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

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.

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.

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.