Pancreatits Associated with Severe Hypertriglyceridemia in Pregnancy Treated with Plasmapheresis

Presentation Number: SAT 509
Date of Presentation: April 1st, 2017

Francisco Cordero*1, Alejandra Lanas2 and Jorge Alfaro3
1Clínica Davila, 2Hospital Clínico Universidad de Chile, Santiago, Chile, 3Clinica Davila

Abstract

Background: During pregnancy serum triglyceride (TG) increase, however levels usually remain <300 mg/dl. In women with genetic forms of hypertriglyceridemia, pregnancy may cause extremely elevated TG levels leading to potentially life-threatening pancreatitis. The only safe medical treatment during pregnancy is omega 3 fatty acids, which have a moderate effect. Therapeutic apheresis could be used in particular cases during pregnancy.

Clinical case: A 30 years old female diagnosed in childhood with primary hypertriglyceridemia. No family history of dyslipidemia. Clinical history of acute pancreatitis associated to hypertriglyceridemia in 2008. At clinical examination BMI 19 kg/m2, without skin xantomas, no signs of insulin resistance, normal ocular fundus.

After pancreatitis treatment with fibrates was initiated. On clinical course the treatment was adjusted several times and Omega-3 were added with partial response. At June 2012, patient suspended treatment because of pregnancy. She was evaluated at week 12. Laboratory tests demonstrated: TG 3010mg/dl and glycemia 74 mg/dl.

A 1600 kcal diet with 150g fractionated carbon hydrates without sucrose and medium chain fatty acids 15-20% was initiated. She started omega 3 (EPA 300mg DHA 300mg) 2 tablets every 8 hours and topical sunflower oil. At week 13 fenofibrate 200mg was added. Treatment response was poor and TG reached 9186 mg/dL. She started orlistat 120mg with each meal and metformin was added to reduce any influence of physiological insulin resistance of pregnancy on triglycerides.

At week 24 she presented with abdominal pain and was admitted to hospital. Laboratory test demonstrate lipase 1176 IU/L (<160) and TG 4293 mg/dl. Abdominal ecography showed signs of pancreatitis. The clinical course was complicated with severe abdominal pain, persistent tachycardia and inflammatory parameters increased. Given the severity of the case plasmapheresis was programmed. Two plasmapheresis were made lowering TG to 245 mg/dl, with marked clinical improvement.

A week later TG raised and serial plasmapheresis were programmed. Medical therapy was restarted. Patient is discharged after the third plasmapheresis. Weekly control of TG and plasmaréresis scheduled approximately every 2 weeks to keep triglycerides under 3000 mg/dl. A total of 9 plasmapheresis were performed. At week 37 she was hospitalized for elective caesarean section after the last plasmaferesis. Newborn was healthy without complications.

Clinical conclusions: In pregnancy severe hypertrigliceridemia therapy should include a multidisciplinary team, dietary fat restriction, appropriate supplements and pharmacological therapy. Plasmapheresis is an alternative for cases resistant to medical treatment and severe cases associated to pancreatitis. We successfully used plasmapheresis to manage hypertriglyceridemia-induced pancreatitis during pregnancy.

 

Nothing to Disclose: FC, AL, JA