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About the Author
F. Gary Cunningham, MD is holder of the Miguel and Beatrice Distinguished Chair of Obstetrics and Gynecology at the University of Texas Southwestern Medical Center. He is also chair emeritus of the Department of Obstetrics and Gynecology, having served in that position for 22 years. Dr. Cunningham received his MD degree from the Louisiana State University School of Medicine and completed a residency in Obstetrics and Gynecology at Charity Hospital of New Orleans. Following this, he completed a fellowship in Maternal-Fetal Medicine at UT Southwestern and Parkland Hospital in Dallas, Texas. His early career was influenced by Dr. Jack Pritchard, and together they performed extensive clinical and laboratory research in preeclampsia and eclampsia, coagulopathies and other hematological complications of pregnancy, as well as a myriad of medical and surgical disorders complicating pregnancy. He has served as an examiner for the American Board of Obstetrics and Gynecology, served as tor for an NIH consensus conference, and is a member of the Society for Maternal-Fetal Medicine, Society for Gynecologic Investigation, and the American Gynecological and Obstetrical Society. Dr. Cunningham has served as senior editor of the 18th through 24th editions of Williams Obstetrics.
Dr. Marshall Lindheimer, a professor (emeritus) of Medicine, Obstetrics&Gynecology, and Clinical Pharmacology at the University of Chicago is a longtime admirer and was a longtime friend of the late Leon Chesley. Chief Editor of the second and third editions of this text and leader of the search for its current chief editor, Dr. Lindheimer prefers to be called “editor emeritus despite continuing to comment and publish in the area of the hypertension and renal disease in pregnancy. His CV contains over 400 publications including a monograph, other edited texts, reviews, text chapters and articles devoted to both basic and clinical research. Boarded in Internal Medicine and Nephrology, he is the recipient of many awards and honors that include an honorary membership in the Society of Maternal Fetal Medicine and an ad eundem of the Royal College of Obstetrics and Gynecology London. He has received an Honoris Causa degree from Bern University, the Chesley award from the International Society for the Study of Hypertension in Pregnancy, the Belding Scribner Award from the American Society of Nephrology and the Joseph Bolivar DeLee Humanitarian award from the Board of Directors at Lying-in Hospital, Chicago. Both the National Kidney Foundation of Illinois and the Preeclampsia Foundation have honored him as well. Of note on his wall is a congratulatory letter from President Obama, recognizing his accomplishments in regard to the health of pregnant women and their unborn children.
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CHESLEY'S HYPERTENSIVE DISORDERS IN PREGNANCY
Academic PressCopyright © 2009 Elsevier Inc.
All right reserved.
Chapter OneIntroduction, History, Controversies, and Definitions
MARSHALL D. LINDHEIMER, JAMES M. ROBERTS, F. GARY CUNNINGHAM AND LEON CHESLEY
The first edition of Leon Chesley's Hypertensive Disorders in Pregnancy was first published in 1978. Then, as now, hypertension complicating pregnancy was a major cause of fetal and maternal morbidity and death, particularly in less developed parts of the world. Most of this morbidity was and remains associated with preeclampsia, a disorder in which high blood pressure is but one aspect of a disease that has devastating effects in many organ systems. The first edition was single authored, written entirely by Dr Chesley, a PhD in physiology, who originally found employment during the Great Depression as a chemist at the Margaret Hague Maternity Hospital, in Newark, New Jersey. Curious as to why certain tests were being performed on convulsing pregnant women, Dr Chesley went to the wards, and the research that followed resulted in signal contributions about preeclampsia–eclampsia published from the late 1930s through the early 1980s. His many works 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 at that time 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 three editors of this text are among many of those for whom he served as a role model, nurturing us in early and mid-career. The initial edition, and other signal events during the 1970s (summarized as "editors update" later in this chapter) spurred rapid progress in many areas including prevention trials, observations regarding pathogenesis, and management considerations. Thus, like the second and now the third edition, to be useful, required multiauthorship. In the previous edition our stated goal was that this text will do scholarly justice to Dr. Chesley's 1978 tour de force. Obviously this goal persists for this the third edition.
The remainder of this introductory chapter will focus on historical perspectives, a guide to controversial issues, and definitions. The format will be as follows:
Dr Chesley's original chapter entitled "History" is reprinted in its entirety. Unable to improve on it, we have added an EDITOR'S UPDATE where his classic text ends. The chapter ends with a reprint of Dr Chesley's banquet address before a workshop held in 1976 entitled "False Steps in the Study of Preeclampsia." This 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, Fisher, 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.
Bernhart wrote that eclampsia was mentioned in the ancient Egyptian, Chinese, Indian, and Greek medical literature. 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. 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." Menascha cited the paper of Griffith 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." 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." 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.
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. There are several references to pregnancy in the Atharva-Veda (translated by Whitney). 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). 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) 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. 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. 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). 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]). 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, Chap. 29, translated by Lee). 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" (Chapters 22, 23, translated by Ricci).
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. 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). 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.
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. 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).
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Table of ContentsForeword
Frederick P. Zusp