J Clinical Chiropractic Pediatrics 2012 (Dec); 14 (1): 1032–1036 ~ FULL TEXT
Sharon Gordon, BAppSc(Chiro), DICCP and Sherryn Silverthorne, M Clinical Chiro, RN, RM
Sharon Gordon, BAppSc(Chiro), DICCP
Gippsland, Victoria, Australia
Sherryn Silverthorne, M Clinical Chiro, RN, RM
Melbourne, Victoria, Australia
Up to 10% of women develop pre-eclampsia during pregnancy. It is a significant cause of mortality, responsible for 10-15% of maternal deaths. Its diagnosis is based on the presence of hypertension, with or without proteinuria and edema. As primary contact health care providers, chiropractors must be aware of the risk factors, clinical signs of pre-eclampsia, and the need to modify their management appropriately. An open internet search was conducted for current guidelines in scientific journal databases, in the diagnosis and management of pre-eclampsia. Although there is little literature outlining the role of the chiropractor in patient management, it is clear that specific history and examination procedures must be performed for appropriate co-management and referral.
Key Words: pre-eclampsia, eclampsia, toxemia, hypertension, pregnancy, chiropractic
From the Full-Text Article:
Pre-eclampsia (also known as toxemia of pregnancy) is one of the major causes of maternal mortality and morbidity. 10%-15% of maternal deaths are directly associated with pre-eclampsia and eclampsia.  Up to 10% of pregnant women develop pre-eclampsia.  The incidence of pre-eclampsia in the nulliparous woman is cited as being between 3%–7% and for the multiparous woman 1%–3%. [1, 3] This diagnosis is based on the presence of hypertension, proteinuria, with or without edema. As primary contact health care providers, chiropractors must be aware of the risk factors, clinical signs of pre-eclampsia, and the need to modify their management appropriately.
To review the diagnostic criteria, risk factors and complications of pre-eclampsia, and discuss how this may affect chiropractic management of the pregnant patient.
An open literature search of ‘pre-eclampsia’,‘preeclampsia’, ‘eclampsia’, and ‘toxemia of pregnancy’, was conducted. In addition, these terms were combined with ‘chiropractic’. Other terms entered in combination with ‘chiropractic’ were ‘pregnancy’ and ‘hypertension’. The search was performed with Google, and journal databases PubMed, Medline, Proquest, Cochrane, CINAHL, Medscape, and Index to Chiropractic Literature. Collectively, more than 20,000 articles have been published in scientific journals on ‘pre-eclampsia’, ‘preeclampsia’, ‘eclampsia’ and ‘toxemia of pregnancy’. There were no articles found on chiropractic management of these conditions. In this paper, 29 articles were cited. Six of these were RCTs, 17 were reviews of literature, and 5 were surveys, commentary, cross-sectional studies, case studies and media publications. Inclusion was based on year of publication (2000–2012), research design (RCT and Review of literature prioritized), publication in a peer-reviewed journal, the number of citations of the given article (higher rate of citation given priority), other publications by author, and articles with unique insight into the topic.
A diagnosis of pre-eclampsia in the pregnant patient is made in the presence of hypertension and proteinuria, with or without edema. [4, 5]
Hypertension may be considered mild to moderate (Blood pressure greater than 140/90mmHg) or severe (Blood pressure greater than 160/110mmHg). The severe form often features hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome, which occurs in approximately 5% of pre-eclamptic patients). [5, 9]
A 2011 study of 400 pregnant women, 100 hypertensive, found that mean arterial pressure was a better predictor of pre-eclampsia in the first and second trimesters of pregnancy. Third trimester was best measured by systolic and diastolic blood pressure. 
Proteinuria may be detected by a dipstick urinalysis. A protein sample of 30 mg, which is equal to >+1 is diagnostic. It must be found in 2 or more random urine samples, at least 4–6 hr apart, but no more than 7 days apart. Alternatively, a 24–hour urine test greater than or equal to 0.3g is positive for proteinuria. 
Diagnosis of edema is subjective, based on observation, and manual palpation. It is usually performed at the lower extremity about the ankle, where the practitioner assesses for bilateral pitting edema, consistent with that found in pre-eclampsia. [1, 7]
A review of literature by Sibai in 2005 found that ‘Other than early detection of preeclampsia, there are no reliable tests or symptoms for predicting the development of eclampsia’. 
The exact cause of pre-eclampsia is unknown. Placental vascular dysfunction is linked to the cascade of events and symptoms. A review of the literature suggests “alterations of placental vessels required for adequate perfusion of the placenta, which leads to ischemia. The mechanisms that link the ischemic placenta to endothelial lesions and to stimulation of vasoconstrictors and inhibition of vasodilators are still subject of speculation.” 
Other clinical findings may be seen in the preeclamptic patient. These include, but are not limited to, hyper-reflexia, clonus, visual disturbances, epigastric pain, and headaches.
Onset of symptoms is usually around 20 weeks gestation with hypertension and proteinuria, with or without peripheral edema. [5, 10]
A case report in 2002 documented the case of a 28–year old women in her 37th week of pregnancy, experiencing reversible cortical blindness due to vasogenic edema. One month postpartum, her vision returned to 20/20. 
Complications for the pregnant mother include eclampsia (pre-eclampsia plus seizures, occurring every 1/250 pre-eclamptic patients),  rapid weight gain, DIC, nausea, vomiting, headaches, visual disturbance, hyper-reflexia, clonus, convulsions, cerebral ischemia, right upper quadrant pain or epigastric pain, HELLP syndrome. 
A retrospective study of 453 pre-eclamptic patients found that giving birth by cesarean section increased the risk of complication during the post-partum period.  In a critical review of the literature, Rinehart et al in 1999, found the three most common symptoms of preeclampsia associated hepatic haemorrhage were epigastric pain, hypertension and shock. 
For the fetus, they include death, placental insufficiency, growth restriction and premature delivery. [7, 10] A study of 239 pregnant women by Haddad, Kayem, Deis, Sibai in 2006, found that in severe cases of preeclampsia and intrauterine growth restriction, risk of death was higher in the fetus, but had no impact on maternal complications. 
A pregnant patient with pre-eclampsia is considered ‘high risk’ due to the potential complications of gestation and delivery. For this reason, management is predominately overseen by an obstetrician and/or midwife.
The following are documented risk factors for the development of pre-eclampsia in the pregnant woman: Age over 40, nulliparity or history of pre-eclampsia, family history of pre-eclampsia, diabetes, smoking, hypertension, renal disease, fetal congenital abnormality, and characteristics such as twin or molar pregnancy, autoimmune disease, antiphospholipid syndrome, longer intervals between pregnancies, high BMI (Body mass index >25), and proteinuria. [1, 3, 4, 16]
In a systematic review of controlled trials, Kirsten Duckitt’s controlled cohort studies showed that the risk of pre-eclampsia is increased in women with a previous history of pre-eclampsia, those with antiphospholipids antibodies, pre-existing diabetes, multiple (twin) pregnancy, nulliparity, family history, raised blood pressure (diastolic ≥ 80 mm Hg) at booking, raised body mass index before or at booking or maternal age ≥ 40. Other studies, also noted interval of 10 years or more since a previous pregnancy, autoimmune disease, renal disease, and chronic hypertension all increase the risk of developing pre-eclampsia. 
A Taiwanese hospital study confirmed that BMI> 24kg/m2 increased the risk of diabetes, pre-eclampsia and pre-term labor. 
A multi-centre placebo-control study looked at 4,589 nulliparous women to identify pre-eclampsia risk factors, and whether it was impacted by calcium supplementation. They found raised body mass, as well as with increased systolic and diastolic blood pressure increased the risk of pre-eclampsia. These results were independent of calcium supplementation. 
Medical management involves routine monitoring of blood pressure and urinalysis. Magnesium sulfate is given for severe pre-eclampsia and eclampsia. It has been shown to significantly lower the risk of eclampsia and maternal death, but no impact on fetal death. [19, 20] Antihypertensive medications are only recommended in the presence of other complicating factors. There is insufficient evidence to support the many recommended lifestyle changes (aerobic exercise, altered protein intake, Vitamin C, Vitamin E), however low-dose aspirin, calcium and fish oil supplementation have the strongest evidence. [21–23]
The World Health Organization RCT on calcium supplementation for pregnant women found that it did not prevent pre-eclampsia, but did reduce severity, maternal morbidity and neonatal mortality. 
In a review of the literature, Rossi & Mullen (2011) looked at vitamins C and E and low-dose aspirin supplementation for the prevention of pre-eclampsia. They found no evidence to support their role in prophylaxis. 
A double blind RCT investigated fish oil supplementation for the prevention of gestational diabetes and preeclampsia. They found that supplementation in the first half of pregnancy had no impact on the incidence of either. 
There is little evidence documenting chiropractic management, or evidence of its impact on natural history. With commonly associated symptoms such as hypertension and diabetes, chiropractic management must be modified to accommodate the patient with pre-eclampsia and its risk factors.
Chiropractors are primary health care practitioners. Therefore, initial consult with the pregnant patient should include screening for pre-eclampsia risk factors in the health history. Examination should also include a baseline blood pressure analysis, regardless of gestation. In the presence of hypertension in a pregnant patient, the chiropractic clinician should refer for medical co-management as appropriate.
Follow-up chiropractic management may include the following:
Regular screening for recent onset of pre-eclampsia symptoms such as edema, rapid weight gain, visual disturbances, headaches, etc. from 20 weeks gestation.
Monthly monitoring of blood pressure, and indicators for neurological re-examination.
Modify care using low-force chiropractic techniques, or in some cases, be aware of contraindications to cervical adjusting.
Lifestyle advice on lowering BMI in the pre-natal period, or between pregnancies
Dietary counselling on foods appropriate for diabetes and optimal health
With the increased risk of pre-eclampsia in subsequent pregnancies it is vital for the chiropractor to work with the woman to urge a healthy lifestyle. 
In a recent review on the management of pre-eclampsia by Petitt and Brown (2012), published in the European journal of obstetrics and gynecology, it was noted that ‘the extensive vascular and metabolic long-term associations with pre-eclampsia are now apparent and as clinicians we have a major responsibility to urge healthy lifestyle for these women after any pre-eclamptic pregnancy. 
A cross-sectional survey of 112 pregnant women investigated their knowledge of pre-eclampsia symptoms, consequences and actions. They concluded that women generally have a poor understanding of pre-eclampsia that improved with patient education, with the potential to reduce the risk of complications. 
A prospective cohort study in 2010 looked at the accuracy of women self-reporting pre-eclampsia. This was thought to be lack of patient-doctor communication. It reinforces the need of all health practitioners to appropriately monitor and educate their patients on preeclampsia. 
Pre-eclampsia is a significant cause of maternal mortality and morbidity. It carries known risk factors, and classic clinical symptoms, which the chiropractor must be aware of, along with their impact on management. There is extensive medical research into pre-eclampsia, but little research documented in the chiropractic literature. Further research is needed in the area of chiropractic-based and adjunctive techniques, to determine their impact on patient outcomes.
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