An Unexpected Showing at Nineteen Weeks Pregnant

Abstract

A 31-year-old Nigerian female in the 19th week of her 5th pregnancy with a past medical history of diabetes mellitus presented with one week of intermittent right upper quadrant and epigastric abdominal pain with radiation to her back. She also reported associated nausea, decreased appetite, bloating, and steatorrhea. She had similar pain three years ago during her last pregnancy, but had no known history of pancreatitis or gallstone disease, and denied alcohol abuse. Her physical exam was normal except for a gravid abdomen and tenderness to palpation in the right upper quadrant and epigastric regions. Liver enzymes, lipase and amylase were normal. MRI of the abdomen demonstrated a 20 x 12 x 13 cm thick-walled, lobular cyst arising from the proximal pancreatic body. EGD showed significant external compression of gastric antrum and duodenum. Endoscopic ultrasound guided diagnostic cyst fluid aspiration was performed with cyst fluid demonstrating elevated amylase (value >1300 U/L), low CEA (4.8 ng/mL), and cytology was negative for malignancy, consistent with a pancreatic pseudocyst. We performed endoscopic cystogastrostomy placing a fully covered metal biliary stent. This was followed by cyst re-expansion on MRI with extrinsic compression on the common bile duct and an infected pseudocyst which was managed with intravenous antibiotics and cystoduodenostomy with copious drainage of purulent material and resolution of abdominal pain. At 37 weeks of pregnancy, she presented with contractions and complete breech presentation. A cesarean section was performed and she delivered a viable male infant. A CT scan after delivery showed complete resolution of the pseudocyst. Pancreatic pseudocysts complicating pregnancy are rare with only 10 cases reported in the literature since 1980. Although pseudocysts may regress spontaneously, approximately 30%-40% are complicated by infection, rupture, hemorrhage, or obstruction of the stomach, small bowel, colon, or bile duct. The natural history of pancreatic pseudocysts in pregnant patients seems to be similar to non-gravid patients, however there is concern for increased risk of rupture during vaginal delivery. Symptomatic, enlarging, very large, or complicated pseudocysts require drainage. While the management of pancreatic pseudocysts is not standardized in pregnant patients, the second trimester is generally considered the safest time to intervene.Figure 1Figure 2Figure 3