Familial hypertriglyceridaemia and type 2 diabetes in pregnancy: prevention of acute pancreatitis with diet control and omega-3 fatty acids

Management of Severe Hypertriglyceridemia in Pregnancy With Niacin: Reevaluating Safety and Therapeutic Benefits

Background: Severe hypertriglyceridemia (triglycerides (TGs) >1000 mg/dL, >11.3 mmol/L) is a rare but potentially morbid condition in pregnancy. Physiological changes in pregnancy may unmask or exacerbate an underlying defect in TG metabolism. When conventional therapies are ineffective in controlling TG levels, a personalized management approach is needed. We present a case of severe hypertriglyceridemic pancreatitis successfully managed with niacin, a treatment that has seen limited use in pregnancy due to the paucity of available data. Case Presentation: A 29-year-old pregnant woman with a history of cholecystectomy and a prepregnancy BMI of 30.6 kg/m2 presented at 12 weeks' gestation with acute pancreatitis and severe hypertriglyceridemia (6900 mg/dL, 77.9 mmol/L). After initial management with intravenous (IV) fluids, insulin infusion, and a low-fat diet, her TG levels improved. However, she was readmitted at 23 weeks' gestation with recurrent hypertriglyceridemia (2872 mg/dL, 32.4 mmol/L), requiring a more aggressive insulin regimen. Despite various interventions, including omega-3 fatty acids (O3FAs), fenofibrate, and central venous catheter insulin infusion, her TG levels remained elevated, necessitating early delivery at 34 weeks' gestation. Her postpartum recovery included continued TG management with fenofibrate and O3FAs. Four years later, during a second pregnancy, she presented with similar hypertriglyceridemia, managed with diet, metformin, fenofibrate, and insulin. Due to persistent hypertriglyceridemia (>3000 mg/dL, 33.9 mmol/L), niacin was added as an additional therapy and titrated to 2000 mg/day, which successfully sustained TG levels below 1000 mg/dL (11.3 mmol/L) through the remainder of her pregnancy. She delivered her second child via cesarean section at 35 weeks' gestation due to preeclampsia. Both children had developmental issues, with her first child diagnosed with attention-deficient hyperactivity disorder (ADHD) and her second child with autism spectrum disorder and motor delays. The patient was encouraged to remain on long-term management for her metabolic condition. Conclusions: Managing severe hypertriglyceridemia during pregnancy is challenging due to uncertainties about treatment efficacy and safety. Timely reduction of maternal TGs is essential to prevent complications and requires adjustments throughout pregnancy. This case demonstrates the effectiveness and safety of niacin, often underutilized due to perceived side effects, in managing severe hypertriglyceridemia in pregnancy when other treatments were inadequate.

Dyslipidemia in Pregnancy: A Systematic Review of Molecular Alterations and Clinical Implications

BACKGROUND

Dyslipidemia in pregnancy presents unique clinical challenges due to its effects on maternal and fetal health. This systematic review hypothesizes that molecular alterations in lipid metabolism during pregnancy contribute to adverse pregnancy outcomes and seeks to identify the clinical implications of these changes. The rationale behind this review stems from the increased risk of complications such as preeclampsia, intrauterine growth restriction, and acute pancreatitis associated with dyslipidemia in pregnancy. The primary objective is to examine the interplay between lipid metabolism and pregnancy outcomes.

METHODS

To achieve this, a systematic review following PRISMA guidelines was conducted, with a comprehensive search of the PubMed database covering articles from January 2014 to June 2024. Inclusion criteria focused on studies assessing molecular alterations and clinical outcomes of dyslipidemia in pregnancy, while case reports and relevant clinical trials were analyzed to evaluate both maternal and fetal outcomes. A total of 12 studies were included in the final analysis.

RESULTS

This study provided evidence of the need for early detection and management strategies to reduce risks. The outcomes revealed significant associations between dyslipidemia and adverse maternal outcomes such as preeclampsia, gestational diabetes, and pancreatitis, as well as fetal outcomes like preterm birth and fetal distress.

CONCLUSIONS

Early lipid monitoring and intervention are crucial in mitigating these risks and suggests that a multidisciplinary approach is necessary to improve maternal and fetal health in pregnancies complicated by dyslipidemia.

Acute Pancreatitis in Pregnancy: A Propensity Score Matching Analysis and Dynamic Nomogram for Risk Assessment

BACKGROUND

Acute pancreatitis is easily confused with abdominal pain symptoms, and it could lead to serious complications for pregnant women and fetus, the mortality was as high as 3.3% and 11.6-18.7%, respectively. However, there is still lack of sensitive laboratory markers for early diagnosis of APIP and authoritative guidelines to guide treatment.

OBJECTIVE

The purpose of this study was to explore the risk factors of acute pancreatitis in pregnancy, establish, and evaluate the dynamic prediction model of risk factors in acute pancreatitis in pregnancy patients.

STUDY DESIGN

Clinical data of APIP patients and non-pregnant acute pancreases patients who underwent regular antenatal check-ups during the same period were collected. The dataset after propensity matching was randomly divided into training set and verification set at a ratio of 7:3. The model was constructed using Logistic regression, least absolute shrinkage and selection operator regression, R language and other methods. The training set model was used to construct the diagnostic nomogram model and the validation set was used to validate the model. Finally, the accuracy and clinical practicability of the model were evaluated.

RESULTS

A total of 111 APIP were included. In all APIP patients, hyperlipidemic pancreatitis was the most important reason. The levels of serum amylase, creatinine, albumin, triglyceride, high-density lipoprotein cholesterol, and apolipoprotein A1 were significantly different between the two groups. The propensity matching method was used to match pregnant pancreatitis patients and pregnant non-pancreatic patients 1:1 according to age and gestational age, and the matching tolerance was 0.02. The multivariate logistic regression analysis of training set showed that diabetes, triglyceride, Body Mass Index, white blood cell, and C-reactive protein were identified and entered the dynamic nomogram. The area under the ROC curve of the training set was 0.942 and in validation set was 0.842. The calibration curve showed good predictive in training set, and the calibration performance in the validation set was acceptable. The calibration curve showed the consistency between the nomogram model and the actual probability.

CONCLUSION

The dynamic nomogram model we constructed to predict the risk factors of acute pancreatitis in pregnancy has high accuracy, discrimination, and clinical practicability.

Pancreatitis in Pregnancy-Comprehensive Review

Acute and chronic pancreatitis, until recently observed incidentally in pregnancy, has occurred much more frequently in the last 2-3 decades. Particularly severe complications for the mother and fetus may be a consequence of acute pancreatitis. Therefore, it is important to know more about the diagnostic and therapeutic possibilities of pancreatic diseases in the course of pregnancy. Epidemiology, causes, clinical characteristics, differential diagnosis, and complex management are presented in this review. Particular emphasis is on the prevention of acute pancreatitis (AP) through the proper diagnosis and treatment of cholelithiasis and hypertriglyceridemia, both before and during pregnancy. The most up-to-date reports and management strategies are presented. This publication contributes to a wide group of scientists and practitioners better understanding the discussed issues, and indicates the directions of research for the future.

Efficacy of insulin in treating severe hypertriglyceridaemia in the third trimester of pregnancy

This study aims to investigate the efficacy of insulin in treating severe hypertriglyceridaemia (HTG) during the third trimester of pregnancy. Women with severe HTG (TG ≥ 11.30 mmol/L) in the third trimester of pregnancy who received clinical examination and delivered in Hubei Maternal and Child Health Hospital from 01 January 2017 to 30 September 2021 were recruited. Patients with TG ≥ 11.30 mmol/L at 30–32 weeks of gestation were treated with a low-fat diet and insulin as the insulin treatment group. For the control group, patients with TGs of 5.65–11.30 mmol/L at 30–32 weeks of gestation who developed severe HTG (TG ≥ 11.30 mmol/L) before delivery were treated with a low-fat diet only. General maternal information, delivery, perinatal treatment and laboratory examination information were collected from electronic medical records and compared. We found that in the insulin treatment group, there were higher values of progestational body mass index (BMI) (Z = −2.281, P = 0.023), higher incidence of diabetes (χ2 = 20.618, P < 0.001) and higher incidence of fatty liver (χ2 = 4.333, P = 0.037) than in the control group but also a higher pregnancy weight gain compliance rate (χ2 = 4.061, P = 0.044). Laboratory examination before delivery revealed that compared with the control group, insulin treatment significantly decreased prenatal TG (Z = −10.392, P < 0.001), cholesterol (Z = −8.494, P < 0.001), low-density lipoprotein (Z = −3.918, P < 0.001), apolipoprotein A1 (t = 2.410, P = 0.019), cystatin (Z = −4.195, P < 0.001), incidence of hypocalcaemia (P = 0.036), and absolute number of lymphocytes (Z = −3.426, P = 0.001). Delivery outcomes were also improved in the insulin treatment group compared with the control group, including lower neonatal weight (Z = −2.200, P = 0.028), incidence of macrosomia (χ2 = 4.092, P = 0.043), gestational age (Z = −3.427, P = 0.001), and rate of intensive care unit (ICU) conversion (P = 0.014). In conclusion, insulin therapy for HTG in the third trimester of pregnancy could increase the pregnancy weight gain compliance rate, decrease blood lipid levels and the incidence of severe complications such as HTG acute pancreatitis (HTG-AP), and improve pregnancy outcomes.

Mendelian randomization in blood metabolites identifies triglycerides and fatty acids saturation level as associated traits linked to pancreatitis risk

Background

There is very limited evidence on the causal effects of blood metabolites on pancreatitis risks. To reveal the causal associations between plasma metabolites and pancreatitis risks, we performed two-sample Mendelian randomization (MR) and Bayesian model averaging (MR-BMA) analyses in European ancestry.

Methods

The summary-level statistics from two genome-wide association studies with 249 and 123 metabolic traits derived from two separate cohorts involving ~115,000 (UK Biobank) and ~25,000 individuals from European ancestry were used for the analyses. The summary statistics of four pancreatitis datasets from FinnGen R5 and two pancreatitis datasets from UK Biobank were exploited as the outcome. We first performed univariable MR analysis with different metabolic GWAS data on multiple pancreatitis datasets to demonstrate the association pattern among different metabolites categories. Next, we exploited the MR-BMA method to pinpoint the dominating factors on the increased risk of pancreatitis.

Results

In the primary analysis with 249 traits, we found that plasma triglycerides were positively associated with pancreatitis risk. Intriguingly, a large number of traits associated with saturation or unsaturation of fatty acids also demonstrated causal associations. The replication study analyzing 123 metabolic traits suggested that bisallylic groups levels and omega-3 fatty acids were inversely correlated with pancreatitis risk. MR-BMA analyses indicated that the ratio of triglycerides to total lipid in various HDL particles played leading roles in pancreatitis susceptibility. In addition, the degree of unsaturation, the ratio of polyunsaturated fatty acids to monounsaturated fatty acids and the level of monounsaturated fatty acids showed causal associations with either decreased or increased pancreatitis susceptibility.

Conclusions

Our MR study provided an atlas of causal associations of genetically predicted blood metabolites on pancreatitis, and offered genetic insights showing intervention in triglycerides and the supplementation of unsaturated fatty acids are potential strategies in the primary prevention of pancreatitis.