Abstract 4360739: Severe Hypertriglyceridemia in Pregnancy: A Case Highlighting Therapeutic Challenges

Introduction: Severe hypertriglyceridemia (HTG) in pregnancy increases the risk of acute pancreatitis and preeclampsia, carrying a high maternal and fetal mortality rate. Management of severe HTG during pregnancy is challenging, as pharmacologic options are limited due to potential fetal risks. Description of Case: A 34-year-old G1P000 woman with type 2 diabetes mellitus and HTG was referred to cardio-obstetrics clinic at 16 weeks of gestation with a triglyceride (TG) level of 1,562 mg/dL. Prior to conception, she had been treated with a biguanide for diabetes and a combination of fish oil, fenofibrate, and a statin for HTG, which were discontinued for fetal safety. Given the markedly elevated TG level, a multidisciplinary decision was made to urgently reinitiate lipid-lowering therapy with omega-3 acid ethyl esters 4g daily (Lovaza) and subcutaneous insulin glargine. In addition, she received counseling on lifestyle modification, including a low-fat, low-carbohydrate diet and a goal of 150 minutes of moderate physical activity per week. At two-month follow-up, her TG level had significantly improved to 328 mg/dL, with a further decrease to 287 mg/dL by four months without maternal or fetal complications. Discussion: This case highlights the complexities involved in managing HTG during pregnancy. While total cholesterol and TG levels naturally increase throughout pregnancy, levels typically remain below 250 mg/dL. Traditional lipid-lowering agents, including statins, PCSK9 inhibitors, ezetimibe, bempedoic acid, and lomitapide, are generally avoided during pregnancy due to limited fetal safety data. In high-risk women with dyslipidemia, an individualized treatment approach can include insulin and omega 3 fatty ethyl esters or even LDL apheresis to prevent life-threatening complications. Lifestyle modification with a low-fat diet and omega-3 fatty acids must be balanced with both maternal and fetal nutritional needs to prevent abnormal fetal development. Thus, cardio-obstetric management of high-risk women with metabolic disorders should center around preconception risk assessment, multidisciplinary care, intensive lifestyle modification, selective use of non-statin agents or apheresis, and vigilant monitoring throughout pregnancy. There remains a significant gap in evidence regarding the safety and efficacy of lipid-lowering therapies during pregnancy, underscoring the urgent need for further research to guide management of severe HTG in pregnancy.