How can I manage hypercholesterolemia during pregnancy?

Managing Hypercholesterolemia During Pregnancy

During pregnancy, lipid-lowering medications should be discontinued for most women, with lifestyle modifications being the primary management strategy for hypercholesterolemia, except in very high-risk cases such as homozygous familial hypercholesterolemia or established cardiovascular disease. 1

Risk Assessment and Management Approach

General Approach for Most Pregnant Women

• Discontinue lipid-lowering medications:

  • Stop statins, ezetimibe, PCSK9 inhibitors, and other systemically absorbed lipid-lowering drugs ideally 3 months before planned conception 1, 2
  • If pregnancy is discovered while on these medications, discontinue immediately and reassure that fetal harm is unlikely 1, 2

• Understand normal physiological changes:

  • A progressive rise in both LDL-C and triglycerides is physiologic during pregnancy 1
  • Routine monitoring of lipid levels during pregnancy is not necessary unless results would change management 1

Lifestyle Management (First-Line Therapy)

• Dietary modifications:

  • Implement a heart-healthy diet emphasizing fish, low-fat meats and dairy products, oils, whole grains, fruits, vegetables, and legumes 2, 3
  • A cholesterol-lowering diet during pregnancy has been shown to lower maternal total and LDL cholesterol levels without affecting cord blood or neonatal lipid levels 3
  • One study found that a cholesterol-lowering diet was associated with reduced risk of preterm delivery (RR 0.10; 95% CI 0.01-0.77) 3

• Physical activity:

  • Maintain appropriate physical activity as recommended for pregnancy 2

• Weight management:

  • Focus on appropriate weight gain during pregnancy 2

Special Considerations for High-Risk Patients

Very High-Risk Patients

For women with homozygous familial hypercholesterolemia (HoFH) or established atherosclerotic cardiovascular disease (ASCVD), special considerations apply:

• Pre-pregnancy assessment:

  • Cardiovascular imaging (CT angiography or echocardiography) should be offered before planned pregnancy 1
  • Consultation with a lipid specialist is strongly recommended 2

• Treatment options during pregnancy:

  • Bile acid sequestrants are the preferred pharmacological option during pregnancy 1, 2

    • Require monitoring for vitamin K deficiency 1, 2
    • Should be initiated ideally 3 months before planned pregnancy 1

  • Lipoprotein apheresis:

    • Should be continued or initiated during pregnancy in women with HoFH 1
    • Also recommended for women with severe heterozygous FH with lipoprotein(a) ≥125 nmol/l 1

  • Statin therapy:

    • May be considered after the first trimester in women with HoFH and clinical ASCVD if LDL-cholesterol goals are not achieved and lipoprotein apheresis is not available 1
    • Recent evidence suggests statin use during pregnancy may not be detrimental in selected high-risk cases 4, 5
    • A retrospective review of 39 pregnancies in women with HoFH showed no maternal cardiac complications or deaths during pregnancies with statin exposure 4

Monitoring During Pregnancy

• Monitor for significant elevations in LDL-C and triglycerides during pregnancy 1
• For women using bile acid sequestrants, monitor for vitamin K deficiency (check international normalized ratio) and folate levels 1, 2
• Elevated maternal triglyceride levels during early pregnancy have been associated with increased risk of pregnancy-induced hypertension, preeclampsia, large for gestational age infants, and induced preterm delivery 6

Post-Pregnancy Considerations

• Lipid-lowering medications may be resumed after completion of breastfeeding 1, 2
• Regular monitoring of lipid levels should be conducted during this transition 2

Common Pitfalls and Caveats

• Unplanned pregnancies: Women of childbearing potential taking lipid-lowering medications should use effective contraception 2
• Monitoring limitations: Avoid unnecessary lipid testing during pregnancy as physiologic increases are expected and results rarely change management 1
• Medication misconceptions: If a woman becomes pregnant while taking a statin or other lipid-lowering therapy, she should be reassured that this exposure is unlikely to harm the fetus 1
• Risk assessment: The decision to continue lipid-lowering therapy during pregnancy should be based on the woman's cardiovascular risk profile, with continuation generally limited to those with HoFH or established ASCVD 1

Remember that for most women with hypercholesterolemia, the temporary discontinuation of lipid-lowering therapy during pregnancy has little impact on long-term outcomes for primary hyperlipidemia 7.