Total Parenteral Nutrition in Management of Hyperlipidemic Pancreatitis During Pregnancy

SEVERE HYPERTRIGLYCERIDEMIA IN PREGNANCY: A CASE REPORT AND REVIEW OF THE LITERATURE

Objective

Severe gestational hypertriglyceridemia is a rare disease, and there are no published guidelines to assist the clinician in management. However, due to the elevations in lipids that occur during pregnancy, this condition is encountered in clinical practice and presents a therapeutic dilemma. We report the successful management and treatment of a patient with severe gestational hypertriglyceridemia and conducted a review of the literature regarding treatment modalities.

Methods

We conducted a search in PubMed from 1990 to 2018 for the following terms: "severe hypertriglyceridemia in pregnancy;" "management of hypertriglyceridemia in pregnancy;" "apheresis for severe gestational hypertriglyceridemia;" "TPN for severe gestational hypertriglyceridemia;" "insulin for severe gestational hypertriglyceridemia;" and "heparin for treatment of severe hypertriglyceridemia." We then reviewed the literature.

Results

Given the risks to the mother and fetus of severe hypertriglyceridemia, aggressive therapy should be initiated within a multidisciplinary team. There are multiple treatment modalities, including restrictive diet, various medications such as niacin, fibrates, intravenous heparin, insulin, and apheresis. Choice of treatment will depend on the patient's comorbidities, clinical status, and if there are any associated complications.

Conclusion

Treatment for severe gestational hypertriglyceridemia should be initiated immediately and aggressively to avoid risk to the mother and infant, including pancreatitis, hyperviscosity syndrome, preeclampsia, fetal death, and preterm labor.

Diagnosis and treatment of severe hypertriglyceridemia

Severe hypertriglyceridemia is associated with acute pancreatitis and can be a manifestation of lipoprotein lipase (LPL) deficiency. It is associated with a spectrum of disorders, ranging from heterozygous LPL deficiency allied with environmental factors to rare severe cases of homozygous LPL deficiency. The genes associated with reduced LPL activity include LPL, its cofactor apoC-2, a controlling protein apoA-5 and the LPL receptor GPI-HBP1. The effects of mutations are exacerbated by environmental factors such as diet, pregnancy and insulin resistance. Treatment of clinical LPL deficiency is by ultra-low-fat diet along with the use of fibrates, omega-3 fatty acids, niacin, statins and insulin-sensitizing therapies, depending on the extent of residual LPL activity. Novel therapies that target lipoprotein particle assembly through the antisense oligonucleotides or by interference with triglyceride-loading microsomal transport protein inhibitors offer new potential options for treating hypertriglyceridemia.