title: Malignant primary hypertension in pregnancy treated with lisinopril.
abstract: OBJECTIVE
  To report a case of a patient treated with an angiotensin-converting enzyme (ACE) inhibitor with a good neonatal outcome.
  
  
  METHODS
  A 39-year-old African-Caribbean patient who had chronic hypertension presented at 18 weeks' gestation with acute hypertension. She was being treated for chronic hypertension with lisinopril, but had self-discontinued treatment. Attempts to control her hypertension with labetolol, nifedipine, and methyldopa were ineffective. She was therefore offered termination of pregnancy so treatment with lisinopril could be restarted. The patient elected to continue with the pregnancy in spite of the fetal risks associated with the use of an ACE inhibitor. She was delivered of a girl at 26 weeks' gestation. The baby initially had renal failure and also developed acute necrotizing enterocolitis. The renal failure improved simultaneously with the latter complication, and it is postulated that there was enteric excretion of lisinopril. The baby was discharged home on day 102 with no further complications.
  
  
  CONCLUSIONS
  ACE inhibitors are acceptable medications to use in the first trimester of pregnancy; however, fetal malformations and neonatal complications 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 feces unchanged, and its half-life is prolonged in anuric neonates. Peritoneal dialysis eliminates lisinopril; however, this neonate improved after treatment for necrotizing enterocolitis and simultaneous improvement in bowel 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 medications. The patient should be fully counseled about the adverse effect profile and neonatal outcome. This case report documents a successful outcome for mother and baby in these circumstances.
authors.affiliation: Department of Obstetrics and Gynaecology, St. James' University Hospital, Leeds, England. jtomo@thecafe.co.uk
authors.forename: A J
authors.initials: AJ
authors.lastname: Tomlinson
authors.forename: J
authors.initials: J
authors.lastname: Campbell
authors.forename: J J
authors.initials: JJ
authors.lastname: Walker
authors.forename: C
authors.initials: C
authors.lastname: Morgan
mesh_terms: D000328:Adult; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D006974:Hypertension, Malignant / Q000188:drug therapy*; D007231:Infant, Newborn; D017706:Lisinopril / Q000009:adverse effects / Q000627:therapeutic use*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000188:drug therapy*; D011256:Pregnancy Outcome
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D017706:Lisinopril