Abstract Body (Do not enter title and authors here): Introduction
Severe hypertriglyceridemia (HTG) in pregnancy increases the risk of acute pancreatitis and preeclampsia, carrying a high maternal and fetal mortality rate. Management of severe HTG during pregnancy is challenging, as pharmacologic options are limited due to potential fetal risks.

Description of Case
A 34-year-old G1P000 woman with type 2 diabetes mellitus and HTG was referred to cardio-obstetrics clinic at 16 weeks of gestation with a triglyceride (TG) level of 1,562 mg/dL. Prior to conception, she had been treated with a biguanide for diabetes and a combination of fish oil, fenofibrate, and a statin for HTG, which were discontinued for fetal safety. Given the markedly elevated TG level, a multidisciplinary decision was made to urgently reinitiate lipid-lowering therapy with omega-3 acid ethyl esters 4g daily (Lovaza) and subcutaneous insulin glargine. In addition, she received counseling on lifestyle modification, including a low-fat, low-carbohydrate diet and a goal of 150 minutes of moderate physical activity per week. At two-month follow-up, her TG level had significantly improved to 328 mg/dL, with a further decrease to 287 mg/dL by four months without maternal or fetal complications.

Discussion
This case highlights the complexities involved in managing HTG during pregnancy. While total cholesterol and TG levels naturally increase throughout pregnancy, levels typically remain below 250 mg/dL. Traditional lipid-lowering agents, including statins, PCSK9 inhibitors, ezetimibe, bempedoic acid, and lomitapide, are generally avoided during pregnancy due to limited fetal safety data. In high-risk women with dyslipidemia, an individualized treatment approach can include insulin and omega 3 fatty ethyl esters or even LDL apheresis to prevent life-threatening complications. Lifestyle modification with a low-fat diet and omega-3 fatty acids must be balanced with both maternal and fetal nutritional needs to prevent abnormal fetal development. Thus, cardio-obstetric management of high-risk women with metabolic disorders should center around preconception risk assessment, multidisciplinary care, intensive lifestyle modification, selective use of non-statin agents or apheresis, and vigilant monitoring throughout pregnancy. There remains a significant gap in evidence regarding the safety and efficacy of lipid-lowering therapies during pregnancy, underscoring the urgent need for further research to guide management of severe HTG in pregnancy.