Diabetic nephropathy, hypertension and pregnancy outcome

ABSTRACT

Nephropathy is a complication of diabetes mellitus that can affect women in their reproductive years. Modern management has improved the outcome of class F diabetic mothers and their infants. Drug therapy to control glucose levels, and blood pressure, as well as identifying preconceptionally, women at high risk for complications are the cornerstone for the achievement of good outcomes. Fetal survival rates of 95 percent are achievable. Although many woman with diabetic neuropathy experience a transient decline in renal function during pregnancy, pregnancy per se does not appear to hasten the natural progression to end stage renal disease. The association between the progression of renal disease in individuals with diabetes mellitus and inadequate blood pressure control requires aggressive treatment. Systolic blood pressure above 130mmHg and diastolic above 85 mmHg in pregnant women with diabetic nephropathy should be treated. Although angiotensin converting enzyme (ACE) inhibitors should be avoided during pregnancy, agents such as calcium channel blockers can be used with equally good results. Furthermore, these agents seem to have similar long-term effects of antihypertensive drug use on normotensive pregnant women with overt proteinuria. Nevertheless, preconceptional treatment with either ACE-inhibitors or calcium channel blockers seem to have a positive effect on the development of proteinuria throughout pregnancy. Therefore, patients with diabetic nephropathy contemplating pregnancy may be counseled that pregnancy is not contraindicated; that with stringent metabolic and blood pressure control, maternal and perinatal survival rates as high; that maternal and neonatal morbidity remains increased; however, the intercurrent pregnancy is not expected to accelerate the rate of decline of renal disease in lost patients with diabetic nephropathy. However, selected subpopulation of patients with moderate to severe baseline renal impairment may experience acceleration in their renal disease. These patients would benefit from renal transplant or stable dialysis therapy before initating pregnancy.(Au)