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, non-gallstone pancreatitis is associated with more complications and poorer outcome, for example, hypertriglyceridemia-induced 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 × 109/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 pregnancy, the concentration of triglycerides, fatty acids, cholesterol, and so on, is affected by liver function and lipid metabolism; the difference of lipids level between early pregnancy and non-pregnancy is less, but gradually increases after the second trimester and is significantly higher in the third trimester. The lipids level of the third trimester is about two to four times as compared to the non-pregnancy period. However, pregnancy-associated hyperlipidemia occurs only in a very few pregnant women, and the mechanism is not clear until now. The illness of hypertriglyceridemia-induced SAP in pregnancy is generally serious; we should take into account the security of pregnant women and fetuses. Therefore, the therapy needed to be done is according to maternal risk status and fetal maturation condition. In this study, the average level of triglyceride was reduced by one third after the first plasmapheresis. Saravanan et al. showed that the level of triglyceride was reduced by 73 and 82 %, respectively, after the second plasmapheresis [2]. As for the timing of plasmapheresis, the results were different in the literatures [3]. It could be more effective when plasmapheresis was done earlier. Kyriakidis et al. reported nine cases of ten patients who were given with plasmapheresis therapy; only one person died and other patients survived [4]. Our result also showed only two patients died while 37 patients were cured and discharged. Therefore, we believed that plasmapheresis could be quickly and safely lower the level of triglycerides and improve symptoms.