Pregnancy-induced severe gestational hyperlipidemia mimicking familial hyperlipidemia

Recurrent Pancreatitis in a Pregnant Woman with Severe Hypertriglyceridemia Successfully Managed by Multiple Plasmapheresis

Hypertriglyceridemia (HTG) is a state of increased serum triglyceride (TG) affected by multigenetic and multifactorial causes. Serum TG concentration can be markedly elevated if exposed to precipitating factors, such as estrogen hormone and pregnancy. We report the case of a patient with severe HTG who suffered from recurrent pancreatitis during the second trimester of pregnancy conceived within vitro fertilization-embryo transfer (IVF-ET) and was successfully controlled by multiple sessions of plasmapheresis.

A 24-year-old pregnant woman was admitted because of a sudden onset of severe abdominal pain at 26 weeks of gestation conceived by IVF-ET. She has experienced recurrent pancreatitis despite low-fat diet and dyslipidemia medications allowed in pregnancy. At admission, serum amylase and lipase were elevated to 347 and 627 U/L, respectively, along with fasting TG to 4809 mg/dL. A clinical diagnosis of HTG-induced acute pancreatitis was made, and plasmapheresis was performed. After plasmapheresis, serum TG, amylase, and lipase levels decreased to 556 mg/dL, 60 U/L, and 69 U/L, respectively, along with subsequent pain relief. The patient underwent a total of nine sessions of plasmapheresis to retain serum TG lower than 1,000 mg/dL during pregnancy, with no further recurrence of acute pancreatitis. After delivery, the serum TG level was maintained below 500 mg/dL with a combination treatment of fenofibrate, statin, and ezetimibe.

Although severe HTG is usually asymptomatic, if exposed to precipitating factors, it can cause acute pancreatitis, a fatal complication. Early application of plasmapheresis may be a useful option in HTG-induced acute pancreatitis intractable to medical treatment; however, its indications, risks, and benefits should be carefully evaluated.

Pregnancy-induced hyperlipoproteinemia: review of the literature

It is well known that with the effect of hormonal changes during pregnancy, plasma lipid levels increase. Expected elevations for triglyceride and cholesterol levels during a normal gestational period usually do not exceed 332 mg/dL and 337 mg/dL, respectively (corresponding 95th percentile values). However, elevations over the 95th percentile values can be observed during pregnancy, and patients with levels over these expected adaptation levels can be divided into 2 groups: (1) supraphysiologic hyperlipoproteinemia during pregnancy and (2) extreme hyperlipoproteinemia limited to gestational period (triglyceride level >1000 mg/dL). Regarding the first group, some of these patients may develop hyperlipoproteinemia in their future life. What percentage of these women will translate into hyperlipoproteinemia later in life and how efficiently these women can be screened during pregnancy is an enigma. The underlying disorders in the second group of patients at least include dysbetalipoproteinemia, partial lipoprotein lipase deficiency, and apoprotein E3/3 genotype. Pregnancy had been reported to induce severe hyperlipoproteinemia that is limited to gestational period in these disorders. Dysbetalipoproteinemia, partial lipoprotein lipase deficiency, and apoprotein E3/3 genotype probably bring risks and implications to the future life of the carrying individuals although the true extent of the risks is yet to be defined. When disorders unique to gestational period such as gestational diabetes are considered, pregnancy may be accepted as an opportunity to identify women under risk of cardiovascular morbidity and mortality.