There is a summary and list of suggestions at the end of this page

Elevated blood pressure in an otherwise healthy pregnancy, often called "Pregnancy Induced Hypertension", is caused by low blood volume. This in turn is caused by a lack of the kinds of foods necessary for expanding the pregnant mother's blood volume and maintaining a healthy pregnancy.

One of the main tasks of the pregnant body is to increase the blood volume by 50-60%. The liver works at increasing the blood volume by making albumin from the protein that the mother eats. The salt that the mother eats also helps to increase the blood volume. Both albumin and salt create osmotic pressure, which helps to hold fluid in the mother's circulation, so that it doesn't leak out into the tissues of her ankles and fingers.

When the mother doesn't eat enough salt, and protein, and calories (to save her protein from getting burned up for calories), the blood volume stops increasing, and it plateaus or begins to drop. When the blood volume is less than it should be for that stage of pregnancy, the body reacts the same way as it would if the blood volume were too low due to hemorrhaging. The kidneys produce renin to constrict the capillaries and send all the available blood to the internal organs, as they would do in the case of hemorrhaging, to save the internal organs at the expense of the limbs, if necessary. In the case of pregnancy, however, where the inadequate blood volume is due to lack of proper nutrition, and not from hemorrhage, this constriction of the capillaries makes the blood pressure go up.

Salt in Pregnancy

	High Salt Diet	Low-Salt Diet
Toxemia	37/1000	97/1000
Perinatal deaths	27/1000	50/1000
C-section	9/1000	14/1000
Abruptio placenta	17/1000	32/1000

If the mother will increase the amount of salt, protein, and calories that she eats, the blood volume will increase, and the blood pressure will come down to a normal level. Sometimes this means that she will need to eat an ounce or two of protein every hour. Some examples of items that she could eat every hour are a handful or two of nuts, or cheese cubes, or trail mix. She could also eat a hard-boiled egg, or a slice of cold cuts, or a cup of yogurt, or 1/4 cup of cottage cheese.

See here for details from several studies regarding the link between nutrition and elevated BP

Nutritional Deficiency in Pregnancy

Complications	Control Group (750)	Nutrition Group (750)
Preeclampsia	59	0
Eclampsia	5	0
Prematures (5 lb. or less)	37	0*
Infant Mortality	54.6/1,000	4/1,000

Once the process of pre-eclampsia has started, Anne Frye recommends having the mother eat a high protein item every waking hour. She also suggests, "Initially recommend an increase to 150 to 200 grams of protein daily (250 to 350 grams or more with multiple gestations), with 3,000 to 4,000 calories and 500 mg of choline daily...If the woman has a history of liver disorders, recommend less protein (120-150 grams for a single fetus); her liver may be overwhelmed otherwise, and monitor her lab work closely for changes...Once liver enzymes and blood proteins have normalized, the hemoglobin has dropped appropriately, the fetus is an appropriate size for dates and secondary symptoms have subsided, the woman can cut back to 100 grams of protein daily (150 grams with multiples)."

See here for more information on the best ways to treat pre-eclampsia

If she also wants to use herbs to help address her elevated blood pressure, the herb that I have seen work is Passionflower. According to Wise Woman Herbal for the Childbearing Year, the recommended dose is 2-4 capsules daily, or 15 drops of the tincture three times a day. However, in my experience the best results occur when the hourly doses of protein, and the other aspects of the Brewer Diet, are used alongside the use of the Passionflower, because in the absence of some kind of heart or kidney problem, the basic cause of the elevated blood pressure in pregnancy is the lack of enough of the right kinds of food.

She can also try adding beet juice to her daily nutrition (see news item below). But here again, she needs to use beet juice in addition to beefing up her food intake (adding more foods from the Brewer food groups), rather than instead of adding more food to her daily eating plan.

Susun Weed suggests up to 4 oz a day of beet juice, in her book titled "Wise Woman Herbal for the Childbearing Year." She also suggests that women can grate one raw beet and combine it with one grated raw apple, for a tasty and healthy snack that can help relieve elevated blood pressure and pre-eclampsia.

Susun Weed also suggests taking 2-10 capsules of garlic oil a day for lowering blood pressure. Once again, if you try this, do it alongside your hourly doses of protein, rather than instead of the protein. If you are expecting to have some kind of surgery soon, pass on this one, since garlic can lengthen the clotting times of your blood.

I do not recommend using herbs if you are on some kind of prescription medication. If your midwife or doctor is knowledgeable about herbs and their interactions with prescription medications, you can consult with her/him on this issue. If you want to try the beet or garlic suggestions, take care to start with the lower doses of the range suggestions and gradually increase them, keeping an eye on your blood pressure day by day, so that your blood pressure doesn't drop too fast.

Please see the "Physiology" page of this website, for a more detailed description of how an inadequate blood volume can cause an elevated blood pressure. You can also read one or more of the Brewer books, available in most public libraries, or through inter-library loan, and consult with your midwife, and decide what the best path is for you and your baby.

See Physiology Page here

Prevention of Convulsive MTLP (Eclampsia)

	Number of Pregnancies	Cases of Convulsive MTLP (Eclampsia)
Tompkins 1941	750	0
Hamlin 1952	5,000	0
Bradley 1974	13,000	0
Davis 1976	500	0
Brewer 1976	7,000	0
Total	26,250	0

Note from Joy: Please note that the use of diuretics in pregnancy was much more common when Dr. Brewer first started working with pregnant women. I believe that Dr. Brewer can be given a lot of the credit for the fact that they are rarely or never used in pregnancy now. The principle that weight control and salt restriction during pregnancy is hazardous to both the mother and the baby still stands, regardless of whether diuretics are used to assist in that control or not.

Unfortunately, some areas of the "alternative medicine" community have followed mainstream medicine in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties. Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant women to watch which herbs they are taking.

See here for more information about the use of herbal diuretics in pregnancy

In September of this year (2008) a study came out from Denmark which seems to emphatically support something which the Brewers and their supporters have been saying for over 30 years. That is that pregnant women who lose extra salt, or burn extra calories, through extra exercise NEED to compensate for those losses by adding extra salt and calories to their diets. When they do not make special allowances for their unique needs in this way, their blood volume will drop, and they will develop rising BPs, pathological edema, pre-eclampsia, HELLP, IUGR, premature labor, underweight babies, and other complications associated with low blood volume. This particular study was looking at only pre-eclampsia, and only at recreational exercise, but those of us who understand the Brewer principles understand that the same principles do apply to all of these other complications, and to any source of salt/fluid/calorie loss, as well.

"Pregnant exercise 'unsafe'"

Read more.......

"Women who exercise during pregnancy face risk of pre-eclampsia, researchers warn"

Read more.......

"Exercise in pregnancy linked to fatal raised blood pressure condition"

Read more.......

At the Salt & Pregnancy Forum of May 2006 (1), organized by EuSalt, Prof. Dr. Markus G. Mohaupt already underlined that pregnancy is no time to reduce salt intake and that additional salt may benefit women suffering from pre-eclampsia.

Recently, Prof. Dr. Mohaupt published a case study (2) showing that an additional salt intake of 20g stopped hypertension during pregnancy… In this case, a 33-year-old woman with normal renin activity was diagnosed with essential arterial hypertension 15 years ago. During the 6 month period before conception, her blood pressure was well-controllable by dual antihypertensive treatment. Throughout pregnancy, blood pressure recordings were collected daily, and at five weeks of gestation in her first pregnancy, she stopped all antihypertensive drugs. As a result, the average blood pressure increased, whereas the expected increase in aldosterone synthase activity in pregnancy did not show. Given this hypoaldosteronism, sodium supplementation aiming at 20g total NaCl intake per day was initiated, and pursued throughout pregnancy, and resulted in a decrease of the blood pressure during pregnancy.

After delivery, maternal blood pressure rose again, NaCl supplementation was terminated and antihypertensive treatment was reinstalled. The observation that blood pressure was responsive to NaCl supplementation is in line with the hypothesis that intravascular volume decrease causes increased blood pressure in pregnancy. The absence of the expected increase in aldosterone synthesis was associated with a mutation of the aldosterone synthase gene, similar to earlier findings in pre-eclamptic women. This persistenthypoaldosteronism together with earlier findings on NaCl supplementation led the researchers to supplement salt in this woman. This salt supplementation was associated with a reduced blood pressure throughout pregnancy. In addition to this case, Mrs Sabine Kuse, founder of a support group (1984) for women in acute state and after pregnancy with pre-eclampsia or HELLP-syndrome, and her team have been advising more than 20.000 women during their high-risk pregnancies over the past 22 years.

They found that in most cases, additional salt helped within hours. More importantly, during all those years, they haven’t seen one case where salt supplementation has caused negative effects. The worst effect was no effect. (1) Support for this critical role of NaCl intake during pregnancy, was already provided by Robinson in 1958, who found a reduced incidence of pre-eclampsia in pregnant women on a high salt diet (3).

This study introduced substantial data for bias in other studies, of which all data suggest that salt restriction during pregnancy does not seem promising for the prevention of pre-eclampsia. Or, as the study of Mohaupt et.al concludes: pregnant women with even subtle signs of volume deficiency might benefit from salt supplementation in pregnancy.

Footnotes:
1. EUSALT Newsletter. Salt, blood pressure and pregnancy: a critical relationship? August 2006.
2. Markus G. MOHAUPT et.al . Blood pressure reduction in pregnancy by sodium chloride. Oxford University Press, 2006.
3. M. ROBINSON. Salt in Pregnancy. Lancet, 1958, 1: 178 – 181.

Source: 4th April 2007 12:23:26 / Femalefirst.co.uk

Lifestyle Adjustments: As you evaluate your nutrition and lifestyle, it would also be helpful to evaluate your level of activity and add extra nutritious calories if you use extra calories during the week, with jogging, biking, skating, skiing, or other sports, or other extra calorie-depleting activities, like teaching, dancing, waitressing, nursing, doctoring, or other activities that keep you on your feet all day. Caring for other children, working both outside and in the home, caring for other family members, and housework would also use up a lot of calories, especially as the baby gets bigger and you burn up calories just carrying around the extra weight of the baby, uterus and extra blood volume. You can also evaluate whether other stresses in your life might be using up extra calories. If you have had extra stresses in your life, then adding extra nutritious calories and other nutrients to compensate for those calorie-burning stresses would help to keep your blood volume expanded and your pregnancy and baby healthy.

See here to help you evaluate your daily nutrition patterns

See here for a nutrition/lifestyle self-assessment which I highly recommend

Eating Patterns:The usual eating pattern that we suggest that pregnant women can use to keep up with their nutritional needs is as follows: breakfast, mid-morning snack, lunch, mid-afternoon snack, supper, bedtime snack, middle-of-the-night snack. If you are having trouble keeping up with the amount of food that you need, or if you are having trouble keeping your blood pressure within a normal range, we suggest that you eat something with protein in it (glass of milk, cheese cubes, handful of nuts, handful of trail mix, etc), every hour that you are awake.

Please be aware that traveling and moving can break up your eating routine just enough to trigger a low blood volume problem which can start the rising BP/pre-eclampsia/HELLP/premature labor/IUGR/abruption process. Putting the brakes on that process can be more difficult than preventing it. Sometimes just being aware of this danger is enough to help you to remind yourself to continue providing for your nutritional needs, in spite of any changes and stresses which may be going on in your life.

Morning Sickness: If you are dealing with nausea, vomiting, or diarrhea, it is vitally important to try to alleviate those problems as soon as possible, since they also contribute to depleting your blood volume. You can try frequent, small snacks, herbs, and homeopathy to help you in this effort. If you decide to try using ginger, which can be very effective for "morning" sickness, use it only in small amounts, and only just before eating some kind of food, since too much ginger can cause bleeding and possibly miscarriage.

See a resource for homeopathy for morning sickness here

Adjusting for Salt Loss: It would also be helpful for you to evaluate whether you are ever in situations that result in your losing extra sweat and salt--situations such as gardening in hot weather, exercising, living in hot homes during the winter, or living without air-conditioning in the summer, or working in over-heated working conditions. If you do have one of those situations, it would be helpful for you to add extra salt and nutritious fluids to your daily nutrition. This extra effort will help to keep your blood volume expanded to where it needs to be to prevent elevated blood pressure, pre-eclampsia, and other complications.

See here for more information about the importance of salt in pregnancy

Calories plus Salt plus Protein: Eating the recommended amount of protein every day isn't enough to keep your blood volume expanded to where it needs to be for preventing complications in pregnancy. It is also vitally important to make sure that your intake of nutritious calories and salt are also at the recommended levels, with special extra allowances added as needed for your unique situation.

See here for more information on the importance of calories in pregnancy

Herbal Diuretics: Unfortunately, some areas of the "alternative medicine" community have followed mainstream medicine in the belief that diuretics are important and useful for treating edema and elevated blood pressure in pregnancy. Many pregnancy teas and some supplements and juices include nettle, dandelion, alfalfa, bilberry, or celery, all of which have diuretic properties. Diuretics are no safer for pregnancy in herbal form than they are in prescription medications, so it is important for pregnant women to watch which herbs they are taking.

See here for more information about the use of herbal diuretics in pregnancy

Empowering Women: I would also like to add here the assurance that Dr. Brewer was not blaming the mother for her situation, as some would claim that he was, and neither am I. He is clearly blaming her doctor for not having the routine of examining her nutritional status and doing a differential diagnosis for her. He is saying that if her doctor is not doing this with her, then it is most important for her to do it for herself, for the sake of her own health and that of her baby.

At the first sign of a rising BP, pathological edema, pre-eclampsia, IUGR, premature labor, or HELLP, a Brewer Diet counselor should sit down with the mother and help her to evaluate her lifestyle and her diet to see if any adjustments can be made to optimize the fit between her pregnancy, her diet, and her lifestyle. For example, to compensate for her salt and calorie losses, she can cut back on her exercise program and her work schedule, she can stay out of the heat (outdoors, at work, or at home), she can postpone a move until after the birth (and 6 weeks postpartum), and she can increase her salt/calorie/protein intake. One way that she can increase her diet intake is to add 200 calories and 20 grams of protein for each of the following situations:

The above information is reprinted and adapted from the work of Agnes Higgins, and Gail Brewer's "The Complete Pregnancy Diet: Meeting Your Special Needs" from Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

See here for more information on adjusting the Brewer Diet to fit your lifestyle

Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

Please be aware that traveling and moving can disrupt your eating routine just enough to trigger a low blood volume problem which can start the rising BP/pre-eclampsia/HELLP/premature labor/IUGR/abruption process. Putting the brakes on that process can be more difficult than preventing it. Sometimes just being aware of this danger is enough to help you to remind yourself to continue providing for your nutritional needs, in spite of any changes and stresses which may be going on in your life.

Placenta

As Figure 8 shows, it is also the action of your uterus that separates your placenta and expels it in the third stage of labor. This organ allows nutrients and oxygen to pass from your bloodstream into your baby's and also permits the removal of waste products from the baby's body. The placenta originated in cells from the fertilized egg. Enzymes on the surface of the ovum dissolved away a tiny portion of the surface of your uterine wall, opening a few arteries and veins in the process. With each beat of your heart, from that moment until your placenta comes away from the wall of your uterus, those arteries spurt jets of nutrient- and oxygen-rich blood against the surface of the placenta. This is the only blood supply to this most important organ, and only what is present in your bloodstream can nourish it and your developing baby.

The placenta is firmly anchored to the wall of your uterus by threads of collagen throughout and by a seal around its margin. Because of this, the blood that swirls up against the placenta stays in a "lake," continuously bathing the placental tissue. This blood does return to your heart after spending some time in the "lake," via the open veins that now function like the drain in you tub or shower stall: the pooled blood is pushed into the veins by the force of new blood coming into the "lake" from the open arteries. Technically, this sort of blood supply is termed an a-v (arterio-venous) shunt, meaning that the blood passes directly from arteries to veins without first passing through capillaries (the usual way things are done in the body).

Since the supply of blood encourages and supports placental growth, and a larger placenta requires more blood to keep it functioning optimally, ever-increasing amounts of blood are required as pregnancy advances to satisfy the needs of the placenta. If you are carrying a single baby, your blood volume will expand approximately 60 percent (if you eat well enough) to service your placenta. If you have twins (and therefore a double placenta or two separat placentas), your blood volume must expand by 100 percent or more to stay even with the demand. A falling blood volume or a blood volume that is below the needs of your pregnancy is recognized as a major cause of premature labor, underweight babies, and high blood pressure during pregnancy. When you recognize the importance of keeping your blood volume up and your placenta healthy (even though you can't see it or feel it), you will have a strong inducement to stay on your excellent pregnancy diet every day.

See here to better understand the evolution of the mainstream medical perspective on nutrition and salt in pregnancy

Nine Months, Nine Lessons available here

The following is reprinted from "Chapter 1" of Eating for Two, by Isaac Cronin and Gail Sforza Brewer, 1983.

"The Complete Pregnancy Diet: Meeting Your Special Needs", by Gail Sforza Brewer (p.1)

CORRECTIVE ALLOWANCES

Agnes Higgins, past president of the Canadian Dietetic Society and director of the Montreal Diet Dispensary [as of 1983], has developed a procedure for estimating calorie and protein requirements in excess of the pregnancy levels we've already established as a baseline. She emphasizes that any of the following factors increases a mother's nutritional needs:

As a corrective allowance, Mrs. Higgins and her staff counsel mothers to add twenty grams of protein and two hundred calories to their basic daily pregnancy diets for each condition listed above (an individual mother may be experiencing more than one of these stress conditions).

Multiple pregnancy is the only exception: each extra baby requires a nutritional supplement of thirty grams of protein and five hundred calories per day. Higgins comments that this requirement can be met most economically by adding one quart of whole milk a day to the expectant mother's diet (to be drunk, used in cream soups, custards, milkshakes, cream pies and tarts, or as exchanges in yogurt, ice milk, and natural cheeses). Of course, there are many other ways to increase the protein and calories during pregnancy by eating an additional four-ounce serving of meat, fish, shellfish, poultry, or meat substitute as detailed on the diet list. A sample daily menu plan for a mother expecting twins would look something like this:

Generally speaking, these conditions result in an increased appetite; however, women who are working, moving their households, or under emotional stress sometimes fail to pay attention to their bodies' signals for more food. Calling special attention to their extra needs by assigning specific goals for extra protein and calorie consumption makes it much less likely that their nutritional needs will go unfulfilled.

Undernutrition means any protein deficit between what you're used to getting from your food and the minimum adequate pregnancy requirement (eighty to a hundred grams per day). The Higgins nutrition intervention method uses a twenty-four hour diet recall, a technique you can use on your own to see how close your regular diet has been coming to what you actually need. You will need to write down everything you've eaten for the past twenty-four hours (pick a typical day for you), including all snacks, all beverages, and all second helpings. Note what the food was, how much you ate, then consult the Protein-Calorie Counter (see Appendix) to check the amount of protein contained in those portions of those foods. For each gram of protein you lack, add that to your personal protein goal, plus an additional ten calories to free that protein for its most important work in pregnancy: keeping you own tissues healthy and building those of your unborn baby. If you come up with a deficit of ten grams of protein, then, you also need to add a hundred calories to your basic requirements.

See here for entire chapter, "The Complete Pregnancy Diet: Meeting Your Special Needs"

Eating for Two, by Gail Sforza Brewer and Isaac Cronin, available here

I would also like to add a caution about taking prescription medications for PIH. From what I've read of Brewer's writings, he seems to be saying that those medications can add to the liver damage that is a part of the cause of PE. At the same time, I do not recommend that anyone just take themselves off of those medications, if they are on them. But I would recommend that anyone who might want to go off of their anti-hypertensive medications find a doctor who understands the Brewer methods and uses them, and look to that doctor for guidance on how to wean yourself off of those medications safely.

The following section says more about that perspective...

See here for most of the quotes used in this paragraph

See this source (p. 15-16) for the rest of the quotes from this paragraph

In fact, in a 2004 interview for Townsend Letter, Dr. Brewer described the further damage that can be caused by anti-hypertensive drugs, to mothers' livers and kidneys already ravaged by the pre-eclampsia process...

Brewer: "Low blood volume, which is the inevitable result of dehydration and the use of diuretics, contributes directly to eclampsia, premature birth, and low birth weight. (23,35,36,38) And now there's a whole group of hypertension drugs that have come out in the last 10 to 15 years. These drugs just ravage women. They cause direct damage to all of the cells in the mother's body, particularly to the liver, a little to the kidneys, and then to the placenta and fetus."

See here for more of this 2004 interview with Dr. Brewer in Townsend Letter

See here for a timeline of the Brewer Diet history and development

Anne Frye, CPM
Portland, Oregon
www.LabrysPress.com
www.AnneFrye.com
www.midwiferybooks.com
503-255-3378
(Pacific time--three hours earlier than EST)
afryemdwf@gmail.com

Anne provided full maternity care for women seeking homebirths for 14 years. When she studied to be a midwife, she was trained to use the Brewer diet as a primary means of optimizing each woman's chance of achieving a healthy pregnancy. In working with a poor immigrant population on the Texas/Mexican border she saw first-hand what a powerful tool diet can be to make this possible. Since that time she stopped actively practicing and focused on teaching as well as authoring professional-level textbooks with an emphasis on preventive care, including the nutritional management of pregnancy. Her textbooks include Understanding Diagnostic Tests in the Childbearing Year, Holistic Midwifery, A Comprehensive Textbook for Midwives in Homebirth Practice, Vol I Care during Pregnancy and Vol II Care of the Mother and Baby during Labor and Birth and Healing Passge: A Midwife's Guide to the Care and Repair of the Tissues Involved in Birth. These texts are available through her website. She also regularly offers consultations to care providers of all kinds as well as mothers who have questions about diet in pregnancy, troubleshooting preeclampsia, nutritional support for multiple gestation, interpretation of laboratory results, as well as other issues. Feel free to call her if you would like to talk to someone who has first-hand experience regarding the value of nutrition in ensuring a healthy pregnancy.

Swelling: A Benign Side-Effect of Diuretic Use in Pregnancy?

Joy Jones, RN

February 9, 2009

I just became aware of a situation in which one pregnant mother is taking a diuretic through a prescription from her OB, and experiencing extra swelling (edema) as a side effect. I also just became aware of at least one other pregnant mother (whose husband is a doctor), who is also on a diuretic, and who is under the impression that extra swelling is a normal, benign side effect of being on a diuretic. She also believes that diuretics are presumed to be the safest blood pressure medication for pregnant women! She is also of the opinion that diuretics are currently the most prescribed medication for pregnant women!

I don't know if the second mother has her facts straight, but if her impressions are even remotely accurate, modern US American obstetrics has certainly taken a huge leap backwards! For several years now those who are critical of the Brewer writings have been asserting that one proof that those writings are outdated and out of touch with current obstetrical practices is the emphasis that Dr. Brewer places on avoiding the use of diuretics in pregnancy. Those critics have been ridiculing his writings by saying that Dr. Brewer and those who would support him should know that doctors never prescribe diuretics for their pregnant patients any more. Well, if this mother's statements are anywhere near being accurate, it seems that unfortunately those criticisms were a little premature.

Personally, I am shocked and amazed and horrified that there is still even one OB out there, let alone possibly more than one, who is prescribing diuretics for a rising BP in pregnancy! In 1975, an entire 34 years ago, there was extensive testimony given to the FDA regarding the hazards of using diuretics in pregnancy, to the extent that the FDA finally had to concede and issue regulations requiring a change of labeling on the drugs, removing the indication that they are effective in toxemia!!!

According to the account of this FDA hearing, as it is reported in What Every Pregnant Woman Should Know, in his testimony "Dr. Chesley blamed diuretics for aggravating a significant abnormality present in mothers with toxemia, low blood volume (hypovolemia). The diuretics act to drive salt and water from the circulation, thus shrinking the blood volume even more. When used in conjunction with a low-salt diet from early pregnancy on, as the drug companies urged in their promotions, the diuretics may actually bring on the toxemia the doctor seeks to prevent.

You can read more about that testimony to the FDA in this Brewer timeline, under the entry for 1975

What Every Pregnant Woman Should Know available here

In fact, there was actually a precedent-setting lawsuit in 1985, a full 24 years ago, in which the OBs, the hospital, and the drug company which produced the diuretic used to treat a pregnant woman, were successfully sued for the detrimental effects that the diuretic had had on her!

See here for more details about that lawsuit

Suffice it to say that any obstetrician should know better by now than to prescribe a diuretic for edema or a rising blood pressure in pregnancy, 24 years after this lawsuit, and 34 years after the FDA decreed that the use of diuretics in pregnancy is not a good idea.

There is most definitely a direct link between the use of diuretics in pregnancy and the increased amount of swelling (edema) that the mother will experience as a side effect of that treatment.

It is vitally important for everyone who cares for pregnant women, or who prescribes diuretics for pregnant women, or who creates diuretics or supplements or teas for pregnant women, or who sells any form of herbs to pregnant women, to understand that one of the most important functions of the pregnant body is to increase the mother's blood volume by 40-60% by the end of her second trimester--and more than that if there is more than one baby. Then in the third trimester, the pregnant body needs to maintain that expanded blood volume. That extra blood volume is vital for the healthy implantation and function of the placenta, and for the healthy function of the liver and kidneys, and for the adequate nutrition of the baby, the placenta, and the uterus.

If the blood volume is too low for pregnancy, when it does not increase by 40-60%, due to inadequate nutrition (salt, calories, and protein), or due to the use of diuretics (herbal or prescription), the kidneys secrete a substance called renin. Renin is a substance that the kidneys secrete at any time that the blood volume is below normal, whether a person is pregnant or not. The action of renin on the body is to constrict the capillaries, for the purpose of sending most of the blood supply, inadequate as it is, to the vital internal organs, to preserve the life of the body for as long as possible. In pregnancy, this renin response by the kidneys to a lower-than-normal blood volume causes the mother's blood pressure to rise. Making the blood volume drop even more by giving the mother diuretics (either herbal or prescription), makes her kidneys secrete more renin, which makes her blood pressure rise even higher.

To say that in another way--diuretics in any form can force the kidneys to lower the mother's blood volume by removing more fluid from her blood and losing it in the form of urine. A lower blood volume triggers the secretion of renin, which causes a rise in blood pressure. Thus, in normal pregnancy the use of diuretics from any source can cause a rise in blood pressure and the beginnings of the pre-eclampsia/HELLP process.

Pathological swelling (edema) in pregnancy is another symptom caused by an inadequate blood volume, and it is also made worse by the use of diuretics, regardless of the source of those diuretics. Much of the swelling/edema in pregnancy is normal, or physiological--caused by the hormones of pregnancy and the weight of the baby limiting the return of the blood flow from the legs to the heart. But when the mother is on an inadequate diet, or on diuretics, the loss of fluids from the blood can also cause pathological swelling/edema.

This pathological edema is caused by another response by the kidneys which is triggered when the blood volume is too low. This second response is an effort by the kidneys to conserve fluid by sending less fluid to be expelled with the urine. The kidneys send this conserved fluid back to the blood stream, in an attempt to increase the blood volume to more normal levels. If there is not enough osmotic pressure in the blood to hold this conserved fluid in the blood stream, osmotic pressure normally created by the presence of albumin (protein) and salt in the blood, this conserved fluid will not stay in the blood stream. Instead, it will leak out of the capillaries into the tissues in the ankles, legs, fingers, and face. This is what causes the pathological swelling/edema in pregnancy. The use of diuretics to try to force the fluid out of the tissues, and to force the kidneys to lose this fluid in the urine, only makes the blood volume fall even more, which eventually causes even more swelling/edema as the kidneys try to compensate by conserving more fluid.

It is vitally important for pregnant women to understand, and for those who care for them and supply them with diuretics to understand, that there is a huge difference between the edema and hypertension of people with heart disease, kidney disease, or circulatory disease; and the edema and hypertension of normal, otherwise-healthy pregnant women. The edema and hypertension of the diseased body is caused by an abnormally expanded blood volume, and that condition must be treated with various therapies which help the body deal with that expanded blood volume--therapies which may include diuretics. The normal pregnant body that is developing pathological edema or hypertension is suffering from an abnormally contracted blood volume, and the only way to turn that condition around is to assist the body in its efforts to expand that blood volume. Using diuretics counteracts the pregnant body's efforts to increase the blood volume. Helping the pregnant mother to eat more calories, more salt, and more protein is the therapy which will help her body to expand its blood volume to the level that is needed for sustaining a healthy pregnancy.

Thus the only situation in which diuretics might be indicated in pregnancy is one where the mother was already on diuretics before the pregnancy for some pre-existing condition, such as heart or kidney disease, or one where she developed that condition during the pregnancy, and even then she would have to be closely monitored to see if her dosage of the diuretic should be decreased during the pregnancy.

One of the great tragedies of this situation is that some of the mothers using and seeing the effects of these diuretics may have been working very hard to follow the Brewer Diet--a nutrition plan that they expected would keep their blood volume well-expanded, a nutrition plan that they expected to help them prevent the PIH, pathological edema, pre-eclampsia, HELLP, IUGR, premature labor, placental clots, placental abruption, and/or low birth weight babies that can result from an abnormally contracted blood volume in pregnancy. Some mothers may have been taking herbal diuretics to help feed and sustain their livers, which is actually another goal of the Brewer diet and philosophy. Little did they know that by taking either prescription or herbal diuretics they were actually undoing some of their diligent nutritional work with which they'd intended to keep their blood volume well-expanded and healthy.

See here for more about how extra swelling can be caused by low blood volume (from the use of diuretics, or from inadequate amounts of salt, calories, and protein)

Having the perspective that swelling is a normal side effect of using a diuretic in pregnancy all depends on your definition of "normal". The result, or side effect, of swelling, when you are on a diuretic during pregnancy is a common and very expected side effect, so therefore it is "normal" for a woman to have swelling as a side effect of being on a diuretic. But while it is "normal" for a pregnant woman to see swelling as a side effect of being on a diuretic, it is also not a safe side effect at all. It is very, very, very dangerous for a pregnant woman to be on a diuretic, unless she has pre-existing or co-existing heart or kidney disease. And for the mother's care-givers, the appearance of this "normal" side effect of swelling (edema) should raise all kinds of red flags and set off all kinds of alarms that the pregnant patient's blood volume is dropping to dangerously low levels.

Anyone who considers the extra swelling that is the result of the use of diuretics in pregnancy to be a "normal" and benign side effect is someone who does not fully understand the physiology of the situation. Adding the use of diuretics to the already volatile situation of salt-deprivation and low blood volume creates a situation which is literally life-threatening. To illustrate that perspective, I would like to change the word "normal" to the term "natural consequence" and add an analogy. It is a "natural consequence" for a pregnant woman to get extra swelling when she is on a diuretic. It is also a "natural consequence" for us to get an explosion if we light a match while we are putting gasoline in a car. But although it would be normal for us to expect that "natural consequence", that does not mean that that explosion would be an acceptable "natural consequence" for us to experience. In the same way, the side effect of swelling due to diuretic use is not an acceptable "natural consequence" in pregnancy.

See here for more information about the risks of using herbal or prescription diuretics during pregnancy

Here is Dr. Brewer's perspective on the use of diuretics in pregnancy, as he wrote it in What Every Pregnant Woman Should Know: The Truth About Diets and Drugs in Pregnancy, a book that he wrote in partnership with his wife Gail Brewer (available from Amazon.com, or from your local public library, or through inter-library loan).....

During pregnancy the liver is working overtime
to meet the stress of increased metabolic functions of all kinds.
If the mother is malnourished in the last half of pregnancy,
impairment of albumin synthesis can occur in a matter of weeks!

If the mother's diet is not improved, the blood volume continues to fall.
Her body compensates in at least three ways:

At this point in the traditional management of the severely toxemic patient, the answer has been to administer ever more potent diuretics to the mother in hopes of boosting her urinary output
and reducing abnormal swelling.

In these circumstances, the diuretics are lethal. They act in the body only to remove more water from the already perilously shrunken blood volume. They are unable to affect the abnormal swelling because they do not contain any substance capable of attracting tissue fluid back into the circulation. Instead, they rob the patient of the very fluid she needs in her bloodstream
to keep heart, lungs and brain functioning.

With repeated doses of the diuretics, the mother eventually lapses into hypovolemic shock: exactly the same condition as if she had been in an auto accident and were bleeding uncontrollably.
In both cases the mother lacks enough blood to sustain normal body functions.

Dr. Brewer has some suggestions for the pregnant mother when her care-giver prescribes a diuretic for her. They are as follows:

If the doctor suggests diuretics at any time in pregnancy, the mother must ask questions.

First, of herself: Am I eating a good, balanced diet for pregnancy? Am I getting enough protein, calories and salt? Swelling can result from deficiencies of any of these nutrients.

Next, of the doctor: Do I have any medical disease which causes an abnormal increase in blood volume, such as heart failure or nephritis? Diseases in which excess fluid is retained in the circulation may be aided by judicious diuretic therapy. An internist should be consulted and careful evaluation of the mother's condition made if any of these medical diseases are suspected. The good obstetrician recognizes his limitations and will seek consultation from other specialists when indicated.

Women must know that these diseases are exceedingly rare during the childbearing years. So rare, in fact, that if a doctor prescribes a diuretic for her, she must ask why she needs it. If he assures her she has no abnormal increase in her blood volume due to underlying medical disease, she should refuse to take the pills. Diuretics can do nothing but harm except in these rare situations.
Dr. Douglas R. Shanklin,
professor in both the departments of OB/GYN and Pathology
at the University of Chicago Medical School
and past editor of the Journal of Reproductive Medicine,
declared in 1973:

Modern renal physiology makes it clear that the use of diuretics in pregnancy has little or no basis. There is a strong body of belief that they are causative of complications. The use of diuretics in pregnancy should be banned; they should be abandoned in modern prenatal care.

See here for this quote and more from that chapter of the book

What Every Pregnant Woman Should Know available here

Over the past 100 years, many doctors have written or testified about this phenomenon--the link between low blood volume and the syndrome which includes edema, rising blood pressure, and pre-eclampsia. In addition, I do not believe that the FDA has reversed its 1975 judgement that diuretics should not be used in these situations. In fact, the 1985 legal precedent is apparently still on the books, to the effect that doctors and hospitals and drug companies can be liable if they prescribe diuretics to a pregnant woman, or if they are connected in any way to a pregnant woman taking diuretics for swelling, or elevated BP, or pre-eclampsia, or eclampsia/toxemia. If the obstetricians of today actually are reverting back to attempting to treat the symptoms of the pre-eclampsia syndrome with diuretics, they should also make themselves well aware of the medical, legal and ethical risks that they engage as they do so.

To summarize, here are some suggestions for a rising BP in pregnancy:

1) Print out the weekly record on this page and post it on your refrigerator and make sure that there is a check mark in every box by the end of the day. That is the minimum intake needed. The next suggestions are for adding on top of that baseline.

See here for a weekly record chart that you can print and post on your refrigerator

2) Eat something with protein in it every hour of the day that you are awake, setting an egg timer or your watch or cell phone to go off every hour during the day, so that you do not skip one of these snacks. Some suggestions for these snacks include a handful of nuts, or cheese cubes, or an egg, or a cup of yogurt, or some trail mix, or a glass of milk. Keep a protein snack by your bedside for eating/drinking when you wake up during the night (suggestions: nut butter sandwich, cup of milk, cup of kifer). Try to increase the daily intake to 150-200 grams of protein (singleton pregnancy).

Also, for three days, eat 17 eggs a day and 2 quarts of milk a day.

3) Increase the number of nutritious calories eaten each day to 3,000-4,000 calories (singleton pregnancy). Avoid using junk food or refined carbohydrates to help with this increase.

One way to help your needed increase of calories is to start drinking a form of milk with a higher fat content--like switching from skim to 2%, or from 2% to whole, or whatever increase you can tolerate (like a mixture of 1/2 2% milk and 1/2 whole milk).

4) Make sure that you add salt to every serving of food that you eat. The Brewer Diet is actually a triad of salt PLUS calories PLUS protein, so an effort to bring down the BP needs to include an increase of all three factors.

See here for more information about the benefits of salt in pregnancy

5) Add 500 mg. of choline to the daily supplements.

See here for more information about the above four suggestions

6) Evaluate your lifestyle and see if you can cut down on some kinds of physical activity, or live or work in a cooler environment, or cut out some stress-producing factors. All of these factors can add to your losses of salt, fluids, and calories. See this page for more ideas about this process (scroll to halfway down the page for the beginning of the suggestions)....

See here for suggestions for finding an optimal fit between your pregnancy and your lifestyle and your nutritional needs

7) Make sure that you avoid all herbs which have diuretic properties. Check the list of ingredients of all supplements and herbal teas that you use, to make sure that they do not contain any of the herbs listed on the page in the following link. My only exception to that would be Floradix, unless the use of all of the above suggestions has no effect, in which case I would suggest eliminating Floradix as well IF it includes one of the herbs listed here....

See here for more information on the hazards of herbal diuretics in pregnancy

8) You can also see this page for more suggestions for dealing with a rising BP (it includes some herbal suggestions)......

See the beginning of this page for some herbs to take alongside the added protein snacks

9) Take care to drink only fluids that have some kind of nutritious content. You can see more about that on this page....

See here for information about which kinds of fluids are optimal for treating the pre-eclampsia syndrome

10) If you have protein in your urine, make sure that the protein is not from a discharge from the vagina, or from a bladder or kidney infection. Sometimes at the end of pregnancy, as everything ripens, there is more discharge from the vagina, or if there's a yeast infection, some protein from the vagina can show up in the urine. To decrease the chances of protein from the vagina showing up in the urine, you can ask your midwife to help you do a "clean catch" of your urine sample. You can also ask your midwife to send your urine to a lab to be tested for other factors which may indicate a bladder or kidney infection.

11) Ask your midwife to test your hematocrit and hemoglobin. If it is stable or rising, then there's a good possibility that you are in an early PE process. For more information about that, and what to do for that, you can see the following link....

See here for Anne Frye's suggestions for testing and treatment of the pre-eclampsia syndrome

Perinatal Support Services: pregnancydiet@mindspring.com