case_images: PMC11824309_01
case_images: Impact of pregnancy hormones on maternal TG levels and therapy interventions. Schematic diagram illustrating the pathways upon which estrogens and hPL act to increase TG levels. Lipase enzymes hydrolyze circulating TG, allowing FFAs to be taken into the liver or other organs such as adipose tissue. Estrogens increase liver synthesis of TGs and decrease the clearance of circulating TGs by inhibiting the activity of hepatic lipase and LpL. This inhibition of lipase activity results in higher circulating TG levels. In the third trimester, hPL promotes lipolysis of maternal adipose tissue to further increase circulating TG levels. Furthermore, hPL also increases insulin resistance. This resistance prevents insulin from activating LpL, thus ensuring higher circulating TG levels. FFA, free fatty acids; hPL, human placental lactogen; LpL, lipoprotein lipase; TG, triglycerides.
case_images: CRIE2025-2644678.001.jpg
case_images: PMC11824309_01_CRIE2025-2644678.001.jpg
case_images: fig1
case_images: Due to persistently elevated TG levels, medium chain TG oils were added, but quickly discontinued due to nausea (Figure 1); therefore, fenofibrate 160 mg once daily was added as its use was demonstrated in the obstetrics and endocrine literature.
case_images: Triglyceride (TG) values throughout first pregnancy. Values for this patients' TG levels and weeks' gestation with noted onboard therapies, initiated therapies (added therapies noted with "+"), and associated events are detailed here. Inpatient hospital admission duration noted on x-axis bars with "H." "Insulin" is insulin infusion with dextrose D10 concentration clamp targeted postprandial glucose 90-140 mg/dL (1.0-1.6 mmol/L), steady state insulin infusion rates indicated in units per hour (u/h). CGM, continuous subcutaneous glucose monitor; FF, fenofibrate; MCT, medium chain TGs; NPO, oral restriction excluding medications; O3, omega-3 fatty acid fish oil.
case_images: CRIE2025-2644678.002.jpg
case_images: PMC11824309_01_CRIE2025-2644678.002.jpg
case_images: fig2
case_images: Significant labs (Figure 2) included TGs of 6900 mg/dL (78.0 mmol/L; normal < 150 mg/dL, <1.7 mmol/L) and lipase of 67 U/L (normal <60 U/L).
case_images: Triglyceride (TG) values throughout second pregnancy. Values for this patients' TG levels and weeks' gestation with noted onboard therapies, initiated therapies (added therapies noted with "+"), and associated events are detailed here. Throughout the second pregnancy, she was maintained on metformin 1500 mg daily, omega-3 fatty acids 2 g twice daily, and a 40 g/day low-fat diet. Inpatient hospital admission duration noted on x-axis bars with "H." "Insulin" is insulin infusion with dextrose 10% clamp targeting postprandial glucose 90-140 mg/dL (1.0-1.6 mmol/L), steady state insulin infusion rates indicated in units per hour (u/h). FF, fenofibrate; N, niacin; O3, omega-3 fatty acid fish oil. Corresponding mmol/L units are noted in the text.
case_images: CRIE2025-2644678.003.jpg
case_images: PMC11824309_01_CRIE2025-2644678.003.jpg
case_images: fig3
case_images: Fenofibrate was reinitiated (Figure 3).