Severe dyslipidemia in pregnancy: The role of therapeutic apheresis

Characteristics, Physiopathology and Management of Dyslipidemias in Pregnancy: A Narrative Review

Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD). During pregnancy, physiological changes elevate cholesterol and triglyceride levels to support fetal development, which can exacerbate pre-existing conditions and lead to complications such as pre-eclampsia, gestational diabetes, and increased ASCVD risk for both mother and child. Effective management strategies are necessary, especially for pregnant women with inherited forms of dyslipidemia (i.e., familial hypertriglyceridemia, hyperchylomicronemia), where personalized dietary adjustments are crucial for successful pregnancy outcomes. Pharmacological interventions and lipoprotein apheresis may be necessary for severe cases, though their use is often limited by factors such as cost, availability, and potential fetal risks. Despite the promise of advanced therapies, their widespread application remains constrained by limited studies and high costs. Thus, a personalized, multidisciplinary approach is essential for optimizing outcomes. This review provides a comprehensive overview of current strategies and evidence-based practices for managing dyslipidemia during pregnancy, emphasizing the balance of maternal and fetal health. Additionally, it discusses the physiological changes in lipid metabolism during pregnancy and their implications, particularly for women with inherited forms of dyslipidemia.

Lipid Disorders and Pregnancy

Practicing endocrinologists are likely to confront 2 major issues that occur with dyslipidemias during pregnancy. The most dramatic is the development of severe hypertriglyceridemia leading to acute pancreatitis. The second is the approach to treatment of familial hypercholesterolemia, a common genetic disorder. This article reviews the normal physiology and the pathophysiology of lipoproteins that occurs with pregnancy and then discusses the approaches to prevention and/or treatment of dyslipidemia in pregnancy with a focus on lifestyle and acceptable drug therapies.

Dyslipidaemia management in pregnant patients: a 2024 update

Over several decades, the approach to treating dyslipidaemias during pregnancy remains essentially unchanged. The lack of advancement in this field is mostly related to the fact that we lack clinical trials of pregnant patients both with available as well as new therapies. While there are numerous novel therapies developed for non-pregnant patients, there are still many limitations in dyslipidaemia treatment during pregnancy. Besides pharmacotherapy and careful clinical assessment, the initiation of behavioural modifications as well as pre-conception management is very important. Among the various lipid-lowering medications, bile acid sequestrants are the only ones officially approved for treating dyslipidaemia in pregnancy. Ezetimibe and fenofibrate can be considered if their benefits outweigh potential risks. Statins are still considered contraindicated, primarily due to animal studies and human case reports. However, recent systematic reviews and meta-analyses as well as data on familial hypercholesterolaemia (FH) in pregnant patients have indicated that their use may not be harmful and could even be beneficial in certain selected cases. This is especially relevant for pregnant patients at very high cardiovascular risk, such as those who have already experienced an acute cardiovascular event or have homozygous or severe forms of heterozygous FH. In these cases, the decision to continue therapy during pregnancy should weigh the potential risks of discontinuation. Bempedoic acid, olezarsen, evinacumab, evolocumab and alirocumab, and inclisiran are options to consider just before and after pregnancy is completed. In conclusion, decisions regarding lipid-lowering therapy for pregnant patients should be personalized. Despite the challenges in designing and conducting studies in pregnant women, there is a strong need to establish the safety and efficacy of dyslipidaemia treatment during pregnancy.

The impact of overweight on lipid phenotype in different forms of dyslipidemia: a retrospective cohort study

PURPOSE

Dyslipidemia plays a pivotal role in increasing cardiovascular risk. In clinical practice the misleading association between altered lipid profile and obesity is common, therefore genetically inherited dyslipidemias may not completely be addressed among patients with overweight. Thus, we aim to investigate the influence of overweight and obesity on the lipid phenotype in a cohort of patients with different forms of dyslipidemia.

METHODS

A retrospective analysis was conducted on patients with dyslipidemia from 2015 to 2022. Patients were stratified in familial hypercholesterolemia (FH), familial combined hyperlipidemia (FCHL), non-familial hyperlipidemia or polygenic hypercholesterolemia (PH). Clinical characteristics and lipid profile were evaluated.

RESULTS

Of the total of 798 patients, 361 were affected by non-familial hyperlipidemia (45.2%), while FCHL, FH and PH was described in 19.9%, 14.0% and 20.9% of patients, respectively. Overweight prevalence was higher in FCHL and non-familial hyperlipidemia patients than FH and PH patients. Subjects with overweight and obesity were independently associated with lower levels of high-density lipoprotein cholesterol (HDL-C) compared to patients with normal weight (52.4 and 46.0 vs 58.1, respectively; p < 0.0001); levels of triglycerides (TG) and non-HDL-C were higher in patients with overweight and obesity than patients with normal weight (257.3 and 290.9 vs 194.8, and 221.5 and 219.6 vs 210.1, p < 0.0001 and p = 0.01, respectively), while no differences were observed between patients with overweight and obesity.

CONCLUSION

While dyslipidemias can be influenced by various factors, an important determinant may lie in genetics, frequently acting as an underlying cause of altered lipid profiles, even in cases of overweight conditions.

The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review

Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.

Preventative plasmapheresis in a diabetic pregnant patient with hypertriglyceridemia and distal pancreatectomy

BACKGROUND

Pregnant patients with a history of hypertriglyceridemia are at increased risk for development of acute pancreatitis. When conservative management fails to maintain triglyceride levels less than 250-500 mg dL-1 , implementation of pregnancy category C medications to prevent pancreatitis must be considered. Plasmapheresis rapidly reduces triglyceride levels and has been reported as a successful third-line therapy for hypertriglyceridemia-induced acute pancreatitis in a limited number of pregnant patients. Use of preventative plasmapheresis as a bridge to delivery is not well characterised.

CASE PRESENTATION

We report an outpatient plasmapheresis regimen for the control of hypertriglyceridemia in a pregnant patient with a history of diabetes mellitus, hypertriglyceridemia, distal pancreatectomy, and repeat pregnancy loss. During the second trimester, refractory triglyceride levels increased up to 3438 mg dL-1 by 28 weeks gestation. Given the patient's high risk for recurrent pancreatitis and limited remaining pancreatic parenchyma, she was treated acutely with two single-plasma-volume exchanges with 100% albumin over 2 days, decreasing the triglyceride level to 559 mg dL-1 . Subsequent plasmapheresis every 7 to 9 days maintained a triglyceride level of 320-1296 mg dL-1 . The patient experienced no adverse effects and remained outpatient until successful scheduled delivery for hypertension at 33 weeks gestation.

DISCUSSION

For select patients, early escalation to plasmapheresis may prevent morbidity and mortality associated with acute pancreatitis. An individualised plasmapheresis regimen can serve as a bridge to delivery, which requires close observation and the coordination of a multidisciplinary team.

2023 Update on European Atherosclerosis Society Consensus Statement on Homozygous Familial Hypercholesterolaemia: new treatments and clinical guidance

This 2023 statement updates clinical guidance for homozygous familial hypercholesterolaemia (HoFH), explains the genetic complexity, and provides pragmatic recommendations to address inequities in HoFH care worldwide. Key strengths include updated criteria for the clinical diagnosis of HoFH and the recommendation to prioritize phenotypic features over genotype. Thus, a low-density lipoprotein cholesterol (LDL-C) >10 mmol/L (>400 mg/dL) is suggestive of HoFH and warrants further evaluation. The statement also provides state-of-the art discussion and guidance to clinicians for interpreting the results of genetic testing and for family planning and pregnancy. Therapeutic decisions are based on the LDL-C level. Combination LDL-C-lowering therapy-both pharmacologic intervention and lipoprotein apheresis (LA)-is foundational. Addition of novel, efficacious therapies (i.e. inhibitors of proprotein convertase subtilisin/kexin type 9, followed by evinacumab and/or lomitapide) offers potential to attain LDL-C goal or reduce the need for LA. To improve HoFH care around the world, the statement recommends the creation of national screening programmes, education to improve awareness, and management guidelines that account for the local realities of care, including access to specialist centres, treatments, and cost. This updated statement provides guidance that is crucial to early diagnosis, better care, and improved cardiovascular health for patients with HoFH worldwide.

A novel homozygous nonsense variant of LMF1 in pregnancy-induced hypertriglyceridemia with acute pancreatitis

Hypertriglyceridemia (HTG)-induced pancreatitis during pregnancy could lead to maternal and fetal death. However, its genetic bases are not fully understood, and its treatment strategies are yet to be established. Here we report a case with a novel homozygous nonsense variant of LMF1 in pregnancy-associated HTG with acute pancreatitis. Our patient had childhood-onset severe HTG that had been well-controlled by dietary management in the non-pregnant period with plasma triglyceride (TG) levels at around 200 mg/dL. Milky plasma was noted at the first-trimester pregnancy checkup, followed by a severe increase in plasma TG (10,500 mg/dL) that resulted in pancreatitis in the last trimester. The implementation of strict dietary fat restriction (less than 4 grams per day) reduced plasma TG levels and led to successful delivery. Exome sequencing revealed a novel homozygous nonsense variant in LMF1 (c.697C>T, p.Arg233Ter). The activities of lipoprotein lipase (LPL) and hepatic lipase in post-heparin plasma were not abolished but reduced. The use of pemafibrate decreased plasma TG levels with a concomitant increase in LPL activity. HTG in childhood or early pregnancy is commonly assumed to be polygenic in origin but should be regarded as a feature suggestive of monogenic hyperchylomicronemia. Adequate TG monitoring and dietary fat restriction should be implemented to prevent potentially lethal events of pancreatitis.

Considerations for treatment of lipid disorders during pregnancy and breastfeeding

Adequate management of lipid disorders during pregnancy is essential given the association of dyslipidemia with adverse pregnancy outcomes. While there are physiologic changes in lipid levels that occur with normal pregnancy, abnormal alterations in lipids can lead to increased future risk of atherosclerotic cardiovascular disease. There are inherent challenges in the treatment of dyslipidemias during pregnancy and the postpartum period given the lack of adequate data in this population and the contraindication of traditional therapeutic agents. However, it remains of utmost importance to optimize screening and identification of patients at high-risk for atherosclerotic cardiovascular disease so that proper counseling can be provided and the risk for pregnancy complications and downstream cardiovascular complications can be addressed. In this review, we summarize the literature on the association of dyslipidemia in pregnancy with adverse outcomes and discuss considerations for the management of lipid disorders during both pregnancy and breastfeeding.

Lipid-Lowering Therapy in Woman of Childbearing Age: a Review and Stepwise Clinical Approach

PURPOSE OF REVIEW

Women are less often recognized to have cardiovascular disease (CVD) risk and are underrepresented in randomized trials of lipid-lowering therapy. Here, we summarize non-pharmacologic and pharmacologic strategies for lipid-lowering in women of childbearing age, lipid changes during pregnancy and lactation, discuss sex-specific outcomes in currently available literature, and discuss future areas of research.

RECENT FINDINGS

While lifestyle interventions form the backbone of CVD prevention, some women of reproductive age have an indication for pharmacologic lipid-lowering. Sex-based evidence is limited but suggests that both statin and non-statin lipid-lowering agents are beneficial regardless of sex, especially at high cardiovascular risk. Pharmacologic lipid-lowering therapies, both during the pregnancy period and during lactation, have historically been and continue to be limited by safety concerns. This oftentimes limits lipid-lowering options in women of childbearing age. In this review, we summarize lipid-lowering strategies in women of childbearing age and the impact of therapies during pregnancy and lactation. The limited sex-specific data regarding efficacy, adverse events, and cardiovascular outcomes underscore the need for a greater representation of women in randomized controlled trials. More data on lipid-lowering teratogenicity are needed, and through increased clinician awareness and reporting to incidental exposure registries, more data can be harvested.

Statins in Pregnancy: Can We Justify Early Treatment of Reproductive Aged Women?

PURPOSE OF REVIEW

Statins are the pillar of secondary prevention in reducing cardiovascular disease in high-risk adults. However, statin discontinuation is the standard recommendation in pregnant and lactating patients. This review evaluates whether we can justify the early treatment of reproductive aged women with statin therapy.

RECENT FINDINGS

Statins have several potential benefits including its antioxidant, anti-inflammatory, and anti-thrombogenic properties that may prevent the worsening of atherosclerosis in high-risk women. Nevertheless, most studies on statins and teratogenicity have a limited sample size and the effects of long-term statin use on fetal and neonatal health remain unknown. Not all statins may be safe and pravastatin's cholesterol-lowering properties may be too limited to provide much maternal benefit in pregnancy. While emerging evidence supports the use of pravastatin in pregnancy, we need to better assess the risk of early cardiovascular disease and acute progression of atherosclerosis before and during pregnancy to better understand the risks and benefits of statin use.

Prevention and Management of Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Systematic Review

Severe gestational hypertriglyceridemia can lead to acute pancreatitis, with maternal mortality rate of approximately 20%. The recent National Lipid Association part 2 expert panel recommendations provide guidance on monitoring pregnant women at high risk for hyperlipidemia. We suggest that high-risk women have triglyceride levels checked once every trimester. Fasting triglycerides >250 mg/dL should prompt monthly triglyceride levels, screening for gestational diabetes, and implementing a strict low-carbohydrate, low-fat diet, exercise. Fasting triglycerides >500 mg/dL, despite a strict dietary and lifestyle modifications, should prompt treatment with omega-3-fatty acids and continue a fat-restricted diet (<20 g total fat/d or <15% total calories) under the guidance of a registered dietician. The use of fibrates should be considered as a second-line therapy due to their unclear risk versus benefit and potential teratogenic effects. Plasmapheresis should be considered early in asymptomatic pregnant women with fasting triglyceride levels >1000 mg/dL or in pregnant women with clinical signs and symptoms of pancreatitis and triglyceride levels >500 mg/dL despite maximal lifestyle changes and pharmacologic therapy.

Dyslipidemia Management in Pregnancy: Why Is It not Covered in the Guidelines?

PURPOSE OF REVIEW

Despite the elevation of lipid values during pregnancy is mostly physiological, evidence suggest that it may be associated with adverse events. This article reviews the characteristics of lipid disorders and the possible management with dyslipidemia in pregnant women.

RECENT FINDINGS

Among many available groups of lipid-lowering drugs, only bile acid sequestrants are approved for the treatment of dyslipidemia during pregnancy. Ezetimibe and fenofibrate might be considered if benefits outweigh the potential risk. Statins are still contraindicated due to the results mainly from animal studies and series of human cases. However, recent systematic reviews and meta-analyses showed that their use may not be detrimental, and in some selected cases may be beneficial. Especially, in some groups of pregnant patients with very high cardiovascular risk-those already after an event, or with established cardiovascular disease, with homozygous familial hypercholesterolemia; in such cases the final decision should weight the potential risk of discontinuation of therapy. Finally, we need to wait for the data with new drugs, including PCSK9 inhibitors and especially inclisiran, which (still hypothetically) might be a very interesting option as it may be used just before the pregnancy and immediately after with the duration of about 9 months between injections. The decisions on lipid-lowering therapy in pregnant patients should be individualized. Despite design and ethical difficulties with such studies, further investigations on dyslipidemia treatment during pregnancy are highly awaited.

Management of familial hypercholesterolemia in pregnancy

PURPOSE OF REVIEW

To highlight quandaries and review options for the management of familial hypercholesterolemia (FH) during pregnancy.

RECENT FINDINGS

Women with FH face barriers to effective care and consequently face significant disease related long term morbidity and mortality.Pregnancy includes major maternal physiological changes resulting in exacerbation of maternal hypercholesterolemia compounded by the current practice of cessation or reduction in the dose of lipid-lowering therapy during pregnancy and lactation that may impact short and long term cardiac morbidity and mortality. Although lipoprotein apheresis is the treatment of choice for high- risk FH patients, reassuring safety evidence for the use of statins during pregnancy is mounting rapidly. However, it will be some time before subtle effects on the development of the offspring can be definitively excluded. Women with homozygous FH or with an established atherosclerotic vessel or aortic disease should be offered therapy with statins during pregnancy if lipoprotein apheresis is not readily available. Pregnancy outcomes tend to be favourable in women with FH. We have reviewed the currently available evidence regarding the risks and benefits of treatment options for FH during pregnancy.

Management of Hypercholesterolemia in Pregnant Women with Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

In this review, we discuss strategies for managing dyslipidemia in pregnant women with ASCVD.

RECENT FINDINGS

Cardiovascular disease (CVD) is the leading cause of mortality in women as well as the leading cause of pregnancy-related mortality in the USA. It is paramount to screen, identify, counsel, and treat women of childbearing age who have existing atherosclerotic disease to mitigate the risks of complications and mortality. Dyslipidemias, including hypercholesterolemia and hyperlipidemia, can further enhance the risk for future CVD events. Treating hypercholesterolemia during pregnancy is crucial, and this is an opportune time for cross-collaboration of subspecialties in cardiology, obstetrics, and gynecology.

Therapeutic plasma exchange for hyperlipidemic pancreatitis: Current evidence and unmet needs

With changes in lifestyle and diet worldwide, the prevalence of hyperlipidemic acute pancreatitis (HLAP) has greatly increased, and it has become the most common cause of acute pancreatitis not due to gallstones or alcohol. There are many available therapies for HLAP, including oral lipid-lowering agents, intravenous insulin, heparin, and therapeutic plasmapheresis (TPE). It is believed that the risk and severity of HLAP increase with rising levels of serum triglycerides (TG), thus a rapid decrease in serum TG level is the key to the successful management of HLAP. TPE has emerged as an effective modality in rapidly reducing serum TG levels. However, due to its cost and accessibility, TPE remains poorly evaluated until now. Some studies revealed its efficacy in helping to treat and prevent the recurrence, while some studies suggested that TG levels were not correlated with disease severity, mortality, or length of hospital stay. Thus TPE might have no beneficial effect for the outcome. This article gives an overview of the published evidence of TPE in the treatment of HLAP and outlines current evidence regarding individual outcome predictors, adverse effects of the procedure, and TPE in special occasions such as for pregnant patients and patients with diabetic ketoacidosis. Future direction of TPE research for HLAP is also discussed in this review.

Insulin can be used to treat severe hypertriglyceridaemia in pregnant women without diabetes

Severe hypertriglyceridaemia can lead to acute pancreatitis, which is associated with maternal and perinatal mortality when it occurs in pregnancy. Rapid reduction of triglyceride levels is a primary goal in the management of severe hypertriglyceridaemia, however, there are limited safe option for treatment in pregnancy. We present a case of a woman without diabetes presenting with severe hypertriglyceridaemia in late gestation who was safely and successfully treated with insulin and review the literature surrounding the management of this important condition.

Current Diagnosis and Management of Primary Chylomicronemia

Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.

PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes ( LPL , LMF1 , GPIHBP1 , APOC2 , and APOA5 ). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).

The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive.

The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life.

Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease.

Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.

High-cholesterol diet during pregnancy induces maternal vascular dysfunction in mice: potential role for oxidized LDL-induced LOX-1 and AT1 receptor activation

The lectin-like oxidized low-density-lipoprotein (oxLDL) receptor-1 (LOX-1) has been shown to induce angiotensin II (AngII) type 1 receptor (AT1) activation, contributing to vascular dysfunction. Preeclampsia is a pregnancy complication characterized by vascular dysfunction and increased LOX-1 and AT1 activation; however, whether LOX-1 and AT1 activity contributes to vascular dysfunction in preeclampsia is unknown. We hypothesized that increased oxLDL levels during pregnancy lead to LOX-1 activation and subsequent AT1 activation, resulting in vascular dysfunction. Pregnant wild-type (WT) and transgenic LOX-1 overexpressing (LOX-1tg) mice were fed a control diet (CD) or high-cholesterol diet (HCD, to impair vascular function) between gestational day (GD) 13.5-GD18.5. On GD18.5, AngII-induced vasoconstriction and methylcholine (MCh)-induced endothelium-dependent vasodilation responses were assessed in aortas and uterine arteries. HCD decreased fetal weight and increased circulating oxLDL/cholesterol levels in WT, but not in LOX-1tg mice. HCD did not alter AngII responsiveness or AT1 expression in both vascular beds; however, AngII responsiveness and AT1 expression were lower in aortas from LOX-1tg compared with WT mice. In aortas from WT-CD mice, acute oxLDL exposure induced AT1-mediated vasoconstriction via LOX-1. HCD impaired endothelium-dependent vasodilation and increased superoxide levels in WT aortas, but not uterine arteries. Moreover, in WT-CD mice oxLDL decreased MCh sensitivity in both vascular beds, partially via LOX-1. In summary, HCD impaired pregnancy outcomes and vascular function, and oxLDL-induced LOX-1 activation may contribute to vascular dysfunction via AT1. Our study suggests that LOX-1 could be a potential target to prevent adverse outcomes associated with vascular dysfunction in preeclampsia.

Therapeutic plasma exchange in pregnancy: A literature review

Therapeutic plasma exchange (TPE) is indicated as a treatment for a wide array of diseases, extensively addressed in the Guidelines of the American Society for Apheresis. In pregnancy, TPE is an uncommon event and application is largely based on extrapolation of efficacy and safety in a non-pregnant population. This review intends to describe the currently available experience of TPE in pregnancy to help clinicians recognise indications during pregnancy and to support current guideline recommendations with literature-based experiences. In order to identify the clinical indications for which TPE is applied in pregnant women, we performed a literature search including studies till November 2019, without a start date restriction. Data extraction included medical indication for TPE and safety of TPE in pregnant women. 279 studies were included for analysis. Nowadays, TPE is predominantly applied for thrombotic microangiopathies, lipid disorders and a variety of autoimmune diseases. The application of TPE during pregnancy remains largely empiric and relies on individual case reports in the absence of high-quality studies and definitive evidence-based guidelines. Safety profile of TPE during pregnancy appears to be comparable to application of TPE in non-pregnant patients. In conclusion, based on the limited evidence that we found in literature with a high risk of publication bias, TPE procedures can be used safely during pregnancy with the appropriate preparation and experience of a multidisciplinary team.

Probiotic intervention as a potential therapeutic for managing gestational disorders and improving pregnancy outcomes

Recent molecular investigations have significantly developed our knowledge of the characteristics of the reproductive microbiome and their associations with host responses to provide an ideal milieu for the development of the embryo during the peri-implantation period and throughout pregnancy as well as to provide a successful in vitro fertilization and appropriate reproductive outcomes. In this context, the establishment of microbial homeostasis in the female reproductive tract, in various physiological periods, is a substantial challenge, which appears the application of probiotics can facilitate the achievement of this goal. So that, currently, probiotics due to its safe and natural features can be considered as a novel biotherapeutic approach. In this review, we comprehensively discuss the bacterial, fungal, and viral diversity detected in the reproductive tract, and their associations with the establishment of dysbiosis/eubiosis conditions as well as we present the significant outcomes on probiotic intervention as an efficient biotherapeutic strategy for management of gestational disorders and improve pregnancy outcomes.

Women Living with Familial Hypercholesterolemia: Challenges and Considerations Surrounding Their Care

PURPOSE OF REVIEW

To highlight the gender-based differences in presentation and disparities in care for women with familial hypercholesterolemia (FH).

RECENT FINDINGS

Women with FH experience specific barriers to care including underrepresentation in research, significant underappreciation of risk, and interrupted therapy during childbearing. National and international registry and clinical trial data show significant healthcare disparities for women with FH. Women with FH are less likely to be on guideline-recommended high-intensity statin medications and those placed on statins are more likely to discontinue them within their first year. Women with FH are also less likely to be on regimens including non-statin agents such as PCSK9 inhibitors. As a result, women with FH are less likely to achieve target low-density lipoprotein cholesterol (LDL-C) targets, even those with prior atherosclerotic cardiovascular disease (ASCVD). FH is common, under-diagnosed, and under-treated. Disparities of care are more pronounced in women than men. Additionally, FH weighs differently on women throughout the course of their lives starting from choosing contraceptives as young girls along with lipid-lowering therapy, timing pregnancy, choosing breastfeeding or resumption of therapy, and finally deciding goals of care during menopause. Early identification and appropriate treatment prior to interruptions of therapy for childbearing can lead to marked reduction in morbidity and mortality. Women access care differently than men and increasing awareness among all providers, especially cardio-obstetricians, may improve diagnostic rates. Understanding the unique challenges women with FH face is crucial to close the gaps in care they experience.

A complicated pregnancy in homozygous familial hypercholesterolaemia treated with lipoprotein apheresis: A case report

BACKGROUND AND AIMS

During pregnancy total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) levels increase significantly and lipoprotein apheresis (LA) is considered the most effective therapy in homozygous familial hypercholesterolaemia (HoFH) for modulating lipid and lipoprotein levels and reducing maternal and foetal complications.

CLINICAL CASE

A primigravida 28 years old Caucasian female patient, previously diagnosed as to be HoFH, was admitted at our outpatient service at the beginning of pregnancy.

METHODS

The patient was continuously submitted to LA every two weeks without foetal complication. During pregnancy two methods have been utilised: selective apheresis, and later plasma exchange. At 33 weeks gestational age the patient developed progressively hypertension, associated to LDL-C levels increase. Weekly LA was favoured.

RESULTS

At 34 weeks +5 days patient suddenly experienced acute chest pain and abnormal electrocardiogram heart tracing and cardiac enzymes increase. An emergency caesarean section was performed without complications and the foetus was healthy. The patient was immediately transferred to Coronary Intensive Care Unit, where she was diagnosed non-ST elevation myocardial infarction (NSTEMI). Notwithstanding the patient improved in few days and was quickly discharged in fair clinical condition.

CONCLUSIONS

LA is a safe and effective tool in HoFH subjects even in pregnancy. Evidence based guidelines for the management of these patients during pregnancy are still lacking.

Gut microbiota and probiotic intervention as a promising therapeutic for pregnant women with cardiometabolic disorders: Present and future directions

Maternal cardiometabolic disorders, such as gestational diabetes mellitus, pre-eclampsia, obesity, and dyslipidemia, are the most common conditions that predispose offspring to risk for future cardiometabolic diseases, needing appropriate therapeutic approach. The implications of microbiota in the pathophysiology of maternal cardiometabolic disorders are progressively emerging and probiotics may be a simple and safe therapeutic strategy for maternal cardiometabolic management. In this review, we argue the importance of cardiometabolic dysfunction during pregnancy and/or lactation on the offspring risk for cardiometabolic disease in later life. In addition, we comprehensively discuss the microbial diversity observed in maternal cardiometabolic disorders and we present the main findings on probiotic intervention as a potential strategy for management of maternal cardiometabolic disorders. Current data reveal that gut microbiota may be transmitted from mother to offspring. Whether targeting microbiota with probiotic intervention during the periconceptional period prevents or delays the onset of cardiometabolic disorders in adult offspring should be tested in future clinical trials.

Therapeutic plasma exchange in secondary prevention of acute pancreatitis in pregnant patient with familial hyperchylomicronemia

INTRODUCTION

Hormone changes during pregnancy lead to increased plasma lipid levels. When there is added disorder of lipid metabolism, this otherwise physiological change can cause extremely high triglyceride levels with potentionally life-threatening complications, such as non-biliary acute pancreatitis.

MATERIALS AND METHODS

We present a case report of a 27-year-old pregnant woman with familial hyperchylomicronemia and a history of 7 hypertriglyceridemia-induced acute pancreatitis attacks. Three attacks occured during her first pregnancy with the last one leading to its termination at 33 weeks owing to the death of the fetus. During her second pregnancy, standard treatment was not able to lower the triglyceride levels sufficiently and she suffered another acute pancreatitis attack. Therapeutic plasma exchange was therefore chosen as the treatment method.

RESULTS AND CONCLUSION

Plasma exchange was succesful in the secondary prevention of acute pancreatitis attack and she delivered a healthy baby at 36 weeks of gestation. Treatment was very well tolerated by the mother and the fetus and this supports the use of apheresis as a safe and efficient method in tackling gestational hypertriglyceridemia.