Control microalbuminuria in pregnant diabetics. ('We Must Be Aggressive').

SAN FRANCISCO -- It's possible to control microalbuminuria in a pregnant diabetic woman without worsening her kidney disease or endangering her fetus, Dr. Robert E. Ratner said at the annual scientific sessions of the American Diabetes Association.

Unfortunately, the two best renoprotective agents for diabetic patients--the angiotensin-converting enzyme inhibitors (ACEIs) and the angiotensin receptor blockers (ARBs)--are associated with significant intrauterine complications, including skull hypoplasia, oligohydramnios, and fetal/neonatal death.

Both are listed as pregnancy category C in the first trimester and category D for the second and third trimesters of pregnancy.

On the other hand, microalbuminuria during pregnancy is also associated with significant morbidity.

One recent review showed a 74% cesarean section rate, 41% for preeclampsia, and 17% end-stage renal disease during 5 years' follow-up. In the neonate, maternal microalbuminuria was associated with a 25% preterm delivery rate, 20% respiratory distress, 15% intrauterine growth retardation, and other complications (J. Matern. Fetal Med. 9[1]:70-78, 2000).

"We can't be sanguine. We must be aggressive," said Dr. Ratner, medical director of Medlantic Clinical Research Center, Washington, D.C.

If a diabetic woman who is taking an ACEI or ARB becomes pregnant, the drug must be stopped immediately and switched to another antihypertensive agent. But if she comes in for prepregnancy planning, data suggest that she can continue taking ACEIs up until the time of conception, although the timing of the switch may be tricky, he noted.