How to Manage FH During Pregnancy

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For women with the genetic disorder known as Familial Hypercholesterolemia (FH), their inherited high cholesterol becomes an even more serious condition if they become pregnant.Patients with FH have a chromosomal abnormality which leaves the liver incapable of metabolizing low-density lipid (LDL) cholesterol.  FH leads to dangerously high LDL levels that can lead to arterial blockage and premature cardiovascular disease, including heart attacks, strokes and congestive heart failure. In pregnant women, it is critically important to properly manage the condition for the health and safety of the mother and the baby.

The Challenge of Inherited High Cholesterol

Almost all women experience a significant increase in cholesterol during pregnancy, by as much as 25-50 percent. Women with FH experience the same increase, but because their baseline levels are already so much higher, their cholesterol levels can become extremely elevated during pregnancy.

Reconsider Medication

Because FH is genetic, it causes inherited high cholesterol, rather than levels that are lifestyle-induced. This means that FH patients almost always need medications because diet, exercise and avoiding tobacco smoke are not sufficient to lower their cholesterol to acceptable levels  FH is most often treated by a combination of medicines, each of which serves a different function and complements the others. Statins are a commonly recognized category of medicines that inhibit the production of cholesterol in the liver. They are often prescribed in combination with a cholesterol absorber and a bile acid sequestrant, which prevents cholesterol from being absorbed by the intestine. Other cholesterol-lowering medications are fibrates, niacin, phytosterols, fish oils/omega 3 fatty acids, and PCSK9 inhibitors.

Most cholesterol-lowering medications are not recommended to be taken during pregnancy, and some doctors recommend that their FH patients who are trying to get pregnant stop taking cholesterol-lowering medications months in advance. The exception is the category of drugs known as bile acid sequestrants (BAS). The BAS are not absorbed into the bloodstream, so they pose no risk to the mother or her baby. Patients with inherited high cholesterol who have not been on a BAS in the past may need to begin taking one to help combat the effects of eliminating other medicinal treatments to control the effects of FH.

Eat a Healthy Diet

Diet During PregnencyEating a low fat, low cholesterol diet during pregnancy is recommended for all women, but it is even more important for pregnant women with FH. Working with a registered dietitian — especially one who has experience in a lipid, cardiology, or endocrinology clinic — can be extremely helpful to patients with inherited high cholesterol.

Some ways to reduce fat intake include:

  • Choosing leaner cuts of beef and pork, such as eye of round and pork tenderloin, and trimming visible fat before cooking.
  • Reducing meat portions to 3 ounces (about the size of a deck of cards) and eating more fruits and vegetables.
  • Removing skin from poultry before eating.
  • Eating more fish. The American Heart Association recommends eating 3.5 ounces of fish (especially oily, omega-3 rich fish) at least twice a week.
  • Dining on a meatless meal once a week, or even switching to a vegetarian diet. .
  • Replacing butter with liquid or spray versions of canola, extra virgin olive, peanut, or sesame oil.
  • Switching to fat free or 1% milk, or soy or almond milk.
  • Replacing high fat ice cream and desserts with naturally sweet and colorful fruits or sherbet.
  • In casseroles, soups and stew, cut the amount of animal protein in half and substitute cooked beans.
  • Eat more plant-based fiber, such as fruits, vegetables, whole grains, nuts, and seeds. Research shows that eating more than 25 grams of fiber per day can reduce risk of heart disease.

Exercise Regularly

Exercise is another important component in managing FH during pregnancy. Working at least 30 to 60 minutes of moderately intense physical activity into most days of the week will help contribute to heart health. Even short amounts of exercise offer heart benefits, and the same health benefits can be achieved from three to six 10-minute sessions each day.

Avoid Tobacco Smoke    

All pregnant women should avoid tobacco smoke, especially those with FH. Smoking is widely recognized as a leading cause of heart disease in the general population, and those with FH are already at a 20 times higher risk for cardiovascular problems. It’s clear that not smoking (as well avoiding secondhand smoke) is critical to the success of FH patients trying to avoid early heart disease.

Discuss LDL-apheresis with Your Physician

For some people with FH, drug therapy and lifestyle changes aren’t enough to lower their LDL cholesterol to a safer level. These individuals may need a simple, regularly-scheduled treatment called LDL-apheresis, during which blood or plasma is taken out of the body, the LDL cholesterol is filtered out, and the filtered blood or plasma is returned to the body. Any woman with FH who undergoes LDL-apheresis and becomes pregnant should discuss her options with her physician.

For more information about inherited high cholesterol and how to manage FH during pregnancy, contact theFH Foundation, a patient-centered non-profit organization dedicated to education, advocacy and research of Familial Hypercholesterolemia.

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