HELLP is a serious complication that can sometimes occur in the last trimester of pregnancy. The letters HELLP represent Hemolysis, Elevated Liver enzyme levels, and Low Platelet count. It can cause bleeding problems in late pregnancy, during labor, and during the postpartum period. Women can lose a lot of blood from this complication, particularly during the time when their placenta is detaching (third stage of labor) and the uterus is involuting, in the immediate postpartum period.

Hemolysis = The destruction of red blood cells

Elevated Liver enzymes = Lab test results which indicate liver damage

Low Platelet count = Low levels of platelets.

Platelets help stop bleeding by helping with clotting, and low platelet counts can cause large amounts of blood loss during surgery or during the third stage of labor and postpartum.

[Low platelet counts can also be caused by the use of Heparin (sometimes used in pregnancy), but Heparin-induced thrombocytopenia (Heparin-caused low-platelet-count) also causes very high rates of thrombosis (the formation of clots that obstruct blood vessels)].

See more about the issue of HELLP and the Brewer Diet here on the FAQ page

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

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

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

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.

See here for information on adjusting the Brewer Diet to fit your lifestyle, as a way of preventing HELLP

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

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).

I had my first two children fifteen and thirteen years ago and was "knocked out" both times. My second husband and I are looking forward to sharing our coming birth, but I'm worried about bleeding. I hemorrhaged both times before. Does your diet help prevent this? (p. 189)

By staying on your excellent diet during pregnancy, you've taken care of the main factors associated with excess blood loss during childbirth: premature separation of the placenta (abruption), failure of the uterus to contract and control bleeding at the placental site after the placenta is delivered, trauma to the genital tract from too hurried a delivery or one that required instrument assistance, a Caesarean operation, and coagulation disorders caused by an inadequate supply of nutrients to the liver.

When you have met the nutritional demands of your pregnancy, the placenta does not shear off prior to the birth of your baby, the uterus behaves as it should in staying firmly contracted in the hours after birth, the chances of having a major tear or requiring forceps or a Caesarean are minimized, and your liver keeps up with all its 500 metabolic functions--including the manufacture of essential clotting factors.

General anesthesia and/or large doses of pain-relief medications given during labor are also significant hemorrhage-inducing agents. They relax the uterus so completely that it has difficulty contracting after your baby and placenta are out, so, as you learned, you bleed considerably more than someone who has been able to make it through labor with little or no medication.

A final obstetric practice you should discuss with your doctor is not hurrying the third stage of labor (delivery of the placenta), either by hormone injections or by exerting traction on the cord to hasten the separation of the placenta from the uterine wall. Generally speaking, it is safer to allow the uterus to separate and expel the placenta spontaneously--there is less chance that fragments of the placental tissue will remain adherent inside the uterus. When this happens, blood vessels behind the still-attached tissue open up--usually within the first twenty-four hours after delivery--in an attempt to dislodge the material and cleanse the uterus. In other words, you hemorrhage.

Put your baby to breast shortly after birth or have your husband massage your breasts to stimulate uterine contractions; the placenta should come out within the next fifteen minutes. This shouldn't be too long to wait in the interest of reducing the incidence of hemorrhage.

As we've mentioned in connection with other questions, should you need to have a Caesarean or some other procedure that increases your blood loss, the expanded blood volume you've developed as the result of your good pregnancy diet serves as protection against shock--even if you lose an extra two or three pints of blood. So keep eating!

The Brewer Medical Diet for Normal and High-Risk Pregnancy available here

The following is reprinted from Metabolic Toxemia of Late Pregnancy: A Disease of Malnutrition, by Thomas H. Brewer, M.D., 1963 & 1983. (p. 63)

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 fibrinogen fast enough to keep up with the loss. Hypofibrinogenemia has recently been reported in a variety of bleeding complications of pregnancy including placenta praevia, abortion, ruptured ectopic pregnancy and postpartum hemorrhage. Further research will elucidate this question.

Note from Joy: If you eat well enough to nourish your liver well, your liver will be more able to create the albumin that is needed to keep your blood volume adequately expanded for the prevention of pre-eclampsia. A well-nourished liver is also more able to synthesize the level of fibrinogen that is necessary for the prevention of the development of HELLP.

Metabolic Toxemia of Late Pregnancy available here

See more about the issue of HELLP and the Brewer Diet here on the FAQ page

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'"

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

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

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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.

Email me if you have any questions: pregnancydiet@mindspring.com