Published: 5 September 2024

Publications

Reminder: angiotensin converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy

Published: 5 September 2024
Prescriber Update 45(3): 55–56
September 2024

Background

The Centre for Adverse Reactions Monitoring (CARM) received a suspected adverse reaction report for losartan and empagliflozin (co-suspect medicines) in a fetus exposed to these medicines in utero (report ID 145301). The reported reactions were fetal distress syndrome, fetal disorder and Potter’s syndrome (a rare condition associated with decreased amniotic fluid and kidney failure in the fetus¹). There is limited data on the safety of empagliflozin during pregnancy. For information on management of diabetes during pregnancy refer to local clinical guidelines.

This article is a reminder that ACEi/ARBs are contraindicated in pregnancy.

Hypertension in pregnancy

Uncontrolled hypertension in pregnancy may progress to pre-eclampsia and has been linked to adverse maternal and fetal outcomes.^2,3

Antihypertensives are recommended in all pregnant people with severe hypertension to acutely lower blood pressure. They should also be considered in pregnant people with gestational hypertension, especially with other risk factors for pre-eclampsia and/or co-morbidities.²

Risks associated with ACEi and ARBs

ACEi (enalpril, lisinopril, perindopril, quinapril, ramipril) and ARBs (candesartan, losartan) are first-line treatments for hypertension in adults. However, they are contraindicated in pregnancy.^3,4

Use of these medicines in pregnancy has been associated with fetal and neonatal toxicity, including skull defects, oligohydramnios (decreased amniotic fluid volume), hypotension, hyperkalaemia, renal failure and fetal death.^3,5

When prescribing ACEi and ARBs to patients of childbearing potential

• Exclude pregnancy prior to treatment initiation and ask the patient if they are planning to become pregnant.
• Inform patients that ACEi/ARBs may be harmful to the baby if taken during pregnancy, and to seek medical advice if they become pregnant.
• If your patient is planning to become pregnant, consider switching them to an alternative antihypertensive before conception.
• If a patient becomes pregnant during ACEi/ARB treatment, discontinue the medicine and replace it with another antihypertensive if clinically indicated.

Further information

For information about the management of hypertension in pregnancy, refer to local clinical guidelines.

The following links provide additional information about hypertension and medicines.

• Te Whatu Ora - Health New Zealand: Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand
• bpac^NZ: Hypertension in adults: the silent killer
• Medsafe: Data sheets and Consumer Medicines Information search

References

1. Kaneshiro NK, Dugdale DC and Conaway B. 2023. Potter syndrome. In: Mount Sinai Health Library URL: www.mountsinai.org/health-library/diseases-conditions/potter-syndrome (accessed 26 July 2024).
2. Te Whatu Ora – Health New Zealand. 2022. Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand October 2022. URL: www.tewhatuora.govt.nz/assets/Publications/Evidence-Statements-Hypertension-and-Pre-Eclampsia.pdf (accessed 5 July 2024).
3. New Zealand Formulary (NZF). 2024. NZF v.145: Drugs affecting the renin-angiotensin system 1 July 2024. URL: nzf.org.nz/nzf_1240 (accessed 5 July 2024).
4. bpac^NZ. 2024. Hypertension in adults: the silent killer 23 May 2024. URL: bpac.org.nz/2023/hypertension.aspx (accessed 5 July 2024).
5. Servier Laboratories Ltd. 2023. Coversyl New Zealand Data Sheet 16 February 2023. URL: www.medsafe.govt.nz/profs/Datasheet/c/Coversyltab.pdf (accessed 5 July 2024).