Highlighting severe lipid disorders in pregnancy

During pregnancy, significant physiological changes occur in lipid metabolism, which are fundamental for fetal development, but which may pose risks when associated with maternal dyslipidemias. Elevation of lipids such as LDL-cholesterol and triglycerides is common and physiological, but in women with genetic dyslipidemias, such as heterozygous or homozygous familial hypercholesterolemia, levels can reach pathological values. Despite this, most of these pregnant women do not present an increase in maternal-fetal risk, as long as they are adequately monitored. Severe dyslipidemias, such as hypertriglyceridemias (> 1,000 mg/dL), are associated with complications such as pancreatitis and preeclampsia. Lipoprotein (a), another risk factor, rises during pregnancy and may be linked to thrombotic events and preterm births. Lipid screening in pregnancy is recommended especially for women with a history of dyslipidemia. Preconception cardiovascular evaluation is ideal in cases of severe hypercholesterolemia. Treatment includes a balanced diet and, in specific cases, medications. Statins, although traditionally contraindicated, have been reevaluated: recent studies indicate relative safety, especially for women at high cardiovascular risk. Pravastatin has the best safety profile. Other therapeutic options include exchange resins (allowed), lipoprotein apheresis (indicated for severe cases), and omega-3 (effective in hypertriglyceridemias). Ezetimibe, PCSK9 inhibitors, ANGPTL3, bempedoic acid, lomitapide, and fibrates should be avoided or used with caution, depending on the severity and individualized risk-benefit. The therapeutic decision during pregnancy should be shared between physician and patient, balancing fetal risks and maternal benefits, always based on the most current evidence.