Asymptomatic Hypertriglyceridemia in pregnant lady diagnosed during Delivery in WGH
A.F.Mohamed, R. Murray , A.Ayman , S.babu
33 years Asian lady presented at term in labour and had spontaneous vaginal delivery complicated by primary PHH with grade two perineal tear noticed to have strawberry milk shake bloods and grase blood when samples taken for group cross match and u&E , LFT . All samples had failed to be processed except for FBC due to lipaemia .
Her lipid profile showed hpertriglycemia 80 times above the upper normal limit though patient was asymptomatic.with mild raise in serum lipase Amylase couldn’t be processed as well.
Background
The pregnancy hormones can lead to change in lipid profile and for TG to be increased 3 times by third trimester and this can be happening more if there is a background family history of hypertryglyceridemia or the women her self develop GDM or known case of insulin resistance. And that high level can put the patient under risk of having pancreatitis or develop hypervescosity and preeclampsia. There is few cases out side pregnancy for infants as well as adults for same condition but there is few cases seen or diagnosed for first time during pregnancy , in this case there was no previous personal or family history of same as well as the patient was not diabetic, her GTT normal as per Irish reference.
Case presentation
Asian origin Kora
P1 +1 now
No significant Medical or Surgical History
NKDA
BMI 23.2
Booked at 18 wks +5 days
ORh+ve
Vaccinated COVID 19 x3
Rubella non immune
Waiting her Cx smear
Normal Anomaly scan
Started as MLC then has one episode of palpitations around 28/40 wks then transfer to CLC Went for FBC &TSH all normal
She presented at 40 wks in labour, delivered sponontenous
PPH of 1320 ml
With one spike of temperature , her bloods noticed to be strawberry as she bleeding per vagina as well the blood which has been taken to investigate her PPH and spike temperature bloods in bottles noticed to be milky
Medical team involved and ask for her triglycerides and cholesterol levels
Discussion
Investigations
The first sample which has been sent couldn’t be process because of lipaemia
Triglycerides comes as 136. 1mmol/L Upper limit is 1.7 mmol/L . No cholesterol or HDL
because of lipaemia.
Lipase level 103 unit (8-78)
She has been started on fenofibrate 160 mg OD replaced with micronised fenofibrate 200
mg OD to reduce lipid level as well as prevent pancreatitis she has been counselled about
this medication and breast feeding .
Pt put in Prophylactic dose of LMWH and has been seen by dietitian
She has been followed and the level has been dropping dramatically from 136.1 mmol/L to
34.6 mmol/L over 5 days of the use of fenofibrate
Discharged home after stopping the medication .
For review by medics in 2/52.
Discovering hypertryglcemia in pregnancy as first presentation is rare , and is really associated with insulin resistance or DM , but some times could be there was a similar case but pt was GDM and her bloods show change in electrolytes ( hyponatermia) but in this case the diagnosis was with the change in blood colour ( strawberry milkshake ) as well as the look in the blood bottles .and the level of triglycerides was more high 136 mmol/L compared with > 50 mmol/L which is highlighting the degree of hyperglycaemia is more. In our case the lady was happy to go for fenofibrate and she considered to stop breast feeding but the lactation is not completely contraindicated with this medication so she continued breast feeding while on this medication and she has been managed with the reducing fat in diet as well.
The other options of treatment is controlling diabetes if not well controlled using insulin and there was a case of a man who presented with DKA coma and found to have hypertryglycedima and has been managed with exchange bloods and he recovered from the coma . Plasma pharesis is the last resort for people whom the presention is critical or didn’t respond to regular measures( diet ,fenofibrate , insulin , exchange transfusion) In view that there is few cases reported and no consensus regarding treatment, multidisciplinary team is important and the need for urgent treatment should be highlighted.
Reference:
1-https://casereports.bmj.com/content/15/8/e249000. | 2-https://doi.org/10.2217/clp.15.25 | 3-https://www.researchgate.net/publication/285759702. | 4-https://www.uptodate.com/contents/hypertriglyceridemia-in-adults-management | 5-https://emedicine.medscape.com/article/126568-overview.