Malignant primary hypertension in pregnancy treated with lisinopril

OBJECTIVE: To report a case of a patient treated with an angiotensin-conver ting enzyme (ACE) inhibitor with a good neonatal outcome. CASE REPORT: A 39-year-old African-Caribbean patient who had chronic hypert ension presented at 18 weeks' gestation with acute hypertension. She was be ing treated for chronic hypertension with lisinopril, but had self-disconti nued treatment. Attempts to control her hypertension with labetolol, nifedi pine, and methyldopa were ineffective, She was therefore offered terminatio n of pregnancy so,treatment with lisinopril co;ld be restarted. The patient elected to continue with the pregnancy in spite of the fetal risks associa ted with the use of an ACE inhibitor. She was delivered of a girl at 26 wee ks' gestation. The baby initially had renal failure and also developed acut e necrotizing enterocolitis, The renal failure improved simultaneously with the latter complication, and it is postulated that there was enteric excre tion of lisinopril. The baby was discharged home on day 102 with no further complications. DISCUSSION: ACE inhibitors are acceptable medications to use in the first t rimester of pregnancy; however, fetal malformations and neonatal complicati ons have been associated with their use later in pregnancy, and they have a perinatal mortality rate of 97/1000. Lisinopril is excreted in urine and f eces unchanged, and its half-life is prolonged in anuric neonates. Peritone al dialysis eliminates lisinopril; however, this neonate improved after tre atment for necrotizing enterocolitis and simultaneous improvement in bower function. CONCLUSIONS: ACE inhibitors should not be used in pregnancy beyond the end of the first trimester, In exceptional cases, they may be indicated for the control of severe hypertension when the patient is refractory to other med ications. The patient should be fully counseled about the adverse effect pr ofile and neonatal outcome, This case report documents a successful outcome for mother and baby in these circumstances.