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Acute Hypertriglyceridemia Pancreatitis in Term Pregnancy: a case report
Abstract Number: RF2BB-181
Abstract Type: Case Report Case Series
Acute pancreatitis (AP) is rare in pregnancy but can cause serious maternal and fetal morbidity. Patients with familial hypertriglyceridemia (HTG) can develop acute gestational pancreatitis (4-56%) due to increased triglycerides (TG) during pregnancy.
40 y female G2P0 at 36w1d presented with severe epigastric abdominal pain radiating to the back found to have AP. She had a family history of HTG, but had never been tested herself. Her initial labs revealed elevated TG of 7000mg/dl, lipase of >400 U/L and absence of gallstones on ultrasound. She was transferred to the ICU due to the severity of her epigastric pain, compensated anion gap metabolic acidosis with a pH of 7.29 and associated hypocalcemia. Fetal heart rate (FHR) on admission was 130bpm with moderate variability and accelerations.
She was managed with aggressive fluid resuscitation and an insulin drip with dextrose. Apheresis to rapidly lower HTG was discussed, but not initiated as TG began to decline with conservative management. The FHR tracing began to show minimal variability, with a category 3 tracing. This was felt to represent developing fetal acidemia despite improved maternal acidemia.
A multidisciplinary decision was made to proceed with urgent cesarean delivery under general anesthesia using nitrous oxide with remifentanil infusion, and avoiding Propofol, which could potentially worsen her HTG. She required two vasopressors and additional fluid resuscitation intraoperatively. She remained intubated postop for volume overload and suspected acute lung injury. She was extubated postoperatively day 1 and started on a low fat, semi-elemental tube feed, improving her TG levels. Her neonate was diagnosed with hypoxic ischemic encephalopathy, transitioned to comfort care and died on day two of life. The patient was hospitalized for an additional 8 days for diuresis (10L), HTG and diet management.
No formal treatment recommendations exist for gestational HTG pancreatitis. Initial management of all AP should focus on stabilizing maternal hemodynamics, acidosis and pain. Fetal intrauterine distress is more commonly seen with HTG pancreatitis and severe pancreatitis. However, until the maternal condition has stabilized, proceeding with emergent cesarean section for fetal indications can lead to further maternal and fetal morbidity. In severe cases of maternal gestational HTG pancreatitis, insulin infusion, heparin and apheresis have shown clinical improvement but with limited and conflicting reports. Aggressive maternal resuscitation should not be delayed for unproven treatment options. In addition, risks and benefits regarding use of continuous versus intermittent FHR monitoring should be addressed with the patient especially if emergent delivery could compromise maternal stability.
Pandey, R. et al. Acute pancreatitis in pregnancy: review of three cases and anesthetic management. IJOA (2012) 21, 360-379