MKSAP quiz: Preconception medication management

This month's quiz asks readers to evaluate the medications of a patient with hypertension, type 2 diabetes, and depression who hopes to become pregnant.

A 34-year-old woman is evaluated during a follow-up visit for blood pressure control. She states that she hopes to become pregnant and would like to stop her oral contraceptive. She does not smoke, drink alcohol, or use illicit drugs. She is in a monogamous sexual relationship and has had no sexually transmitted infections. Medical history is significant for hypertension, type 2 diabetes mellitus, and depression since childhood. Medications are an oral contraceptive, lisinopril, metformin, citalopram, and acetaminophen as needed.

On physical examination, vital signs are normal. The remainder of the examination is unremarkable.

In addition to starting folic acid, which of the following medications should be stopped at this time?

A. Acetaminophen
B. Citalopram
C. Lisinopril
D. Metformin

MKSAP Answer and Critique

The correct answer is C. Lisinopril. This item is available to MKSAP 18 subscribers as item 122 in the General Internal Medicine section. More information about MKSAP 18 is available online.

This patient should discontinue the ACE inhibitor lisinopril. Medication adjustments are an important component of preconception counseling in women who are planning pregnancy. All antihypertensive medications cross the placenta. Some antihypertensive medications are absolutely contraindicated during pregnancy, including ACE inhibitors, angiotensin receptor blockers (ARBs), and, likely, renin inhibitors. Women taking ACE inhibitors or ARBs should be counseled about the associated teratogenicity throughout all trimesters, and these medications should be stopped if pregnancy is anticipated or possible. Blood pressure goals with medical therapy in patients with chronic hypertension during pregnancy are 120 to 160/80 to 105 mm Hg. However, treatment of hypertension during pregnancy is controversial. If blood pressure control is not adequate after stopping lisinopril, methyldopa and labetalol have been used safely. Calcium channel blockers (such as long-acting nifedipine) can also be used during pregnancy. Diuretics may induce oligohydramnios if initiated during pregnancy but generally can be continued if the patient was taking a diuretic preconception. Spironolactone and eplerenone should be avoided because their safety has never been proven.

Although acetaminophen is generally considered safe during pregnancy, caution is needed with the use of NSAIDs due to their effect on organogenesis during pregnancy.

A goal for preconception wellness is the absence of uncontrolled depression. Evidence shows that women who are depressed during pregnancy have worse birth outcomes. Selective serotonin reuptake inhibitors, including citalopram, fluvoxamine, and sertraline, are pregnancy category C agents that can be continued during pregnancy. An alternative to antidepressant therapy is psychotherapy, specifically cognitive behavioral therapy, which is equally as efficacious as pharmacologic therapy. In this patient who is already taking an antidepressant, it would be more important to continue therapy than to discontinue treatment.

Optimal glycemic control with a goal hemoglobin A1c value of less than 6.5% is recommended for women with diabetes mellitus who are contemplating pregnancy. Metformin is a diabetes medication deemed safe during pregnancy, as it is FDA category B. Category B denotes that animal reproduction studies have not demonstrated a fetal risk, and no controlled studies in pregnant women have shown adverse effects.

Key Point

  • Antihypertensive medications absolutely contraindicated during pregnancy include ACE inhibitors, angiotensin receptor blockers, and, likely, renin inhibitors.