OBJECTIVE Acute pancreatitis during pregnancy is a rare and dangerous disease. This study attempts to present a comprehensive analysis of severe acute pancreatitis (SAP) during pregnancy and to identify the factors associated with poor outcomes. METHODS This study was a retrospective review of the medical records of SAP patients during pregnancy consecutively admitted into the Research Institute of General Surgery from 1999 to 2010. RESULTS Information was collected on presentation, management, and outcome. Eighteen patients were identified to have been diagnosed with SAP during pregnancy. Eleven patients (61.1%) were nulliparous; most attacks (88.9%) occurred during the third trimester. There were seven cases with preterm labor, six with fetal losses, and no maternal death. The etiology was biliary disease in seven patients (38.9%), hypertriglyceridemia in five patients (27.8%), both biliary and hypertriglyceridemia in four patients (22.2%), and idiopathic in two patients (11.1%). Patients with failure in more than one (≥2) organ were more likely to result in fetal loss (OR = 25, P = 0.016). CONCLUSIONS SAP during pregnancy is predominantly biliary in etiology, but a significant proportion is caused by hypertriglyceridemia. Patients with failure in at least two organs result in relatively worse fetal outcomes.