A 30-year-old woman at 33.4 weeks of gestation who had a history of gestational diabetes was admitted for acute epigastric pain and respiratory distress. On admission, her triglyceride (TG) level was 7716 mg/dL, total cholesterol was 1638 mg/dL, lipase was 349 U/L, and amylase was 208 U/L; thus, she was diagnosed with acute pancreatitis. Because pharmacologic treatment options for hypertriglyceridemia are limited in pregnancy, therapeutic plasma exchange (TPE) was performed emergently to acutely decrease the level of TGs in the Labor and Delivery Unit, with full support from the Obstetrical Service in case emergency delivery was necessary ( Fig. A shows her lipemic plasma compared with nonlipemic plasma from a control patient in Fig. B). Briefly, the plasma component containing TG is separated extracorporeally by centrifugation and is replaced by 5% albumin as the replacement fluid, as in this case. Other inflammatory cytokines may also be removed during the process. 1 Furthermore, several changes during pregnancy should be considered. For example, plasma volume (PV) can increase by 10 to 15% by the second half of the first trimester, further expanding through 30 to 34 weeks; therefore, accounting for this fact, we calculated the blood volume based on Nadler's formula and exchanged 1.5 PVs in this patient. [2][3][4] Low resistance in the uteroplacental circulation and other vessels contributes to a total decline in vascular resistance, so replacement fluids should be readily available for procedure-induced hypotension, if needed. 5 Finally, although heparin may release lipoprotein lipase that enhances TG clearance, and although pregnancy is a hypercoagulable state, we elected to use citrate as the anticoagulation during TPE, because the procedure also removes coagulation factors and thus may predispose the patient to an increased bleeding risk. 6 After two procedures, her TGs decreased to 750 mg/dL. She was then started on a low-fat diet and omega-3-acid ethyl esters for lipid control for the remainder of her pregnancy, with a goal TG <1000 mg/dL. Another TPE was performed 16 days later, because her TGs had increased to 974 mg/dL (Fig. C shows the relationship between TG level and TPEs). She From the