Management of a Pregnant Woman With Fibromuscular Dysplasia
2018; Lippincott Williams & Wilkins; Volume: 71; Issue: 4 Linguagem: Inglês
10.1161/hypertensionaha.118.10819
ISSN1524-4563
AutoresE. Berra, Anna F. Dominiczak, Rhian M. Touyz, Sophie Piérard, Frank Hammer, Gian Paolo Rossi, Rubén G. Micali, Jan A. Staessen, Michael Bursztyn, Thomas Kahan, Alexandre Persu,
Tópico(s)Renal Diseases and Glomerulopathies
ResumoHomeHypertensionVol. 71, No. 4Management of a Pregnant Woman With Fibromuscular Dysplasia Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBManagement of a Pregnant Woman With Fibromuscular Dysplasia Elena Berra, Anna F. Dominiczak, Rhian M. Touyz, Sophie Pierard, Frank Hammer, Gian Paolo Rossi, Ruben Gabriel Micali, Jan A. Staessen, Michael Bursztyn, Thomas Kahan and Alexandre Persu Elena BerraElena Berra From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Anna F. DominiczakAnna F. Dominiczak From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Rhian M. TouyzRhian M. Touyz From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Sophie PierardSophie Pierard From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Frank HammerFrank Hammer From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Gian Paolo RossiGian Paolo Rossi From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Ruben Gabriel MicaliRuben Gabriel Micali From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Jan A. StaessenJan A. Staessen From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Michael BursztynMichael Bursztyn From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). , Thomas KahanThomas Kahan From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). and Alexandre PersuAlexandre Persu From the Department of Cardiology, Cliniques Universitaires Saint-Luc (E.B., S.P., A.P.), Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique (S.P., A.P.), and Department of Radiology, Cliniques Universitaires Saint-Luc (F.H.), Université Catholique de Louvain, Brussels, Belgium; Internal Medicine and Hypertension Division, Department of Medical Sciences, AOU Città della Salute e della Scienza, Turin, Italy (E.B.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D., R.M.T.); Division of Internal Medicine and Hypertension Unit, Department of Medical Science, University of Padova, Italy (G.P.R.); Department of Hypertension, Hospital Italiano de Buenos Aires, Argentina (R.G.M.); Department of Hypertension, Instituto Cardiovascular Lezica, San Isidro, Argentina (R.G.M.); Abbott Argentina, Buenos Aires (R.G.M.); Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (J.A.S.); Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel (M.B.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (T.K.). Originally published26 Feb 2018https://doi.org/10.1161/HYPERTENSIONAHA.118.10819Hypertension. 2018;71:540–547Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2018: Previous Version 1 IntroductionA 39-year-old woman of Moroccan origin presented to the Cardiology Department with high blood pressure, with systolic blood pressure repeatedly measured at 170 mm Hg in the office. She was 10 days pregnant. Her treatment included nebivolol 5 mg and barnidipine 10 mg.Her medical history included migraines, an early miscarriage in 2001, and a second pregnancy with delivery at 27 weeks for preeclampsia in December 2014. At post-partum, she had received amlodipine, and then bisoprolol at another hospital. In September 2015, she had consulted at a third hospital for persistent hypertension with moderate to high blood pressure (systolic blood pressure: 170–190 mm Hg). Blood pressure was measured at 170/80 mm Hg in the office. Cardiac test results were normal. The physician concluded that the patient experienced chronic, rather than pregnancy-related hypertension, and replaced bisoprolol 5 mg with nebivolol 5 mg; barnidipine 10 mg was maintained, and the patient was asked to adhere to the therapeutic regimen. Despite mentioning that the hypertension was likely essential, he ordered an etiologic work-up. Renal function was normal (plasma creatinine: 58 μmol/L; estimated glomerular filtration rate: 100 mL/min per 1.73 m2). Urinary analysis revealed a mildly increased proteinuria of one-half gram per 24 hours. Urinary metanephrines were in the normal range, and the renal duplex study suggested a differential diagnosis of right renal artery stenosis and an arterial loop.Discussion: Managing the HypertensionDr Micali: I would check the urinary sodium to confirm whether the patient is adhering to the hyposodic diet. This is one approach to check and determine whether the patient is consuming salt or not.Professor Persu: Yes, I think this is a good point, but this patient is not very adherent, and we had instances where we did not succeed in obtaining 24-hour urine samples. Additionally, this was performed in another hospital. I do not have details, so we must continue without this information.Dr Micali: In that case, I would consider a third drug or perhaps a combination to make the treatment easier.Professor Persu: I agree.Professor Staessen: I am wondering, Alexandre, whether you should have performed other imaging studies in addition to a renal duplex.Professor Persu: This was done before we saw her. Yes, I agree that a renal duplex with such an ambiguous result is definitely not sufficient.Case History (Cont.)When the patient presented initially to our hospital at the Cardiology Department, she was slightly overweight (body mass index: 27.6 kg/m2). We confirmed high blood pressure (left arm: 180/110 mm Hg; right arm: 190/105 mm Hg). No heart, abdominal, or carotid murmurs were observed, and the examination was otherwise unremarkable. Echocardiography showed no evidence of left ventricular hypertrophy or aortic coarctation.Because the patient was pregnant, the recommendation was to replace the nebivolol and barnidipine with α-methyldopa and nifedipine extended release; after that, my colleague referred the patient to us.Professor Staessen: I am wondering what the rationale is to replace nebivolol and barnidipine with alpha-methyldopa and nifedipine extended release. I can understand replacing nebivolol with alpha-methyldopa because there is considerable experience with alpha-methyldopa in pregnancy. However, nifedipine extended release is basically a short-acting drug, which is made long acting by utilizing it in the galenic format. I would have preferred to prescribe amlodipine or a long-acting drug that is considered long-acting per se.Professor Persu: I think this is controversial. Indeed, amlodipine is probably better regarding the duration of action. Though, while there are no good studies with calcium antagonists in pregnancy, there is considerable experience with nifedipine,1 and some groups of obstetricians consider it to be a first-choice drug, so I can understand this choice.Professor Dominiczak: There is another potential suggestion. Many obstetricians around Europe and those who deal with these cases would suggest labetalol. Do you want to address this?Professor Persu: Yes. This would also be an appropriate second choice after alpha-methyldopa.1 Some studies using first-generation beta-blockers, such as atenolol, have shown growth restriction,2 and thus some clinicians think it is better to avoid administering beta-blockers old or new at the beginning of a pregnancy. This can be discussed.Professor Dominiczak: Labetalol is a mixed alpha-beta, so these concerns may not apply.Professor Persu: Indeed, there is no clear evidence that labetalol causes problems during pregnancy, but some clinicians have reservations using it in the first trimester. Overall, there is little evidence on the best antihypertensive treatments in pregnancy.1We saw the patient for the first time at the hypertension consultation in January 2016, at which time she had experienced 9 weeks of amenorrhea. She complained of nausea and vomiting. At that time, her treatment was mostly unchanged, but acetylsalicylic acid 80 mg was added. Her blood pressure remained high (seated: 168/111 mm Hg; standing: 166/112 mm Hg); she was poorly adherent to the treatment because she could not tolerate it well, she said. In addition, vomiting made it challenging.At that time, she also informed us that she underwent an abdominal computed tomographic (CT) angiography at another hospital when she was at the beginning of her pregnancy but was not aware of it.We decided to examine the recently performed CT study and to perform a 24-hour ambulatory blood pressure measurement (ABPM) and schedule another appointment within 3 weeks because it was difficult to convince the patient to take any medications; and we wanted to follow-up and determine the severity of hypertension.Professor Rossi: Alexandre, one reason for replacing a beta-blocker with alpha-methyldopa could be to plan the measurement of renin because with a beta-blocker, renin would be zero.Professor Persu: That is true and a good point. However, I think that the main reason for prescribing alpha-methyldopa was that, in current practice in Belgium, it remains the first choice in pregnancy.Professor Rossi: In addition to that, it is very surprising to learn that in spite of nine weeks of amenorrhea, they did a CT scan. We do not do this unless they are negative for pregnancy.Professor Persu: The CT scan was performed several weeks before the first consultation in our center. The patient was probably not aware that she was pregnant. Also, the fact that examinations were performed at several different hospitals increases the risk of such occurrences.Professor Rossi: Yes, but at least at my institution, the radiologists would not perform any X-ray if they can't exclude pregnancy.Professor Persu: We have the same policy in our hospital. They would not accept it.Professor Dominiczak: This is a very important learning point. I think that we are going to put this in the paper: every woman of child-bearing age is pregnant until proven otherwise. That is what I was taught as a junior doctor.Professor Persu: In our hospital, even without evidence of pregnancy, we would not have performed it without a pregnancy test. That is true.Dr Micali: The patient is pregnant. She still has very high blood pressure. You could increase the alpha-methyldopa dose, and consider hospitalizing the patient, taking into account the fact that she is not taking the medication.Professor Persu: I think you could. However, this patient was difficult to manage. This is a real-life case. She would not accept medication or hospitalization easily. You may consider either quick 24-hour ambulatory monitoring or hospitalization for monitoring. We chose the first option.Professor Bursztyn: I do not think that, with repeated high blood pressure as in this patient, ambulatory monitoring is going to be of any help.Professor Persu: I agree that we were very sure she was hypertensive. However, ABPM might still be useful for grading the severity of hypertension and also to convince her that antihypertensive treatment was truly required.Kidney ImagesThe images can be observed. We see the abdominal CT angiography, which will be followed by better images later. Currently, this is the one we can examine. You can see irregularities in the mid-distal right renal artery. In addition, we do not have all images from this hospital, but we know that the right kidney was slightly reduced in size with delayed uptake of contrast.Another point mentioned was that this patient has no celiac trunk. She has a separate emergence of the splenic and hepatic arteries and stenosis of the hepatic artery. This does not change her follow-up now, but I am interested in how the audience would interpret these images.Professor Williams: She is young, and she has multiple stenotic lesions, which are irregular. Thus, she has fibromuscular dysplasia (FMD). It is likely she has FMD in multiple vascular beds.My question is if the film was examined a few weeks prior, was any action taken then? The tragedy is, of course, this is one of the easiest conditions to treat.Professor Persu: One of the messages of this case is that, in these patients who go from one doctor to another, there is a major risk of loss of information, dilution of responsibility, and so on.Professor Bursztyn: I am not completely sure about the diagnosis. There are other diseases in young women that may cause obstructive stenosis. For instance, Takayasu arteritis is one pathology. I would, if this was not initially done, have examined the peripheral pulses.Professor Persu: Peripheral pulses were present, she has no inflammatory syndrome, and later, you will see images that are much more typical. For the hepatic artery lesion, we cannot be sure, but, in the context of renal artery irregularities, I agree with Professor Williams that it is probably from FMD as well.Professor Williams: In Takayasu arteritis, you do not usually see beading of the artery. You might observe stenosis, but you will not see beading; she had multiple beads along the renal artery, which is very characteristic of renal FMD.Images (Cont.)Another image shows that the hepatic stenosis was severe. I would like to make the point that this might be an anatomic variant. However, such variants seem to be rare. Therefore, an FMD-related lesion is a more likely explanation.At the next consultation, blood pressure was a little lower (seated: 167/102 mm Hg; standing: 153/99 mm Hg). Daytime and night-time mean ambulatory blood pressures were 159/106 and 144/86 mm Hg, respectively. As indicated by a colleague, the hypertension was confirmed, but a little less severe than expected. Renal function was normal (plasma creatinine: 64 μmol/L; estimated glomerular filtration rate: 103 mL/min per 1.73 m2), and proteinuria was moderately increased (1 g/24 h).Discussion: Proteinuria?Professor Dominiczak: She is 12 weeks pregnant, which is less than 20 weeks. It cannot be preeclampsia.Professor Persu: Indeed. She already had baseline proteinuria to some extent.Professor Dominiczak: This is chronic hypertension of pregnancy that is worsening and heading towards preeclampsia, superimposed on pregnancy-related hypertension.Professor Rossi: First, it would be very important to know what her blood pressure was before pregnancy, and if she previously had proteinuria, and, second, it would be important to know the resistive indexes inside both kidneys because that would provide an idea of the impact of the kidney stenosis.Professor Persu: The few measurements we have before pregnancy suggest grade 2 to 3 hypertension, so she likely suffers from preexisting, chronic hypertension. She already had 500-milligram 24-hour proteinuria before pregnancy as revealed by analysis of a single sample. Finally, the resistive indexes were normal in both kidneys.Professor Bursztyn: Normally, you have no proteinuria in renovascular hypertension unless there is an occlusion. The increasing proteinuria by the gram or perhaps grams suggests imminent occlusion.Professor Waisman: In the first trimester of pregnancy, if proteinuria and hypertension are present, molar pregnancy should be considered.Professor Persu: This is a good point, but it was not confirmed. It was not molar in this case.Dr Tsanova: When you have proteinuria and hypertension in a young woman before pregnancy, we must always consider chronic glomerulonephritis or other chronic renal disease. Although renal function is normal, this may be the beginning of such a disease. Often, we do not think about the urine and urine sediments, and whether something else is present.Professor Persu: This may be; however, it is difficult to accept that a patient has two relatively uncommon diseases simultaneously. Many patients with severe hypertension can have some degree of proteinuria, which will increase during pregnancy. This is my view.Therapy Discussion as Pregnancy ProgressesWe added labetalol and ensured that she took the other medications. We had planned to see her soon after this. We told her that, after delivery, we should consider confirming the diagnosis of FMD by renal angiography and performing renal angioplasty. In addition, a more extended vascular work-up was needed.Dr Amar: Alexandre, she has very severe hypertension with severe renal artery stenosis. At some point, without angiotensin-converting enzyme (ACE) inhibitor treatment, her hypertension would never be controlled during pregnancy and as she cannot be treated with ACE inhibitors,1 thus termination of pregnancy should be discussed?Professor Persu: We will discuss this later, but we did not consider this option because, as you will see, we ultimately succeeded in achieving better, albeit suboptimal, blood pressure control. However, in some cases, I agree that this can be a major issue.At this time, she is probably more compliant with taking her medication and has had amenorrhea for 15 weeks. Her high blood pressure is less severe with an estimated home blood pressure of 140/90 mm Hg, which is not optimal, but certainly acceptable in pregnancy.1 However, this result was obtained with a therapeutic regimen, including most medications recommended in first-line treatment of hypertensive women.We now can
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