Is toxemia of pregnancy a better concept?

Abstract

Sibai et al. (Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets [HELLP syndrome]. AM J Obstet Gynecol 1993;169:1000-6) have continued their monumental presentation of data about the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP). As I argued before, their gloom-and-doom presentation is not entirely warranted for the general population.1Goodlin RC HELLP does not mean immediate HELP!.AM J OBSTET GYNECOL. 1990; 163: 1091Abstract Full Text PDF PubMed Google Scholar With its long-recognized rare association with maternal death, the HELLP syndrome is not a new disease.2Prichard JA Weisman Jr, R Ratnoff OD Vosburg G Intravascular hemolysis, thrombocytopenia and other abnormalities associated with severe toxemia of pregnancy.N Engl J Med. 1954; 250: 87-90PubMed Google Scholar, 3Goodlin RC Severe preeclampsia: another great imitator.AM J OBSTET GYNECOL. 1976; 48: 117-122Google Scholar As Sibai et al. noted, delivery does not necessarily improve or prevent the syndrome. They do not mention steroids, which ameliorate the abnormal laboratory findings,4Goodlin RC Preeclampsia as the great impostor.AM J OBSTET GYNECOL. 1991; 164: 1577-1580Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 5Magann EF Martin RW Isaacs JD et al.Corticosteroids for the enhancement of fetal lung maturity: impact on the gravida with preeclampsia and the HELLP syndrome.Aust N Z J Obstet Gynaecol. 1993; 33: 127-131Crossref PubMed Scopus (45) Google Scholar or furosemide, which diminishes the abnormal venous tone found in these pregnant women and alleviates the signs and symptoms of pulmonary edema.6Goodlin RC Woods RE McKinney ME Hofschire PJ Churchill GA Elevated static pressure and pregnancy well-being.AM J OBSTET GYNECOL. 1985; 152: 462-468Abstract Full Text PDF PubMed Scopus (6) Google Scholar These drugs could well improve the authors' experience with postpartum patients. It is surprising that after 16 years of discussion health care personnel still do not recognize that right upper quadrant pain in pregnant women may represent severe preeclampsia.3Goodlin RC Severe preeclampsia: another great imitator.AM J OBSTET GYNECOL. 1976; 48: 117-122Google Scholar (Actually, DeLee emphasizes this relationship in his 1913 text Principles and Practice of Obstetrics.7DeLee JB Principles and practice of obstetrics. WB Saunders, Philadelphia1913Google Scholar) Dealing with perhaps a more informed group, my experience was the opposite, in that pregnant women with gallbladder disease were diagnosed as having HELLP.5Magann EF Martin RW Isaacs JD et al.Corticosteroids for the enhancement of fetal lung maturity: impact on the gravida with preeclampsia and the HELLP syndrome.Aust N Z J Obstet Gynaecol. 1993; 33: 127-131Crossref PubMed Scopus (45) Google Scholar The 1993 edition of the American obstetric classic Williams' Obstetrics does not mention the HELLP syndrome. It also claims that “toxemia of pregnancy is an archaic term that was variously applied to any or all hypertensive disorders accompanied by proteinuria or edema and to a variety of other disorders including liver disease.”8Cunningham FG MacDonald PC Gant NF Leveno KJ Gilstrap LC Williams' obstetrics.in: 19th ed. Appleton & Lange, Norwalk, Connecticut1993: 763Google Scholar Hypertension, whether it is gestational, transient, pregnancy induced, or pregnancy aggregated (or it even if absent) is often the result and not the cause of toxemia of pregnancy.9Goodlin RC Holdt D Impending gestosis.Obstet Gynecol. 1981; 58: 743-745PubMed Google Scholar, 10Friedman SA Taylor RN Roberts JM Pathophysiology of preeclampsia.Clin Perinatol. 1991; 18: 661-675PubMed Google Scholar Given the recent discussions of toxins in preeclampsia,10Friedman SA Taylor RN Roberts JM Pathophysiology of preeclampsia.Clin Perinatol. 1991; 18: 661-675PubMed Google Scholar, 11Roberts JM Redman CW Preeclampsia: more than pregnancy-induced hypertension.Lancet. 1993; 341: 1447-1451Abstract PubMed Scopus (1115) Google Scholar and with great interest in elevated liver enzymes and thrombocytopenia associated with pregnancy, it seems appropriate to return to the all-inclusive concept of “toxemia of pregnancy.” As noted by Roberts and Redman,11Roberts JM Redman CW Preeclampsia: more than pregnancy-induced hypertension.Lancet. 1993; 341: 1447-1451Abstract PubMed Scopus (1115) Google Scholar preeclampsia is often more than pregnancy-induced hypertension. The term “toxemia” is not restrictive and implies that all organ systems are at risk, in contrast to terms such as preeclampsia or pregnancy-induced hypertension. The HELLP acronym, although less restrictive, does not represent a pathologically coherent syndrome12Kirschbaum TH Editorial comments.in: Year book of obstetrics and gynecology. Year Book, Chicago1987: 59Google Scholar and could be deleted. The toxemia concept also avoids the oxymoron of the pregnant woman without severe hypertension being diagnosed as having “severe pregnancy-induced hypertension” because she has the HELLP syndrome.