What is the recommended management for hyperlipidemia in pregnancy?

Management of Hyperlipidemia in Pregnancy

During pregnancy, statins and other systemically absorbed cholesterol-lowering medications should be discontinued, with lifestyle modifications becoming the primary management strategy for most women with hyperlipidemia, except in very high-risk cases such as homozygous familial hypercholesterolemia (HoFH) or established atherosclerotic cardiovascular disease (ASCVD). 1, 2

Physiological Changes and Monitoring

• Pregnancy naturally causes progressive increases in both LDL-cholesterol and triglyceride levels
• Routine monitoring of lipid levels during pregnancy is not recommended unless results would change management 1, 2
• The rise in lipids is driven by increased estrogen, progesterone, and lactogen levels, which mobilize fat stores to support fetal growth and placental steroid synthesis 3

Pre-Pregnancy Planning

For women with hyperlipidemia who are planning pregnancy:

1. Discontinue statins and other systemically absorbed lipid-lowering medications 3 months before planned conception 1
2. If pregnancy is unplanned, stop these medications immediately upon confirmation 1
3. Provide pre-pregnancy counseling for all women with familial hypercholesterolemia (FH) before starting lipid-lowering therapy 2
4. For women with HoFH or high-risk heterozygous FH (HeFH), offer cardiovascular imaging (CT angiography or echocardiography) before planned pregnancy 1

Management During Pregnancy

First-Line Approach: Lifestyle Modifications

• Emphasize heart-healthy diet, appropriate physical activity, and weight management 1, 2
• Reinforce and optimize these behaviors before, during, and after pregnancy 1

Pharmacological Options

1. Bile Acid Sequestrants:

   • The only lipid-lowering drugs considered safe during pregnancy 2, 4
   • Should be initiated ideally 3 months before planned pregnancy 1
   • Require monitoring for malabsorption of fat-soluble vitamins (especially vitamin K) and folate 1, 2

2. For Women with HoFH and Clinical ASCVD:

   • Consider continued use of statins, particularly after the first trimester 1
   • Consider ezetimibe, PCSK9 inhibitors if LDL-cholesterol goals are not achieved and lipoprotein apheresis is unavailable 1
   • Lipoprotein apheresis should be continued or initiated 1, 2

3. For Women with Severe Hypertriglyceridemia:

   • Monitor triglyceride levels closely, especially in the third trimester 5
   • For triglycerides >500 mg/dL: implement strict low-fat diet (<20g total fat/day) 5
   • For triglycerides >1000 mg/dL or signs of pancreatitis: consider plasmapheresis 5

Special Considerations for High-Risk Patients

Homozygous Familial Hypercholesterolemia (HoFH)

• Continue lipoprotein apheresis during pregnancy 1, 2
• Consider statins after first trimester if LDL goals not achieved 1

Severe Heterozygous FH with Lipoprotein(a) ≥125 nmol/L

• Consider lipoprotein apheresis during pregnancy 1

Women with Established ASCVD

• Individual risk-benefit assessment required 2
• May need to continue lipid-lowering therapy 1

Post-Pregnancy Management

• Resume appropriate lipid-lowering medications after completion of breastfeeding 2
• Avoid methyldopa post-partum due to risk of post-natal depression 1
• Implement lifestyle modifications, regular blood pressure control, and metabolic factor management after delivery 1

Common Pitfalls and Caveats

1. Unplanned Pregnancy: If a woman becomes pregnant while taking statins or other lipid-lowering therapies, these should be stopped immediately, and she should be reassured that this therapy is unlikely to harm the fetus 1

2. Triglyceride Monitoring: Women with pre-pregnancy triglyceride levels ≥500 mg/dL are at high risk for severe hypertriglyceridemia in the third trimester, which can lead to pancreatitis 1, 5

3. Maternal-Fetal Risk: Hyperlipidemia during pregnancy has been associated with preeclampsia, preterm birth, and gestational diabetes, with potential implications for offspring atherosclerosis risk 3

4. Contraception Importance: Women of childbearing potential taking lipid-lowering medications should use effective contraception 2

By following these evidence-based recommendations, clinicians can effectively manage hyperlipidemia during pregnancy while minimizing risks to both mother and fetus.