Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in women of childbearing age: risks versus benefits

Abstract

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are effective and widely used antihypertensive drugs. Exposure to these agents is known to be harmful to the fetus in the second and third trimesters of pregnancy. Concerns have also been raised about the risk of congenital malformations if ACEIs or ARBs are taken during the first trimester of pregnancy. The evidence to date, however, is conflicting and observed malformations may be due to confounders such as undiagnosed diabetes or maternal obesity, other antihypertensive medications or the hypertension itself. Nonetheless, in women who become pregnant while taking an ACEI or ARB, the drug should be stopped as soon as possible. In women with chronic kidney disease and proteinuria, it may be appropriate to continue taking an ACEI or ARB until the pregnancy is confirmed because of the significant benefit to their kidney function and the lower fertility rate in these patients.

Keywords:

• angiotensin receptor blockers
• angiotensin-converting enzyme inhibitors
• chronic kidney disease
• congenital malformations
• first trimester
• hypertension
• pregnancy
• teratogenicity

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Blood pressure in young women needs to be diagnosed accurately with ambulatory or home blood pressure monitoring.

• Most young women with stage 1 hypertension will not need treatment with blood pressure lowering drugs.

• Patients with stage 2 hypertension, or with stage 1 hypertension and high cardiovascular risk, for example, because of diabetes or chronic kidney disease, will need treatment with antihypertensive drugs.

• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are recommended as first-line agents in non-black women of childbearing age.

• Some studies have shown that ACEIs and ARBs may cause major congenital malformations if taken by the mother in the first trimester of pregnancy, although these studies have considerable weaknesses. Other studies have suggested that any observed increase in malformations is likely to be because of other antihypertensives and/or the hypertension itself.

• Women being started on ACEIs of ARBs should be warned about the potential risks to the fetus should they become pregnant, and adequate contraception should be a priority.

• In general, ACEIs or ARBs should be avoided in women planning to become pregnant and treatment should be switched to safer alternatives.

• In women who become pregnant while taking an ACEI or ARB, the drug should be stopped as soon as possible, under the supervision of an appropriate medical professional, and changed to pregnancy-suitable alternative such as labetalol, nifedipine or methyldopa.

• In women with chronic kidney disease and proteinuria who are planning a pregnancy, it may be appropriate to continue taking an ACEI or ARB until the pregnancy is confirmed, but this decision should be made by a specialist in close conjunction with the patient.

Notes

ABPM: Ambulatory blood pressure monitoring; HBPM: Home blood pressure monitoring.