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Sometimes what looks like "toxemia syndrome" is actually something else

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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