Endocrine Abstracts

Case history: A 35-year-old woman with known hypertriglyceridaemia presented with a one day history of abdominal pain, vomiting and fever. She was 14 weeks pregnant having conceived spontaneously following a period of infertility. She had discontinued her lipid-lowering medication and was managed with diet alone. On examination, she was pyrexial, tachycardic (HR=100 bpm), normotensive (BP=111/71 mmHg), oxygen saturation was 96% on air and she had a tender distended abdomen. A fetal US confirmed a viable pregnancy. She was diagnosed with acute pancreatitis. Initial management was conservative but she developed acute respiratory distress syndrome (ARDS), requiring respiratory support and transfer to the intensive care unit.

Investigations: Venous blood gas showed a mild acidosis (pH 7.338), raised lactate (3.2 mmol/l) and glucose of 7.6 mmol/l. Blood investigations were limited by high levels of triglycerides precluding automated measurement. After multiple dilutions, triglyceride level was confirmed at 115 mmol/l and lipase level at 293 U/l. A CT abdomen demonstrated extensive peri-pancreatic fluid collections and peri-pancreatic fat stranding in keeping with acute necrotising pancreatitis presumed secondary to hypertriglyceridaemia.

Results and treatment: Initial management was focused on lowering the triglyceride levels. She was started on an intravenous insulin and heparin infusion and transferred to a tertiary centre for consideration of plasmapharesis. Her triglyceride level fell to 5.1 mmol/l with insulin and heparin alone. Plasmapheresis was not required. She was started on Fenofibrate, high-dose Omega3 and a low-fat diet which has maintained her triglyceride level below 5 mmol/l (currently 2.8 mmol/l). She subsequently developed a distended gallbladder and septicaemia requiring intravenous Tazocin, a gallbladder drain and a period of parenteral nutrition. Medical termination of pregnancy was discussed as a potential option to ensure maternal survival. She is currently 23 weeks gestation, approaching viability, with a growth scan showing normal growth but reduced uterine-artery-dopplers suggesting an increased risk of fetal-growth-restriction and placental insufficiency. Her care is being co-ordinated by a multidisciplinary team including hepatobiliary, obstetrics and metabolic medicine teams.

Conclusions and points for discussion: Acute pancreatitis in pregnancy has a high morbidity and mortality rate for both mother and fetus. Due to medical and ethical challenges, such cases must be managed via the multidisciplinary team. This case highlights the efficacy of insulin and heparin in lowering triglyceride levels. Plasmapheresis remains an option where triglycerides do not fall. It also highlights the importance of pre-conception care and effective use of diet, Omega3 and Fenofibrate in lowering triglyceride levels during pregnancy.