Swelling

Swelling of your ankles can simply be a sign of your body getting ready for labor, creating your own IV fluid supply, so to speak. Or it can be caused by the weight of the baby and uterus restricting the flow of the blood through your legs, as it returns to your heart. Or swelling of your ankles, fingers, or face can be a sign of pre-eclampsia, or toxemia. Or it could be simply a sign of a blood volume that is less than optimum for your stage of pregnancy. The healthy swelling can look the same as the unhealthy swelling. The easiest way to tell the difference between healthy swelling and unhealthy swelling is to ask yourself what you've been eating.

If you've been getting enough calories, protein, and salt, according to the Brewer Diet, then your swelling is probably the healthy kind.

If you haven't been getting enough calories, protein, or salt, according to the Brewer Diet, then you can probably reduce your swelling by eating something with protein in it every hour that you're awake, and by salting your food to taste.

Often, during conditions which cause you to sweat a lot, such as hot weather, or hot working conditions, or an over-heated home, or exercise, you can lose enough salt and fluids to lower your blood volume and cause this swelling. You can reduce this kind of swelling the same way--by increasing your protein and salt intake (by eating something with protein in it every hour, and by salting your food to taste).

	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

Your liver makes albumin out of the protein that you eat. Albumin and salt have osmotic pressure which is needed to hold fluids in your blood circulation. The swelling that you see implies that you do not have enough albumin and salt to hold the fluids in your circulatory system, which is resulting in the fluids leaking out into your tissues--in your ankles, for example. Eating additional protein and calories, and salting your food to taste should provide additional osmotic pressure and pull the extra fluids out of your tissues and back into your circulation. Once this fluid has returned to your blood stream, any extra fluid that you don't need will be excreted by your kidneys.

For more information, please refer to the "Diet" page and the "Physiology" page of this website.

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.

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:

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.

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.

Note from Joy: Please note that the use of diuretics in pregnancy was much more common when the following excerpts were first written. 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.

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.

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, 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.

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.

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.

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.

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 was clearly blaming her doctor for not having the routine of examining her nutritional status and doing a differential diagnosis for her. He was 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.

The following is reprinted from What Every Pregnant Woman Should Know, by Gail Sforza Brewer with Tom Brewer, M.D., 1977.

"Understanding Swelling: water retention is normal" (p. 34)

Eighty to ninety percent of women swell up at some time in the course of their pregnancies. Most American obstetricians look on this normal swelling with alarm. The spectre of toxemia is never far from their minds, and toxemic women swell up.

Physicians have been trained to view swelling as a potential danger sign. When they see swelling of the face or hands, they recoil in horror. This is definitely a "condition" to be "treated." They attack the swelling with therapeutic frenzy. They de-salt. They drug. They dehydrate. Then they are confounded when their patients develop toxemia, anyway.

Dr. Leon Chesley, distinguished author of the toxemia chapter in Williams Obstetrics, the most widely used obstetrics textbook, now challenges this traditional approach to pregnancy swelling. After forty years of research in the field, he has concluded that normal swelling, or physiologic edema, is a sign of health in pregnant women, and not a pathological condition.

At a July 17, 1975, hearing of the Food and Drug Administration on the use of "water pills," or diuretics, in pregnancy, Dr. Chesley testified that 60 to 70 percent of normal pregnant women will have benign swelling of their faces and hands--in addition to that of their feet and ankles.(1)

This single statement is of enormous significance because up to two million pregnant women a year since 1958 [as of 1977] have been placed on potent diuretics to "treat" the very edema Professor Chesley termed normal.

Citing study after study, going back as far as Dexter and Weiss's classic book on toxemia (1941), Dr. Chesley criticized the routine American obstetrical practice of "treating" pregnancy edema at all. Instead, he argued for an appreciation of its underlying physiologic causes.

Normal water retention comes about in pregnancy chiefly from an impressive rise in the level of female hormones, principally estrogens, manufactured by the placenta. These hormones are the same ones which cause many women to have water build-up and swelling in the few days preceding their menstrual periods, or when they are taking birth control pills. During pregnancy these hormones influence connective tissue throughout the body to retain extra fluid. Hence, the pregnant women commonly experiences swelling of her face and hands (generalized edema) in addition to that of her feet and lower legs (dependent edema).

The retained fluid is of benefit to mother and baby. Like a reservoir, it provides a water storage system in the mother's body. The stored fluid serves as a safeguard, a backup for the expanded blood volume we have learned is needed to nourish the placenta. At the time of the birth, when some blood loss is unavoidable, the extra fluid protects the mother from going into shock. Remaining tissue fluid is mobilized in the early breast-feeding period to insure the mother an adequate milk flow.

In women pregnant with twins, the process of physiologic swelling is exaggerated. Their larger placentas manufacture more hormones, which cause more water to be retained in their bodies--normally! This additional water, plus the weight of the second baby, dramatically increases the weight gain of the mother carrying twins. Weight gains of fifty to sixty pounds are typical when mothers are encouraged to eat well. Unfortunately, in the United States, where rigid weight control, salt restriction and diuretic therapy have characterized standard prenatal care, diagnosis of a twin pregnancy automatically assigns a mother to the so-called "high-risk" category. It is easy to understand why twins have had so much trouble when their intrauterine growth has been consistently subverted by these practices. It has even come to be accepted by doctors and mothers alike that "twins come early"--that they are born three or four weeks ahead of time, and that each must weight less at birth than a single infant would. People have the idea that the mother's uterus had stretched as much as it could--"there was no more room"--so the babies had to be born.

When mothers of twins are counseled to eat correctly for three throughout gestation they meet their increased nutritional demands. When they refuse diuretics and low-salt diets for their extra physiologic edema they usually give birth, at term, to infants of normal birth weight. Twins are not of necessity "high-risk." They only become so when management incompatible with physiology is imposed by the physician.

Dr. Chesley, in his FDA testimony, consistently associated the presence of physiologic edema with better infant outcome. On two critical measures, birth weight and infant mortality, mothers with normal swelling did far better than those without it.

Drawing attention to a major conclusion of the 1968 NIH Collaborative Study of Cerebral Palsy, Dr. Chesley noted that babies born to mothers with normal swelling were of higher birth weight than those born to mothers with no swelling.

The Collaborative Study also found that a baby's birth weight is the most reliable indicator of future neurologic development. Low-birth-weight babies have a much higher likelihood of starting life with significant brain damage or growing up to face learning difficulties in school.

Dr. Chesley also reported a review of the medical records of 17,000 American mothers pregnant for the first time. In this study edema was associated not only with higher birth weight, but also with lower infant mortality. In 10,126 mothers who at no time had edema of the hands or face, the infant death rate was 26 per thousand. In the 6,963 mothers who did have edema of hands and/or face, the infant death rate was 18 per thousand. There was 44 percent higher infant mortality in the no-edema group.

After presenting this evidence and a very erudite discussion of the other harmful effects of "water pills" (which called into question the validity of the research which had originally persuaded the FDA to allow them to be used in pregnant women), Dr. Chesley went on record in opposition to the use of diuretics in human pregnancy. He stipulated only one exception to the blanket contra-indication. Diuretics may appropriately be used when the mother suffers heart failure, kidney malfunction, or other medical disease which results in abnormal water retention in both the tissues and the circulation.

This exception does not apply to toxemia, Dr. Chesley asserted. He adamantly stated that diuretics do not prevent or ameliorate toxemia. This bold conclusion descredited the slick, four-color spreads promoting diuretics which have appeared in every American OB/GYN journal since 1958. To the contrary, 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.

What has been the outcome of this hearing? Up to now, most practicing obstetricians do not even know it was held. No testimony from the several physicians who appeared at the hearing has been publicized. The FDA has not called a public press conference to warn our public directly about the hazards of these drugs, even though millions of women and unborn babies continue to be exposed to them. Nor have the customary warnings been sent to physicians as was done recently after the disclosures that certain hormones often used to prevent spontaneous abortions cause vaginal cancer in female children born to mothers who took them in early pregnancy. Rather, the FDA has merely issued regulations requiring a change of labeling on the drugs, removing the indication that they are effective in toxemia. Most obstetricians practicing today have been trained to use these drugs as part of routine pregnancy management. Without special warnings, this labeling change in the fine print of the doctors' portion of the package insert will probably go unnoticed by the busy physician. Alarmingly, the American College of Obstetricians and Gynecologists, whose representative at the hearing argued that the drugs should continue to be prescribed if the mother is "too uncomfortable" at the end of pregnancy due to edema, still clings to this position [as of 1977]. As a result, many thousands of women each year will continue to take these drugs because their doctors will continue to write the prescriptions.

Without the correct information from their physicians about normal swelling, many women are dismayed by the way they look when they begin to swell a bit. Many physicians play on the mother's glum assessment of her looks as a way of forcing compliance with their low-salt diets and diuretics. If the mother refuses to cooperate, other forms of pressure may ensue. She is often told that her swelling is related to unnecessary accumulation of fat during pregnancy which will lead to permanent obesity. Or that her husband might lose interest in her if she becomes obese. The mother, not realizing that her swelling is probably normal and will vanish after the baby is born, accepts her doctor's appraisal.

One suburban mother angrily recalls how her obstetrician was so disgusted with her twenty-eight-pound weight gain and open disregard for his diet during her second pregnancy that he refused, point blank, to attend her delivery. He "taught her a lesson" by leaving her in the hands of an inexperienced resident she had never met before!

Her healthy baby boy weighed seven pounds--a marked difference from her first child, who weighed three and a quarter pounds and was born prematurely after an induced labor due to toxemia. This mother had followed the doctor's diet the first time, and the child has had an endless series of health problems since birth, a victim of intrauterine malnutrition.

Popular women's magazines stacked in the doctor's waiting room are of no help, either. Their pages are full of advertisements for mild diuretics to relieve swelling before a woman's period, or for "quick weight loss" when her favorite dress is a little too tight. Diet soda and junk food layouts promise satisfaction without nutrition. A barrage of underweight models promote emaciation as the American standard of beauty. Each issue rhapsodizes over the latest Hollywood diet guaranteed to keep readers vibrant and sexy while subsisting on only grapefruit, only rice, or only fluids. Little wonder the pregnant woman is on the defensive about her size and shape for nine straight months! No wonder she worries about swelling.

When swelling becomes uncomfortable, as it might toward the end of the pregnancy, the mother should take the following steps:

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.

The following is reprinted from The Brewer Medical Diet for Normal and High-Risk Pregnancy, by Gail Sforza Brewer, with Tom Brewer, M.D., 1983.

"Group 11: Salt and Other Sodium Sources--Daily Exchanges: unlimited" (p. 22)

Salt your food to taste. Cutting back on salt can cause a fall in the amount of blood circulating through your placenta, thus reducing the supply of nutrients passing to your baby. Too little salt in the diet leads to leg cramps as well, since all the muscles of your body require sodium for efficient action.

But if I salt my food to taste for nine months, won't that cause a lot of swelling from excess water retention? Many women cut out all added salt during the last few days of their menstrual cycles, anyway, because it helps get rid of that bloated feeling. Aside from the discomfort, isn't swelling a danger sign in pregnancy? (p. 48)

It certainly can be a danger sign--but only when the swelling is caused by not eating enough of the right foods (including sodium-rich ones) or by a medical condition that would cause swelling in a non-pregnant woman or a man as well, such as heart failure or kidney disease.

The swelling that accompanies the normal course of pregnancy while you are on the Brewer Medical Diet is attributable to an entirely different cause--your healthy, well-functioning placenta. The same hormones that you've noticed make you swell up somewhat just before your period (some women hold an extra 5 to 7 pounds of water) are made in ever-increasing amounts by your placenta as pregnancy goes along. By the eighth month, in the well-nourished mother, the placenta makes--every day--the equivalent of the hormones in a hundred birth control pills! This swelling is not hazardous to you or to your baby. In fact, it's a natural way for your body to prepare for labor and breastfeeding by storing fluids you may need to avoid dehydration if your labor lasts a long time and to establish and maintain quality milk production.

Though all swelling may look the same, the situation inside your body is critically different when you are swelling on a good diet. On a nutritionally sound diet your liver has all the building blocks it needs to manufacture adquate amounts of a protein, albumin, that holds water in your circulation--the primary means by which your increased blood volume needs are met during pregancy. The larger volume of nutrient-rich blood servicing your placenta results in the larger production of female hormones and, so, more water retention than in a mother with average nutrition. It is possible for your tissues to hold 10 to 15 pounds of fluid for this reason without causing much change in your appearance--perhaps the fine lines in your face disappear and your rings feel somewhat tighter.

This "hidden" water retention in the well-fed pregnant woman (plus the increased size of her baby) has seldom been accounted for in the charts that break down the components of average weight gain in pregnancy, so they typically show a total of 24 to 28 pounds, whereas women on the Brewer Medical Diet gain, on the average, 35 to 45 pounds. Of course, many women gain less and many gain more based on their prepregnancy weights, metabolism, and activity level. We do not use the average as a rule (either a floor or a ceiling) for weight adjustment in pregnancy; it only demonstrates that the average figure you see elsewhere fails to consider the additional, beneficial water retention that comes with a good diet.

When your diet is not meeting your nutritional needs, the internal events are exactly the opposite. If the liver is undersupplied with the nutrients needed to produce albumin (and this is one of the most complicated functions the liver performs, so it's one of the first to go when nutrients are scarce), it cuts back. This decrease in production is detectable by analyzing a sample of blood: anything below 3 grams per 100 cubic centimeters of serum indicates a problem. With less albumin circulating and drawing water into the circulation, water that should be held inside your blood vessels cannot stay there. Instead, it leaks out into your tissues. Voila! You're swelling up, and the scales tell you about the water you're retaining--but they don't tell you where it is. Nor do they tell you that your blood volume is falling below the needs of a healthy pregnancy and that your placenta is starting to malfunction because of the reduced amount of blood flowing through it.

The pregnant woman on a poor diet (or even one on a basically nutritious diet who is not eating enough to meet her calorie needs) is not swelling from the influence of an increase in female hormones generated by a generous, healthy placenta. She is experiencing a shift of essential body fluids out of her circulation and into her tissues. If the situation continues, her other critical body organs, like the kidneys, liver, heart, lungs, and brain, become adversely affected by the dwindling blood supply (the kidneys respond, for example, by raising the blood pressure), and her baby begins to suffer intrauterine malnutrition. Most commonly this situation is diagnosed after a few weeks when the baby's failure to grow is noted at subsequent prenatal appointments. The medical terminology for this condition is intrauterine growth retardation (IUGR). If caught early enough, the situation can be reversed with appropriate nutritional intervention--by getting the mother on a diet suitable for her pregnancy needs and keeping her on it for the rest of her pregnancy. This includes salting to taste.

This interconnection between the foods you eat, how your liver works to keep your blood volume expanded, and the transfer of nutrients to your baby via the placenta is central to every successful pregnancy. It is impossible for anyone to evaluate what's happening internally from looking at your swelling or pressing your shinbone to see if you have water retention. Laboratory work measuring your blood proteins and hematocrit reading must be done before any diagnosis is made.

Swelling on a good diet is a sign of health in pregnancy. So salt to taste as an integral part of your pregnancy nutrition program. Do not restrict salt. Do not take diuretics or appetite suppressants to control your weight. Any of these actions is a direct attack on the expansion of your blood volume and places you and your baby in jeopardy for the most serious pregnancy complications.

The following is reprinted from The Very Important Pregnancy Program: a personal approach to the art and science of having a baby, by Gail Sforza Brewer, 1988.

I am a nursery school teacher in the twentieth week of pregnancy. For the past three weeks I've had persistent numbness, tingling, and at times the sensation that my fingers and hands are on fire. I can't even button the children's coats anymore! Is this related to my nutrition? My midwife said to cut out salt. (p. 123)

Even people who aren't pregnant experience a similar difficulty when they become deficient in B vitamins, particularly B6. It's called carpal tunnel syndrome because the nerve running through the wrist passes through a narrow tube, the carpal tunnel. In some individuals the carpal tunnel is considerably smaller in diameter than in others. So any situation that affects the tunnel of the nerve passing through it is more noticeable in such people.

John Ellis, M.D., author of The Doctor Who Looked at Hands (New York: Arco, 1980), treats carpal tunnel syndrome with three doses of B6 daily, 50 milligrams per dose. If no improvement is noted in a week's time, he believes the problem isn't vitamin related but is probably caused by the edema that is a normal part of pregnancy.

Swelling of your tissues, even though not too obvious to the casual observer at this point in your pregnancy, still can be significant enough to cause pressure on the carpal tunnel, compressing the nerve within. The tingling and numbness you describe are typical complaints when this happens. Do not cut down on salt: You need it to help maintain your expanded blood volume, the critical key to nourishing your baby.

It may help to apply a splint to your slightly flexed wrist must before going to bed. This will alleviate some of your discomfort for part of the day if you can discover a position that gives you a bit of relief. Apart from the very real loss of motor function (some women find it impossible to set the table, do dishes, fold clothes, type, or handle household appliances), carpal tunnel syndrome has no effect on you or the baby. It does not indicate the presence of any other type of pregnancy problem.

My due date is three weeks away and the doctor says my baby will easily weigh 8 pounds. He's becoming worried about one thing, though: I've started having marked swelling of my feet and legs (when the doctor presses in on my shinbone, the skin stays indented for a minute or two) and I can't get my wedding ring off anymore. Because I've been following your program, I know some swelling is normal owing to the hormones made by the placenta, but is this much still O.K.? The doctor says he no longer prescribes diuretics for swelling, but he wants me to stop salting my food at the table and in cooking and cut out milk and milk products because they're so high in sodium. Can I cut back just a little on salt, reduce my swelling somewhat, and still stay in the best condition for giving birth? (p. 160)

First, the amount of swelling you describe is perfectly normal if you're sure you're having everything from the basic diet exchange list every day and you haven't stepped up your activity so that you need more calories than before. Women with larger babies tend to have more dependent edema, that is, swelling of the feet and legs, just by virtue of the fact that the heavy uterus presses more on the veins that return blood to the heart, causing a pooling of blood and water in the legs. The best remedy for this (though it may not provide complete relief) is to lie down three or four times a day, for ten minutes at a stretch, with your legs elevated. Wear flat, soft open shoes such as sandals or bedroom slippers to avoid pinching your tender feet.

Under no circumstances should you cut back on your salt or start limiting your servings of sodium-rich foods. Just a couple of weeks on such a regimen late in pregnancy can bring about a reduction in your blood volume, triggering a rise in your blood pressure--just what your doctor does not want to see! [emphasis by Joy] Asking you to cut back just a little on sodium is like asking you to cut back just a little on oxygen. This is the stage of pregnancy when your sodium needs are greatest, and you can only throw the delicate balance you've maintained thus far into disarray by starting to deny yourself and your baby essential nutrients.

If anything, you might try adding more salt and extra servings of protein foods (Groups 1, 3, and 4 on the diet list), just in case you are falling the slightest bit behind on your diet. This can happen easily in the last month of pregnancy when your abdomen is so crowded--your appetite tapers off slightly without your really being aware that it's happened. Then your swelling becomes more marked. Excess swelling also commonly accompanies twin pregnancy. Are you sure your one big baby isn't two or more?

Other questions to consider are: Have you just moved? Are you working extra hours now in order to have a longer maternity leave after the baby comes? Have you been away on a trip with your husband--a second honeymoon before your family changes permanently? Have you been involved in a flurry of civic activities, commitments you made long ago and now have to carry through before you give birth? Have you been pushing yourself to get the baby's room ready, although you'd rather take a nap in the afternoon? All these situations demand extra energy from you and may absorb your attention to the point that you're skipping some snacks, or maybe even a meal or two. Get back on the track, adding extra protein and salt, and you will have the stamina to carry on as well as much less swelling to bother your doctor. Keep a careful food record for the next three days to see if you're really following the diet as you need to.

If you are well nourished according to the needs of your pregnancy, the only other reason for marked edema would be the rare medical disease that causes swelling even in the non-pregnant individual. Examples are heart failure, kidney diseases such as nephritis, and cirrhosis of the liver. In such a case, you would, of course, be experiencing other symptoms besides swelling that would lead your doctor to the correct diagnosis.

You can expect to have a postpartum diuresis, that is, dramatically increased urinary output, in the first two or three days following delivery. After your baby is born, you no longer need the reserve of water in your bloodstream and tissues, and this is the mechanism for excreting it. In other words, your swelling is not permanent. It is meeting a current need of your baby and will stand you in good stead during labor if you don't feel like drinking anything or have nausea. It is a protection against dehydration and shock in case you have some extra blood loss during labor or at delivery. Look upon your temporary discomfort as a sign that you have all the extra water you need to ensure your welfare and your baby's now and throughout labor.

The following is from a chapter reprinted by permission from 21st Century Obstetrics Now! (David Stewart, PhD, and Lee Stewart, CCE, Editors), National Association of Parents & Professionals for Safe Alternatives in Childbirth, 1977. (p. 387)

In an extensive study of 2,019 pregnant women, Robinson demonstrated unequivocally that sodium is an essential nutrient during pregnancy.[88] The women were divided into a high salt group (these women were told to increase their salt consumption) and a low salt group (these women were instructed to decrease their salt intake). Other than dietary sodium advice, the women in the two groups, who were of comparable age, parity, and socioeconomic status, were not placed on diverse dietary or medical regimens. The rates of miscarriage, perinatal death, toxemia, edema, and placental infarcts were much higher among the women who were told to restrict their salt concumption than among the women who were told to use additional salt.

	# of Women	Perinatal Mortality Rate	% Toxemia	% Edema	% Placental Infarcts
Restricted Salt Intake	1,000	50.0	9.7	28.7	1.3
Increased Salt Intake	1,019	26.5	3.7	16.0	3.2

It may seem ironic that those who restricted their salt intake had the higher rate of edema, which is usually thought of as being caused by excess sodium intake. The inverted conception of the role of sodium in pregnancy represents one of the most misunderstood aspects of internal medicine.[36] The prevailing theory that sodium restention is a pathological condition caused by excess sodium intake has led to a vast amount of maternal and infant morbidity and mortality. Low-salt diets further deplete the woman of the essential nutrient, causing her renin-angiotensin-aldosterone mechanism to be stimulated even further to retain more sodium, the vicious cycle of which can lead to pathological edema.[84,86]

The speculative theory that sodium should be restricted provided some justification for the drug industry to promote diuretics, which cause sodium depletion. Despite the publication of double-blind studies which conclusively demonstrated that diuretics are of no value in human pregnancy,[89-91] approximately half of all obstetricians still prescribe them [as of 1977].[2] Besides leading to impaired placental function [92] and fetal growth, diuretics can lead to fetal malformations,[92] neonatal thrombocytopenia,[93] hypoglycemia,[36] or electrolyte imbalance [36,92] and maternal complications, such as toxemia [36,41-42] or pancreatitis.[94]

The use of diuretics and low-salt diets can, especially in malnourished women, lead to maternal death.[38,95] One obstetrician attributed the increase in maternal deaths from 5 to 19 during three-year periods at one hospital center largely to the indiscriminate use of low-salt diets and diuretics.[95] In reviewing the medical records of 67 maternal deaths from toxemia, he stated:

The incidence of toxemia can be sharply reduced simply by encouraging pregnant women to salt their foods to taste and refraining from prescribing diuretics. In one clinic where such management was followed, there was only one case of toxemia in 5,300 pregnancies,[41] which is far below the U.S. incidence of 7%.[96] At a nearby clinic, where the hazardous regimens are utilized, the toxemia rate was 98 times higher.

Infant deaths are also associated with the administration of diuretics. In a study of more than 17,000 pregnant women, the infant mortality rate among full-term infants was 16% higher in those who had been prescribed diuretics.[97]

The FDA recently [as of 1977] cited all of the nine drug firms which manufacture diuretics for pregnant women for promoting the drugs on no scientific basis.[98] In stating new regulations for the use of diuretics (which in essence state that the drug is contraindicated and possibly hazardous during pregnancy), the FDA noted:

The restriction of salt during pregnancy (and the justification for the prescription of diuretics) is based upon the historically accepted, but never proven, speculation that toxemia is caused by impairment of salt excretion.[86] In reality, among toxemic women, salt retention is not a cause of toxemia but, rather, an impending sign of sodium depletion, which causes the toxemia.[99]

A major reason that the myth that sodium restriction is a prophylaxis of toxemia continues to predominate obstetrical thinking is that physiological edema is seldom differentiated from pathological edema. Physiological edema usually signifies a normal pregnancy, whereas pathological edema reflects pretein/calorie, sodium, and/or related dietary deficiencies or a medical disorder unrelated to pregnancy. Differential diagnosis as well as a thorough dietary history can invariably determine the origin of the edema.[36]

Approximately 60% of all healthy pregnant women will develop edema, including generalized edema.[36,100] A study of nonproteinuric women showed that edema was associated with a 58% reduction in perinatal mortality.[93]

	# of Women	# of Still- Births	# of Neonatal Deaths	Perinatal Mortality Rate
No Edema of Hands or Face	2,268	33	40	32.2
Edema of Hands or Face	1,890	15	10	13.2

As has been shown above, edema, instead of being physiologic, can develop as a result of sodium deficiency. Pathological edema can also result from protein and/or calorie deficiency. This type of edema is mediated by a decrease in the plasma proteins as a result of lowered serum albumin concentration.[101-102]

By measuring the serum osmotic pressure of 65 pregnant women, all of whom were at seven months' gestation, Strauss demonstrated that the pressure was directly related to protein intake.[102] Serum osmotic pressure, serum albumin, and dietary protein were highest among the 35 nontoxemic women in the study, second highest among the 20 women who had nonconvulsive toxemia, and lowest among the 10 women who had eclampsia.

At the eighth month of gestation, 15 of the 20 nonconvulsive toxemic women were placed on a diet which consisted of 260 grams of protein and were given vitamin injections; the other 5 were placed on an isocaloric diet which provided 20 grams of protein. The osmotic pressure among the women on the high-protein diet increased by an average of 7%; that of the latter group declined 9%. Strauss noted that the average daily protein intake of the 20 women was less than 50 grams.

After three weeks on the high-protein diet,the symptoms of toxemia (including a reduction in the blood pressure of all 15 women) subsided. There was not one case of fetal mortality. The women lost an average of 6 1/2 pounds. In contrast, only two of the five toxemic women who had been placed on a low-protein diet showed a reduction in blood pressure. In addition, they gained an average of 1/2 pound.

The following is reprinted from Metabolic Toxemia of Late Pregnancy: A Disease of Malnutrition, by Thomas H. Brewer, M.D., 1966 & 1982.

"Dietary Salt and Diuretics" (p. 72)

My own clinical experiences working with many normal and toxemic pregnant women have led me to the firm conviction that restriction of salt in the diet of pregnant women produces no clinical benefit. Several investigators in this country and in England and in Canada have recorded similar experiences. 43,44,45 Of course this does not apply to the women with significant cardiovascular or renal disease during pregnancy.

Salt restriction has some undesirable results, particularly when combined with the use of saluretic diuretics. Many women have told me that both physicians and public health nurses had told them not to drink milk because it contains too much salt. This is wrong, because milk is one of the most important and cheapest sources we have available for high biological quality proteins. A low salt diet is not very savory, and the patients often do not eat well when actually following such a diet.

It is in the hospitalized patients that one of the most glaring errors is often made in pregnancy nutrition. Here we have opportunity to provide the patient with an optimum diet planned and prepared by expert nutritionists. I have been in several hospitals in our nation where the routine management of the toxemic patient calls for a "low salt diet" which on inquiry is found to contain only 50 gm of protein. To reduce the toxemic patient's protein intake below that of the requirements of normal pregnancy is to make a grave physiological and biochemical mistake.

Figure 11 (Chap. 4, p. 52) demonstrates a common clinical phenomenon: a diuretic which causes the kidneys to excrete an excessive amount of sodium and potassium, and water associated therewith does not have any effect upon the underlying metabolic disorder in MTLP, for as soon as the diuretic is stopped, the sodium and water retention immediately recurs. A diuresis may blind the physician to the fact that the patient is really getting worse. Diuretics are absolutely contraindicated in the severely toxemic patient who has a contracted blood volume, low serum albumin and hemoconcetration. The following three cases [to be added to this website at a later date] are presented in detail to illustrate the clinical reality of these ideas. It was from the careful study of these and other similar cases that I began to crystallize my ideas about the pathogenesis of metabolic toxemia of late pregnancy and to turn from concentration upon sodium, water, diuretics and the kidneys to concentration upon nutrition and hepatic dysfunction.

43. Robinson, Margaret: Salt in pregnancy. Lancet, 1:178 (Jan. 25), 1958.

44. Mengert, W.F., and Tacchi, D.A.: Pregnancy toxemia and sodium chloride, Amer. J. Obstet. Gynec., 81:601, 1961.

45. Bower, David: The influence of dietary salt intake on pre-eclampsia. J. Obstet. Gynec. Brit. Comm., 71:123, 1964.

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)

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.

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.

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!

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.

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.

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.

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.

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

--Adapted from Winslow Tompkins. Journal of International College of Surgeons 4:417, 1941.
(*Smallest baby weighed 6 lb. 4 1/2 oz.)

	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