A 38-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the emergency department due to severe epigastric pain that started 6 hours ago. The pain began suddenly, is constant, and radiates to her back. She also has associated nausea and has had multiple episodes of vomiting. The patient has a history of hypertriglyceridemia, and her fibrate medication was discontinued at her initial prenatal visit. Her only current medication is a prenatal vitamin. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 134/82 mm Hg, pulse is 92/min, and respirations are 18/min. Fetal heart tones are 155/min. The abdomen is tender over the epigastric region; there is no rebound or guarding. Bowels sounds are normal. The uterus is nontender and has no palpable contractions. Laboratory results are as follows: A right upper quadrant ultrasound reveals no biliary sludge or dilation of the biliary tree. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the emergency department due to severe epigastric pain that started 6 hours ago.  The pain began suddenly, is constant, and radiates to her back.  She also has associated nausea and has had multiple episodes of vomiting.  The patient has a history of hypertriglyceridemia, and her fibrate medication was discontinued at her initial prenatal visit.  Her only current medication is a prenatal vitamin.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 134/82 mm Hg, pulse is 92/min, and respirations are 18/min.  Fetal heart tones are 155/min.  The abdomen is tender over the epigastric region; there is no rebound or guarding.  Bowels sounds are normal.  The uterus is nontender and has no palpable contractions.  Laboratory results are as follows:  A right upper quadrant ultrasound reveals no biliary sludge or dilation of the biliary tree.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d3d7_454a_bc81_6f3266ab02a2_MD0003_00 This patient at 30 weeks gestation has severe epigastric pain radiating to the back and elevated lipase (>3 times normal), consistent with acute pancreatitis (AP). The most common causes of AP are alcohol use and gallstones. Although pregnancy increases the risk for gallstones (progesterone-related decreased gallbladder motility), this patient has a normal right upper quadrant ultrasound (eg, no biliary sludge, no dilation of the biliary tree). After alcohol and gallstones have been excluded, other less common causes of AP (eg, hypercalcemia, hypertriglyceridemia) should be explored. Triglyceride levels typically increase two- to four-fold in pregnancy, particularly in the third trimester (increased triglyceride-rich lipoprotein production and decreased lipoprotein lipase activity). In this patient with hypertriglyceridemia who discontinued fibrate therapy in pregnancy, this effect is likely compounded. A lipid panel showing a triglyceride level >1000 mg/dL is required for diagnosis and has implications on patient management. In addition to intravenous fluid therapy and pain control (used in any case of AP), management of triglyceride-induced pancreatitis may include insulin infusion (limits fatty-acid release from adipocytes) or apheresis (removes triglyceride-rich plasma). AP in pregnancy is associated with significant maternal and fetal morbidity (eg, sepsis, preterm delivery, intrauterine fetal demise) and requires hospitalization. (Choice A) Uncomplicated AP is an inflammatory process that does not benefit from antibiotics. Antibiotics are used for infected pancreatic necrosis or extrapancreatic infection, which typically develop days following AP onset and are unlikely in this afebrile, hemodynamically stable patient. (Choice B) AP can be diagnosed in the presence of 2 of 3 classic features: classic symptoms (eg, severe epigastric pain radiating to the back); elevated amylase/lipase; or characteristic imaging findings. This patient with classic symptoms and laboratory findings does not require a CT scan, particularly given that she is pregnant and that imaging would not change management. If her condition worsens (eg, hemodynamic decompensation, persistent fevers), imaging may be performed to exclude complications (eg, infected necrosis) or other serious processes. (Choice C) Endoscopic retrograde cholangiopancreatography is used to evaluate choledocholithiasis, which can cause biliary pancreatitis. Although patients with choledocholithiasis sometimes have no biliary tree dilation on ultrasound, they typically have biliary sludge, residual gallstones, and elevated aminotransferase levels (>150 U/L). (Choice E) Preeclampsia (eg, elevated urine protein/creatinine ratio) can present with epigastric pain but would cause hypertension (ie, systolic ≥140 mm Hg, diastolic ≥90 mm Hg). Educational objective: Pregnant patients, particularly those with a history of hypertriglyceridemia, are at increased risk for triglyceride-induced pancreatitis. A serum lipid panel can confirm hypertriglyceridemia as the underlying etiology. References: Hypertriglyceridemia triggered acute pancreatitis in pregnancy - diagnostic approach, management and follow-up care. (http://www.ncbi.nlm.nih.gov/pubmed/31901241) Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25072837) Presentation and management of acute hypertriglyceridemic pancreatitis in pregnancy: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/27512482)

A 38-Year-Old Woman, Gravida 1 Para 0, at 30 Weeks