SESSION TYPE: Critical Care Cases II
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Familial hypertriglyceridemia is a known cause of acute pancreatitis especially when serum triglycerides level exceeds 1,000 mg/dl (ref1). Due to hormonal influences, pregnancy can dysregulate otherwise controlled lipid levels in women with familial hypertriglyceridemia, and predispose them to acute pancreatitis, which can lead to a significant morbidity in both the mother and fetus.
CASE PRESENTATION: A 24-year-old, non smoker non alcoholic, pregnant female G9P2+6 (gestational age: 28 weeks), with past medical history of hypertriglyceridemia type IV and recurrent fetal demises related to gestational hypertriglyceridemia induced acute pancreatitis (GHIP), presented to the emergency department with s epigastric pain and vomiting. Physical examination showed epigastric tenderness with normal fundal height and a closed cervix. Lab results showed a triglyceride level of 2661 mg/dl (normal, 40-200 mg/dl), serum amylase of 802 U/L (25-125 U/L), and an elevated prothrombin time (PT) at 19.4 seconds (10-13 seconds). Ultrasonography of the abdomen revealed pancreatic calcifications, peripancreatic edema and a viable fetus (fig1). Patient was started on conservative management and further underwent nine sessions of therapeutic plasmapheresis throughout pregnancy to decrease triglyceride level to less than 1000 mg/dl (fig2). Each session consisted of a single plasma volume (3,522 ml) exchange with 5% albumin replacement. The first session resulted in a greater than 80% reduction of triglycerides level while subsequent sessions showed less response. At 35 weeks, the response was abolished, and patient underwent cesarean section with delivery of a healthy preterm male infant. She was discharged on benzofibrate and nicotinic acid.
DISCUSSION: Total serum cholesterol and triglyceride levels increase markedly during pregnancy due to two factors: increased hepatic lipase activity, and reduced lipoprotein lipase activity. These changes take place mostly in the third trimester, increasing the need for further plasmapharesis sessions with advancing pregnancy. Elevated triglycerides level can falsely elevate PT measurements, as was seen in two occasions with return to normal values following plasmapheresis (ref2).Treatment of GHIP includes plasmapheresis, insulin infusion, and heparin infusion (ref3).
CONCLUSIONS: Plasmapheresis is a safe and effective approach to treat GHIP and prevent maternal and fetal bad outcome. More case reports and trials are needed to study the effect of its prophylactic use in such cases.
1) Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin North Am. Dec 1990;19(4):783-791
2) Kamal AH et al. How to interpret and pursue an abnormal prothrombin time, activated partial thromboplastin time, and bleeding time in adults. Mayo Clin Proc. Jul 2007;82(7):864-873.
3) Sivakumaran P et al. Management of familial hypertriglyceridemia during pregnancy with plasma exchange. J Clin Apher. 2009;24(1):42-46.
DISCLOSURE: The following authors have nothing to disclose: Fadi Safi, Mahmoud Qa'dan, Anis Toumeh, Ragheb Assaly
No Product/Research Disclosure InformationUniversity of Toledo, Toledo, OH