Plasmapheresis for the treatment of hypertriglyceridemia-induced severe acute pancreatitis in pregnancy: it could be a good choice

Abstract

Dear Editor: Acute pancreatitis (AP) in pregnancy is a rare event with an incidence rate of about three cases per 10,000 pregnancies [1]. The most common cause of AP in pregnancy is gallstones, while the relatively rare cause in pregnancy is hypertriglyceridemia-induced pancreatitis. However, nongallstone pancreatitis is associated with more complications and poorer outcome, for example, hypertriglyceridemiainduced AP. Moreover, pregnancy is a special period as pregnancy-related physiological alterations influence the diagnosis and management for many diseases. Severe acute pancreatitis (SAP) in pregnancy severely affected mother and fetus and developed a serious condition resulting in a higher risk of intrauterine fetal death; therefore, how to manage hypertriglyceridemia-induced SAP in pregnancy remains challenging. In this letter, we reviewed the management of hypertriglyceridemia-induced SAP in pregnancy for a 10-year single-center experience. This is a retrospective study of 10 years conducted at Intensive Care Unit of Hangzhou First People's Hospital in China from June 2004 to June 2014. The study included 39 patients with hypertriglyceridemia-induced SAP in pregnancy, and the diagnosis was based on an elevated serum amylase and/ or a lipase level higher than three times the normal values; all patients' Ranson scores were more than 3. The average age of 39 patients was 27.6±5.0 (21-38)years, the pregnancy weeks of all patients were more than 28 weeks. None was found with gallstones and/or common bile duct stones by ultrasound and/or magnetic resonance cholangiopancreatography. The average value of triglyceride was 24.32±6.59 (9.36-35.68)mmol/L, blood amylase was 737.52±331.42 U/L, urine amylase was 7814.59 ± 2132.25 U/L, and white blood cell count was 20.26±4.38×10 9 /L. Computed tomography showed pancreatic swelling, local necrosis with effusion, fuzzy boundary, and ascites in all of patients. The average value of acute physiology and chronic health evaluation II(APACHE II) was 14.3±3.2 at admission. All patients received ventilator treatment because of systemic instability, 35 cases of acute respiratory failure and 4 cases of ketoacidosis. All patients with intrauterine fetal distress received uterine incision deliveries; then, they were treated mainly by plasmapheresis besides the conventional therapy including inhibition of gastric acid and trypsin secretion, nutritional support, anti-inflammatory therapy, and correction of water-electrolyte imbalance and acid-base disturbance. Plasmapheresis was performed within 24 h of admission for all patients, 1600 to 2400 mL for each time and two to five times for each patient. The average value of triglyceride dropped to 15.28±5.43 mmol/L after the first plasmapheresis. Moreover, the average value of APACHE II was 6.8±2.4 at 72 h after admission. In 39 patients, two cases of pregnant women and one case of fetus died; other patients were cured and discharged, and the rescued success rate was 94.9 %.Lipids level occurring with physiological change in normal pregnan...

Conservative management in hypertriglyceridemia‐associated pancreatitis

“…Heparin and/or insulin infusions have been successfully used in cases of HTG‐related pancreatitis, especially when hyperglycaemia was present . Uncontrolled and retrospective case reports and series showed reduced TG levels following plasmapheresis , but minimal outcome data. A systematic review of apheresis used in HTG‐associated pancreatitis could not determine benefit for morbidity, mortality or pancreatitis severity .…”

Hypertriglyceridemia and acute pancreatitis: clinical and basic research—a narrative review

“…Several case reports described the successful use of plasmapheresis in pregnant patients with HTG-AP with no negative side effects noted to the mother or fetus. [90][91][92] DKA and HTG-AP DKA is a complication of diabetes and is characterized as relative insulin deficiency-induced hyperglycemia, ketosis, and high anion gap metabolic acidosis. Lack of insulin results in lipolysis in adipose tissue with the release of FFAs, which, when coupled with the inhibition of LPL, results in moderate to severe HTG.…”

“…Several case reports described the successful use of plasmapheresis in pregnant patients with HTG-AP with no negative side effects noted to the mother or fetus. [90–92]…”