Critical Care-Based Decision-Making and Timing of Pregnancy Termination in Hypertriglyceridemia-Induced Acute Pancreatitis Complicated by Diabetic Ketoacidosis and Intrauterine Fetal Demise: A Case Report.

Abstract

Background: Acute abdominal pain accompanied by severe metabolic acidosis during pregnancy is frequently attributed to pregnancy-related conditions. Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) complicated by diabetic ketoacidosis (DKA) is rare in pregnancy and may be overlooked because of overlapping clinical and laboratory features.

Case presentation: We report a critically ill pregnant woman in the late second trimester who presented with abdominal pain and vomiting. Initial evaluation revealed severe metabolic acidosis and marked hypertriglyceridemia, and the patient was ultimately diagnosed with HTG-AP complicated by DKA. During the disease course, with confirmed intrauterine fetal demise (IUFD), management goals transitioned to maternal-centered critical care. However, the patient also exhibited profound metabolic derangement, intra-abdominal hypertension, and systemic stress responses, rendering immediate pregnancy termination associated with a high perioperative risk. The patient was admitted to the intensive care unit (ICU) and received continuous renal replacement therapy (CRRT) to correct refractory metabolic acidosis, followed by therapeutic plasma exchange to rapidly reduce triglyceride burden. These interventions stabilized the internal milieu and served as a bridging strategy for definitive critical care decision-making. After multidisciplinary evaluation, cesarean delivery was performed once maternal metabolic status had sufficiently stabilized. The patient's condition gradually improved, and she was discharged in good recovery.

Conclusions: This case highlights the diagnostic pitfalls of HTG-AP complicated by DKA during pregnancy and underscores the importance of individualized decision-making regarding the timing of pregnancy termination in the setting of IUFD. Multidisciplinary collaboration and the appropriate use of extracorporeal organ support may play a crucial role in optimizing maternal outcomes in such complex critical care scenarios.