Preventative plasmapheresis in a diabetic pregnant patient with hypertriglyceridemia and distal pancreatectomy.

BACKGROUND: Pregnant patients with a history of hypertriglyceridemia are at increased risk for development of acute pancreatitis. When conservative management fails to maintain triglyceride levels less than 250-500 mg dL-1 , implementation of pregnancy category C medications to prevent pancreatitis must be considered. Plasmapheresis rapidly reduces triglyceride levels and has been reported as a successful third-line therapy for hypertriglyceridemia-induced acute pancreatitis in a limited number of pregnant patients. Use of preventative plasmapheresis as a bridge to delivery is not well characterised.

CASE PRESENTATION: We report an outpatient plasmapheresis regimen for the control of hypertriglyceridemia in a pregnant patient with a history of diabetes mellitus, hypertriglyceridemia, distal pancreatectomy, and repeat pregnancy loss. During the second trimester, refractory triglyceride levels increased up to 3438 mg dL-1 by 28 weeks gestation. Given the patient's high risk for recurrent pancreatitis and limited remaining pancreatic parenchyma, she was treated acutely with two single-plasma-volume exchanges with 100% albumin over 2 days, decreasing the triglyceride level to 559 mg dL-1 . Subsequent plasmapheresis every 7 to 9 days maintained a triglyceride level of 320-1296 mg dL-1 . The patient experienced no adverse effects and remained outpatient until successful scheduled delivery for hypertension at 33 weeks gestation.

DISCUSSION: For select patients, early escalation to plasmapheresis may prevent morbidity and mortality associated with acute pancreatitis. An individualised plasmapheresis regimen can serve as a bridge to delivery, which requires close observation and the coordination of a multidisciplinary team.