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Marshall D. Lindheimer MD FACP, James M. Roberts, F. Gary Cunningham, "Chesley's Hypertensive Disorders in Pregnancy, Third Edition"

From The New England Journal of Medicine

Preeclampsia remains a lethal enigma of pregnancy. Encompassing more than just hypertension, it can include abnormalities of platelet behavior and clotting mechanisms and of endothelial, hepatic, and renal function. The first edition of Leon Chesley's Hypertensive Disorders in Pregnancy (1978) was a scholarly monograph, written by a scientist with a passionate interest in the condition. Since then, the number of maternal deaths from preeclampsia and eclampsia per million pregnancies has been halved in developed countries. Nevertheless, preeclampsia, together with eclampsia, remains one of the two most frequently cited causes of maternal death in the West.

The second edition is a multiauthored book. The three editors are researchers who have made a particular effort to achieve a degree of homogeneity in the presentation. The contents are divided into six main sections, each overseen by one of the three editors. Each chapter is also coauthored by one of the editors, which has resulted in coherence in the writing among chapters. Most of the chapters begin with a paragraph about how the topic was considered by Chesley that emphasizes the forward-looking and comprehensive nature of his interest.

The first section, "Orientation," includes the entire first chapter of Chesley's monograph. This historical overview was a great pleasure to read. I plan to recommend it to my research fellows as an example of how a scholar can, in an accessible way, convey a wide general knowledge of the background of a particular field of research. Chesley's wide-ranging historical knowledge is presented in flowing English, with references going back to original works whenever possible and recension of the more questionable ones. In this edition, the chapter ends with the full text of Chesley's speech at the 1975 Workshop on Hypertension in Pregnancy, from which sprang the International Society for the Study of Hypertension in Pregnancy, which now has members in nearly 40 countries. This speech could be required reading for the novice researcher.

The second section is entitled "Cardiovascular Adaptation to Normal Pregnancy." Providing a physiologic background is logical and useful, but this section is perhaps too limited. A broader title would have allowed inclusion of the normal changes in the clotting cascade and endothelial and liver function, all of which are deranged in severe preeclampsia. The third section, "Clinical Spectrum of Preeclampsia," usefully outlines the bases for differential diagnosis.

The fourth section, "Pathology and Pathophysiology of Preeclampsia," is an overview of the important pathologic consequences of the disease, and the fifth section is on etiology. Both sections are comprehensive and up to date. I particularly enjoyed the three overview chapters in section 5, which are on endothelial-cell dysfunction, genetics, and lipid metabolism and oxidative stress. Each of these chapters is written by authors who are deeply involved in their respective fields.

The book ends, as did Chesley's lecture in 1975, with a section on the prevention and management of preeclampsia. Do not get too excited about the word "prevention"; the problem of preeclampsia has not yet been solved. As various authors throughout the book point out, the prevention of disease requires knowledge of underlying mechanisms and reliable predictors, neither of which are currently available. However, the evidence supporting the use of parenteral magnesium sulfate to prevent the recurrence of seizures in eclampsia, and possibly prophylactically in severe preeclampsia, is usefully reviewed; it gives a gleam of scientifically based hope for management.

My criticisms are minor. In the book as a whole, there is perhaps a slight overemphasis on volume control and its anomalies; because of some repetition among chapters, about 20 percent of the book relates to the topic. I would have liked to see a chapter on the fetus and newborn of the mother with preeclampsia.

More young obstetricians are becoming fascinated by research into preeclampsia, which allows the practical application of many investigative techniques. This book is an authoritative compilation of knowledge in the area, with many references from the second half of the 1990s. It should certainly be in the library of every academic department, although, sadly, the price of $135 may be too much for a research fellow's pockets.

Reviewed by Fiona Broughton Pipkin, D.Phil., F.R.C.O.G.

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