Analysis of a case of severe pancreatitis complicated with preeclampsia

Abstract

Preeclampsia combined with pancreatitis is a rare condition in pregnant and postpartum women, potentially leading to severe complications. Severe pancreatitis is even more uncommon, making early diagnosis, detection, and appropriate treatment essential. We report the case of a 34-year-old woman who was admitted with scleral jaundice; severe pancreatitis was identified during examination. After magnetic resonance imaging confirmation, prompt and appropriate treatment was provided, resulting in a favorable outcome.

Introduction

Preeclampsia with severe pancreatitis is a critical clinical condition that poses significant risks to the lives and health of both the mother and fetus. ¹ Its nonspecific clinical signs and laboratory findings can mimic those of other rare conditions, such as acute fatty liver of pregnancy (AFLP) or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.^2,3 Moreover, pregnant women with severe preeclampsia may experience multiorgan damage, including hepatic damage, which can result in elevated transaminase levels and persistent upper abdominal pain.^4,5 Notably, in cases where preeclampsia is further complicated with intrahepatic cholestasis of pregnancy, similar symptoms may occur, because these conditions are all pregnancy-specific disorders.^6,7 Although the management of preeclampsia is similar to the treatment of other pregnancy-related conditions, severe pancreatitis requires specialized care, particularly in pregnant and postpartum women. Importantly, the presence of pancreatitis further heightens the risk of maternal and fetal mortality.

Case report

A 34-year-old woman at 36⁺⁶weeks of pregnancy, with a history of one pregnancy and no births, was admitted to the Department of Obstetrics and Gynecology at the 940th Hospital of the Joint Logistics Support Force of the Chinese People’s Liberation Army (Lanzhou, China) on 12 July 2024. She reported a 3-day history of scleral yellowing and blurred vision. Furthermore, her parents and sisters were healthy, and there was no family history of infectious or genetic diseases. Her menstrual cycle was regular (menarche at 14 years old, 3-day cycles every 26–27 days) with no history of blood clots or dysmenorrhea. Her last menstrual period occurred on 27 October 2023, and the expected delivery date was 3 August 2024. The pregnancy was uneventful, with normal prenatal checkups. Ten days before admission, she experienced pruritus localized to her abdominal skin; notably, her palms, soles, and chest were unaffected, and she did not seek any intervention for this symptom. Over the previous week, the patient had developed lower limb edema without an apparent cause, occasional blurred vision, and visual disturbances. On 9 July 2024, she noticed yellowing of the skin and sclera throughout her body accompanied with occasional nausea, vomiting, and persistent blurred vision without dizziness or headache. Routine prenatal checkups at the outpatient department revealed a blood pressure of 138/109 mmHg, prompting admission with a diagnosis of “gestational hypertension at 36⁺⁶ weeks; severe preeclampsia; first pregnancy, breech presentation.” Upon admission, her vital signs were as follows: body temperature, 36.5°C; pulse rate, 82 beats per minute; respiration rate, 20 breaths per minute; and blood pressure, 147/115 mmHg. The patient presented with yellow discoloration of the whole-body skin and sclera. The uterus was palpated two horizontal fingers below the xiphoid process, with the fetal head positioned in the upper left abdomen. Measurements included a fundal height of 33 cm, abdominal circumference of 100 cm, and an estimated fetal weight of 2400 g. The fetus was in the left sacral anterior position with a heart rate of 129 beats per minute. Irregular uterine contractions were present, and fetal heart rate monitoring showed unsatisfactory results on the nonstress test. Oxygen therapy and repeat testing provided no significant improvement. The patient denied a history of hypertension. Her medical history included a cholecystectomy at our hospital in 2012 due to acute cholecystitis and pancreatitis.

Ultrasound after admission revealed the following: (a) late pregnancy, singleton fetus in a breech position with the umbilical cord wrapped around the neck twice; (b) the fetal head was positioned on both sides of the upper right abdomen, with a biparietal diameter of 9.0 cm, head circumference of approximately 32.0 cm, and abdominal circumference of approximately 30.9 cm; (c) the placenta was attached to the posterior wall with grade II maturity; (d) good acoustic permeability of the amniotic fluid index of 9.8 cm and femur length of 6.6 cm on one side; and (e) no W-shaped indentation on the fetal neck. The blood test results were as follows (Figure 1): plasma D-dimer level, 7.38 mg/L; white blood cell (WBC) count, 13.82 × 10⁹/L; neutrophil percentage, 79.2%; red blood cell (RBC) count, 5.19 × 10¹²/L; and platelet count, 177 × 10⁹/L. Moreover, biochemical test results were as follows: gamma-glutamyl transferase level, 75 IU/L; alanine aminotransferase level, 349 IU/L; aspartate transaminase level, 330 IU/L; albumin level, 29.3 g/L; total bilirubin, 233.60 µmol/L; direct bilirubin, 177.24 µmol/L; indirect bilirubin, 56.36 µmol/L; total protein, 61.0 g/L; and total bile acid, 153.5 µmol/L. Finally, an ophthalmic examination of the fundus revealed hypertensive retinopathy in both eyes, congenital residual iris membrane in the right eye, and refractive errors in both eyes.

Figure 1.

Patient MRI image. (a) T1-weighted image and (b) T2-weighted image. MRI: magnetic resonance imaging.

The patient was diagnosed with a 36⁺⁶-week pregnancy complicated with severe preeclampsia, coagulation dysfunction, abnormal liver function, intrahepatic cholestasis of pregnancy, first pregnancy in breech presentation, fetal intrauterine distress (fetal heart type), and presence of the umbilical cord wrapped around the neck twice. Furthermore, she experienced sudden onset and rapid progression of multisystem symptoms, which, given her history of pancreatitis and gallbladder surgery, posed significant risks to both mother and child. Consequently, a multi-disciplinary team (MDT) conducted a comprehensive assessment and determined that immediate termination of the pregnancy was necessary. Under general anesthesia, the full-term uterus was observed to contain a small amount of yellow ascites, and membrane rupture was confirmed with approximately 600 mL of amniotic fluid present. A male infant was then delivered with an Apgar score of 10 and a birth weight of 2490 g. Intraoperative bleeding was minimal; however, surgical blood loss was approximately 200 mL. No blood transfusion was required; the uterus was sutured routinely. Postoperatively, the patient was transferred to the obstetrics ward, where on day 1, her blood pressure had normalized; however, her mental state remained poor. Additionally, a small amount of exudate was noted from the abdominal incision, with satisfactory uterine healing evidenced by a fundus palpable one transverse finger below the navel, an unobstructed urinary catheter producing normal yellow urine, and minimal, non-fetid bloody lochia.

The first re-examination of the blood routine showed a WBC count of 26 × 10⁹/L and a neutrophil percentage of 88.9%. Biochemical results included the following: uric acid level, 527.9 µmol/L; creatinine level, 194.5 µmol/L; total bile acid, 137.1 µmol/L; aspartate transaminase level, 160 IU/L; alanine aminotransferase level, 197 IU/L; total bilirubin, 188.60 µmol/L; direct bilirubin, 145.25 µmol/L; and indirect bilirubin, 43.35 µmol/L. The patient was treated with fasting water, anti-infection therapy, liver protection, and bile acid-lowering treatment. On postoperative day 2, the patient’s abdominal wound showed a significant pale-yellow exudate, accompanied with abdominal distension, difficulty lying flat, and shortness of breath. A re-examination of routine blood parameters showed the following results: WBC count, 28.79 × 10⁹/L; neutrophil percentage, 87.4%; RBC count, 3.34 × 10¹²/L; and hemoglobin level, 91 g/L. Biochemical test results showed the following: uric acid level, 490.0 µmol/L; creatinine level, 166.0 µmol/L; gamma-glutamyltransferase level, 53.00 IU/L; total bile acid, 120.6 µmol/L; indirect bilirubin, 29.19 µmol/L; alanine aminotransferase, 121 IU/L; aspartate transaminase, 67 IU/L; albumin, 21.1 g/L; globulin, 19.6 g/L; total bilirubin, 166.62 µmol/L; direct bilirubin, 137.43 µmol/L; and total protein, 40.7 g/L. The patient developed significant abdominal fluid accumulation due to hypoalbuminemia and received symptomatic supportive treatment, such as albumin infusion. On postoperative day 4, an abdominal magnetic resonance imaging (MRI) examination (Figure 2) revealed the following: (a) pancreatic swelling with significant abdominal fluid accumulation and exudation in the abdominal cavity, consistent with acute pancreatitis; (b) duodenal stasis; (c) extensive subcutaneous exudate in the abdominal wall and waist; (d) postoperative absence of the gallbladder; and (e) bilateral pleural effusion. Although liver enzymes levels normalized and bile acids significantly decreased after surgery, bilirubin remained elevated. The patient had pancreatitis; therefore, she was transferred to the intensive care unit in the gastroenterology department for fasting, acid and enzyme suppression, pancreatic juice secretion inhibition, fluid replacement, electrolyte imbalance correction, and external application of mirabilite to reduce exudation. Esomeprazole (40 mg/12 h), ulastatin (200,000 U/12 h), somatostatin (3 mg/12 h), and meropenem (1 g/8 h) were administered. Following treatment, the ascites significantly decreased, and after removing the abdominal drainage tube, the cesarean section wound healed well without exudate. Biochemical examination showed the following: albumin level, 38.7 g/L; total bilirubin, 124.30 µmol/L; direct bilirubin, 93.97 µmol/L; glycocholic acid level, 5.9 ug/mL; and WBC count, 10.29 × 10⁹/L (Table 1). Two weeks post-discharge, liver function tests showed normal transaminase, total bilirubin of 38.5 µmol/L, and direct bilirubin of 25.28 µmol/L, with full liver function recovery expected 42 days postpartum. Patient consent to treatment and publication was obtained. This study was reported following the Case Report (CARE) guidelines. ⁸

Figure 2.

Changes in hematological indicators of patients. (a) ALT changes. (b) AST changes. (c) WBC and neutrophil changes. (d) RBC changes. (e) TBIL and DBIL changes. (f) Hb changes. (g) Total protein and albumin changes and (h) PLT changes. ALT: alanine aminotransferase; AST: aspartate aminotransferase; WBC: white blood cell; RBC: red blood cell; TBIL: total bilirubin; DBIL: direct bilirubin; Hb: hemoglobin; PLT: platelet.

Table 1.

Patient hematological examination indicators.

Assessment indicators	WBC (×109/L)	N (×109/L)	RBC (×1012/L)	Hb (g/L)	PLT (×109/L)	AST (IU/L)	ALT (IU/L)	Tp (g/L)	A (g/L)	TBIL (µmol/L)
Preoperative	12.8	10.95	5.19	145	177	330	349	61	29.3	233.6
Postoperative	26	23.12	3.67	104	152	160	197	45.9	22.8	188.6
	28.79	25.15	3.34	91	179	67	121	40.7	21.1	166.6
	25.24	19.16	3.94	110	188	38	54	49.3	27.1	229.2
	18.14	13.32	3	83	172	30	37	43.9	22.4	203.6
	12.81	8.82	3.11	87	177	24	24	44.7	28.1	159.9
	10.29	7.46	3.24	92	246	25	21	54.5	38.7	124.3
Follow-up after discharge	6.03	2.78	3.69	103	328	50	55	70.9	41	38.5

WBC: white blood cell; N: neutrophil; RBC: red blood cell; Hb: hemoglobin; PLT: platelet; AST: aspartate transaminase; ALT: alanine aminotransferase; Tp: total protein; A: albumin; TBIL: total bilirubin.

Discussion

Idiopathic liver disease during pregnancy is rare, with clinical manifestations and laboratory results often resembling those of AFLP during pregnancy.^9,10 AFLP typically presents with nausea, vomiting, abnormal elevation of liver enzymes and bilirubin in late pregnancy, high blood ammonia, hepatic encephalopathy, acute kidney failure, abnormal thrombin, and hypoglycemia. Known as acute yellow liver atrophy, AFLP is a life-threatening obstetric condition characterized by sudden onset and rapid progression, with high maternal and neonatal mortality rates. ¹¹ AFLP typically occurs between 35 and 36 weeks of pregnancy and is characterized by the infiltration of microencapsulated fat into liver cells without inflammation or necrosis. The liver lobular structure remains intact, and a typical “bright liver” appears on ultrasound. In the present case, the patient did not exhibit hyperammonemia, hepatic encephalopathy, or imaging findings supporting a diagnosis of AFLP. HELLP syndrome, a severe complication of gestational hypertension, is characterized by hemolysis, elevated transaminase levels, and low platelet counts; ¹² however, it rarely involves coagulopathy, disseminated intravascular coagulation, hypoglycemia, or consciousness disorder. ¹³ The patient showed no thrombocytopenia or dark urine (soy sauce urine), and despite abdominal pain, nausea, vomiting, and elevated direct bilirubin levels, HELLP syndrome was not diagnosed. She was ultimately diagnosed with intrahepatic cholestasis of pregnancy combined with severe preeclampsia. After the surgery, her blood pressure normalized, itching subsided, and total bile acids decreased; however, the transaminase levels and total bilirubin level declined gradually. The patient experienced significant upper abdominal distension, pain, and leukocytosis. Considering her history of acute pancreatitis and cholecystectomy, pancreatic or liver complications were suspected. A complete abdominal MRI examination was performed while her vital signs remained stable, confirming the diagnosis of pancreatitis.

Preeclampsia primarily manifests as liver and kidney dysfunction, often accompanied with secondary coagulation dysfunction.^14,15 Upon admission, the patient received prompt treatment and underwent a timely cesarean section to terminate the pregnancy. The complex nature of the condition required MDT treatment, which ultimately resulted in successful management. Ongoing treatments and monitoring during the subsequent treatment process were essential for patient recovery. A complete abdominal MRI was performed while the patient’s vital signs remained stable, which was critical for accurate diagnosis and intervention. Preeclampsia progresses rapidly, making urgent intervention critical for both the pregnant woman and the fetus. In this case, the patient’s condition deteriorated significantly after the cesarean section, highlighting the importance of promptly addressing coagulation dysfunction, liver protection, bile acid reduction, and hypoalbuminemia.