Editor: These 2 questions address the topics of management of chronic hypertension in pregnancy and the management of renovascular disease.
The answers are as follows.
Question -1, the answer is (E). There is room to further increase the methyl dopa. The patient can receive upto 3 g of methyl dopa in divided doses. It doesn't make sense to add another agent, especially one of the agents mentioned in the question. If one were to add a second agent, I would add labetalol or hydrallazine. The article by Tiina Podymow and Phyllis August in Hypertension in 2008 is really fantastic and definitely worth a read.
Question -2, the answer is B. Studies (ASTRAL, Star) demonstrate that in patient's like the one presented, medical therapy is as good as a percutaneous intervention. I would recommend that you read the article by Lance Dworkin in the New England Journal of Medicine. It is very well written.
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Question 1. A 22-year old woman with biopsy proven lupus nephritis, that is in remission, becomes pregnant. She is G0P0. She has a serum creatinine that is stable at 1.3 mg/dL. Her blood pressure had been controlled prior to pregnancy on lisinopril 20 mg/day. As part of her family planning process her lisinopril was stopped and methyl dopa 250 mg two times per day was started. She is seen by her OB early in the first trimester and her blood pressure is 158/92 mmHg, the dose of her methyl dopa is increased to 500 mg two times/day. She returns 1 week later and her blood pressure is 149/90 mmHg.
What should be the next step?
A. start losartan
B. start lisinopril
C. start nifedipine
D. start hydrochlorthiazide
E. increase the dose of methyl dopa further
Question 2. A 58 year old white male with a long-standing history of well controlled hypertension and hypercholesterolemia undergoes a cardiac catheterization for work-up of atypical chest pain associated with an abnormal stress test. At the end of his cath, his cardiologist calls you and tells you that he noticed a tight ostial lesion at the origin of his left renal artery and is planning to schedule a renal angioplasty next week.
Your response is:
A. "Great, I appreciate the follow-up, please go ahead"
B. "Thanks for the information, I will discuss this with the patient, but we can wait on the angioplasty
