Chesley's Hypertensive Disorders in Pregnancy

Robert N. Taylor, James M. Roberts, Gary F. Cunningham, Marshall D. Lindheimer

• Publisher: Academic Press
• Year: 2014
• eBook ISBN: 9780124079458
• Edition: 4
• Topic: Medicine
• Subtopic: Pharmacology

Chesley's Hypertensive Disorders in Pregnancy continues its tradition as one of the beacons to guide the field of preeclampsia research, recognized for its uniqueness and utility. Hypertensive disorders remain one the major causes of maternal and fetal morbidity and death. It is also a leading cause of preterm birth now known to be a risk factor in remote cardiovascular disease. Despite this the hypertensive disorders remain marginally studied and management is often controversial.The fourth edition of Chesley's Hypertensive Disorders in Pregnancy focuses on prediction, prevention, and management for clinicians, and is an essential reference text for clinical and basic investigators alike. Differing from other texts devoted to preeclampsia, it covers the whole gamut of high blood pressure, and not just preeclampsia.- Features new chapters focusing on recent discoveries in areas such as fetal programming, genomics/proteomics, and angiogenesis- Includes extensive updates to chapters on epidemiology, etiological considerations, pathophysiology, prediction, prevention, and management- Discusses the emerging roles of metabolic syndrome and obesity and the increasing incidence of preeclampsia- Each section overseen by one of the editors; each chapter co-authored by one of the editors, ensuring coherence throughout book

Chapter 1

Introduction, History, Controversies, and Definitions

Marshall D. Lindheimer, Robert N. Taylor, James M. Roberts, F. Gary Cunningham and Leon Chesley^†

This chapter contains Leon Chesley’s introduction from his sole-authored first edition, including an in-depth and scholarly review of our knowledge of preeclampsia through the ages. Also included is his lecture, “False steps in the history of preeclampsia,” presented in September 1975 at an International Workshop; both meeting and lecture considered the impetus for renewed focus on this devastating disease. The chapter also contains an “EDITORS’ UPDATE” summarizing progress made since Chesley’s single-authored first edition, including the new classification schema in the American College of Obstetricians and Gynecologists’ Hypertension Task Force 2013 recommendations.

Keywords

introduction; history of preeclampsia; classification schema

Leon Chesley’s Hypertensive Disorders in Pregnancy was initially published in 1978.¹ Then, as now, hypertension complicating pregnancy was a major cause of fetal and maternal morbidity and death, particularly in less developed nations. Most of this morbidity was and remains associated with preeclampsia, a disorder with devastating effects in many organ systems, high blood pressure being but one aspect of the disease. The first edition was single authored, written entirely by Dr. Chesley, a PhD in physiology, who originally found employment as a chemist at the Newark New Jersey’s Margaret Hague Maternity Hospital, during the Great Depression of the 1930s. Curious why certain tests were being performed on convulsing pregnant women, he went to the wards, observed, and was stimulated to study that enigmatic disorder preeclampsia, the result being signal contributions published from the late 1930s through the early 1980s. His contributions included major observations in such diverse areas as epidemiology, remote prognosis, vascular and renal pathophysiology, and treatment, all focusing on hypertension in pregnancy. A compendium of his achievements is but one aspect of the initial edition of this text, which for the next two decades was a leading resource for clinicians and investigators who wished to learn more about high blood pressure in pregnant women.

In 1978 a text devoted to the hypertensive disorders in pregnancy could be single authored, due in part to the energy, intellect, and other attributes of Leon Chesley, but also because research in this important area of reproductive medicine was still sporadic and unfocused, and progress regrettably slow. Leon almost singly energized the field, and the editors of this text are among many of those for whom he served as a role model, nurturing three of us in early and mid-career. The initial edition, and other signal events during the 1970s (summarized further later in this chapter as “EDITORS’ UPDATE”), spurred rapid progress in many areas including prevention trials, observations regarding pathogenesis, and management considerations. Thus, just like the second and third, the fourth edition again aims to be a leading reference text, multi-authored by leaders in the field. Again our stated goal of the previous editions, that this text will do scholarly justice to Dr. Chesley’s 1978 tour de force, remains the major and obvious goal for the fourth edition.

The remainder of this chapter is as follows: We reproduce Dr. Chesley’s original chapter entitled “History” in its entirety. Unable to improve on it, we add an EDITORS’ UPDATE, and then conclude by republishing Dr. Chesley’s 1975 workshop banquet address “False Steps in the Study of Preeclampsia.”² That meeting led to the formation of the International Society for the Study of Hypertension in Pregnancy, and Dr. Chesley’s message about how to study preeclampsia remains valid today.

History (Fig. 1.1)

Several German authors, such as von Siebold, Knapp, Kossmann, Fasbender, Fischer, and Bernhart, have written on the history of eclampsia, but all too often they did not document their sources and made errors that live on in second-, third-, and nth-hand reviews.^3–8

Figure 1.1 This portrait of Francois Mauriceau inaugurated the “History” chapter in the first edition of this text.

Bernhart wrote that eclampsia was mentioned in the ancient Egyptian, Chinese, Indian, and Greek medical literature.⁸ One of the oldest sources that he cited, without specific reference, was the Kahun (Petrie) papyrus dating from about 2200 BC. His source is likely to have been Menascha.⁹ Griffith had translated Prescription No. 33, on the third page of the papyrus, as: “To prevent (the uterus) of a woman from itching (?) auit pound — upon her jaws the day of birth. It cures itching of the womb excellent truly millions of times.”¹⁰ Menascha cited Griffith’s paper but rendered the translation (in German) as: “To prevent a woman from biting her tongue auit pound — upon her jaws the day of birth. It is a cure of biting excellent truly millions of times.”⁹ He suggested that the untranslated word “auit” means “small wooden stick.” In a later book on the Kahun papyrus, Griffith changed his translation to: “To prevent a woman from biting (her tongue?) beans, pound — upon her jaws the day of birth.”^10,11 Curiously, Menascha did not cite Griffith’s later translation and he included the word “auit” from the first version. Possibly the ancient scribe had eclampsia in mind, but that interpretation is tenuous at best.¹²

Bernhart also wrote, again without references, that both the Indian Atharva-Veda and the Sushruta, of old but unknown dates, mention eclampsia. He said that the Atharva-Veda described an amulet to be worn in late pregnancy for warding off convulsions during childbirth.⁸ There are several references to pregnancy in the Atharva-Veda (translated by Whitney).¹² One is a description of a protective amulet to be put on in the 8th month of gestation (Bk. VIII, 6, pp. 493–498), but there is not the remotest indication of any specific disorder such as convulsions. The ceremonial verses are clearly directed toward protecting the woman’s genital organs against demons and rapists, who are characterized by such epithets as “after-snuffling,” “fore-feeling,” and “much licking” (to name the milder ones).

There are two possible references to eclampsia in the Sushruta (English translation edited by Bhishagratna).¹³ In Volume II, Chapter 8, p. 58: “A child, moving in the womb of a dead mother, who had just expired (from convulsions etc.)” should be delivered by cesarean section. The parenthetic “from convulsions etc.” was supplied by the editor and comparison with the Latin translation (Hessler)¹³ indicates that it probably was not in the original text. In Chapter 1, p. 11 of Volume II: “An attack of Apatànkah due to excessive hemorrhage, or following closely upon an abortion or miscarriage at pregnancy (difficult labor) or which is incidental to an external blow or injury (traumatic) should be regarded as incurable.” Again the parenthetic words are editorial explanations and the “Apatànkah” (convulsions) might well be those associated with severe hemorrhage. By comparison with the Latin translation, the English version seems to have been embellished, for the Latin version specifies only abortion and hemorrhage. An editorial note (pp. 58–60, Vol. II) asserts that the ancient Indians delivered living eclamptic women by cesarean section, but the editor provided no documentation whatever.

Bernhart’s reference to the old Chinese literature was to Wang Dui Me, whose work was translated into German by Lo.¹⁴ The work, originally published in 1832 AD, was thought to be free of any influence of Western medicine but even it if were, there is no indication that it recorded only ancient observations. In several respects it seems to have been contemporary; the author described what Lo translated as “Eklampsie” and wrote: “I use recipe No. 232 ….”

Several of the German authors cite Hippocrates as commenting on the susceptibility of pregnant women to convulsions and on their prognosis. None of the quotations appears in The Genuine Works of Hippocrates as translated by Adams, or in any of the half-dozen other translations that I have seen. Some of the quotations can be found in other Greek sources.¹⁵ Earlier translators, for instance, had attributed the Coacae Praenotiones to Hippocrates, but most scholars agree that it was written before Hippocrates’s time. One such quotation, appearing in several German papers is: “In pregnancy, drowsiness and headache accompanied by heaviness and convulsions, is generally bad.” It comes from the Coacae Praenotiones (Coan Prognosis), XXXI, No. 507. The Greeks of that time recognized preeclampsia, for in the Coan Prognosis, XXXI, No. 523, we find: “In pregnancy, the onset of drowsy headaches with heaviness is bad; such cases are perhaps liable to some sort of fits at the same time” (translated by Chadwick and Mann).¹⁶ Hippocrates (4th century Be), in his Aphorisms (Sec. VI, No. 30), wrote: “It proves fatal to a woman in a state of pregnancy, if she be seized with any of the acute diseases.” Galen, in the 2nd century AD commented that epilepsy, apoplexy, convulsions, and tetanus are especially lethal (Vol. 17, pt. II, p. 820, Kühn [ed]).¹⁷ It may be significant that Galen specified convulsive disorders and perhaps he had in mind what we now call eclampsia, which was not to be differentiated from epilepsy for another 1600 years.

Celsus, in the first century AD, mentioned often fatal convulsions in association with the extraction of dead fetuses (Bk. VII, Chapter 29, translated by Lee).¹⁸ In the same connection, Aetios, in the 6th century AD, wrote: “Those who are seriously ill are oppressed by a stuporous condition …,” “Some are subject to convulsions …,” and “The pulse is strong and swollen” (translated by Ricci).¹⁹

There is a possible reference to eclampsia in Rösslin’s Der Swangern Frawen und Hebammen Rosengarten, a book that was the standard text of midwifery in Europe and England for almost two centuries.²⁰ In discussing the maternal prognosis in difficult labor with fetal death, Rösslin listed among the ominous signs unconsciousness and convulsions (Bk. I, Chapter 9, p. 67). The book was largely based upon the older classics, and the relevant section is reminiscent of Celsus, Aetios, and, especially, Paul of Aegina (translated by Adams).²¹ The book was translated into English from a Latin version of what probably was the second edition and appeared in 1540 as The Byrth of Mankinde. Raynalde revised and amplified the second edition of 1545, and the text was little altered thereafter. Ballantyne’s quotation of the relevant paragraph in Book II, Chapter 9, from the edition of 1560 is virtually identical with that published 53 years later (Raynalde), except for the variable and carefree spelling of the times.^22,23

Gaebelkhouern (variously, Gabelchoverus, Gabelkover) distinguished four sorts of epilepsy in relation to the seats of their causes, which he placed in the head, the stomach, the uterus, and chilled extremities.²⁴ He further specified that only the pregnant uterus causes convulsions, particularly if it carries a malformed fetus. “The mothers feel a biting and gnawing in the uterus and diaphragm that leads them to think that something is gnawing on their hearts (epigastric pain?).” The description of that symptom is usually credited to Chaussier, 1824, 228 years later).²⁵

Although eclampsia is dramatic, it is not astonishing that there are so few references to it in the older writings, which covered the whole field of medicine. Eclampsia had not been differentiated from epilepsy, and obstetrics was largely in the hands of midwives. Even some relatively modern textbooks of obstetrics have barely noticed eclampsia, and those of Burton and Exton made no mention whatever of convulsions.^26,27 In the first edition of Mauriceau’s book, the only comment on convulsions relates to those associated with severe hemorrhage, of which his sister died.²⁸ The literature of eclampsia, for practical purposes, began in France because it was there that male physicians first took up the practice of obstetrics on a significant scale. Viardel, Portal, Peu, and de la Motte each published notable books in the late 17th and early 18th centuries.

In later editions of his book, Mauriceau devoted more and more attention to what we now call eclampsia. Hugh Chamberlen published purported translations of Mauriceau’s later editions, but they seem to have been impostures and really were reissues of the translation of the first edition.²⁹ Such fraud befits a family that kept so important an invention as the forceps secret through three generation...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Preface
• Chapter 1. Introduction, History, Controversies, and Definitions
• Chapter 2. The Clinical Spectrum of Preeclampsia
• Chapter 3. Epidemiology of Pregnancy-Related Hypertension
• Chapter 4. Genetic Factors in the Etiology of Preeclampsia/Eclampsia
• Chapter 5. The Placenta in Normal Pregnancy and Preeclampsia
• Chapter 6. Angiogenesis and Preeclampsia
• Chapter 7. Metabolic Syndrome and Preeclampsia
• Chapter 8. Immunology of Normal Pregnancy and Preeclampsia
• Chapter 9. Endothelial Cell Dysfunction
• Chapter 10. Animal Models for Investigating Pathophysiological Mechanisms of Preeclampsia
• Chapter 11. Tests to Predict Preeclampsia
• Chapter 12. Prevention of Preeclampsia and Eclampsia
• Chapter 13. Cerebrovascular Pathophysiology in Preeclampsia and Eclampsia
• Chapter 14. Cardiovascular Alterations in Normal and Preeclamptic Pregnancy
• Chapter 15. The Renin-Angiotensin System, its Autoantibodies, and Body Fluid Volume in Preeclampsia
• Chapter 16. The Kidney in Normal Pregnancy and Preeclampsia
• Chapter 17. Platelets, Coagulation, and the Liver
• Chapter 18. Chronic Hypertension and Pregnancy
• Chapter 19. Antihypertensive Treatment
• Chapter 20. Clinical Management
• Index
• Color Plates