Abruption of the Placenta

Abruption of the placenta that is not caused by some kind of trauma is usually caused by the clotting of the lake of maternal blood which is normally behind the placenta. The cause of that clotting is usually an inadequate blood volume, which results from inadequate nutrition.

When the placenta first implants on the inner uterine wall, it secretes enzymes which dissolve the ends of the capillaries which come to the inner surface of the uterus. As a result, the open ends of the arterial capillaries spout little fountains of blood behind the placenta, and the open ends of the venous capillaries return the blood to the mother's heart, like little bathtub drains. This is called an arterial-venous shunt. A lake of blood forms behind the placenta, and the baby's capillaries in the placenta, which remain intact (like little loops), are continually bathed in this lake of the mother's blood. Through this process, oxygen and nutrients pass from the mother's lake of blood, through the baby's capillary walls, and into the baby's blood stream, and waste products pass from the baby's capillaries to the mother's blood.

As the placenta grows, the lake of blood behind the placenta needs to grow, and the mother needs to grow more blood in order to keep this lake of blood well-supplied. By the end of the pregnancy, she needs to grow her blood volume by 60% for a singleton pregnancy (about 2 quarts/liters of blood) and 100% for a twin pregnancy (about 3.5 quarts/liters of blood). In order to help her body to increase her blood volume in this way, the mother needs to eat a daily minimum of 2600 calories, salt to taste, and 80-100 grams of protein for a singleton pregnancy, and more than that for a multiple pregnancy.

When the mother's blood volume fails to keep up with the growth of the placenta, through inadequate food intake, loss of salt and fluids (from over-heated conditions or herbal diuretics), or through lifestyle conditions which use up extra calories, the flow of blood through the a-v shunt behind the placenta slows down. The blood that is supposed to be spurting out of the open arterial capillaries behind the placenta like little fountains, slows to a trickle, and the blood flowing through the lake of blood behind the placenta to the open venous capillaries slows down to such a very slow rate that it begins to clot, as blood always does when it is not flowing at a good rate.

The best way to prevent this clotting behind the placenta is for the mother to eat according to the recommendations of the Brewer Pregnancy Diet, plus making daily adaptations, increasing the minimum levels of the Basic Plan to accommodate her personally unique lifestyle and needs. By doing this, she will enable her body to continually expand her blood volume to normal levels, and maintain it at a well-expanded level for the rest of the pregnancy--keeping the little capillary fountains spurting at a good pressure, and the little capillary drains draining at a good rate, and the lake of blood behind the placenta flowing at a good pace so that it doesn't begin to clot.
(Joy Jones)

There are two central facts which need emphasis:

1. The human placenta creates an ARTERIO-VENOUS SHUNT (A/V) in the maternal circulation. During the last trimester of normal pregnancy, 50 to 60 jets of arterial maternal blood spurt up against the fetal cotyledons with each maternal cardiac systole. This blood swirls about in the intervillous space and passes via "tub drains" back into the uterine venous system.

2. The A/V shunt requires for optimal fetal growth and development an INCREASING MATERNAL BLOOD VOLUME throughout the second trimester to a plateau which must be maintained throughout the entire third trimester.

Failure to recognize these two well-established facts has created havoc in human maternal-fetal health throughout the whole western world, especially in the USA, Canada, and the United Kingdom. The observed reduction in utero-placental blood flow associated with common human reproductive pathology has not been correctly interpreted as the result of hypovolemia, failure to maintain a physiological expansion of maternal blood volume.

Physicians commonly carry out dietary restrictions of calories and sodium and give drugs, diuretics, sodium substitutes, anorexiants, vasodilators etc. which actually cause and/or enhance maternal hypovolemia. Intrauterine fetal growth retardation (IUGR) and small for gestational age (SGA) babies have increased dramatically since the 1950s, especially in these three nations, where the role of prenatal malnutrition in causing human reproductive casualty in still universally denied by medical authorities. Applied physiology and basic nutrition science in human prenatal care as a routine for all women all through gestation much form the basis of true, primary prevention in this field.

The following is reprinted from What Every Pregnant Woman Should Know, a book on the Brewer Diet, by Gail Sforza Brewer [Krebs] and Tom Brewer, MD, first published in 1977. This excerpt is found in the chapter titled "The Afflicted Child: Preventing Low Birth Weight".

Abruption of the Placenta (p. 94)

Abruption of the placenta (its premature separation from the wall of the uterus before the baby is born) is one of the most lethal complications in obstetrics. Traumatic abruption is the unfortunate result of an accident in which the mother suffers puncture wounds to the abdomen. This freak occurrence could happen to anyone, well nourished or not. Typically, however, abruption is a severe manifestation of malnutrition. Seen most frequently among the poor, medical literature reports case after case of recurrent abruptions in the same mother. Abruption often accompanies underlying metabolic disease, such as MTLP.

Any degree of abruption is an immediate hazard to the baby's survival. Once the placenta has separated, no oxygen can be transferred to the baby. Toxic wastes soon build up in the baby's tissues. The brain can only survive eight minutes of oxygen deprivation without irreversible damage. Roughly 50 percent of babies die before mothers with this complication can reach the hospital. Immediate delivery is the only treatment. An attempt is made to save the baby if possible, at the same time attention is being given to minimize the internal blood loss and resulting shock which can kill the mother, too.

Nontraumatic abruptions do not occur in well-nourished women. Good nutrition early in pregnancy fosters secure implantation of the placenta on the uterine wall. Continued good nutrition assures that the placenta will grow to meet the demands of the developing baby.

	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

The following is reprinted from The Brewer Medical Diet for Normal and High-Risk Pregnancy (first published in 1983), excerpted from the chapter titled "The Brewer Medical Diet for Pregnancy: The Basic Plan".

Each time you become pregnant, you must grow and nourish a new placenta. Therefore, each pregnancy presents a unique nutritional challenge. By following the program outlined in this book in cooperation with your doctor or midwife, you will be able to meet your nutritional challenge and avoid the serious problems that result from failure of your blood volume to expand normally--placental malfunction, premature separation of the placenta from the wall of the uterus (placental abruption), metabolic toxemia of late pregnancy, and premature labor.

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 (first published in 1983), excerpted from the chapter titled "High Risk Pregnancies".

A placenta abrupts when it separates prematurely from the site where it implanted on the uterine wall. Abruption commonly occurs in women suffering from metabolic toxemia of late pregnancy (MTLP), which is discussed later in this chapter. Both diseases are caused by underlying poor nutrition--maternal diets during pregnancy that fail to meet the nutritional needs of the individual in question. Protein, vitamin C, and folic acid deficiencies have been identified in some women with abruptions of the placenta. However, as we have already noted in connection with several other pregnancy problems, the chances that anyone will have a single nutrient deficiency are virtually impossible outside of a laboratory setting. Consequently, the best protection against an abruption is not the simple addition of protein or vitamin C or folic acid on a selective supplementation basis, but rather the provision of all the nutrients needed to support normal pregnancy development. That simply translates into eating an adequate diet every day throughout the pregnancy.

The placenta can abrupt during pregnancy or during labor. The placenta is anchored to the wall of the uterus by strands of connective tissue that run from the surface of the placenta deep into the surface of the uterus. These strands are like guy wires that hold a circus tent in place: They need to have enormous tensile strength to hold up under stress and strain. In the case of the circus tent, the stress might be a gale-force wind. During pregnancy, the connective tissue strands must respond to the gradual, but thirty-fold, growth of the uterus itself and, of course, during labor, they must hold fast during the hours of powerful contractions necessary to accomplish the birth of your baby. When the strands cannot withstand these stresses, the placenta shears off from its moorings, and internal bleeding results. The baby loses its sources of oxygen and food. Abruption is one of the most dangerous complications in obstetrics and a major cause of stillbirth.

The connective tissue strands holding your placenta secure are composed of collagen, a protein substance that is strongest when you are well nourished. If your diet does not keep up with the demands of your pregnancy, defective collagen synthesis leads to weaker connective tissues and the threat of abruption.

We have counseled numerous women who have experienced two or more abruptions and lost their babies. When they corrected their diets, they were able to carry their subsequent pregnancies to term with no abruptions. Good nutrition made the critical difference.

Placenta (p. 50)

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

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

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

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

"Toxic Abruptio Placentae"--(p. 61)

Premature separation of a normally implanted placenta often occurs in our southern states among women in our lowest socioeconomic class associated with severe MTLP [metabolic toxemia of late pregnancy]. I will refer to this as "toxic abruptio placentae," for I consider it one of the severe manifestations of the underlying metabolic disease. I think it is directly analogous to the abruptions of the placenta which McKay has produced by feeding pregnant rats a low protein, high oxidized fat diet. Hibbard of Liverpool has recently reported evidence that abruptio placentae in his area associated with folic acid deficiency. He did not note a high correlation with MTLP, and this suggests that the woman who develops MTLP in our southern states associated with abruptio has multiple dietary deficiencies and/or the specific bacterial flora in her GI tract may be particularly biochemically malignant, that is, certain strains of bacteria may produce more potentially toxic compounds than others and thereby make greater demands on the liver and damage it more easily. There is strong evidence that good nutrition will prevent this toxic abruption of the placenta. Recently I talked with an obstetrician who has practiced here in the San Francisco Bay Area for over twenty years and has not had one of his private patients develop this sometimes lethal complication. It is possible to see two or three such cases come in during a thirty-six-hour shift working in our big city-county hospital labor units in the South.

It is a clinical teaching passed from resident to resident in our southern hospitals that when you first encounter a patient with a toxic abruption, you are "already three units (1500 ml) of blood behind." These women undoubtedly have markedly contracted blood volumes before they have the abruption and begin to bleed, either externally or behind the placenta. This contracted blood volume plays a role in the pathenogenesis of the abruption. It has long been observed clinically that these women develop signs of blood-loss shock "out of proportion" to the amount of blood lost. These women occasionally develop anuria associated with renal cortical or tubular necrosis, and this must be caused by a prolonged period of inadequate renal blood flow. For these reasons it is necessary to be liberal in transfusing these women and to avoid procrastination in getting them delivered if their lives are to be saved. The use of intravenous human serum albumin to expand plasma volume and to improve renal plasma flow in these women needs to be investigated.

During four years of residency at Jackson Memorial Hospital, where I helped care for a number of severely ill women with toxic abruptio placentae, certain ideas occurred to me concerning the pathogenesis of this serious complication. What are the common biochemical and physiological conditions associated with MTLP which could lead to the premature separation of a normally implanted placenta? Elisabeth Ramsey and her co-workers have given us a clear, scientific picture of how the placental circulation works. Maternal blood enters the intervillous space by small uterine veins on the floor of the intervillous space. Thus, the placenta has been shown anatomically to be an arteriovenous shunt, a condition for which have had good evidence from clinical pysiological observations. Any conditions which will lead to clot formation in the intervillous space may be regarded as playing some role in the pathogenesis of abruption.

The following factors occur in severe MTLP and can play a role in promoting the formation of a clot behind the placenta:

1. Reduction in velocity of blood flowing through the intervillous space associated with arteriolar spasm (of uterine spiral arterioles);

2. Increased viscosity of maternal blood associated with hemoconcentration, hypoalbuminemia, and hypovolemia;

3. Increased fibrinogen concentration of maternal blood associated with hemoconcentration and probably hepatic injury; and

4. Widespread endothelial injury of unknown cause which can damage the fetal cotyledons and release thromboplastin to trigger the clotting mechanism.

Much clinical interest has been focused on hypofibrinogenemia in abruptio placentae, but it develops in a relatively small percentage of cases. I agree with Pritchard that this hypofibrinogenemia is related to loss of fibrin from the blood. In some women the liver is unable to synthesize fibrin fast enough to keep up with the loss. Hypofibrinogenemia has recently been reported in a variety of bleeding complications of pregnancy including placenta preavia, abortion, ruptured ectopic pregnancy and postpartum hemorrhage. Further research will elucidate this question.

It is of much practical clinical importance for the obstetrician to view toxic abuptio placentae as one of the manifestations of an underlying metabolic disease, for then it will emphasize in his mind the vital importance of a careful differential diagnosis of third trimester hemorrhage. The basic differences between the mechanical separation of the marginal sinus, as the cervix begins to efface and dilate and a toxic abruption associated with profound physiological and biochemical abnormalities will indicate the greatly increased hazards to both mother and infant in the latter case. It will be understood why it is a definite mistake to classify bleeding from a ruptured marginal sinus, which is a mechanical problem, as a "first degree abruption." This indicates that it might progress into a "second degree" or "third degree" abruption. Likewise, any degree of abruption associated with MTLP will be seen clearly as an immediate hazard to fetal survival, for the placenta may abrupt totally at any time when conditions develop as outlined above. Among our impoverished and malnourished women in the southern states with severe toxic abruptio placentae, approximately 50 per cent have already had intrauterine fetal deaths before they reach the labor unit. An alert resident staff is often responsible for saving the life of an infant when fetal haert tones are not heard on admission, immediate delivery is likewise indicated to minimize maternal blood loss, shock and damage to the maternal kidneys which can lead to death.

The following 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.

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:

You must have, every day, at least:
(plus 30 g protein and 500 calories for each additional baby):

Group 1 (milk and milk products)--8 choices
Group 2 (calcium replacements)--as needed
Group 3 (eggs)--2 choices
Group 4 (protein sources)--12 choices
Group 5 (dark green vegetables)--2 choices
Group 6 (whole grains, starchy vegetables & fruits)--5 choices
Group 7 (potato)--1 choice
Group 8 (vitamin C sources)--3 choices
Group 9 (fats and oils)--5 choices
Group 10 (vitamin A sources)--1 choice
Group 11 (liver)--Optional
Group 12 (salt and sodium sources)--unlimited, to taste
Group 13 (water)--unlimited, to thirst
Group 14 (snacks)--4 or more
Group 15 (supplements)--as needed

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.

At the Montreal Diet Dispensary, underweight is defined as weighing five per cent or more less than the weight recommended for your height in the Table of Desirable Weights of the Metropolitan Life Insurance Company, a standard used for thirty years. You should use the column for a "large frame" as the company recently disclosed that they have been underestimating all the optimal weights on the chart by ten per cent ever since they first published it! If you really do have a large frame, use the standard for the next taller height.

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.

If you take supplemental vitamins and minerals, brewer's yeast, wheat germ, or other dietary supplements (such as protein drinks, powders, or pills), be sure to take them with meals, since their absorption is enhanced in the presence of complete foods, which provide enzymes necessary for their metabolism. Many people turn to these nutritional aids when they find they have significant nutritional problems in pregnancy; however, it's important to keep in mind that a pill two or three times a day cannot substitute for the foods on the Complete Pregnancy Diet list. These preparations must be viewed strictly as supplements to a good diet, not the diet itself. There are many factors in food substances, such as enzymes, that are not contained in pills or powders, and there may be other substances in foods that are essential to human life that have not yet been isolated by nutrition scientists. So relying on the protective foods on the diet list is the best guarantee of satisfactory pregnancy nutrition.

This food record chart should help you keep track of your daily progress on the diet. Just check off each requirement as you meet it, day by day, week by week, month by month.

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. As described by Gail Brewer earlier on this page, 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:

Vomiting past the third month of pregnancy.

Pregnancies spaced less than a year apart.

Previous pregnancy with low birthweight, neurologically handicapped, or stillborn child as the outcome.

A history of two or more miscarriages.

A history of toxemia.

Failure to gain ten pounds by the twentieth week of pregnancy.

Serious emotional problems.

Working full-time at a demanding job.

Breastfeeding an older baby during pregnancy.

Multiple pregnancy (twins or more)--add 500 calories & 30 g. protein for each baby.

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.

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

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, 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 can 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 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.