Pregnancies Complicated by Familial Hypertriglyceridemia: A Case Report

Obstetrical Management of Severe Hypertriglyceridemia in Pregnancy: A Case Report

Background  Pregnant people with baseline hypertriglyceridemia are at increased risk of severe hypertriglyceridemia and the associated complications, yet there are no formal recommendations to guide management of these patients during pregnancy. Case  We report a case of a patient with presumed familial hypertriglyceridemia who was taken off triglyceride-lowering medications preconception and developed acute pancreatitis at 23 weeks of gestation. She was managed with a very-low-fat diet, exercise, fenofibrate, omega-3-fatty acids, pravastatin, insulin infusion, and plasmapheresis. She delivered at 33 weeks of gestation after presenting with a placental abruption and subcapsular liver hematoma associated with HELLP (hemolysis, elevated liver enzyme levels, and low platelet) syndrome. Conclusion  While rare in pregnancy, severe hypertriglyceridemia is associated with serious maternal risks. Preconception and antepartum obstetric management should incorporate shared decision-making considering both the potential fetal risks of treatment and the objective maternal risks of untreated disease.

Dyslipidemia management in women of reproductive potential: An expert clinical consensus from the national lipid association

Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.

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.

Perinatal outcomes in pregnancies complicated by acute pancreatitis

OBJECTIVES

Acute pancreatitis is a rare condition that can be associated with significant complications. The objective of this study is to evaluate the maternal and newborn outcomes associated with acute pancreatitis in pregnancy.

METHODS

A retrospective cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from the United States was performed. All pregnant patients with acute pancreatitis were identified using International Classification of Disease-9 coding from 1999 to 2015. The effect of acute pancreatitis on maternal and neonatal outcomes in pregnancy was evaluated using multivariate logistic regression, while adjusting for baseline maternal characteristics.

RESULTS

From 1999 to 2015, there were a total of 13,815,919 women who gave birth. There were a total of 14,258 admissions of women diagnosed with acute pancreatitis, including 1,756 who delivered during their admission and 12,502 women who were admitted in the antepartum period and did not deliver during the same admission. Acute pancreatitis was associated with increased risk of prematurity, OR 3.78 (95% CI 3.38-4.22), preeclampsia, 3.81(3.33-4.36), postpartum hemorrhage, 1.90(1.55-2.33), maternal death, 9.15(6.05-13.85), and fetal demise, 2.60(1.86-3.62) among women diagnosed with acute pancreatitis. Among women with acute pancreatitis, delivery was associated with increased risk of requiring transfusions, 6.06(4.87-7.54), developing venous thromboembolisms, 2.77(1.83-4.18), acute respiratory failure, 3.66(2.73-4.91), and disseminated intravascular coagulation, 8.12(4.12-16.03).

CONCLUSIONS

Acute pancreatitis in pregnancy is associated with severe complications, such as maternal and fetal death. Understanding the risk factors that may lead to these complications can help prevent or minimize them through close fetal and maternal monitoring.

Insulin Treatment of Hypertriglyceridemia During Pregnancy

Objective: This study aims to investigate the efficiency of insulin on the reduction of gestational lipid profiles and try to propose a real-world approach to assist clinicians.

Methods: A retrospective, single-centered cohort study of 35 cases was conducted from October 2018 to July 2021 in Shanghai General Hospital. SPSS version 25.0 was performed to analyze the whole data. For continuous variables, a paired-sample t test was carried out on each variable to make a comparison between before and after treatment.

Results: The average pre-pregnancy TGs and TCs of these patients were about 3.96 ± 1.42 mmol/L and 4.78 ± 1.18 mmol/L, respectively. The maximum of TG before insulin treatment was up to 64.62 and TC 20.43 mmol/L, which decreased to 17.34 and 4.92 mmol/L after intervention of the insulin drip. TG was noticed to fall by 77% and 12.71% of TG, respectively. The difference of TG and TC between pre-treatment and post-treatment were statistically significant (p < 0.01), while this difference has not been found in the other laboratory tests reports. The outcomes of newborns and mothers with management of insulin were proven to be improved.

Conclusion: The use of insulin in the management of gestational hypertriglyceridemia is safe and efficient, and insulin may become a mainstream in the near future to mitigate serum TG and TC levels in the pregnancy period besides regulating the blood glucose level.

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.

Case Report: Management of a Patient With Chylomicronemia Syndrome During Pregnancy With Medical Nutrition Therapy

Background: Hypertriglyceridemia (HTG) during pregnancy may be accompanied by acute pancreatitis, hyperviscosity syndrome, and preeclampsia. HTG during pregnancy should be managed by a multidisciplinary team; however, no clinical guidelines exist for severe gestational HTG.

Case Presentation: We herein present a case of a 36-year-old in the first pregnancy (G1P0Ab0), with a history of severe HTG-induced necrotizing pancreatitis 9 years earlier. There was no family history of HTG. During these years, she did not follow any appropriate diet or medical therapy for HTG. She became pregnant in May 2019, without preconception counseling. Eruptive and tuberoeruptive xanthomas appeared in the 27th week of pregnancy. Serum triglycerides (TGs) and fasting blood sugar (FBS) were 6,620 and 124 mg/dL, respectively, indicating HTG and gestational diabetes (GDM). After admission for the management of severe HTG, she was put on parenteral nutrition with dextrose water 5% and infusion insulin therapy without receiving any enteral carbohydrate for 2 days. Following that, a very low-fat diet and omega-3 fatty acids (1,200 mg/day) were started. After 4 weeks, TG levels reached 1,000 mg/dL, and her self-monitoring blood glucose levels showed appropriate blood glucose for pregnancy. She underwent a successful elective cesarean section in the 39th of pregnancy.

Conclusion: This case report demonstrates that HTG during pregnancy could be managed by medical nutrition therapy (MNT).

Inherited metabolic disorders and dyslipidaemia

Monogenic dyslipidaemia is a diverse group of multisystem disorders. Patients may present to various specialities from early childhood to late in adult life, and it usually takes longer before the diagnosis is established. Increased awareness of these disorders among clinicians is imperative for early diagnosis. This best practice review provides an overview of primary dyslipidaemias, highlighting their clinical presentation, relevant biochemical and molecular tests. It also addresses the emerging role of genetics in the early diagnosis and prevention of these disorders.