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

The cause of pre-eclampsia was discovered in the 1950's and 1960's, by an obstetrician by the name of Dr. Tom Brewer. In the process of his medical education, and researching the work of Hamlin, Strauss, Burke, and Ferguson, doctors who had worked on this problem in the 40 years previously, he discovered that the cause of pre-eclampsia was an abnormal blood volume, caused by malnutrition, or food deficiency.

One of the main functions of the pregnant body is to preserve the pregnancy and nourish the baby. The body's ability to do this well depends a great deal on its ability to increase the mother's blood volume. Normally, this blood volume is expected to increase by 50-60%, over the course of the pregnancy.[4] For a woman with a pre-pregnant weight of 130 pounds, this would be a increase of about 2.1 quarts of blood (from about 3.5 quarts at the beginning of the pregnancy to about 5.6 quarts at the end of the pregnancy).

The liver makes albumin to facilitate this blood volume expansion. Albumin is similar to egg white. When it is in the mother's bloodstream, it creates osmotic pressure, which pulls extra fluid out of her tissues and back into the blood circulating in her blood vessels. The only way that the liver can make this albumin is from protein which the mother eats.

However, if the mother is trying to restrict her weight gain to someone's "ideal" number, by going on a high protein, but low calorie diet, much of the protein that she eats will get burned up for calories. Brewer has found that when a woman eats 1/3 less calories than the 2600 calories that he suggests, or about 1700 calories, half of the protein that she eats will get burned for calories.[5] In that case, only 60 of her 120 grams of protein would get used to make albumin (and baby cells, and uterine muscle cells), and she will probably have trouble expanding her blood volume adequately.

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

Salt also has osmotic pressure which helps to pull extra fluid out of the tissues and into circulation. While salt restriction may be helpful for pregnant women who have unhealthy hearts or kidneys, it is dangerous in healthy women. A healthy woman's taste buds are usually the most accurate indicator of the amount of salt that she needs, and studies have shown that it is not possible for a healthy pregnant woman to eat too much salt. Her kidneys simply excrete whatever extra salt that she eats.[6] In fact, it has also been shown that after just 2 weeks of "salt in moderation", the mother's blood volume begins to drop.

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

When the blood volume stops increasing, or drops, the body has no way of knowing that the mother is just eating less. All it knows is that the blood volume is less than it's supposed to be. So it starts the same processes that it uses when the blood volume is dropping due to hemorrhage. The internal organs must be preserved, at the expense of the limbs, if necessary. So the kidneys produce an enzyme called renin, which causes the blood vessels to constrict.[7] During hemorrhage, this response is a very helpful stop-gap measure, decreasing the amount of blood in the limbs, to send more blood to the internal organs, while help is on the way. During pregnancy, however, when no hemorrhage is occurring, this blood vessel constriction causes a rise in blood pressure. Attempting to treat this rising blood pressure with salt restriction, or weight restriction, only causes the blood volume to drop even more, leading to further formation of renin and more blood vessel constriction. And the blood pressure continues to rise.

Meanwhile, the kidneys are desperately trying to increase the blood volume by reabsorbing as much water and salt as they can, from the fluid that they have filtered out of the blood. They return this reabsorbed fluid and salt to the circulation. However, since there isn't enough albumin and salt in the circulation to hold this reabsorbed water, much of it leaks out into the tissues. The kidneys keep reabsorbing water at one end of the process, the water keeps leaking out of the capillaries at the other end, and the mother sees rapid swelling in her ankles, and rapid weight gain (from the extra water in her tissues).

The mother presents herself to her birth attendant (doctor or midwife), who tells her that she is developing pre-eclampsia. If her nutrition is not improved quickly, or if diuretics are prescribed (in medications or herb teas), her blood volume will continue to drop, and she will develop eclampsia (toxemia). Toxemia can culminate in convulsions, coma, and death. Many sources maintain that there is no known cause of toxemia, and therefore many practitioners continue to try to manage the situation by treating the symptoms alone, but they do so without success.[8] The symptoms not only persist, but the mother also continues to experience one complication after another.

See here for details from several studies regarding the link between nutrition and pre-eclampsia

Note from Joy: Please note that the use of diuretics and amphetamines 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 and amphetamines 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

Treating Pre-eclampsia

One way to treat pre-eclampsia is to educate the mother about the cause of her illness, and strongly encourage her to eat according to the Brewer Diet plan, and suggest that she eat something every hour that has protein in it. When the problem seems to need a more immediate response, the birth attendant can give the mother albumin intravenously,[9] and sometimes put her on antibiotics (to lessen the load on the liver by aromatic toxins from the intestines).[10] Dr. Brewer would often tell of one woman who, unable to find a doctor who would give her IV albumin, brought her blood pressure down by eating 52 eggs and drinking 6 quarts of milk, over a period of 3 days. *

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 the end of this page for the footnotes for this article.

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

See here for "Preventing Toxemia of Pregnancy", by Bob Filice, MD

News Item: "Beetroot 'may cut blood pressure'"

See "Physiology" page here

See "Elevated Blood Pressure" page here

See an overview of the history of Brewer's perspective on pre-eclampsia here

See "Mistaken Diagnosis" here

The truth is that even anti-hypertensive drugs can contribute to liver damage, which can add to the low-blood-volume issue, adding to the development of BP issues, PE, HELLP, or other complications. When the liver is compromised, it cannot produce the amount of albumin that is necessary to help expand the blood volume during pregnancy, and it cannot produce the clotting factors that are necessary for keeping the clotting mechanisms of the body at a normal capacity.

Dr. Tom 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

The truth is that many of the "anti-hypertensive treatments" and "standards of care" of mainstream obstetrics and perinatology can counteract the efforts of the mother to eat the amount and type of food that she needs to maintain her blood volume at the well-expanded level needed for whatever stage of her pregnancy she has come to.

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.

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

"Metabolic Toxemia of Late Pregnancy (MTLP)" (p. 219)

Metabolic toxemia of late pregnancy is a specific disease entity characterized by a history of malnutrition, nausea, and vomiting; low blood proteins, especially low serum albumin; and low blood volume, which causes a marked reduction in blood flow to the placenta, kidneys, and other organs. It is a nutritional-metabolic-liver disease that occurs in the last half of pregnancy, more often in the seventh to ninth months, and disappears a few days after delivery.

As a result of the low blood volume and liver malfunction, the mother's blood pressure rises as the disease progresses, water and salt are retained abnormally, and protein appears in the urine as a result of damage to the capillaries of the kidney glomeruli or filters. In the most severe cases, hemorrhages develop in the mother's liver, brain, and other organs; convulsions, coma, and maternal and fetal deaths occur. This disease was previously termed "toxemia of late pregnancy" or "pre-eclampsia/eclampsia." Eclampsia comes from a Greek word meaning a flash of light; the term was used for the most severe form of the disease when the mother had convulsions and/or coma. Pre-eclampsia was used for the nonconvulsive stage characterized by excess water retention (edema), high blood pressure, and protein in the urine. Pre-eclampsia as used by most doctors and nurses in the United States today is an outdated term because edema, high blood pressure, and protein in the urine occur commonly in human pregnancy from many other causes than MTLP. The causes for these conditions need to be carefully investigated before any diagnosis is made.

The most important message about MTLP for the pregnant woman and her family is that it is now totally preventable. The dietary plan presented in this book will protect mother and baby from the ravages of this disorder, which is still responsible for some 30,000 infant deaths and several dozen maternal deaths each year in the United States alone. The role of good nutrition in the primary prevention of MTLP was recognized by many research workers in various nations in the the late 1920s and early 1930s. It is a paradox that the traditional prenatal care practices for the prevention of MTLP--blind weight control aiming at arbitrary numbers of pounds or "patterns of weight gain" and using low-salt, low-calorie diets as well as salt diuretics, sodium substitutes, and drugs like amphetamines to control appetite--have in fact caused MTLP in large numbers of pregnant women who carefully followed such recommendations without question. A detailed book about MTLP to share with your doctor or midwife is Tom's Metabolic Toxemia of Late Pregnancy: A Disease of Malnutrition (New Canaan, CT: Keats, second edition, 1982). For additional literature, contact the Toxemia of Pregnancy Foundation, P.O. Box 124, Bedford Hills, N.Y., 10507. This nonprofit organization sponsors an information line from nine to five (Eastern time) on weekdays, or for medical consultation in emergencies, twenty-four hours a day: (914) 666-5199.

Note from Joy: Unfortunately, this address and phone number are no longer a way that you can contact the Brewers.

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

The following is reprinted from Medikon International no. 4 - 30-5-1974.

"Iatrogenic Starvation in Human Pregnancy", by Tom Brewer, M.D., County Physician, Contra Costa County Medical Services, Richmond, California, U.S.A.

Frank Hytten tells us in his pregnancy physiology textbook of two pioneers in the field of iatrogenic starvation in human pregnancy.(1) A certain Professor Brunninghausen of Wurzburg decided, for reasons unstated, that it was better for women to eat less food during pregnancy; this was in 1803. A century later Prochownick is given credit in 1899 for introducing the idea that caloric and fluid restrictions during human pregnancy could produce an infant who weighed less at birth.(2) The intention of Prochownick was to minimize the cephalopelvic disproportion in a woman with a borderline contracted pelvis and thus reduce the incidence of surgical intervention in such patients. As surgical techniques developed with the practices of asepsis and improved anesthesia established, Western European obstetricians lost all fear of operative delivery. Prochownick's valuable clinical observation that caloric and fluid restrictions do in fact lower the birth weight of the newborn human infant was forgotten. Thus a very important clue to the mystery of "low birth weight for dates" newborns was buried.

Unfortunately, this still universal misconception became established as a dogma in clinical obstetrical teachings in Western medical culture: the human fetus is a parasite, will grow according to its "genetic code" to a given weight and length before birth, and that this growth and development are in no concrete, material sense influenced by the foods and fluids the pregnant woman is taking in during the course of her gestation.(3,4) Scientific obstetrics still suffers today from what I term "nutritional nonchalance" related to this false belief.

In 1972 officially in the United States the cause of eclampsia, the disease I term convulsive metabolic toxemia of late pregnancy (MTLP), was "unknown."(5,6) [This official assertion continues into 2008] Since this dread disease remains a common cause of maternal, fetal and newborn morbidity and mortality throughout the world, speculations about its etiology continue. It has been long believed that the Nutrition of the pregnant woman during gestation does in fact influence her development of MTLP. Women who develop MTLP are still accused of eating too many calories and too much salt (NaCl). That such an idea remains popular in 1973 stems from the fact that very few Western-trained OB/GYN surgeons have ever taken time or interest to ask these poor women what foods and how much they have been eating and drinking during pregnancy.

When I began to work in the Tulane Service's prenatal clinics at Charity Hospital, New Orleans, Louisiana, as a third year medical student, pregnant patients were being told to restrict their caloric intake and to restrict their dietary salt intake: "So you won't have fits....so you and your baby won't die from toxemia." It is difficult for me to learn what is happening there now since no members of the Tulane faculty will communicate with me, but unofficial sources informed me not long ago that "...nothing has changed in this field since you were here over 20 years ago." I studied this problem for four years in another city-county hospital in our deep south. Jackson Memorial Hospital, Miami, Florida, from 1958 to 1962. A reliable communication from an established ostetrician in Miami in March, 1973 informed me that "...nothing has changed in this field since you left here over ten years ago." The common practices of weight control and dietary salt restriction seem eternal.

Since it is now clear that the sudden, rapid weight gain observed in patients with severe MTLP is a result of malnutrition with a falling serum albumin concentration, hemoconcentration, a falling blood volume with increasing interstitial fluid, we no longer need to blindly "control weight" with starvation type diets. However, fear of the unknown drives the most rational and "scientific" people to irrational actions; millions of pregnant women in Western European medical culture still suffer from iatrogenic starvation diets in the vague hope that caloric and salt restriction will in some way protect them and their unborn from the "ancient enigma of obstetrics," eclampsia.

Iatrogenic starvation in human pregnancy has a long and ignoble history in the United States: its traditions run strong and deep in one of our oldest and most respectable journals of obstetrics, the American Journal of Obstetrics and Gynecology. In its second volume published in 1921 we find this account by Rucker:

"On August 2nd, two weeks after her first visit, her blood pressure was 120/80, the urine was free from albumin and sugar. On August 17 her weight had increased 6 pounds and her legs were swollen up to her knees. She had no headache. Blood pressure was 180/90. Urine was free from albumin and sugar. She was placed upon a bread and water diet." (emphasis added)

"A week later, August 24, in spite of her rigid diet, she had gained 8 3/4 pounds more. (emphasis added) Her blood pressure was 205/110 and she was having pains in the back of her head and was seeing specks before her eyes. The urine showed a trace of albumin. No casts were found."(7)

Subsequently this poor woman had 11 convulsions. It is now clear that a "bread and water diet" is not effective prophylaxis for MTLP!

In the very first volume of The American Journal of Obstetrics and Gynecology published 53 years ago [as of1974], Ehrenfest reviewed "Recent Literature on Eclampsia," and found that venesection was still in common use for this dread disease: "For the purpose of reducing the blood pressure and of eliminating toxins...."

He reported another then widespread approach: "Diuretics should be accompanied by a total or partial restriction of salt. No meat shall be allowed." (emphasis added) Ehrenfest also noted the beginning of a scientific rejection of blood-letting in the management of eclampsia: "Cragin says: Eclampsia patients after convulsions resemble so closely patients in shock, that venesection seems illogical. They seem to need all the blood they have and more too."(8)

Here was the obvious clinical recognition of the hypovolemic shock which so commonly causes maternal and fetal deaths in severe metabolic toxemia of late pregnancy.(9) The illogical use of salt diuretics in this disease may be viewed now as a "modern" form of blood-letting in which electrolytes and water of the blood are forced out of the patient's body via her kidneys, a kind of cell-free venesection!

In April, 1969, I presented a paper to an international meeting on "toxemia of pregnancy" in Basel, Switzerland, by invitation of Dr. E.T. Ripperman, Secretary of the Organization Gestose.(10) Here I learned these interesting facts:

1. Eclampsia has virtually disappeared from Switzerland; there had been no maternal death from this disease in Basel for almost two decades.
   
   
2. Some Swiss OB/GYN professors were still teaching that the pregnant woman must avoid red meat as prophylaxis against eclampsia; for the Swiss this prescription seems to be working.
   
   
3. The incidence of low birth weight babies born in the University Hospital, Basel, in the year 1967, from some 3,000 deliveries was 3.0%.

It soon became apparent here from my discussions with many European OB/GYN authorities that the general nutritional status of the peoples of Central Europe was exceptionally good, and that this adequate nutrition was the basic cause for the elimination of severe MTLP and for the relatively low incidence of low birth weight infants.

My own paper presented in Basel was received with the utmost skepticism: the European obstetricians almost to the man responded: "Surely there is no severe malnutrition in rich America." Surely? The incidence of low birth weight in our nation has risen from 7.0% in 1950 to 10.0% now [1974] with much higher figures for all our poverty areas; MTLP continues to cause maternal-fetal and newborn morbidity and mortality. Iatrogenic starvation during human pregnancy is still widely practiced throughout our nation today because none of our medical or "public health" institutions have taken concrete actions to stop it.

A review of the unbound issues of The American Journal of Obstetrics and Gynecology reveals that for most of the 1950's and 1960's amphetamines and other "diet pills" were widely advertised for "weight control" in human pregnancy. Salt diuretics, long recognized to be lethal to the severely toxemic patient and to her fetus, were promoted by this journal form 1958 to 1972. Professor Leon Chesley finally recognized their harmful effects on the maternal plasma volume.(11) The advertisements for these water pills were then stopped but not their widespread use.

Today in 1973 the problems of rising prices for essential foods like lean meats, chicken, eggs, vegetables and fruits, and the continuing poverty and economic depression in many areas of our nation can not be solved by the nation's physicians. However, do not humane physicians today have a special and moral responsibility to stop the blind errors of iatrogenic starvation in human pregnancy? Do not obstetricians, especially, in charge of human antenatal care in public clinics and private offices, have a responsibility to their pregnant patients to give them scientific nutrition information? The protective effects of applied, scientific nutrition in human antenatal care have recently been dramatically documented by Mrs. Agnes Higgins of the Montreal Diet Dispensary.(12) The rationale for blind weight control to any "magic number" of pounds in human pregnancy has been completely destroyed.(13) What then must the obstetricians of our nation do? What actions must they take to insure maternal-fetal and newborn health for each woman who wants to produce a normal, full term child and remain in good health herself?

1. Recognize the complications of human pregnancy caused by malnutrition.(14)
   
   
2. Teach each pregnant woman as a routine part of modern, scientific prenatal care, the basic principles of applied scientific nutrition.
   
   
3. Insure that she actually eats an adequate, balanced diet all through gestation.
   
   
4. Encourage her to salt her food "to taste." (with rare exception)
   
   
5. Stop "weight control" to any number of pounds. (when nutrition is adequate and balanced, the weight gain takes care of itself with an average gain in healthy pregnancy of about 35 pounds)
   
   
6. Protect each pregnant woman and her unborn from all harmful drugs, especially salt diuretics and appetite depressants.
   
   
7. On the postpartum wards educate all pregnant patients who have suffered nutritional complications during pregnancy--so that those complications will not recur in subsequent pregnancies.(15)
   
   
8. Stop iatrogenic starvation in human pregnancy.

These measures will begin to open a new era in preventive obstetrics in our nation and dramatically reduce the numbers of low birth weight and brain-damaged and mentally retarded children now being born.

Note from Joy: There is more information following these references.

REFERENCES

1. Hytten, F.E. and Leitch, I. The Physiology of Human Pregnancy. 2nd edition, Oxford, Blackwell Scientific Publications, 1970.
   
   
2. Prochownick, L. "Ein Versuch zum Ersatz der Kunstlichen Fruhgeburt" (An attempt towards the replacement of induced premature birth. Zbl. Gynak. 30:577, 1889.
   
   
3. Williams, Sue Rodwell. Nutrition and Diet Therapy, 2nd Edition. St. Louis, Mosby, 1973, Chapter 17.
   
   
4. Brewer, T.H. "Human Pregnancy Nutrition: an examination of traditional assumptions" Aust. N.Z. J. Obstet. Gynaecol. 10:87, 1970.
   
   
5. Pitkin, Roy M., Kaminetzky, Harold A., Newton, Michael, and Pritchard, Jack A. "Maternal nutrition: a selective review of clinical topics" Obstet. Gynecol. 40:773-785, 1972.
   
   
6. Brewer, T.H. "Human maternal-fetal nutrition". Obstet. Gynecol. 40:868-870, 1972.
   
   
7. Rucker, M. Pierce. "The Behavior of the uterus in eclampsia" Amer. J. Obstet. Gynecol. 2:179-183, 1921.
   
   
8. Ehrenfest, Hugo. "Collective review: recent literature on eclampsia". Amer. J. Obstet. Gynecol. 1:214-218, 1920.
   
   
9. Brewer, T.H. "Limitations of diuretic therapy in the management of severe toxemia of pregnancy: the significance of hypoalbuminemia" Amer. J. Obstet. Gynecol. 83:1352, 1962.
   
   
10. Brewer, T.H. "Metabolic toxemia of late pregnancy: a disease entity" Gynaecologia 167: 1-8, 1969. (Basel)
    
    
11. Chesley, Leon C. "Plasma and red cell volumes during pregnancy" Amer. J. Obstet. Gynecol. 112:440-450, 1972.
    
    
12. Primrose, T. and Higgins, A. "A study in human antepartum nutrition" J. Reproduct. Med. 7:257-264, 1971.
    
    
13. Pomerance, J. "Weight gain in pregnancy: how much is enough?" Clin. Pediat. 11:554-556, 1972.
    
    
14. Brewer, T. "Metabolic toxemia: the mysterious affliction." J. Applied Nutrition 24:56-63, 1972.
    
    
15. Brewer, T.H. "A case of recurrant abruptio placentae." Delaware Med. J. 41:325-331, 1969.

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

"Metabolic Toxemia of Late Pregnancy in the Third World" (p. 170)

As U.S. Americans we have a fundamental responsibility to our own people in this field, but we also recognize the worldwide nature of the role of malnutrition during pregnancy in a vast spectrum of preventable human suffering and diseases and deaths of women and babies. That this role can be so distorted, repressed, denied, ignored is one of the modern enigmas of obstetrics in the 1980's [and continuing in the 2000's]. We have received personal communications from physicians who live in Mexico and other Latin American nations, in South Africa and other African nations, in India, in Thailand, in Iran, in Iraq, in Egypt, etc. all of whom have observed a high incidence of MTLP among women in poverty in those nations. Wherever the Western low calorie, low salt diets for blind weight control and use of salt diuretics become popular, MTLP appears with increasing frequency among the upper classes, a result of iatrogenic maternal malnutrition and hypovolemia.

Here are a few recent references from the literature:

AFRICA................Lancet 1;146, 1978, Jan. 21
THAILAND..............Obstet. Gynecol. 54:26, 1979
INDIA.................Am. J. Clin. Nutri. 34:775, 1981
MEXICO................Am. J. Obstet. Gynecol. 142:28, 1982, Jan. 1

The following is from a chapter titled "Why Women Must Meet the Nutritional Stress of Pregnancy", 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)

See here to read the entire chapter

"Consequences of Sodium Deficiency, A Common Cause of Toxemia" (p. 425)

Various dramatic physiological and biochemical adjustments, particularly hormonal changes, accompany pregnancy. One major such adjustment is an increased retention of sodium, the principle electrolyte of the extracellular fluid.[85-86] Potential sodium depletion, which is frequently iatrogenic, is counteracted by a five to tenfold increase in aldosterone, an adrenal hormone which facilitates tubular reabsorption of sodium, representing the largest pregnancy renal adjustment.[42,86] The increase in aldosterone secretion is the last stage of the salt conservation mechanism (known as the renin-angiotensin-aldosterone homeostasis), which helps maintain a near constant concentration of sodium in the extracellular fluid. When this homeostasis is over-stressed (i.e., when the pregnant woman's sodium requirements are not met), juxtaglomerular degranulation [a process in the glomerulus of the kidney, which is caused by elevated BP, which in pregnancy is caused by high levels of renin, which in pregnancy is caused by low blood volume] can occur with its attendant morbidity and mortality.[87]

"Some Effects of High and Low Sodium Intake During Pregnancy in the Rat"

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.

TABLE 25
CONSEQUENCES OF SALT RESTRICTION

	# 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]

[Thrombocytopenia = An abnormal decrease in the number of platelets]

The editor of a major obstetrics journal stated:

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.

The physician supervising the former clinic explained:

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]

TABLE 26
ASSOCIATION OF ABSENCE OF EDEMA
WITH PREMATURE DEATH

	# 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.

Ross, who discovered that the incidence of eclampsia was extremely high in areas where beriberi, pellagra, and other diseases of nutritional deficiencies were found, stated: "We have been struck with the number of patients in eclampsia who are in a very poor state of nutrition...The type of patient we see in eclamptic convulsions is the patient who subsists on a 2900 calorie diet consisting of bat meat, field peas, rice, hominy, grits, cane syrup, brown gravy, lard, and cornmeal...which is deficient in Vitamins B₂, A, C, and D, iron, calcium, phosphorus, and complete proteins."[103]

Hypovolemia (and usually hypoalbuminemia) precedes the onset of metabolic toxemia of late pregnancy.[36, 104] Hypovolemia, which is frequently iatrogenic (when low-salt, low-calorie diets are recommended), is caused by a deficiency of protein, calories, sodium, and/or protein-metabolizing vitamins.[104] Also, hepatic dysfunction usually precedes the clinical symptoms of metabolic toxemia of late pregnancy. Hypoalbuminemia and hypovolemia impair the liver's ability to synthesize sufficient albumin and thereby maintain its detoxification ezymatic functions.[82-85] The fact that severe preeclampsia and eclampsia frequently result in specific hepatic ischemia or periportal lesions or infarction further indicates that maternal malnutrition leads to hepatic dysfunction.[105]

TABLE 27
ASSOCIATION OF HYPOALBUMINEMIA
WITH RISK OF TOXEMIA

	# of Women	Serum Albumin (g/100 ml)	Standard Deviation (Sic)
Toxemic	8	3.87	.03
Nontoxemic on Regular Diets	42	4.04	.04
Nontoxemic on High Protein Diets	12	4.90	.09
Nonpregnant	--	4.90	.06

In the 1930's, Dodge and Frost eradicated eclampsia by instituting a high-protein diet. Toxemic women who were placed on a daily diet consisting of six to eight eggs, one to two quarts of milk, meat, and legumes improved dramatically. The authors discovered that the average serum albumin level among toxemic women was 21% lower than that of those who had been on a high-protein diet and who didn't have toxemia. The probability that the relationship between albumin, toxemia, and protein intake (as exhibited in Table 27) is not significant is infinitesimal.

Tompkins and Wiehl also lowered the incidence of toxemia through dietary supplements.[56] They stated "the so-called 'toxemias of pregnancy' are in reality nutritional deficiency states."

TABLE 28
INCIDENCE OF TOXEMIA
AMONG SINGLE, VIABLE BIRTHS
BY TYPE OF SUPPLEMENTATION (IF ANY)

Group	# of Patients	% With Toxemia (Number of Cases in Parentheses)
Control	170	4.12 (7)
Vitamin Supplementation	244	3.28 (8)
Protein Supplementation	186	2.69 (5)
Protein & Vitamin Supplementation	160	0.63 (1)
TOTAL	760	2.76 (21)

In a previous prospective study of 750 pregnant women who received nutrition education and vitamin supplementation, Tompkins eradicated preeclampsia and eclampsia.[16] Among 750 controls (representing women who attended the same clinic as the well-nourished women but who did not participate in the nutrition program), there were 5 cases of eclampsia and 59 of preeclampsia, for a total incidence of 8.6%.

TABLE 29
INFLUENCE OF PRENATAL DIET
IN REDUCING INCIDENCE OF TOXEMIA

Quality of Prenatal Diet	# of Infants	% Women Who Developed Toxemia
Excellent or Good	31	0
Fair	149	8
Poor or Very Poor	36	44

Burke also demonstrated the relationship between prenatal diet and toxemia.[17,19] Toxemia did not occur in any woman whose daily protein intake was at least 68 grams.

Perhaps the first physician to establish a rigorous nutrition education program for the sole purpose of reducing the incidence of toxemia, Hamlin eradicated eclampsia in 5,000 deliveries and significantly reduced the rate of preeclampsia.[108] He observed:

Brewer, who also implemented a scientific nutrition education program, significantly reduced the incidence of metabolic toxemia of late pregnancy (p<.01).[109] Retrospectively, Brewer discovered that the three women who had developed preeclampsia (none contracted eclampsia) had been inadequately nourished.

TABLE 30
EFFECT OF PRENATAL NUTRITION EDUCATION
IN DECREASING RISK OF TOXEMIA

	# of Women Metabolic Toxemia Of Late Pregnancy Participated in Nutrition Education Program 546 0.55% Did Not Participate in Program 369 2.98%

For more than 20 years, Grieve, by insisting that pregnant women consume one pound of beef every day, has also nearly eradicated toxemia.[110] The differences in toxemia, abruptio placentae, and perinatal death between the 7,331 women whom he considered to be well nourished and the 4,145 whom he considered to be poorly nourished are all extraordinarily significant (p 10^-15).

See here for information on the lacto-ovo and the vegan vegetarian versions of the Brewer Diet

TABLE 31
RELATIONSHIP OF ESTIMATE OF NUTRITIONAL STATUS
TO SEVERE COMPLICATIONS

	# of Women % Toxemia (Hyper- tension, Edema, and Proteinuria) % Abruptio Placentae Perinatal Death Rate Hemoglobin Level At Least 10 g/100ml and Weight Gain of Less than 39.5 lb. 7,331 .01 .03 19.2 Hemoglobin Level Under 10 g/100ml or no Greater than 12 g/100ml and Weight Gain Greater than 39.5 lb. 4,645 .82 1.38 50.6

The fact that protein deficiency causes toxemia was verified in a recent study [as of 1977] in which the administration of protein immediately alleviated the toxemic process.[111] Among the 37 severe toxemics who were given albumin, there was not one instance of RDS and all of their babies received high pediatric ratings.

TABLE 32
PROTECTIVE EFFECTS OF SERUM ALBUMIN
AMONG TOXEMIC WOMEN

	# of Women Induction of Labor Perinatal Mortality Abruption of the Placenta Study Group 135 5% 0.9% 0% Control Group 297 25% 3.7% 3%

See here for entire chapter ""Why Women Must Meet the Nutritional Stress of Pregnancy" Part II

21st Century Obstetrics Now! Vol. 2 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

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.

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.......

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.

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 the Pre-eclampsia syndrome:

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

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

The following references are from the article at the top of this page.

4. Gail Brewer, The Brewer Medical Diet for Normal and High Risk Pregnancy, p 7.

5. Ibid., p 39.

6. Ibid., pp 46-51.

7. Gail Brewer and Janice Presser Greene, Right from the Start (Emmaus, PA: Rodale Press, 1981), p 7.

8. Gail Brewer, BMD, p 220.

9. Thomas Brewer, Metabolic Toxemia of Late Pregnancy pp 15-21, 80.

10. Ibid., pp 27, 33-35.

Perinatal Support Services: pregnancydiet@mindspring.com