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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preconception Counseling for Women with Diabetes and Hypertension
Sponsored by The Indian Health Service Clinical Support Center
Step 5. Renal Protection
Case Scenario #2
RY is a 34 y/o G3P3 with known type 2 diabetes mellitus. Her blood sugars have been fairly well controlled with diet and metformin. She has recently remarried and is trying to conceive. On her most recent evaluation she is found to have the new onset of significant, but not nephrotic syndrome range, proteinuria (1.5 g/24 h). Would it be wise to start her on an ACE inhibitor, or an angiotensin receptor blocker (ARB), at this time?
Discussion
How about Ms. RY, the diabetic with new proteinuria? The renal protective effects discussed above are also very pertinent to her care, but we definitely are more concerned about her because she already has glomerular impairment. Nevertheless, ACE inhibitors are contraindicated because of their teratogenic and fetopathic effects detailed above. We would certainly want to know her baseline creatinine and obtain a 24 hour creatinine clearance. Most women with a creatinine less than 1.4 mg/dL will do well during pregnancy, but women with values above that will have a much higher incidence of poor perinatal outcomes. (Remember that normal serum creatinine during pregnancy is 0.4-0.6 mg/dL.) Tight glycemic control, adequate treatment of elevated blood pressure, in addition to baseline renal function, are the most significant predictors of maternal and perinatal outcomes.
Progression of diabetic nephropathy also depends on baseline renal function before pregnancy. Women without pre-existing proteinuria may develop new proteinuria during pregnancy, but it will usually resolve after delivery. On the other hand, diabetic women with pre-existing nephropathy may develop worsening proteinuria during pregnancy, which will not resolve postpartum. Diabetic women with significant pre-pregnancy nephropathy are also at increased risk for the development of preeclampsia, as well as for proliferative retinopathy. Referral for an ophthalmologic exam to evaluate whether baseline retinopathy already exists is also certainly indicated in her case.
