University of Kansas Medical Center, Kansas, United States
Background/Case Studies: Hypertriglyceridemia (HTg) during pregnancy increases the risk of gestational diabetes, preeclampsia, and acute pancreatitis (AP), risking maternal and fetal mortality. Patients with pre-existing HTg have increased risk and, even with optimized diet and medications, may experience progressively increasing triglyceride (Tg) levels. Therapeutic plasmapheresis (TPE) has been shown to rapidly reduce Tg levels. A small number of cases have reported on the use of TPE for the treatment of HTg-induced AP in pregnancy, generally with positive maternal-fetal outcomes, but rarely address preventative TPE in this setting. This report aims to demonstrate the use of preventative TPE as a successful bridge to delivery.
Study
Design/Methods: The clinical case is reported from a retrospective review of combined laboratory data, clinical management, specialist consultation, and available literature.
Results/Findings: A 23-year-old pregnant female was referred for management of progressive HTg up to 3438 mg/dL by 28 weeks gestation (GA). She had a history of polycystic ovarian syndrome, recurrent pregnancy loss, type 2 diabetes mellitus, HTg, and necrotizing AP leading to distal pancreatectomy. Adherence to a prescribed diet, fatty acid supplementation, and combination insulin therapy maintained glucose control with a hemoglobin A1c of 5.4% even as Tg concentration increased. The addition of gemfibrozil and pravastatin statin at 24 – 26 weeks GA had no appreciable effect. Given the patient’s high risk for recurrent necrotizing AP and limited remaining pancreatic parenchyma, she was treated acutely with two single-plasma-volume exchanges using 100% albumin in two days, decreasing the Tg level to 559 mg/dL. Subsequent TPE maintained a Tg level of 320 – 1296 mg/dL using a seven-to-nine-day treatment interval for a total of eight treatments (see Table 1). The patient experienced no adverse effects and remained outpatient with close observation for hypertension until successful scheduled delivery at 33 weeks GA. Conclusions: For select patients, early escalation to TPE may prevent significant morbidity or mortality. This case demonstrates a successful individualized TPE regimen serving as a bridge to delivery, which requires coordination of a multidisciplinary team.
Importance of research: HTg is a rare cause of AP in pregnancy that risks poor maternal-fetal outcomes. Patients with a predisposition to HTg-induced AP require early intervention and close follow up to determine appropriate escalation of care, including initiation of TPE. The reported case highlights the lack of foundational research to guide the use of TPE to manage HTg in pregnancy and adds to the limited collection of cases describing successful preventative control of Tg levels using TPE.
