by email@example.com (322 Posts), Fri Oct 15, 2010 02:05 pm
Agree with *****. Several times a year, a basic science paper is published that has some relevance to preeclampsia - but is hyped as "one step short of a cure." The logical step from this paper could be use of ACE-inhibitors with appropriate attention to fetal effects.
We have some published experience with intentional use of ACE-inhibitors in pregnancy. In conditions such as branch stenosis of the renal artery where activation of the renin-angiotensin axis is anticipated, they can make uncontrollable hypertension controllable. In advanced preeclampsia with resistant vasoconstriction, they do not seem to make much of a difference - too little too late.
Could use early in pregnancy, justified by the findings of this paper, improve outcomes? It seems plausible. A trial to assess the potential would need to be conducted in a very rigorous environment of fetal surveillance. That said, the paper describes a potential pathway of pathophysiology in preeclampsia. If we have learned anything from trials in the past, the pathways of pathophysiology are probably redundant. The potential positive impact would probably be incremental - not absolute.
There is data from the diabetes literature that use of ACE-inhibitors 6 months prior to pregnancy, (stopped when conception occurs), can dramatically reduce the expression of proteinuria in pregnancy. One can certainly debate whether this impact is relevant to clinical outcomes in pregnancy. Sibai's paper from the high risk ASA study suggested that htn and proteinuria early in pregnancy predicted adverse neonatal outcome.