A Problem in Gestation

A CLINICAL PROBLEM-SOLVING article by Bindu Chamarthi from Brigham and Women's Hospital, Boston.
A 39-year-old woman (gravida 2, para 0) presented to her obstetrician at 32 weeks' gestation with a 2-day history of low back pain. The pain was abrupt in onset and constant. She reported no fever, dysuria, vaginal discharge or bleeding. Preterm labor was ruled out, and she was advised to rest and take acetaminophen as needed.
The patient returned to her obstetrician the next day with worsening pain located in the middle-to-lower back, now with radiation to the upper abdomen. She reported an episode of vomiting that morning. She was referred to the emergency room for further evaluation.
The abdominal examination showed a gravid uterus and epigastric tenderness without rebound or guarding. There was no palpable mass or hepatosplenomegaly and no tenderness at the costovertebral angle.
The patient was transferred to a tertiary-care hospital with a diagnosis of acute pancreatitis.
Pancreatitis is uncommon in pregnancy, and when it does occur, the cause is most often of biliary origin. Plasma triglyceride levels are increased by a factor of two to four during pregnancy, a change that is inconsequential in most pregnant women but that may result, in the presence of an underlying lipid disorder, in severe hypertriglyceridemia, precipitating pancreatitis; however, the triglyceride level is normal in this patient.
An interactive medical case related to this article is available at NEJM.org. [Original Article]