Poster Presentation - SOMANZ ASM Society of Obstetric Medicine of Australia and New Zealand ASM 2023

Managing severe gestational hypertriglyceridaemia: lessons from a complex case (#68)

Umesha Pathmanathan 1 , Abigail Anderson 2 , Suji Prabhaharan 1 , David Watson 2 , Kunwarjit Sangla 1 3
  1. Obstetric Medicine , Townsville University Hospital , Townsville , QLD, Australia
  2. Obstetrics and Gynaecology, Townsville University Hospital , Townsville , QLD, Australia
  3. James Cook University, Townsville, QLD, Australia

Introduction

Lipid homeostasis significantly changes during pregnancy to ensure adequate nutritional support to the foetus. This includes an average 2-4-fold increase in triglycerides by the third trimester.  Usually, this is well tolerated by women with normal baseline triglyceride levels and metabolic pathways [1]. However, in the presence of genetic abnormalities affecting triglyceride metabolism or secondary exacerbating factors such as medications or uncontrolled diabetes; severe gestational hypertriglyceridaemia can occur [2].  This poses significant maternal and foetal risk, including that of acute pancreatitis, hyperviscosity syndrome and pre-eclampsia [3, 4].  Although requiring aggressive treatment to optimise outcomes, the existing management practices rely on observational data and case reports, revealing a gap in the available literature [5].

Case Report

We report the case of a 39-year-old female, G4P2T1 31+5 weeks gestation, living in regional Queensland.  She was transferred to a rural tertiary referral centre with Maternal Foetal Medicine and Obstetric Medicine expertise after an incidental finding of severe hypertriglyceridaemia [41.4mmol/L (<1.5mmol/L)] on routine bloods.  Her pregnancy-related complications included a new diagnosis of both pre-eclampsia and diet-controlled gestational diabetes mellitus (GDM), with a large for gestational age (LGA) foetus on a 31-week ultrasound, measuring at the 93rd centile.  She was also treated with therapeutic enoxaparin after a presentation with pulmonary embolism at 27-weeks gestation.  Her past medical history is pertinent for class III obesity and smoking. 

On admission, she was commenced on a low fat, low carbohydrate diet and high dose fish oil two grams twice daily.  She declined fibrate therapy.  She was placed on an insulin infusion, titrated to 3-5 units per hour according to her blood glucose readings, with 5% dextrose as background maintenance fluids.  There was initial improvement of her triglycerides to a nadir at 18.7mmol/L and a decision was made to commence plasmapheresis at 32+4 weeks.  She required three plasmapheresis sessions before being successfully discharged at 33+3 weeks gestation with triglycerides of 5.7mmol/L.   She was regularly monitored in the community, with weekly plasmapheresis sessions aiming to maintain triglycerides to less than 11mmol/L.  Her blood pressure remained well controlled on anti-hypertensives during this period.   She went on to deliver a healthy term infant at 37+0 weeks gestation via an elective repeat lower uterine caesarean section. 

Discussion Points

  1. Indications for checking and monitoring triglycerides in pregnancy to capture gestational hypertriglyceridaemia
  2. Options and dilemmas for managing hypertriglyceridaemia during pregnancy – both gestation and pre-existing
  3. Monitoring and predicting outcomes of pregnancy with severe hypertriglyceridemia
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  2. Wong, B., T.C. Ooi, and E. Keely, Severe gestational hypertriglyceridemia: A practical approach for clinicians. Obstet Med, 2015. 8(4): p. 158-67.
  3. Kleess, L.E. and N. Janicic, Severe Hypertriglyceridemia in Pregnancy: A Case Report and Review of the Literature. AACE Clin Case Rep, 2019. 5(2): p. e99-e103.
  4. Wiznitzer, A., et al., Association of lipid levels during gestation with preeclampsia and gestational diabetes mellitus: a population-based study. Am J Obstet Gynecol, 2009. 201(5): p. 482 e1-8.
  5. Gupta, M., et al., Prevention and Management of Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Systematic Review. Am J Med, 2022. 135(6): p. 709-714.