No to ACE inhibitors during the first trimester of pregnancy
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Research
Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study
No to ACE inhibitors during the first trimester of pregnancy
Li et al(1) reported that mothers who used ACE inhibitors in the
first trimester had a similar risk regarding foetal malformation as
those who used other antihypertensive drugs.
However, it is surprising that ACE inhibitors are still used, given the high rate of fetal malformations caused by them. Indeed ACE
inhibitors are responsible for malformations of the cardiovascular system
and the central nervous system, which is not the case for other
antihypertensive drugs such as calcium-channel blockers(3). Moreover ACE
inhibitors may cause stillbirths, neonatal deaths, foetal hypotension
oligohydramnios and intrauterine growth restriction (3)
The use of ACE inhibitors was not compared to another single class of
antihypertensive drug but to a heterogeneous group containing diuretics,
beta blockers, methyldopa and calcium-channel blockers, which made the
interpretation of results confused. In addition, the maternal use of
diuretics is not recommended during the first trimester of pregnancy as
they cause hypovolaemia and dehydration (3).
The safety of maternal use of calcium-channel blockers on the foetus
is demonstrated in many studies (3, 4, 5). Therefore they are recommended
to treat hypertension during the first trimester of pregnancy.
As ACE inhibitors have teratogenic and many foetal adverse effects
they should be avoided during the first trimester of pregnancy. They could
be replaced by calcium-channel blockers, which are not responsible for
foetal malformations.
References
1. Li DK, Yang C, Andrade S, Tavares V, Ferber JR. Maternal exposure
to angiotensin converting enzyme inhibitors in the first
trimester and risk of malformations in offspring: a retrospective cohort
study. BMJ. 2011 Oct 18;343:d5931. doi: 10.1136/bmj.d5931.
2. Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S,
Gideon PS, Hall K, Ray WA. Major congenital malformations after first-
trimester exposure to ACE inhibitors. N Engl J Med. 2006 ;354:2443-51.
3. Podymow T, August P. Antihypertensive drugs in pregnancy. Semin
Nephrol. 2011 ;31:70-85.
4. [No authors listed] Chronic hypertension in pregnancy. N Engl J
Med. 2011 ;365:1650.
5. Bortolus R, Ricci E, Chatenoud L, Parazzini F. Nifedipine
administered in pregnancy: effect on the development of children at 18
months. BJOG. 2000 ;107:792-4.
Competing interests:
No competing interests
31 October 2011
Souhail Alouini
Obstetrician and Gynaecologist, MD, PhD
Department of Obstetrics and Gynaecology, Regional Hospital Center of Orleans, 45000, France
Rapid Response:
No to ACE inhibitors during the first trimester of pregnancy
Li et al(1) reported that mothers who used ACE inhibitors in the
first trimester had a similar risk regarding foetal malformation as
those who used other antihypertensive drugs.
However, it is surprising that ACE inhibitors are still used, given the high rate of fetal malformations caused by them. Indeed ACE
inhibitors are responsible for malformations of the cardiovascular system
and the central nervous system, which is not the case for other
antihypertensive drugs such as calcium-channel blockers(3). Moreover ACE
inhibitors may cause stillbirths, neonatal deaths, foetal hypotension
oligohydramnios and intrauterine growth restriction (3)
The use of ACE inhibitors was not compared to another single class of
antihypertensive drug but to a heterogeneous group containing diuretics,
beta blockers, methyldopa and calcium-channel blockers, which made the
interpretation of results confused. In addition, the maternal use of
diuretics is not recommended during the first trimester of pregnancy as
they cause hypovolaemia and dehydration (3).
The safety of maternal use of calcium-channel blockers on the foetus
is demonstrated in many studies (3, 4, 5). Therefore they are recommended
to treat hypertension during the first trimester of pregnancy.
As ACE inhibitors have teratogenic and many foetal adverse effects
they should be avoided during the first trimester of pregnancy. They could
be replaced by calcium-channel blockers, which are not responsible for
foetal malformations.
References
1. Li DK, Yang C, Andrade S, Tavares V, Ferber JR. Maternal exposure
to angiotensin converting enzyme inhibitors in the first
trimester and risk of malformations in offspring: a retrospective cohort
study. BMJ. 2011 Oct 18;343:d5931. doi: 10.1136/bmj.d5931.
2. Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S,
Gideon PS, Hall K, Ray WA. Major congenital malformations after first-
trimester exposure to ACE inhibitors. N Engl J Med. 2006 ;354:2443-51.
3. Podymow T, August P. Antihypertensive drugs in pregnancy. Semin
Nephrol. 2011 ;31:70-85.
4. [No authors listed] Chronic hypertension in pregnancy. N Engl J
Med. 2011 ;365:1650.
5. Bortolus R, Ricci E, Chatenoud L, Parazzini F. Nifedipine
administered in pregnancy: effect on the development of children at 18
months. BJOG. 2000 ;107:792-4.
Competing interests: No competing interests