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Table 1 Acute pancreatitis and HTG induced acute pancreatitis features in pregnant versus non-pregnant patients

From: Hypertriglyceridemia triggered acute pancreatitis in pregnancy – diagnostic approach, management and follow-up care

 Pregnant patientNON-pregnant patient
Acute pancreatitis
Incidence1/1000–10000 [3]10–44/100000 [54]
EtiologyGallstones 65%
Alcohol 5–10%
HTG (up to 14.4%) [9]
Gallstones (40–70%)
Alcohol (25–35%)
HTG (2–4%) [55]
HTG - Acute pancreatitis
PathogenesisPrimary (genetic) & Secondary (acquired) disorders of lipoprotein metabolism
+
Increased lipogenesis & Diminished lipolysis of pregnancy
Primary (genetic) & Secondary (acquired) disorders of lipoprotein metabolism
Clinical predictors- Unhealthy diet
- Metabolic syndrome
- Excessive weight gain in pregnancy.
- Unhealthy diet
- Metabolic syndrome
Mortality- Maternal (37%), fetal (60%) [56]
- 0% maternal and fetal loss rate reported recently but figures are poorer in low income settings
Overall 5–15%, higher for severe disease [57, 58]
Clinical presentation
HTG-AP
- multiparous (75%) [59]
- 3rd trimester of pregnancy (50%), early postpartum (38%)
- may be complicated by the onset of labor, obstetrical emergencies (placental abruption, eclampsia, HELLP syndrome, uterine rupture)
- generally younger than patients, with other etiologies;
- higher chance of systemic inflammatory response syndrome and cardiopulmonary and renal insufficiency;
Management guidelinesThere are no specific pregnancy related mentions in international guidelinesa- 2019 World Society of Emergency
Surgery guidelines for the management of severe acute pancreatitis [57]
- 2018 Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis [60]
SeverityHTG is an independent indicator of poor prognosis in AP. Elevated serum TG independently and proportionally correlate with persistent organ failure in AP patients, regardless of etiology [61].
Prophylactic measuresLifestyle adjustments
Niacin, omega-3 fatty acids
Discontinue fibrates/statins
Currently there are no guidelines for the management of thepregnant patient at risk for HTG-AP
Lifestyle adjustments
Niacin/Fibrates/ Statins
Initial managementFasting, bowel rest
Analgesics
Hydration & electrolite imbalace correction
Measures delayed if diagnostic uncertainty
Fasting, bowel rest
Analgesics
Hydration & electrolite imbalace correction
Lipid lowering therapiesNiacin, omega-3 fatty acids
Insulin/heparin infusion
Plasmapheresis
Antilipemics
Insulin/heparin infusion
Plasmapheresis
Obstetric decison makingEmergency termination of pregnancy
Vaginal delivery preferable
None
  1. a There are no currently available obstetric guidelines which tackle or mention the management of HTG-AP (or AP of other etiologies), nor is there any reference to the obstetric patient in currently available guidelines for the management of AP in the general population