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The following is reprinted from What Every Pregnant Woman Should Know, by Gail Sforza Brewer [Krebs], (1977,
1983).
"Toxemia" in the Well-Nourished: mistaken diagnosis (p. 70)
The majority of obstetricians dismiss the idea that malnutrition causes toxemia. Their reason: they have seen many patients
who were well nourished and still displayed the signs and symptoms of the "toxemia syndrome." Therefore, toxemia, as they
have traditionally thought about it, could not possibly result from malnutrition.
Their position sounds reasonable, but it is based on a common clinical error.
When confronted by a mother with the "toxemia syndrome," these physicians customarily skip the important process of differential
diagnosis. Instead, they make a reflex diagnosis of toxemia whenever one or more of the classic signs is present: swelling
of the hands and face, excess weight gain, protein in the urine or elevated blood pressure. No further evaluation is deemed
necessary.
The result: many thousands of pregnant women have been diagnosed as toxemic and treated for toxemia they did not have.
Serious problems result from this mistake. The mother with some other condition which appears similar to MTLP continues to
suffer her original malady because it goes undiagnosed and untreated. Further, the mother may well develop MTLP as a result
of the low-salt, low-calorie diet and drugs prescribed for her. She and the baby may develop further symptoms from prescribed
diuretics, amphetamines and antihypertensives which cross the placenta.
Differential diagnosis is a routine practice in internal medicine. It means that the doctor carefully considers and selectively
rules out different conditions which produce the same signs or symptoms in an individual case.
In order to make an accurate diagnosis of what is causing the "toxemia syndrome" in a given mother, the obstetrician must
be persuaded to withhold judgment and treatment until all the possibilities have been examined, consultations with specialists
in other medical disciplines have been undertaken and appropriate laboratory tests run whenever indicated.
Unfortunately, under current circumstances in which the obstetrician has not been trained to carry out differential diagnosis
of the "toxemia syndrome," responsibility for insuring that an accurate diagnosis is made rests with the person least likely
to know how to procede--the mother herself! The mother who finds herself in this situation must realize that her prime responsibility
is to her unborn baby. She must insist that the doctor follow through with a complete evaluation of her condition before
deciding whether any form of therapy is warranted. If she is not satisfied with the doctor's performance, she must not feel
disloyal or ungrateful about requesting a consultation with a specialist in the suspected area. If necessary, she should
make such arrangements on her own and request of the office nurse that her complete records be sent to the consulting
doctor. Her main concern is not to appease the doctor but to obtain clear, complete explanations of his medical decisions
before she decides whether to take his advice.
In order to become her own advocate in this troublesome plight, the mother needs to know what conditions other than MTLP account
for the most common signs and symptoms of the "toxemia syndrome." She must also be sure she does not have MTLP!
The first step is responsible evaluation of her diet. MTLP cannot be ruled out unless the mother is obtaining enough protein,
calories, vitamins, minerals, salt and water to keep her liver and other organs functioning optimally throughout pregnancy.
Unless someone has made a special point of giving her correct advice about pregnancy nutrition, she probably assumes her
customary eating habits are satisfactory for pregnancy. The idea that pregnancy is a nutritional stress for every
woman, regardless of her pre-pregnancy diet or economic status, is not widely held. Most mothers, if asked, reply that they
eat well. They usually mean that they eat what they like! Consequently, nutritional nonchalence commonly affects mother
and doctor alike.
To determine the true state of affairs, the mother has to consider what foods she has been eating recently and in what quantities.
She should realize that flu or other gastrointestinal disturbances like nausea and vomiting interfere with her eating pattern.
Her appetite may also suffer if she has been worried or depressed. Any of these conditions may result in malnutrition.
Note from Joy: 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.
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.
If you are dealing with nausea, vomiting, or diarrhea, it is 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
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.
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.
I would also like to add here the assurance that Dr. Brewer is not blaming the mother for her situation. 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.
See here to help you evaluate your daily nutrition patterns
See here for vegetarian versions of the Brewer plan
If her dietary evaluation shows she is well nourished, then MTLP can be ruled out and other explanations for the sign or symptom
under consideration must be found.
A primer of mistaken diagnoses and how to avoid them is a distinct help to mother and physician.
Swelling of hands and face (generalized edema), as we have discussed is probably the most commonly misdiagnosed sign.
Sixty percent of normal women experience swelling of their hands and face as a manifestation of healthy adjustment in pregnancy--if
the mother is well nourished. It does not require treatment of any kind at any time in pregnancy.
Protein in the urine commonly occurs in pregnant women who develop a urinary tract infection, either in the
kidneys or the bladder. Pregnant women are more likely to develop such infections because of continual pressure on the tubes
which drain the kidneys early and late in pregnancy. Simple urinalysis may not reveal the presence of infection, so a quantitive
urine culture should be done to establish the correct diagnosis and appropriate medication to combat the infection.
Note from Joy: It can also be helpful to request instructions on how to do a "clean catch" for your urine sample at
your regular prenatal visit. Sometimes if you just pee into the cup without taking extra care, some of the normally extra
vaginal secretions that often occur during pregnancy can end up in the urine sample which is being tested for protein, and
their presence in the sample can then make the urine test positive for protein.
Many types of kidney disease, such as glomerulonephritis (Bright's disease), chronic pyelonephritis, kidney cysts and
tumors, also cause protein spills in the urine. Differentiation between the various kidney disorders is the specialty of
the renal expert, who should be consulted by the obstetrician when these diseases are under consideration.
Elevated blood pressure (hypertension) may result from many different causes. "Psychic" hypertension, is engendered
by emotional stress of any sort. Many women become anxious during physical examinations or during laboratory testing.
Women whose blood pressure has been normal throughout pregnancy may develop hypertension at the time of admission to the
hospital for labor and birth. These mothers do not have MTLP: the liver is functioning normally and the blood volume is expanded.
"Essential," chronic, or benign hypertension is most common in women over thirty years of age. However, many black teen-agers
have already developed the condition and will continue to have it the rest of their lives. These mothers require exactly
the same diet as mothers with normal blood pressures--including the use of salt to taste--since their blood volumes must expand,
too, as pregnancy advances.
Salt deficiency can trigger hypertension as mentioned previously.
Note from Joy: If you already salt to taste, please also remember that a salt deficiency can result from working in
the garden on a hot day, exercising, living in a hot house in the winter, living in a house without air-conditioning in the
summer, or having a job in an over-heated environment. So in those situations, and other similar ones, please remind yourself
to salt a little more and drink a little more of your nutritious fluids, especially if you notice that your fingers or ankles
are starting to swell.
See more about salt here
See more about water here
Obese women are often incorrectly diagnosed as hypertensive when a standard size blood pressure cuff is used to take
a reading. When the cuff is too small, additional pressure on the mother's arm reads on the meter as elevated blood pressure.
Using a larger cuff prevents this error.
See more about obesity here
Pheochromocytoma, an exceedingly rare tumor of the adrenal gland, also causes hypertension.
Kidney diseases also result in high blood pressure.
Other signs--pregnant women may develop medical diseases that afflict the rest of the population: epilepsy, brain tumor,
stroke, heart failure, cirrhosis of the liver and poorly controlled diabetes mellitus may also be included in the differential
diagnosis if the preceding conditions yield no answers.
Obviously, what was once considered a simple clinical diagnostic problem, is, in reality, quite complex. Varying combinations
of the preceding conditions in a well-nourished woman can easily lead even the most thorough physician astray. It takes more
effort to unravel the "toxemia syndrome" by differential diagnosis than it does to make a snap judgment.
Knowledge that malnutrition is responsible for the onset of MTLP and assiduous efforts to see that all mothers are well nourished
does not mean that swelling, weight gain, protein in the urine, hypertension or convulsions and coma are going to disappear
from the childbearing population. It does guarantee that mothers who are truly well nourished will not display these signs
and symptoms due to MTLP.
The mother should keep in mind through all this that when she maintains a good diet her chances of developing MTLP are reduced
to zero. She is also doing everything possible to reduce to the absolute minimum the chances that she or her baby will suffer
any other complication of pregnancy or labor.
See here for an overview of how the mainstream medical perspective on pre-eclampsia evolved to where we find it today
What Every Pregnant Woman Should Know available here
Note from Joy: While the use of amphetamines and diuretics may no longer be considered the mainstream treatment
of choice for the symptoms of toxemia, other methods of weight control in pregnancy and treatments for toxemia are currently
in vogue which are equally hazardous to both the baby and the mother. And unfortunately, the hazards of these current treatments
are no more recognized by the mainstream practitioners of today than were the hazards of the earlier use of amphetamines and
diuretics by the practitioners of yesterday. I have been witness to some of the current hazardous treatments, just within
the past 5-10 years.
I worked for a homebirth midwifery practice for several years. For most of that time, all the midwives were supportive of
the use of the Brewer Diet by the clients of the practice. The last year of my time there, we got a new midwife on staff
who was very opposed to the use of the Brewer Diet. Whenever we got a new client who was the least little bit on the plump
side, she would apparently tell her to get a little more exercise and eat a little less carbohydrates. When her blood pressure
would start to creep up, she would tell her to cut back on her salt a little bit. No amount of my trying to explain the Brewer
insights to her made any headway. As a result, within the first six months of her being on staff, we had 2-3 clients who
had to be hospitalized with blood pressure problems and premature labor, as I recall, which was very uncharacteristic of our
practice (we usually had possibly 1 case per 1-4 years, if I recall correctly).
So it is very important that we not dismiss the historical accounts that Brewer has documented for us. We need not look down
our noses at his reports of the starvation-amphetamine-diuretic practices of the physicians around him in his early days,
and his efforts to stop those practices. We have our own faulty treatments in our own time, which are based on the same faulty
thinking, and are just as hazardous as the treatments that he witnessed.
In addition, unfortunately, some areas of the "alternative medicine" community have apparently 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 on the hazards of using herbal diuretics in pregnancy
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