Dr Quinn has written regarding our recent publication in which we describe histopathologic findings in placentas of women with preeclampsia in both early- and late-onset in gestation. In our article, we asked, “Is preeclampsia more than one disease?” and found that placentas of women with preeclampsia onset at <34 weeks’ gestation were significantly different compared with those with preeclampsia at term. Specifically, we found that vascular lesions and small placental size were related to the diagnosis of preeclampsia earlier in gestation, whereas the predominant finding in women with preeclampsia who received the diagnosis late in the third trimester was increased placental size. We feel that the obstetric literature is growing with lines of evidence that suggest that preeclampsia is indeed >1 disease or at least is manifest as 2 different phenotypes. Dr Quinn now asks, “Is preeclampsia a result of injuries to uterine nerves at different anatomic sites?” and has hypothesized in a previous publication that events (such as straining to achieve defecation, back injury, or uterine curettage) may be the inciting event that leads to uterine nerve injury and subsequent development of preeclampsia.

The placental implantation site blood vessels in Dr Quinn’s Figure are offered as evidence of placental ischemia that resulted from injuries to uterine vasomotor nerves. This type of injury is one phenotype, according to Dr Quinn, and seems to correspond to our results that implicate overt placental disease in association with pregnancies that are complicated by preeclampsia at <34 weeks’ gestation. Dr Quinn seems to suggest that the second phenotype is analogous to our finding of placental hyperplasia in women with preeclampsia at term and suggests that this phenotype is attributable to increased myometrial tension that leads to injured nerves in the extraplacental uterus.

Describing the validity of Dr Quinn’s “two phenotype, one etiology” theory based on uterine nerve injury is beyond the scope of our ken. As such, we are reluctant to implicate defecation in the pathophysiologic condition of preeclampsia at this time.