Hypertriglyceridemia-Induced Pancreatitis During Pregnancy

A 40-year-old, lean (body mass index 24.8) Asian woman with gestational diabetes presents to the emergency room at 24 weeks gestation with nausea and epigastric pain. Amylase and lipase are elevated as are triglycerides at 3,800 mg/dl, and she is diagnosed with acute pancreatitis. An abdominal ultrasound is negative for gallstones or any pathology of the gallbladder or biliary ducts.

She is admitted to the intensive care unit and remains NPO for the first 24 hours and is treated with intravenous fluids, pain medications, and gemfibrozil, after which a very low-fat diet was added. These treatments result in a subsequent decrease in triglycerides to 437 mg/dl. Glucose levels remain less than 125 mg/dl throughout the hospitalization.

Following discharge, she adheres to the low-fat diet, but discontinues gemfibrozil over concerns of potential harm to the fetus. She is seen in the lipid clinic at 29 weeks gestation, at which time the triglyceride level was 1,225 mg/dl. She has no abdominal discomfort and no eruptive xanthomas. She is advised to continue adhering to a diet that contained no more than 40 grams of fat per day, to take a prescription omega-3 fatty acid (icosapent ethyl esters) 2 grams twice daily, and to use medium chain triglyceride (MCT) oil three times per day. Both the patient and her husband initially agree with these recommendations; however, she ultimately decides not to take the omega-3 fatty acid or MCT oil due to concerns for the fetus.

She presents to the hospital at 32 weeks gestation with severe abdominal pain and is diagnosed with preeclampsia, placental abruption, and fetal demise. Following delivery, she develops a coagulopathy and requires multiple blood products. Triglycerides are 1,200 mg/dl, and gemfibrozil is restarted. Upon discharge, she stops the gemfibrozil and restarts the omega-3 fatty acid.

At a follow-up lipid clinic visit, she and her husband receive extensive counseling regarding her genetic predisposition to hypertriglyceridemia and the importance of adherence to the recommended treatments that included use of a fibrate, prescription omega-3 fatty acids, MCT oil, a low-fat diet, and regular physical activity. A lipid profile is obtained after 4 weeks of uninterrupted treatment and showed: total cholesterol 177 mg/dl, triglycerides 256 mg/dl, high-density lipoprotein (HDL-C) 34 mg/dl, LDL-C 92 mg/dl, and apolipoprotein B 93 mg/dl.

Her 7-year-old son has not had lipids tested, and her family history is unknown.

When considering omega-3 fatty acid usage in this patient, all of the following are TRUE, with the exception of:

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