Background: Severe hypertriglyceridemia in pregnancy is a rare but potentially life-threatening entity through precipitating acute pancreatitis, hyperviscosity syndrome and/or pre-eclampsia. Triglycerides and total cholesterol increase in the third trimester in response to changes in levels of oestrogen, progesterone and human placental lactogen. This can exacerbate any pre-existing abnormalities of lipid metabolism.
Case: A 31yo lady, G2P0, with unremarkable personal or family history, presented with acute pancreatitis at 26/40. Triglycerides were grossly elevated at 87.3mmol (NR <2.5mmol/L). The patient was managed with an insulin-dextrose infusion, gemfibrozil 600mg twice a day (TGA category B3), fish oil 9g, and a low-fat moderate carbohydrate diet sufficient for the nutritional requirements of pregnancy. She was discharged when triglyceride levels were 9mmol/L then monitored with weekly lipid profile and clinical review. A pre-emptive plan for plasmapheresis was developed for consideration if triglycerides again rose above 20mmol/L. Growth scans were reassuring. Despite treatment, triglycerides rose to 14 mmol/L at 35+4/40. Induction was performed at 37+1 weeks. The baby was healthy weighing 3325g with Apgar scores of 9, 9. Genetic test results for hypertriglyceridemia associated mutations are pending.
Discussion: Severe gestational hypertriglyceridaemia is associated with significant risk of adverse fetal and maternal adverse outcomes. In this case, an insulin-dextrose infusion was effective as the mainstay of acute therapy. Dietary measures, fish oil and gemfibrozil were successful in managing the patient to term with no noted ill-effects on the fetus. Plasmapheresis is beneficial in refractory cases of hypertriglyceridaemia but was not required in our case. A multidisciplinary approach including endocrinologists, obstetricians, dieticians and haematologists assisted to achieve a successful outcome. Further research is required to determine optimal evidence-based screening, treatment and prevention. Genetic testing provides an opportunity to look for underlying defects and thus plan care for future pregnancies and screening of family members.