A CASE OF SECONDARY HYPERTENSION DIAGNOSED DURING PREGNANCY

Objective: Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic vascular disease, often causing renal artery stenosis (RAS) and arterial hypertension (AH). There are no recommendations for its management during pregnancy. We report a clinical case of FMD discovered during pregnancy. Design and method: A 33-year-old woman was hospitalized for elevated blood pressure values at the 14th week of gestation. She referred normal blood pressure values during the first 3 months of pregnancy. Results: Standard blood tests did not show significant alterations except for hypokalemia (2.97 mEq/L). The urinary albumin/creatinine ratio was normal. She underwent a complete screening of hypertension-mediated organ damage (HMOD), documenting normal left ventricular mass (LVMI 78 g/mq) and no carotid plaques. A Doppler ultrasound (US) of the renal arteries identified a hemodynamically significant stenosis in the medium-distal tract of the left renal artery, likely due to FMD. After starting potassium supplementation and triple antihypertensive therapy with Alpha2-Adrenergic Agonist (AAA), Calcium Channel Blocker (CCB) and Beta-blocker (BB), all at the maximum doses, her blood pressure control significantly improved (24 h average blood pressure values at the ABPM were 135/80 mmHg). At 38 weeks of pregnancy, she gave birth to a normal-weight baby by spontaneous delivery. Six months after delivery, she underwent MRI angiography of the renal arteries, confirming the presence of the FMD lesion. The patient underwent left renal artery angioplasty. A post-procedural Doppler US showed the absence of renal artery stenosis. Her blood pressure progressively and markedly improved after the procedure, requiring a down-titration of the dose and number of antihypertensive drugs, although she never normalized her blood pressure values. Conclusions: This is the case of arterial hypertension developed during pregnancy and due to a hemodynamically significant renal artery stenosis from FMD. Despite no treatment recommendations are provided in the guidelines for this condition, we document that a triple antihypertensive therapy with AAA, BB and CCB was safe and effective in controlling the patient’s blood pressure. This clinical case highlights the importance of the correct screening for secondary forms of hypertension, that should be performed also in pregnant women.