labor room for monitoring. Suddenly, the patient experienced difficulty breathing and jaw stiffness, with a pulse of 132 bpm, a respiratory rate of 25 bpm, undetectable blood pressure, and oxygen saturation of 60%. Cardiopulmonary resuscitation (CPR) and intubation were performed during the first episode of cardiac and respiratory arrest, which successfully restored breathing and heart rate to 62 bpm, respiratory rate to 30 bpm, blood pressure to 90/50 mmHg, and oxygen saturation to 90%. Thirty minutes later, the patient suffered a second arrest. Following the second rescue, the patient’s heart rate returned, but the pupils were dilated to 4 mm, with no light reflex. Ultrasound revealed necrotizing pancreatitis, maternal ascites, and a single stillborn fetus in a head-down position. Abdominal puncture suggested hemorrhage, as no blood clotting was observed. The partial thromboplastin time was 210.5 seconds, and the thrombin time was unmeasurable (Table 2).

Table 2 Coagulation parameters.

Item	Results	Unit	Standard range display
Partial thromboplastin time	210.5↑	sec	24.0–39.0
Thrombin time	None	sec	14.0–21.0
Prothrombin time	17.6↑	sec	11.0–13.0
Prothrombin activity	45↓	%	70–130
International normalized ratio	1.48		0.80–1.50
Fibrinogen	298.00	mg/dL	200.00–400.00

OUTCOME AND FOLLOW-UP

The unconscious patient intubated with a tracheal tube and central venous catheter, received anesthesia with analgesics and muscle relaxants prior to surgery. During the procedure, significant bleeding and abnormal coagulation necessitated the administration of autologous blood transfusion to stabilize vital signs. Despite efforts including CPR, the patient was transferred to the intensive care unit (ICU) for advanced life support and monitoring. After 1 hour of ICU efforts, with no recovery of breathing or heartbeat, the family decided to cease further attempts and declared clinical death.

DISCUSSION

Severe acute pancreatitis is a critical condition characterized by rapid progression and a high mortality rate, which can range from 20% to 50%[5]. Although acute pancreatitis in pregnancy is rare, with an incidence of approximately 1 in 1000 to 1 in 10000 pregnancies[6], it can lead to severe maternal and fetal complications, including preterm labor, maternal organ failure, and death[7]. This case is particularly severe, as the patient experienced cardiopulmonary arrest, a rare and life-threatening complication.

The pathophysiology of pancreatitis during pregnancy is multifactorial and complex. Hormonal changes, such as elevated levels of placental lactogen, can lead to hypertriglyceridemia, a known risk factor for pancreatitis[8]. Furthermore, the physiological hypercoagulable state of pregnancy may contribute to microvascular thrombosis, exacerbating the condition[9]. The ingestion of certain foods, such as wild mushrooms and cicadas, as reported in this case, could potentially trigger pancreatitis due to toxic or allergic reactions[10]. Differentiating the clinical presentation of pancreatitis from other pregnancy-related conditions, such as preeclampsia or acute fatty liver, can be challenging[11]. Diagnosis relies on a high index of suspicion, supported by imaging studies and laboratory markers, such as serum amylase and lipase levels[12]. In this case, ultrasound imaging was crucial in detecting pancreatic enlargement and confirming the diagnosis.

Management of acute pancreatitis in pregnancy requires a multidisciplinary approach involving obstetricians, gastroenterologists, and intensive care specialists. Initial management typically includes bowel rest, fluid resuscitation, and analgesia[13]. In severe cases, antibiotics may be indicated to prevent infection of pancreatic necrosis[14]. These measures could potentially have mitigated the risk of an adverse prognosis. The occurrence of arrest in the context of pancreatitis is associated with high mortality and is often indicative of severe systemic inflammation and multiple organ dysfunction syndrome[15]. The use of extracorporeal membrane oxygenation and continuous renal replacement therapy has been reported as supportive interventions in such critical cases[16]. In this case, the patient was treated with cefoperazone, an antibiotic, and metoclopramide, an antiemetic, following established guidelines. However, despite aggressive management, the patient’s condition deteriorated rapidly, leading to cardiopulmonary arrest. We analyzed the rapid deterioration of acute pancreatitis attributed to suboptimal fluid resuscitation, inadequate maintenance of tissue perfusion, and insufficient consideration of pharmacological interventions that suppress gastric acid secretion and pancreatic enzyme activity.

The role of surgery in the management of acute pancreatitis during pregnancy remains controversial. While surgical intervention may be necessary in cases of infected pancreatic necrosis, the risks to the fetus must be carefully considered[17]. The patient’s condition did not stabilize in the case presented, and surgical intervention was not pursued. The prognosis of acute pancreatitis in pregnancy is influenced by multiple factors, including the severity of the disease, the presence of complications, and the timeliness of treatment[18]. Over the past decade, maternal mortality rates have decreased due to improvements in critical care and perinatal management[19]. However, fetal loss remains a significant risk, with preterm birth being one of the most concerning outcomes[20]. The key considerations in managing acute pancreatitis during pregnancy include accurately determining the timing of surgical intervention and navigating the complex relationship between surgical treatment for pancreatitis and decisions regarding the continuation or termination of pregnancy. In cases where termination is considered, the preservation of maternal life should take priority, while the condition of the fetus must also be carefully weighed. Pregnancy termination should be promptly considered under the following circumstances: (1) Full-term pregnancy complicated by acute pancreatitis; (2) In cases of severe acute pancreatitis, if paralytic ileus deteriorates after 24 to 48 hours of treatment, along with clear indications of abortion or preterm labor; and (3) Upon diagnosis of acute hemorrhagic necrotizing pancreatitis or hyperlipidemic pancreatitis, immediate termination of pregnancy is advised due to the heightened maternal and fetal mortality risks associated with these conditions. In this case, we analyze that a fetal heart rate decrease to 108 bpm indicates that it is inappropriate to transfer the pregnant to the labor room for delivery. Instead, an active cesarean section should be considered, as this intervention may positively influence fetal prognosis.

CONCLUSION

In conclusion, acute pancreatitis during pregnancy is a rare but life-threatening condition that requires prompt recognition and a multidisciplinary approach. The case discussed emphasizes the importance of a high index of suspicion for pancreatitis in pregnant patients presenting with abdominal pain and underscores the need for aggressive management to prevent catastrophic outcomes.

ACKNOWLEDGEMENTS

We thank the patient, her family, and the clinicians involved in this study.