Angiotensin converting enzyme inhibitors and receptor blockers in pregnancy
- Phyllis August, MD, MPH
Phyllis August, MD, MPH
- Ralph A Baer, MD Professor of Research in Medicine
- Director, Hypertension Center
- Division of Nephrology & Hypertension
- Weill Cornell Medical College
- Section Editors
- Louise Wilkins-Haug, MD, PhD
Louise Wilkins-Haug, MD, PhD
- Section Editor — Prenatal Diagnosis and Genetics
- Professor of Obstetrics, Gynecology, and Reproductive Biology
- Harvard Medical School
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
Several antihypertensive agents, including methyldopa, calcium channel blockers, hydralazine, and labetalol, have a good safety profile for use in pregnant women. In contrast, animal and human data suggest that drugs that inhibit the renin-angiotensin-aldosterone system (RAAS) are associated with an increased risk of fetopathy. This topic will review the known adverse effects of RAAS inhibitors in pregnancy. The treatment of hypertension in pregnant and breastfeeding women is discussed separately. (See "Management of hypertension in pregnant and postpartum women".)
DRUGS TO AVOID
Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are associated with an increased risk of fetopathy (discussed below), and should be avoided in pregnancy [1-11].
Valsartan/sacubitril is the newest drug of this type and is a combination of an angiotensin receptor blocker and a neprilysin inhibitor (ARNI). Although no data are available in pregnancy, this drug has a similar mechanism of action and should not be administered to pregnant women .
RISK OF ADVERSE FETAL/NEONATAL EFFECTS
There are significant fetal risks associated with the use of RAAS inhibitors at all stages of pregnancy.
A systematic review of pregnancy outcome following exposure to ACE inhibitors or ARBs included 72 reports and 186 cases . Approximately one-third of the cases involved first trimester exposure. Major findings were:
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- DRUGS TO AVOID
- RISK OF ADVERSE FETAL/NEONATAL EFFECTS
- First-trimester exposure
- Second and third trimester exposure
- Exposure through breast milk
- HYPOTHESES FOR PATHOGENESIS OF ADVERSE EFFECTS
- LONG-TERM PROGNOSIS OF SYMPTOMATIC NEONATES
- USE OF ACE INHIBITORS AND ARBS IN WOMEN OF CHILDBEARING POTENTIAL
- Our approach
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS