Charles P. McCartney

Pathological Anatomy of Acute Hypertension of Pregnancy

With the possible exception of a unique glomerular lesion, the morphological changes in patients dying with convulsions, coma, and other complications of acute hypertension are not specific for a pathological entity initiated by aberrations peculiar to the pregnant state. Renal biopsies afford a means for classifying pregnant patients with acute hypertension. The glomerular lesion, believed to be pathognomonic of preeclampsia, was not found in 25% of 63 primiparas who fulfilled the clinical criteria for preeclampsia; chronic renal disease was present without the toxemic lesion in 30% of 214 pregnant patients with acute hypertension. These findings suggest that chronic renal disease plays a more important role in the acute hypertension of pregnancy than current statistics indicate, and that data pertaining to the hypertensive disorders of pregnancy must be interpreted with caution when their differentiation is based upon clinical criteria alone.

Etiology of eclampsia

Abstract We have not been able by obstetric and dietetic care to reduce the incidence of pre-eclampsia or prevent the development of an occasional case of eclampsia. The elimination of water given by the oral or intravenous route is delayed in all pregnant patients but more markedly in those with pre-eclampsia than in those who have hypertensive disease. This delay may be due in part to the increased storage of the water in the legs and thighs as a result of the high venous pressure in the lower extremities due to the pregnancy. The antidiuretic substance from the posterior pituitary and the hormones from the adrenal cortex are also involved but the mechanism of control is still in doubt. A urinary volume of 2,000 ml. per twenty-four hours is recommended as requiring minimal work by the normal kidney. The hourly ingestion of water in constant amounts of 150 to 200 ml. seems to produce better elimination of water, electrolyte and nonelectrolyte substances than the irregular ingestion of large amounts. It seems advisable to instruct normal patients not to ingest more than 1 to 2 Gm. of sodium, 4 to 6 Gm. of chloride, and 1 to 2 Gm. of potassium per twenty-four hours during pregnancy.

Protein excretion patterns in pregnancy

Abstract Serum and urinary protein fractions were determined simultaneously in a group of normal and abnormal pregnant patients by electrophoretic separation. A comparison of these urinary and serum protein fractions revealed differences in the pattern of urinary protein excretion which suggest that this method affords a means for differentiating the entities associated with proteinuria in pregnancy.

Kidney biopsies in multiparous patients with vascular renal disease in pregnancy.

Abstract Renal biopsies were obtained at delivery from 66 multiparas who had toxemia in one or more pregnancies and from 10 multiparas whose pregnancies were uncomplicated by toxemia. There were no renal abnormalities in this latter group. Ten individuals who had had previous pre-eclampsia and eclampsia, and 24 individuals in whom the diagnosis of hypertensive disease was made exhibited normal histologic findings. Fourteen individuals presented findings characteristic of nephrosclerosis. Six had chronic renal disease of uncertain etiology. Four had chronic pyelonephritis in the absence of clinical evidence of the disease, and 2 individuals in this group had clinically undiagnosed bilateral polycystic kidneys as an additional finding. Lupus nephritis was present in 2 patients. The so-called “reversible toxemic lesion” was present in a moderate or severe form in 18 per cent of these patients, and the status of this lesion was regarded as uncertain. Many individuals had considerable renal disease with little clinical evidence of it, while others had a clinically severe toxemia of pregnancy in the absence of demonstrable renal disease. It was impossible to predict the presence of organic renal changes or the magnitude of the renal lesion on the basis of the fundoscopic findings. It was concluded that pre-eclampsia and eclampsia did not result in permanent renal damage and evidence was presented to support the contention that an increase in hypertension, proteinuria, and edema, or the initial occurrence of these manifestations of toxemia during the last 14 weeks of gestation in an individual with renal-vascular disease was the result of an exacerbation of this disease rather than the result of superimposed pre-eclampsia.

Alterations in body composition during pregnancy.

Abstract Gross body composition, sodium 22 space, and exchangeable sodium were determined in normal and abnormal pregnant patients. The pattern of alteration in gross body composition which characterized normal pregnant patients, individuals who evidenced excessive weight gain as the only clinical abnormality, individuals with hypertensive disease, and patients with pre-eclampsia-eclampsia are presented. The individuals with pre-eclampsia-eclampsia were unique in that they evidenced marked antepartum and postpartum increases in the proportion of exchangeable sodium contained in their fat-free bodies. It was suggested that this combination of antepartum and postpartum changes may constitute a physicochemical definition of pre-eclampsia-eclampsia.

Serum proteins in patients with toxemic glomerular lesion

Abstract The mean concentrations of total protein and the electrophoretic fractions of the serum proteins, as well as the mean levels of haptoglobin and ceruloplasmin were determined among gravidas with acute hypertension classified by renal morphology. Among these subjects, elevated mean values for alpha-1 globulin and haptoglobin were statistically significant. When comparisons were made with normal gravidas at corresponding periods of gestation, an elevated mean concentration of alpha-1 globulin identified the group of patients with the toxemic glomerular lesion. When comparisons were made between the groups of patients with abnormal renal morphology, an elevated mean level of haptoglobin characterized the group of patients with the lesions of chronic latent glomerulonephritis.