Section 1 Nutritional regulation and requirements for pregnancy and

Chapter
fetal growth

6 Preeclampsia
Fergus McCarthy and Louise Kenny

Definition of preeclampsia proposes that preeclampsia is an exaggerated form of

Preeclampsia is defined by the International Society
for the Study of Hypertension in Pregnancy as gesta-
tional hypertension of at least 140/90 mmHg on two
separate occasions 4 or more hours apart accompanied
by significant proteinuria of at least 300 mg in a 24-
hour collection of urine, arising de novo after the 20th
week of gestation in a previously normotensive woman
and resolving completely by the 6th postpartum week
[1]. It usually occurs during the second half of preg-
nancy and complicates 2% to 8% of pregnancies. Some
women are considered to be at higher risk of develop-
ing preeclampsia than the general female population,
and some of these are listed in Table 6.1. For example,
women with antiphospholipid syndrome have a risk
approximately 9 times greater than that of the general
population of developing preeclampsia.
Implications of preeclampsia
Preeclampsia is a major cause of maternal and perina-
tal mortality and morbidity worldwide, causing 15%
of all direct maternal deaths in the United Kingdom
[2] and a fivefold increase in perinatal mortality with
iatrogenic prematurity being the main culprit [3]. The
Confidential Enquiry into Stillbirths and Deaths in
Infancy report cites one in six stillbirths as occurring
in pregnancies complicated by maternal hypertension
[4]. Preeclampsia also carries implications in adult life,
with offspring of affected preterm pregnancies demon-
strating poor growth in childhood [5] and an increased
risk of hypertension, heart disease, and diabetes [6].
Pathogenesis of preeclampsia
The individual stages in the pathogenesis of
preeclampsia are generally well accepted. However,
debate continues regarding the primary precipitating
factor. Two theories, the two-stage process and the
continuum theory, have emerged to explain the
primary precipitating factor. The continuum theory
the inflammatory response of normal pregnancy. It
is suggested that this occurs in response to a relative
increase in trophoblastic debris, which is released
from a poorly perfused placenta. The exaggerated
inflammatory response can also be triggered by a
normal amount of trophoblastic debris in susceptible
women [7]. The second theory, the two-stage process,
associates the primary event for the development of
preeclampsia appears as a failure of the second wave
of trophoblast invasion from 16 to 20 weeks gestation
with failure to destroy the muscularis layer of the
spiral arterioles. This causes shallow endovascular
cytotrophoblast invasion with enhanced inflamma-
tory response and endothelial cell dysfunction as key
features in the pathogenesis of preeclampsia [8]. This
endothelial dysfunction appears to occur as a result of
oxidative stress and is mediated by high levels of free
radicals and low levels of antioxidants as supported
by the observation that markers of oxidative stress are
present in the maternal circulation of affected women
[9].
Potential contribution by specific
nutritional deficiencies
Many vitamins and food supplements have been advo-
cated for the prevention of preeclampsia, and oth-
ers, in excess or in deficiency, have been impli-
cated in the pathogenesis of the disease. However,
because the precise mechanisms underlying the etiol-
ogy of preeclampsia at a cellular and molecular level
are incompletely understood, it is largely unknown
whether the correction of nutritional deficiencies or
other forms of dietary manipulation may play a part
in primary prevention of this disease. Similarly, it is
not known whether dietary intervention would be
most effective if commenced preconceptually or ante- 53
natally. In this chapter, we discuss the role of maternal

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 Section 1: Nutritional regulation and requirements for pregnancy and fetal growth

Table 6.1 Risk factors for the development of Table 6.2 Summary of role of dietary supplements in the
preeclampsia prevention or treatment of preeclampsia

Unadjusted relative Role in treatment/prevention of

risk (95% confidence Dietary agent preeclampsia
Risk factor interval)
Antioxidants Reduction in relative risk of developing
Age ≥ 40 years, primiparae 1.68 (1.23–2.29) preeclampsia, reduction of incidence of
small for gestational age but an increase
Age ≥ 40 years, multiparae 1.96 (1.34–2.87)
in the incidence of preterm labor
Family history 2.90 (1.70–4.93) Vitamins C and E have conflicting
Nulliparity 2.91 (1.28–6.61) evidence but do not appear to be
beneficial; their use may be associated
Multiple pregnancy 2.93 (2.04–4.21) with adverse outcomes
Preexisting diabetes 3.56 (2.54–4.99) L-arginine Insufficient evidence to recommend its
Pre-pregnancy body mass 4.29 (3.52–5.49) use
index ≥ 35 Calcium Significant reduction in occurrence of
Previous preeclampsia 7.19 (5.85–8.83) preeclampsia particularly in high-risk
groups
Antiphospholipid 9.72 (4.34–21.75) Associated with increased risk of HELLP
syndrome syndrome (hemolysis, elevated liver
enzymes, low platelets)

nutrition in the prevention and development of Chinese herbal Insufficient evidence to recommend its
medicine use
preeclampsia.
Fish oil No evidence of any benefit
Folic acid Insufficient evidence to recommend its
Antioxidants use
Antioxidants protect proteins and enzymes from oxi- Garlic No evidence of any benefit
dation and destruction by free radicals and help to Iron May worsen predisposition to
maintain cellular membrane integrity. Antioxidants developing preeclampsia
can be categorized as either free radical scavengers that Japanese herbal Insufficient evidence to recommend its
trap or decompose existing free radicals, or cellular medicine use
and extracellular enzymes that inhibit peroxidase reac- Magnesium No evidence of any benefit
tions involved in the production of free radicals [10]. Multivitamin Insufficient evidence to recommend its
Free radical scavengers include vitamin C (ascorbate), supplementation use
vitamin E (tocopherols), carotenoids, and glutathione. Salt intake No evidence of any benefit
Antioxidant enzymes include glutathione peroxidase, Zinc No evidence of any benefit
superoxide dismutase, and catalase, which are depen-
dent on the presence of cofactors such as selenium, and lycopene, sometimes with other interventions (e.g.
zinc, and iron. Although antioxidant enzymes are aspirin). Supplementation with any antioxidants dur-
important for intracellular defenses, nonenzymatic ing pregnancy compared with control or placebo was
antioxidants are the major defense mechanism in the associated with a 39% reduction in the relative risk of
extracellular compartment. preeclampsia, which corresponds to an absolute risk
Many studies have been performed to investigate reduction of 3%. There was also a reduction in the
the link between a variety of antioxidants and the incidence of small-for-gestational-age infants, but a
development of preeclampsia. Many of these were of slight increase in preterm birth. However, most of the
poor quality with inconclusive results. Therefore, a data came from poor quality and/or quasi-randomized
Cochrane review was performed. In its final analysis, studies. Data were insufficient to allow reliable conclu-
this included seven trials involving more than 6000 sions about the possible impact of this therapy in sub-
women and assessed the effectiveness of any antiox- groups of high- or low-risk women or to provide guid-
idant supplement during pregnancy for prevention ance on the optimal type and dosage of antioxidants or
of preeclampsia [11]. Supplements included various timing of supplementation.
54 doses and combinations of vitamin C, vitamin E, sele- Vitamins C and E have been studied because
nium, halibut liver oil (containing vitamin A), fish oil, of their perceived function as antioxidants. In one

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randomized trial, vitamin C (1000 mg/day) and vita-
min E (400 IU/day) were administered to women at
high risk of developing preeclampsia during the sec-
ond and third trimesters [12]. Vitamin supplementa-
tion was associated with a significant reduction in the
frequency of preeclampsia. However, subsequent tri-
als have not confirmed these findings. A larger, mul-
ticenter trial in a diverse group of women at high risk
of developing preeclampsia, conducted by the inves-
tigators of the original study, found that the inci-
dence of preeclampsia was similar for women given
vitamin C and E supplementation and those given
placebo [13]. This study also reported that the num-
ber of low birth weight neonates was slightly higher in
treated women. This may have been related to a trend
toward slightly earlier onset and more severe disease
in treated patients. Post hoc analysis showed that vita-
min supplementation was associated with increased
frequency of gestational hypertension and stillbirth.
Another multicenter trial randomly assigned nulli-
parous women without medical or obstetrical com-
plications to receive daily supplementation with vita-
min C plus vitamin E or placebo from the sec-
ond trimester until delivery [14]. The incidence of
preeclampsia was similar for both groups. There were
no significant differences in the incidence of small-for-
gestational-age neonates, death/serious neonatal com-
plications, or preterm birth. The difference in preva-
lence of preeclampsia between these two trials may
be attributed to differences in the populations studied.
Certainly it seems that antioxidant supplementation
does not prevent preeclampsia. Furthermore, there is a
possibility that the therapy increases the risk of adverse
effects in women with specific risk factors for the
disease.
Two studies have addressed the issue of whether
antioxidants alter the course of established preeclamp-
sia [15, 16]. Neither reported a clinical benefit.
A recent systematic review of trials evaluating vita-
min E supplementation in a variety of clinical settings
[17] demonstrated harmful effects associated with
supplementation. A recently published case-control
study investigated the association between maternal
dietary and supplement intake of the antioxidants
vitamin E, retinol, and congenital heart defects [18].
This study demonstrated an association between high
maternal vitamin E intake by diet and supplements
and an increased risk of congenital heart disease in
the mother’s offspring. These findings highlight the
need for controlled evaluation of vitamin E and other
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Chapter 6: Preeclampsia
antioxidant supplementation in pregnancy. Therefore,
at present, antioxidant supplementation in the form of
vitamin C and vitamin E cannot be recommended for
the prevention or treatment of preeclampsia.
Arginine
Arginine is an alpha amino acid that is synthesized
by adults through the urea cycle. Arginine is the
immediate precursor of nitrous oxide, urea, ornithine,
and agmatine. Nitrous oxide is a potent vasodila-
tor; therefore, arginine supplementation has been sug-
gested as a potential treatment in a condition in
which vasodilatation may be beneficial. Administra-
tion of organic nitrates or L-arginine has been shown
to improve uterine-placental circulation and to lower
maternal blood pressure [19–22]. A recent pilot study
by Facchinetti et al. [23] shows promising results in
prolonging the latent period to the development of
preeclampsia in patients with gestational hyperten-
sion by means of arginine supplementation. How-
ever, this benefit needs to be confirmed in larger
studies with adequate power to evaluate the effec-
tiveness of L-arginine in preventing the development
to preeclampsia. Currently, arginine supplementation
cannot be recommended for the prevention or treat-
ment of preeclampsia [24].
Calcium
The relationship between calcium intake and hyper-
tension in pregnancy was first described in 1980, when
epidemiological studies suggested that women who
lived in areas with high dietary calcium intake had a
lower incidence of preeclampsia. A Cochrane system-
atic review including 12 studies of more than 15 000
women compared the use of at least 1 g of calcium
daily during pregnancy with placebo [25]. Preeclamp-
sia was significantly reduced with calcium supplemen-
tation compared with placebo. A similar effect was
observed in nonproteinuric hypertension. The effect
was greatest for women at high risk of developing
preeclampsia and for those with low baseline calcium
intake. Calcium supplementation was also associated
with a significant reduction in the incidence of mater-
nal death or serious morbidity, but somewhat perplex-
ingly, it increased the incidence of HELLP syndrome.
HELLP syndrome refers to a clinical syndrome charac-
terized by hemolysis, elevated liver enzymes, and low
platelets that may occur in pregnancy. It is thought 55
to represent a variant of preeclampsia. The benefit
 Section 1: Nutritional regulation and requirements for pregnancy and fetal growth
from calcium supplementation appears to be mater-
nal as there was no effect on the risk of preterm
birth or perinatal death. There were no reports of
adverse events related to calcium supplementation but
long-term follow-up was minimal. Overall, the bene-
fits of less preeclampsia, fewer maternal deaths, and
reduced severe morbidity support the use of calcium
supplementation during pregnancy for women with
low dietary intake of calcium.
Chinese herbal medicine
Traditional Chinese medicine is a theoretical and
methodological system that incorporates concepts of
cause, diagnosis, and treatment. Several traditional
Chinese medicines are thought to protect the mater-
nal spleen, liver, and kidneys in preeclampsia by
encouraging vasodilatation, increasing blood flow,
and decreasing platelet aggregation. Some of these
medicines have been reported to be effective in the
treatment of preeclampsia [26]. However, in a sys-
tematic Cochrane review, no appropriate good-quality
randomized controlled trials were found for analy-
sis [27]. Therefore, Chinese herbal medicine cannot
be recommended for the prevention or treatment of
preeclampsia.
Fish oil
It has been proposed that fish oil supplements may
have a variety of protective vascular effects includ-
ing reductions in systemic blood pressure and in
the incidence of preeclampsia and pregnancy-induced
hypertension [28, 29]. One randomized double-blind
placebo controlled trial randomized 253 pregnant
women at high risk of developing proteinuric or non-
proteinuric pregnancy-induced hypertension or asym-
metrical intrauterine growth retardation to 2.7 g of
MaxEpa daily (1.62 g of eicosapentaenoic acid and 1.08
g of docosahexaenoic acid) or placebo. There was no
difference in an intention-to-treat analysis between the
placebo and active treatment groups for occurrence of
any of the primary outcomes [30]. A second prospec-
tive trial enrolled 386 pregnant women with a his-
tory of pregnancy-induced hypertension in a previous
pregnancy and randomly assigned them to a fish oil or
olive oil supplement, beginning after 16 weeks of ges-
tation [31]. These and two subsequent trials [32, 33]
56 found that fish oil supplementation had no effect on
the incidence or development of hypertension. Meta-
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analysis of these trials also failed to show a reduction
in the risk of preeclampsia [34].
Folic acid
Homocysteine has been reported to be increased
in the plasma of women who subsequently develop
preeclampsia. Elevated homocysteine levels may dam-
age the lining of blood vessels resulting in the signs
and symptoms of preeclampsia. Folic acid supple-
mentation has been studied in women with hyper-
homocysteinemia because homocysteine levels have
been weakly and negatively correlated with plasma
folate concentrations. Leeda et al. [35] supplemented
a high-risk group of women with hyperhomocys-
teinemia and a history of previous preeclampsia or
intrauterine growth restriction with 5 mg folic acid and
250 mg of vitamin B6 . The supplementation resulted
in a normalized methionine loading test in all patients
in the study and showed a favorable perinatal out-
come. The study had very small numbers and was
not randomized to placebo. Folic acid may have a
role to play in this high-risk group, but in the gen-
eral population, it is not known whether folic acid
has a role to play in the prevention or treatment of
preeclampsia.
Garlic
Garlic is part of the Allium or onion, family. The sug-
gestions that garlic may lower blood pressure, reduce
oxidative stress, inhibit lipid oxidation, and/or inhibit
platelet aggregation have led to the hypothesis that
garlic may have a role in prevention of preeclamp-
sia [36–38]. Experimental studies have demonstrated
that garlic may also increase the production of nitric
oxide [39], which is itself a platelet inhibitor and
vasodilator. A Cochrane review looked at the use of
garlic for preventing preeclampsia and its complica-
tions [40]. Only one trial of 100 women met inclusion
criteria, and it showed no difference between dried
garlic and placebo in the prevention of preeclamp-
sia [41]. There is insufficient evidence to recommend
increased garlic intake for preventing preeclampsia
and its complications. However, because there are now
many varieties of garlic available and there is a lack
of appropriately powered studies, further research is
warranted.

Iron
The placental ischemia and malperfused placenta that
occur in preeclampsia result in the production of free
radicals, which may cause oxidative stress [8]. These
free radicals such as superoxide and hydrogen per-
oxide are unlikely to initiate cellular damage directly.
However, in the presence of metal ions, particularly
iron and copper, they can generate hydroxyl radical,
which can result in endothelial cell damage [42, 43].
Iron is already present in large amounts in the pla-
centa, and levels may further increase in the ischemic
placenta by destruction of red blood cells from throm-
botic, necrotic, and hemorrhagic areas [44]. No trials
have demonstrated that the routine use of iron supple-
mentation in pregnancy can prevent the development
of preeclampsia. Iron supplementation, unlike many of
the other dietary components discussed in this chap-
ter, may also have a detrimental effect when used in
excess in pregnancy by promoting oxidative stress by
decreasing serum antioxidant capacity.
Japanese herbal medicine
In Japan, certain traditional herbal medicines (Kampo
medicines) are used clinically with standardized
quantities and quality of ingredients. One of these
medicines, Tokishakuyaku-san (TS), is used to alle-
viate symptoms of menopause and as a tocolytic in
the treatment of preterm labor. One animal study
performed investigated the effect of TS on pregnant
rats in which a preeclampsia-like syndrome had been
induced [45]. The authors concluded that TS may have
a beneficial effect in preeclampsia, but further studies
are needed.
Magnesium
Magnesium is one of the essential minerals required
by humans in relatively large amounts. Magnesium
works with many enzymes to regulate body tempera-
ture and synthesize proteins as well as to maintain elec-
trical potentials in nerves and muscle membranes. The
MAGPIE (Magnesium Sulphate for the Treatment of
Pre-eclampsia) trial demonstrated the importance of
magnesium in the treatment of preeclampsia and the
prevention of eclampsia [46]. Many women, especially
those from disadvantaged backgrounds, have intakes
of magnesium below average. Makrides and Crowther
[47] systematically reviewed the use of magnesium
supplementation in pregnancy before 25 weeks ges-
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Chapter 6: Preeclampsia
tation. However, of the seven studies included in the
systematic analysis, only one study met the prespec-
ified criteria for a high-quality trial. This one high-
quality study randomized 400 normotensive primi-
gravid women aged 13 to 25 years to receive 365 mg
elemental magnesium or placebo daily from 13 to 24
weeks gestation. The authors concluded that the poor
quality of many of the trials was likely to have resulted
in a bias favoring magnesium supplementation, but
there is not enough high-quality evidence to show
that dietary magnesium supplementation during preg-
nancy is beneficial in reducing the incidence or sever-
ity of preeclampsia. There were also no differences
between the magnesium and placebo groups for the
frequency of preterm birth (⬍37 weeks), gestational
age at birth, birth weight, small for gestational age, the
frequency of admission to a neonatal unit, miscarriage,
and neonatal death [48].
Multiple micronutrient supplementations
Micronutrients are vitamins and minerals required in
minute amounts for normal functioning, growth, and
development. Micronutrients include vitamin A, zinc,
iron, and beta carotene. The resulting micronutrient
deficiencies are exacerbated in pregnancy, leading to
potentially adverse effects on the mother such as ane-
mia, hypertension, complications of labor, and death.
A Cochrane review involving nine trials and more than
15 000 women showed insufficient data to demonstrate
a reduction in the development of preeclampsia by
routine use of micronutrients [49].
Salt intake
Controlled salt intake has long been recommended for
the control of essential hypertension. On this basis,
salt restriction was widely recommended during preg-
nancy for the prevention and treatment of preeclamp-
sia. However, the literature has mixed opinions, and
at one stage in the 1960s, high salt intake was rec-
ommended to prevent preeclampsia [50]. Duley et al.
[51] performed a Cochrane review that included two
trials involving 603 women. Neither trial proved a
reduced incidence of preeclampsia in the presence
of salt [52]. Therefore, in the absence of further evi-
dence, salt intake during pregnancy remains a personal 57
preference [53].
 Section 1: Nutritional regulation and requirements for pregnancy and fetal growth
Zinc
Zinc is one of the mediators of the antioxidant enzymes
such as glutathione peroxidase, superoxide dismutase,
and catalase. A low maternal serum zinc concentra-
tion has been reported in pregnancies complicated by
preeclampsia [54, 55], and it has been suggested that
the incidence of preeclampsia may be reduced by zinc
supplementation [56]. One double-blind randomized
control trial investigated the effect of zinc supplemen-
tation on a healthy middle-class population of more
than 1000 women and concluded that zinc supplemen-
tation does not appear to have any role in the preven-
tion or treatment of preeclampsia [57]. It may have a
role to play in improving birth weight and preventing
prematurity in populations at high risk of poor preg-
nancy outcomes.
The role of diet and lifestyle factors
Rest
Restriction of activity and prolonged resting have tra-
ditionally been advocated for the prevention and treat-
ment of many of the ailments of pregnancy, includ-
ing the prevention and treatment of hypertension [58].
This was based on a belief that exercise may reduce
uteroplacental blood flow and therefore rest would
increase it. Women with preeclampsia suffer from
reduced uteroplacental blood, and therefore it was
hypothesized that rest might prevent or reduce the
severity of preeclampsia. Two studies met inclusion
criteria for a Cochrane review [59, 60]. These two stud-
ies, although included, were themselves substandard,
raising more questions than they answered. There is
insufficient evidence to support recommending rest or
reduced activity to women for preventing preeclamp-
sia and its complications [61]. It is also unclear whether
rest and the resulting immobilization may predis-
pose pregnant women to increased risks of throm-
boembolic disease in the hypercoagulable setting of
pregnancy.
Exercise
The evidence linking the promotion of regular exer-
cise and a reduction in the risk of hypertension in
the nonpregnant person is well established. However,
it remains unclear whether the promotion of exercise
58 in a pregnant woman will reduce her risk of devel-
oping or reduce the severity of preeclampsia. Exercise
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during pregnancy may not be without risks with sev-
eral observational studies linking exercise during preg-
nancy with small-for-gestational-age babies, preterm
birth, and maternal injury [62, 63]. Two studies met
the requirements for a Cochrane review [64]. However,
these trials had small numbers and were unable to pro-
vide reliable conclusions regarding the role of exercise
in the prevention of preeclampsia [65].
Vegans
Veganism is a philosophy and lifestyle that seeks to
exclude the use of animal derived products for food,
clothing, or any other purpose. Vegans do not use or
consume animal products of any kind. Carter et al. [66]
examined the incidence of preeclampsia and repro-
ductive outcomes in a community of vegan mothers.
The study included 775 women, 240 of whom were
primigravidas. This retrospective observational study
revealed only one case of preeclampsia occurring in
this cohort of women suggesting that a vegan diet, a
diet that is low in arachadonic acid, may be protective
against the development of preeclampsia. Other possi-
ble explanations for the low incidence of preeclampsia
in this population include the retrospective nature of
the study, which may have resulted in bias, low levels
of smoking and stress, a “healthy” diet, and high levels
of aerobic exercise.
Obesity
An association between obesity and hypertensive
disorders during pregnancy has been consistently
reported. In particular, maternal weight and body
mass index (BMI) are independent risk factors for
preeclampsia, as well as other hypertensive disor-
ders [67–69]. A review of 13 cohort studies compris-
ing nearly 1.4 million women found that the risk of
preeclampsia doubled with each 5 to 7 kg/m2 increase
in pre-pregnancy BMI [69]. This relation persisted
in studies that excluded women with chronic hyper-
tension, diabetes mellitus, or multiple gestations, or
after adjustment for other confounders. The mech-
anism whereby obesity imparts an increased risk
for preeclampsia is not known. Current hypotheses
suggest that the pathophysiological changes associ-
ated with obesity-related cardiovascular risk, such
as insulin resistance, hyperlipidemia, and subclinical
inflammation, are also responsible for the increased
incidence of preeclampsia in obese pregnant women
[70–72].

What dietary advice can be given and
how does this relate to those with a
genetic predisposition?
The search for dietary supplements that may prevent
or treat preeclampsia continues, and currently there
is no good evidence to support the routine use of
dietary supplements in the prevention and treatment
of preeclampsia in a low-risk antenatal population.
Those patients at high risk of developing preeclampsia
should be considered on an individual basis. Achiev-
ing an ideal BMI relationship between a person’s height
and weight by weight loss before conception may be
the most prudent advice in many patients. Calcium
supplementation may be considered in women at high
risk for developing preeclampsia but only after poten-
tial risks are discussed. Further dietary supplementa-
tion is not recommended outside of the setting of a
clinical trial, and patients should be made aware that
dietary supplementation may have adverse effects on
the mother or fetus.
Potential future research
Unfortunately, more than anything, this chapter high-
lights the significant lack of quality studies from which
to draw conclusions regarding the role of nutrition in
the prevention or treatment of preeclampsia. Further
research is needed to clarify whether potential health
benefits are specific to particular preparations, con-
stituents, or doses. Further trials should be large and
should collect information about perinatal mortality
and morbidity as well as maternal mortality and mor-
bidity associated with any intervention. A particularly
important topic appears to be that of determining the
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Chapter 6: Preeclampsia
effects of calcium supplementation at a community
level.
Key clinical points
r Preeclampsia is a common condition
complicating 2% to 8% of pregnancies.
r Preeclampsia is a leading cause of severe obstetric
morbidity and mortality for both mother and
fetus throughout the world.
r Preeclampsia is associated with a fivefold increase
in perinatal mortality and has medical
implications such as the development of diabetes
late into adult life.
r It is believed to be the result of an exaggerated
form of the inflammatory response of normal
pregnancy.
r The mechanisms underlying this etiology are
poorly understood, and therefore it is difficult to
speculate whether the correction of nutritional
deficiencies may play a part in primary
prevention.
r Many dietary agents and lifestyle factors have
been implicated in its occurrence. However,
good-quality randomized trials comparing these
agents against placebo are generally not available.
It is therefore not possible to recommend the use
of many of these agents in the prevention and
treatment of preeclampsia.
r Some dietary interventions used such as iron
supplementation may be detrimental and further
predispose women to developing preeclampsia.
r Dietary advice with the aim of achieving an ideal
BMI is one of the few dietary interventions known
to reduce the risk of developing preeclampsia.
59
 Section 1: Nutritional regulation and requirements for pregnancy and fetal growth
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