The Hazards of Diuretics in Pregnancy

For several years now it has been a criticism by those who are opposed to the Brewer diet and philosophy that his writings are outdated because they speak so frequently of the hazards of diuretics. These critics maintain that there are no mainstream doctors who use diuretics any more, and that therefore the Brewer people are out of touch with the current needs of pregnant women. My answer to these critics has been that although few if any doctors use diuretics on normal pregnant women these days, Brewer's basic premise is still valid, and that today's doctors still use other means to try to control the weight gain, blood pressures, and edema of their pregnant women--other interventions such as low-salt, low-calorie, low-protein diets, and sometimes anti-hypertensive medications, which are just as hazardous to pregnant women as the diuretic therapies were.

However, it has come to my attention recently that there seems to be a new threat that has grown in our country, from a new source of diuretics which I was not fully aware of until now. It has come to my attention that there seems to be a large number of pregnant women who are using herbs which have diuretic properties during the course of their pregnancies. The herbs which I have become aware of so far are nettle, dandelion, alfalfa, bilberry, and celery. Some of these herbs are found in pregnancy teas, some in liver cleansers, some in iron preparations, and some are used for other reasons. Some women seem to be actually intentionally using these herbs for their diuretic properties--in an attempt to lessen the swelling (edema) that they may be experiencing in their ankles, or in an attempt to lower their rising blood pressures!

There are some who would argue that the herbal diuretics have such a different action in their diuretic activity than prescription diuretics do that they aren't as harmful and harsh as prescription diuretics are, and that therefore they are ok to use during pregnancy.

There are some who would argue that these herbs with diuretic properties also provide vitamins which are essential to the good health of the liver and kidneys and various functions of the pregnant body, and that therefore they are good to use in pregnancy.

There are some who would argue that the benefits of the vitamins in these herbs outweigh the possible risks connected to the diuretic properties of these herbs.

There are even some who would argue that a little bit of a diuretic action can't possibly harm the pregnant woman, and especially those who have some edema.

I think that it is quite possible that at some level, herbal diuretics may be less harsh to the body generally than prescription diuretics are. But in some ways, I also don't understand this point. By definition, a diuretic is any substance (regardless of its source) which forces the kidneys to excrete more fluid than they ordinarily would want to excrete on their own. I can see that possibly an herbal diuretic might not cause the person to excrete some nutrients as prescription diuretics do. But my concern is that all diuretics, regardless of how user-friendly they might be, cause the kidneys to excrete more fluid out of the system than they really want to, which lowers the blood volume, which can compromise the health of the pregnancy, and which can trigger a host of complications.

I have no doubt that these herbs are high in vitamins which are very beneficial to the pregnant body, and which could be very healthy for the liver or kidneys, or could be a good iron source for the blood. But that is not the problem. As long as they have the potential of causing the mother's blood volume to drop, they are potentially lethal to either the mother or baby or both, because a fall in the blood volume can cause a creeping BP and/or pre-eclampsia/HELLP and/or IUGR and/or premature labor and/or low birth weight and/or placental abruption and/or a host of other problems.

What I am very dismayed to discover, however, is the strong assertion by some herbalists that surely a little bit of diuretic action by some herbs can't possibly harm a pregnant woman, and that it can't possibly be harmful for the mom to lose a little of that "extra fluid" that she's carrying around, especially for those mothers who might be a little uncomfortable due to some swelling in her ankles or legs, or those with blood pressures that are creeping up. It is clear to me that those who believe this assertion don't understand what the pregnant body is trying to do, regarding its blood volume, in order to remain healthy. A pregnant woman who is experiencing edema does not have any extra fluid to lose. If she has physiological edema, it's a sign of good health, and she will need that extra fluid for labor. If she has pathological edema, it's a sign that her blood volume is already too low and heading for pre-eclampsia, so lowering it even more with any kind of diuretic could be literally life-threatening.

It is vitally important for everyone who cares for pregnant women, or who creates 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% over the course of her pregnancy--and more than that if there is more than one baby. 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, 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. 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 also 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 and salt in the blood, this conserved fluid will not stay in the blood stream. Instead, it will move 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 herbs and supplements to understand, that there is a huge difference between the edema and hypertension of non-pregnant people with heart disease, kidney disease, and 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 expand its blood volume to the level that is needed for sustaining a healthy pregnancy.

One of the great tragedies of this situation is that many of the mothers using and seeing the effects of these diuretic herbs may have been working very hard to follow the Brewer Diet--a nutritional plan that they expected would keep their blood volume expanded, a nutritional plan that they expected to help them prevent the PIH, pathological edema, pre-eclampsia, HELLP, IUGR, premature labor, placental abruption, and/or low birth weight babies that can result from an abnormally contracted blood volume in pregnancy. They may have been also taking these herbs 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 herbal diuretics they were actually undoing some of their diligent nutritional work with which they'd intended to keep their blood volume expanded and healthy.

So I appeal to the herbalist community to take up the challenge of warning all pregnant women to take care to not use any herbs that have diuretic properties. I urge them to remove herbs such as nettles, dandelion, alfalfa, bilberry, and celery from their pregnancy teas and their pregnancy supplements. I plead with them to find other non-diuretic herbs with equally nutritious qualities, for their iron supplements. I appeal to them to post warnings on their websites, alerting pregnant women to the hazards of using various liver-cleanse or kidney-nurturing supplements if they contain dandelion, nettle, alfalfa, bilberry, or celery, or any other herb with diuretic properties. Let us all work together and assist each woman to have as healthy a pregnancy as possible, by helping each woman to grow as healthy a blood volume as possible.

(Joy Jones, April 9, 2008)

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, by Gail Sforza Brewer with Tom Brewer, M.D., 1977.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This exception does not apply to toxemia, Dr. Chesley asserted. He adamantly stated that diuretics do not prevent or ameliorate toxemia. This bold conclusion descredited the slick, four-color spreads promoting diuretics which have appeared in every American OB/GYN journal since 1958. To the contrary, Dr. Chesley blamed diuretics for aggravating a significant abnormality present in mothers with toxemia, low blood volume (hypovolemia). The diuretics act to drive salt and water from the circulation, thus shrinking the blood volume even more. When used in conjunction with a low-salt diet from early pregnancy on, as the drug companies urged in their promotions, the diuretics may actually bring on the toxemia the doctor seeks to prevent.

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

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

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

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

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

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

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

Women must know that these diseases are exceedingly rare during the childbearing years. So rare, in fact, that if a doctor prescribes a diuretic for her, she must ask why she needs it. If he assures her she has no abnormal increase in her blood volume due to underlying medical disease, she should refuse to take the pills. Diuretics can do nothing but harm except in these rare situations.

Dr. Douglas R. Shanklin, professor in both the departments of OB/GYN and Pathology at the University of Chicago Medical School and past editor of the Journal of Reproductive Medicine, declared in 1973:

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

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

"Dietary Salt and Diuretics" (p. 72)

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

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

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

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

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

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

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

"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 taht 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:

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?

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.

The symptoms of low blood volume in pregnancy, and the complications caused or contributed to by that low blood volume, can include a rising hemoglobin/hematocrit, a rising BP, pathological edema, pre-eclampsia, HELLP (Hemolysis, Elevated Liver enzyme levels, and Low Platelet count), IUGR (intra-uterine growth retardation), abruption of the placenta, premature labor, and low birth weight. My concern is that there is no way to know at the beginning of the pregnancy which women will be more prone to complications due to low blood volume, and which ones will not be as prone to them, or how much that blood volume will need to drop before she starts to show the symptoms. There is also no way to know how early in her pregnancy each mother might be prone to these complications.

For a few months in 2008, I interacted with members of a message board where the pregnant mothers were all very much interested in using herbs of all kinds. As I recall, some of these women were taking a quart or more a day of raspberry tea that had been mixed with nettle. Several of them were having problems with rising BPs, pre-eclampsia, and possibly some of the other complications that I've listed. I looked up the herbs that they were on, and found that many of them had diuretic properties. So I explained to them why that could be a problem. As I recall, those who tried my ideas got better, and those who continued on the diuretic herbs, even adding more diuretic herbs at times, either stayed with their current level of problems, or got worse.

I also have a midwife writing to me whose practice is largely comprised of women who use a lot of herbs. When she read my diuretic herb information, she started taking her pregnant moms off all of the diuretic herbs that they were on. One of those mothers who was having problems that seemed like IUGR gained 5 cm fundal height in one week after going off the herbs and going on the Brewer Diet. Others in her group of pregnant women have reported feeling better when they go off the herbs and go on the Brewer Diet, and they have started telling their friends about this new way of thinking. There have also been other improvements in the health of this group of clients.

There also exists an organization comprised of women who are vehemently anti-Brewer. I interacted with them for about 2-3 months in the winter of 2007-2008, on one of their message boards. They maintain that a number of them have developed pre-eclampsia and some of these other complications as early as 20 weeks, and that sometimes the symptoms progressed to life-threatening degrees in a matter of hours, and that that happened to some of them in spite of their being on the Brewer Diet. Unfortunately, there is no way for us to know whether those women were actually on a legitimate version of the Brewer Diet, or whether they also increased their calorie or salt intake to Brewer levels (along with their protein intake), or whether they adapted the Brewer Diet to their unique lifestyle needs, or whether they were also on some of these herbs. In their belief system the Brewer Diet gets the blame for having failed them. However, I suspect that at least some of these women were on these diuretic herbs. Therefore, as an advocate of the Brewer Diet, I think that it's important for pregnant women and their care-givers to understand the potential risk of using these herbs.

These anti-Brewer mothers are also very much interested in reading all the latest mainstream medical research about the possible causes of pre-eclampsia and HELLP. As a result, they consider these complications to be random, unpredictable acts of nature--situations that we have no control over at all, and which are completely unconnected to the mother's nutrition or lifestyle.

Obviously, they strongly disagree with me, and the Brewer principles, and I strongly disagree with them.

However, I've been listening to some of the things that they have been saying. The various theories that their studies have come up with apparently include the following....

1) that pre-eclampsia is caused by some kind of immunity problem between the mother and the placenta; or

2) that it is caused by some kind of implantation problem of the placenta, resulting in a shallow implantation which triggers all the other symptoms; or

3) that it is caused by some kind of hypoxia problem in the placenta which triggers the constriction of the blood vessels in the placenta; or

4) that it is caused by some kind of protein that is secreted by the placenta which triggers all the symptoms of PE; and

5) possibly some other similar theories.

It is my belief that all of these theories are just the result of mainstream medical researchers trying to "close the barn door after the horse has gone". In other words, it seems like a huge likelihood to me that the physical developments that these researchers are finding and describing are just the end results of low blood volume, which is caused by a lack of certain kinds of food (protein plus calories plus salt).

When I see all of these dire results, all of the mechanisms that are possibly triggered and put into motion by something as simple as low blood volume .... and when I see how far the process can get before any obvious symptoms can alert us to what is going on (according to midwife Anne Frye, the first symptom is often a rising Hgb/Hct--something which we can't see with the naked eye & won't find unless we do weekly blood tests) .... and when I see how hard it can be to get that process to stop and turn around once it's started (as in taking 17 eggs & 2 qts of milk a day for 3 days, for starters, or getting some doctor to give you IV albumin) .... and when I hear how early it can come to a head (sometimes as early as 20 wks) .... and how fast it can progress to a life-threatening situation (sometimes just a matter of hours) .... then I just want to tell everyone that I possibly can how much we are risking here .... how very, very, very important it is to protect that pregnant blood volume as the precious, precious treasure that it is, and how it is no small thing to give the mother some herbs which may stimulate her kidneys to pee out some of that priceless circulatory fluid which she has worked so hard to build up.

In addition, I know that some women find it to be a challenge to keep up with the Brewer Diet on a daily basis. So it just doesn't make sense to me to be encouraging a pregnant woman to build her blood volume with the Brewer Diet on the one hand, and then on the other hand to be encouraging her to take an herb which may cause her body to lose some of that hard-earned blood volume thru its diuretic action. It seems to me as though that would be like taking two steps forward and a half-step backwards every day.

My suggestion to anyone caring for pregnant women is that if they have a woman on a daily cup (or more) of one of these herb teas with diuretic properties, or if she is taking a supplement that contains one of these herbs, and if they see her BPs start to creep up, or her baby's growth start to fall behind, or her swelling start to increase, the wisest thing might be to take her off whatever small amount of these herbs that she is on.

If I were a midwife, I might not want to risk having any of my patients on any amount of diuretic herbs, because once you see the obvious symptoms of a falling or fallen blood volume, the process may be already much progressed, and playing catch-up, by adding extra protein, salt, and calories to the diet, and by discontinuing the doses of herbs, or by giving IV albumin, is often much more difficult than prevention would have been, and occasionally the necessary dietary changes may not come soon enough or work fast enough to make a difference in the outcome.

These are the reasons that I respond so strongly when the discussion comes up about using herbs which have some diuretic properties during pregnancy.

(Joy Jones, January 8, 2009)

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

Joy Jones, RN

February 9, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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