Gebelikte İnsülin Dirençli Hipertrigliseridemiye Bağlı Akut Pankreatit: Plazmaferez ile Başarılı Tedavi

Öz

Amaç: Gebelikte hipertrigliseridemiye bağlı akut pankreatit (HTG-AP), nadir ancak yaşamı tehdit eden ve hem maternal hem de fetal riskleri beraberinde getiren ciddi bir klinik tablodur. Bu yazıda, insülin infüzyonuna dirençli komplike bir gebelik HTG-AP olgusunun albümin eşliğinde çoklu plazmaferez seanslarıyla başarılı yönetimi sunulmaktadır. Vaka: Otuz bir yaşında, gebeliğinin 33. haftasında olan, gestasyonel diabetes mellitus tanılı ve obez (VKİ ~36 kg/m²) nullipar bir kadın hasta, karın ağrısı, bilateral alt ekstremite ödemi ve dispne yakınmalarıyla başvurdu. Trigliserid düzeyi 8904 mg/dL, amilaz 401 U/L, lipaz 684 U/L olarak saptandı. Kontrastsız batın MRG'de pankreatik ödem, T2 sinyal artışı ve peripankreatik inflamatuvar değişiklikler gözlemlendi. Servis yatışının ikinci gününde metabolik asidoz (pH 7,26, HCO₃ 13,8 mmol/L, laktat 3,4 mmol/L), akut böbrek yetmezliği ve hipoksi gelişmesi üzerine hasta yoğun bakım ünitesine (YBÜ) devredildi. İnsülin infüzyonuna dirençli seyir nedeniyle albümin replasman sıvısı kullanılarak plazmaferez uygulandı; YBÜ'de üç, serviste iki seans olmak üzere toplam beş seans gerçekleştirildi. Hasta YBÜ'de altı gün kaldıktan sonra servise devredildi; gebeliğin 36. haftasında elektif sezaryen ile sağlıklı bir bebek dünyaya getirildi. Sonuç: İnsüline dirençli komplike gebelik HTG-AP'sinde erken plazmaferez, klinik tabloyu hızla düzelten ve iyi maternal-fetal sonuç sağlayan etkin bir tedavi seçeneğidir. Albüminin replasman sıvısı olarak tercih edilmesi alerjik komplikasyon riskini azaltmaktadır. Görüntülemede kontrastsız MRG kullanımı ve doğum zamanlamasının 36. haftaya planlanması, multidisipliner yaklaşımın kritik bileşenlerini oluşturmaktadır.

Anahtar Kelimeler

• Hipertrigliseridemi
• akut pankreatit
• gebelik
• plazmaferez
• yoğun bakım

Acute Pancreatitis Due to Insulin-Resistant Hypertriglyceridemia in Pregnancy: Successful Management with Plasmapheresis

Öz

Aim: Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) in pregnancy is a rare but life-threatening condition that carries both maternal and fetal risks. In this report, we present the successful management of a complicated case of HTG-AP refractory to insulin infusion, treated with multiple sessions of plasmapheresis using albumin as the replacement fluid. Case: A 31-year-old nulliparous woman at 33 weeks of gestation with a diagnosis of gestational diabetes mellitus and obesity (BMI ~36 kg/m²) presented with abdominal pain, bilateral lower extremity edema, and dyspnea. Triglyceride level was 8904 mg/dL, amylase 401 U/L, and lipase 684 U/L. Non-contrast abdominal MRI revealed pancreatic edema, elevated T2 signal, and peripancreatic inflammatory changes. On the second day of hospitalization, metabolic acidosis (pH 7.26, HCO₃ 13.8 mmol/L, lactate 3.4 mmol/L), acute kidney injury, and hypoxia developed, necessitating transfer to the intensive care unit (ICU). Due to the insulin-refractory course, plasmapheresis with albumin as the replacement fluid was initiated; a total of five sessions were performed — three in the ICU and two on the ward. The patient was transferred to the ward after a six-day ICU stay, and a healthy neonate was delivered by elective cesarean section at 36 weeks of gestation. Results: In complicated, insulin-resistant gestational HTG-AP, early plasmapheresis is an effective treatment option that rapidly improves the clinical picture and yields favorable maternal and fetal outcomes. The preference for albumin as the replacement fluid reduces the risk of allergic complications. The use of non-contrast MRI for imaging and planning delivery at 36 weeks constitute critical components of the multidisciplinary management approach.

Anahtar Kelimeler

• Hypertriglyceridemia
• acute pancreatitis
• pregnancy
• plasmapheresis
• intensive care

Kaynakça

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