Introduction
Hemolysis, elevated liver enzymes, and low platelets characterize HELLP syndrome. It is one of the most severe manifestations of preeclampsia and is associated with higher maternal mortality. Pancreatitis, although rare in pregnancy, is usually associated with cholelithiasis. Here, we present a rare case of pancreatitis seen as a sequelae of HELLP syndrome.

Case Presentation
31 YOF G1P0 with significant past medical history of Hashimoto’s thyroiditis, history of Lyme disease, and migraines presented to triage at 36w3d gestational age complaining of cough, vomiting and abdominal pain. After arrival, she had severe range blood pressures and complained of worsening abdominal pain. Fetal heart rate tracing was remarkable for fetal bradycardia. Therefore, she underwent an emergent primary low transverse cesarean section. She met criteria for HELLP syndrome based on evidence of hemolysis (LDH 568, haptoglobin <10, prothrombin 9.5, INR 0.81), transaminitis (AST 237 and ALT 101) and elevated blood pressures (140-164 mmHg/79-112 mmHg). She was started on magnesium sulfate for seizure prophylaxis. Postoperative course was complicated by respiratory failure, persistent hyperglycemia, and elevated amylase/lipase. On POD 7, CT of abdomen and pelvis were ordered due to worsening lab abnormalities. CT demonstrated necrotizing pancreatitis with complete replacement of normal pancreatic parenchyma with fluid.

Final Diagnosis: Necrotizing pancreatitis in the setting of HELLP syndrome

Management/Follow Up
Necrotizing pancreatitis was initially managed with antibiotics and insulin for persistent hyperglycemia. She had multiple hospital readmissions for abdominal pain and hyperglycemia. CT scan on POD 39 was notable for persistent necrotizing pancreatitis with possible abscess versus pseudocyst formation. Patient is currently followed by endocrinology with strict glucose control and monitoring of abscess versus pseudocyst with serial CT scans.

Discussion:
Limited case studies are available discussing necrotizing pancreatitis as a sequelae of HELLP syndrome (1,2). Microvascular abnormalities and aberrant immune responses are thought to play a role in the development of HELLP syndrome. Another explanation for the development of necrotizing pancreatitis could be microvascular damage resulting in pancreatic ischemia. Lastly, it can also be due to exaggerated immune response resulting in cytokine-induced pancreatic damage in the setting of a known autoimmune disorder.

References and Resources

1. Pereira Herrera M, Oaks JB, Brensilver J. A Case of Acute Pancreatitis in Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome. Cureus. 2018 Jun 25;10(6):e2877. doi: 10.7759/cureus.2877. PMID: 30155379; PMCID: PMC6110414.
2. Swank M, Nageotte M, Hatfield T. Necrotizing pancreatitis associated with severe preeclampsia. Obstet Gynecol. 2012 Aug;120(2 Pt 2):453-455. doi: 10.1097/AOG.0b013e31824fc617. PMID: 22825263.