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The following is reprinted from Medikon International no. 4 - 30-5-1974.
"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:
- Eclampsia has virtually disappeared from Switzerland; there had been no maternal death from this disease in Basel for
almost two decades.
- Some Swiss OB/GYN professors were still teaching that the pregnant woman must avoid red meat as prophylaxis against
eclampsia; for the Swiss this prescription seems to be working.
- The incidence of low birth weight babies born in the University Hospital, Basel, in the year 1967, from some 3,000 deliveries
was 3.0%.
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?
- Recognize the complications of human pregnancy caused by malnutrition.(14)
- Teach each pregnant woman as a routine part of modern, scientific prenatal care, the basic principles of applied scientific
nutrition.
- Insure that she actually eats an adequate, balanced diet all through gestation.
- Encourage her to salt her food "to taste." (with rare exception)
- Stop "weight control" to any number of pounds. (when nutrition is adequate and balanced, the weight gain takes
care of itself with an average gain in healthy pregnancy of about 35 pounds)
-
Protect each pregnant woman and her unborn from all harmful drugs, especially salt diuretics and appetite depressants.
-
On the postpartum wards educate all pregnant patients who have suffered nutritional complications during pregnancy--so that
those complications will not recur in subsequent pregnancies.(15)
-
Stop iatrogenic starvation in human pregnancy.
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.
REFERENCES
- Hytten, F.E. and Leitch, I. The Physiology of Human Pregnancy. 2nd edition, Oxford, Blackwell Scientific Publications,
1970.
- Prochownick, L. "Ein Versuch zum Ersatz der Kunstlichen Fruhgeburt" (An attempt towards the replacement of induced premature
birth. Zbl. Gynak. 30:577, 1889.
- Williams, Sue Rodwell. Nutrition and Diet Therapy, 2nd Edition. St. Louis, Mosby, 1973, Chapter 17.
- Brewer, T.H. "Human Pregnancy Nutrition: an examination of traditional assumptions" Aust. N.Z. J. Obstet. Gynaecol. 10:87,
1970.
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Pitkin, Roy M., Kaminetzky, Harold A., Newton, Michael, and Pritchard, Jack A. "Maternal nutrition: a selective review of
clinical topics" Obstet. Gynecol. 40:773-785, 1972.
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Brewer, T.H. "Human maternal-fetal nutrition". Obstet. Gynecol. 40:868-870, 1972.
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Rucker, M. Pierce. "The Behavior of the uterus in eclampsia" Amer. J. Obstet. Gynecol. 2:179-183, 1921.
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Ehrenfest, Hugo. "Collective review: recent literature on eclampsia". Amer. J. Obstet. Gynecol. 1:214-218, 1920.
-
Brewer, T.H. "Limitations of diuretic therapy in the management of severe toxemia of pregnancy: the significance of hypoalbuminemia"
Amer. J. Obstet. Gynecol. 83:1352, 1962.
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Brewer, T.H. "Metabolic toxemia of late pregnancy: a disease entity" Gynaecologia 167: 1-8, 1969. (Basel)
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Chesley, Leon C. "Plasma and red cell volumes during pregnancy" Amer. J. Obstet. Gynecol. 112:440-450, 1972.
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Primrose, T. and Higgins, A. "A study in human antepartum nutrition" J. Reproduct. Med. 7:257-264, 1971.
-
Pomerance, J. "Weight gain in pregnancy: how much is enough?" Clin. Pediat. 11:554-556, 1972.
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Brewer, T. "Metabolic toxemia: the mysterious affliction." J. Applied Nutrition 24:56-63, 1972.
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Brewer, T.H. "A case of recurrant abruptio placentae." Delaware Med. J. 41:325-331, 1969.
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