NLA document issued to optimize screening, management of lipids in reproductive-age women
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Key takeaways:
- The NLA issued a statement on behavioral interventions and pharmacologic management of lipids for women of reproductive age.
- The document was published in the Journal of Clinical Lipidology.
The National Lipid Association has issued a clinical consensus statement on the management of dyslipidemia in women of reproductive potential, with a focus on considerations for pharmacologic options, a speaker reported.
The consensus statement, presented at the National Lipid Association (NLA) Scientific Sessions by Anandita Kulkarni, MD, director of cardiovascular disease prevention and cardio-obstetrics at Baylor Scott & White Health and clinical assistant professor at Texas A&M University College of Medicine, details approaches to lipid management for the prevention of atherosclerotic CVD in women during prepregnancy planning, pregnancy and the “fourth trimester” periods.
“Young women are less likely to be treated with statin therapy and less likely to reach their LDL cholesterol therapeutic targets based on their calculated risk for cardiovascular disease. The cardiovascular health of pregnant women is declining in the United States with less than one in 10 pregnant women having high or optimal cardiovascular health. I term this the ‘pregnancy hot potato’ because oftentimes these women are bounced from clinician to clinician and nobody truly takes ownership of treating their cardiometabolic risk factors,” Kulkarni said during the presentation. “Optimizing the diagnosis and management of dyslipidemia in women of reproductive potential can play a large role in mitigating cardiovascular risk during pregnancy and beyond. Currently, there are no specific guidelines regarding when to screen women for lipid and lipoprotein disorders before pregnancy.”
Kulkarni highlighted several important pearls of information from the new consensus statement, now published in the Journal of Clinical Lipidology. Please see the document for full details on the writing committee’s recommendations.
Dyslipidemia screening in women of reproductive potential
“Cholesterol levels increase by about 25% to 50% in pregnancy,” Kulkarni said. “Total cholesterol, LDL cholesterol, triglycerides and lipoprotein(a) levels increase steadily during pregnancy and peak near term to aid in fetal development levels, then decline toward prepregnancy levels in the 3 months postpartum.”
Dyslipidemia screening during pregnancy planning may identify individuals at risk for ASCVD, such as women with advanced maternal age, prior adverse pregnancy outcomes, a family history of dyslipidemia and premature ASCVD or preexisting medical conditions.
In addition, the document provides considerations for dyslipidemia screening and treatment for women with obesity and metabolic syndrome, as well as familial hypercholesterolemia and severe hypertriglyceridemia.
“Familial hypercholesterolemia and severe hypertriglyceridemia are the most common dyslipidemias and should be addressed and managed during pregnancy,” Kulkarni said during the presentation. “Pancreatitis has been estimated to occur in approximately one in 3,000 pregnancies. Up to 30% of cases are ascribed to hypertriglyceridemia, and acute pancreatitis is the most serious consequence of severe hypertriglyceridemia in pregnancy, with mortality rates as high as 3% and 12% in the mother and fetus, respectively, making it very important to identify and treat hypertriglyceridemia.”
Management of dyslipidemia before, during and after pregnancy
For women of childbearing age with severe hypertriglyceridemia, the writing committee recommends nutritional and lifestyle interventions including reducing or eliminating added sugar and alcohol intake, increasing physical activity and reducing adiposity.
For women of childbearing age with familial hypercholesterolemia, the committee recommends individualized prepregnancy counseling, contraceptive advice and minimizing their time off statin therapy.
“In one study, it was shown that women with FH can have an off-statin period of up to 14 years during their childbearing years, which increases their risk of developing ASCVD,” Kulkarni said. “For women with FH who are planning a pregnancy, management with an interdisciplinary team with expertise in FH, including a lipid specialist, should be considered.”
The document also includes details on the safety profile and contraindications of various lipid-lowering therapies during pregnancy and lactation.
“With statins being the most commonly prescribed lipid-lowering agent, it is important to note that in July 2021, the FDA removed the strongest label warning regarding statins in pregnancy,” she said. “Most women should stop statins prior to pregnancy. However, this label change allows more flexibility in treatment, particularly among women who are at the highest risk for ASCVD.”
For reducing excess adiposity in postpartum women with dyslipidemia, the committee stated that physical activity is generally safe before, during and after uncomplicated pregnancies. Kulkarni said all women with uncomplicated pregnancies should aim for at least 150 minutes of moderate physical activity per week.
However, contraindications for exercise include presence of gestational hypertension, preeclampsia, ruptured membranes, incompetent cervix, bleeding during the second or third trimester, multiple gestation at risk for premature labor, placenta previa and premature labor, according to the presentation.
Moreover, the consensus statement provides guidance for dyslipidemia management that extends into the fourth trimester, defined as the period between delivery and 12 weeks postpartum. The writing committee ascribes this period as a key time to address contraception, mental health and CV risk factors and identify potential postpartum complications.
“Optimizing the diagnosis and management of dyslipidemia in women of reproductive potential can play a large role in mitigating cardiovascular risk during pregnancy and beyond,” Kulkarni said. “It is important to leverage the benefits of a multidisciplinary approach, such as a cardio-obstetrics team, including a lipid specialist, dietitian, mental health, etc, that can help optimize care in women peri-pregnancy.”
Reference:
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Kulkarni A, et al. Session IV — Women’s cardiovascular challenges. Presented at: National Lipid Association Scientific Sessions; May 30-June 2, 2024; Las Vegas (hybrid meeting).
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