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Angiotensin converting enzyme inhibitors and receptor blockers in pregnancy

Phyllis August, MD, MPH
Section Editors
Louise Wilkins-Haug, MD, PhD
George L Bakris, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


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".)


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 [12].


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 [13]. Approximately one-third of the cases involved first trimester exposure. Major findings were:

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Literature review current through: Nov 2017. | This topic last updated: May 09, 2017.
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