Herbal remedies in pregnancy and
the post-partum period – is it safe?
Dr. Eeson Sinthamoney
MD (Malaysia) MRCOG (London), DFFP (UK)
Consultant Obstetrician and Gynaecologist
Can I take these herbs in pregnancy and
after delivery?
“Depending on the source, some herbs are
listed as safe, but others say it’s not,
therefore, its better to consult your
healthcare provider ………….”
Introduction
• Alternative medicine use has increased
dramatically over the past decade
• Many health care providers are
recommending its use
• May have potentially more complex
untoward side effects for the parturient as
well as the fetus
Parameters
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6.
Definition
Popularity and recent trends
Current cultural practices and variations
Issues related to herbal remedies
Best available evidence
Recommendations
What is herbal medicine?
• Herbal medicine, also known as phytotherapy, is the
treatment of illnesses using measured doses of specific
plants.
• A qualified medical herbalist can prescribe plants to be
taken internally or used externally in various forms and
concentrations depending on the ailment
• May suggest the addition of certain edible plants to the
diet, or may prescribe a medicinal preparation
• May also recommend an essential oil, distilled from the
plant.
History of herbal remedies
 Ayurverdic medicine practiced for > 5000
years, with > 1250 plants used
 Chinese medicine equally ancient
 1 AD, ‘Shen Nong’ recorded > 250 herbs of
medicinal value and temp. + taste
 Currently up to 8000 plants being
investigated
Why is complementary and
alternative medicine on the rise?
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Desire for personal control over health
Dissatisfaction with conventional treatment and it’s
disregard for a holistic approach
Concerns about side effects of western medications
Perceived safety
Easy access to remedies
Access to information –free & easy
Safety profile grossly downplayed
Popularity and recent trends
 Between 1985 to 1988, the use of
‘alternative drugs’ has risen from 4 to 15%
 Between 1988 and 1997, herbal medicinal
product usage in the US general population
rose by 380%
 In 1998, the total US sales of herbal
medicine products amounted to $4 billion
Popularity and recent trends
 7.1 - 55% reported use of herbal remedies
in pregnancy
 85.4% of them did not consider them as
medications
 46% did so on the recommendation of their
health care provider
Popularity and recent trends
 73.2% of certified nurse midwives recommended
herbal remedies
 A survey of 500 members of the American college
of nurse-midwives suggested that > 50% of them
employed herbal medicine products for the
purpose of inducing labour
 Products commonly used blue cohosh, black
cohosh, red raspberry leaf, castor oil and evening
primrose oil.
Popularity and recent trends
 As dietary supplements, these remedies
cannot claim to cure or treat disease, but
may be marketed for certain “conditions”
 In early pregnancy, common “conditions”
that are targeted are nausea and vomiting
 In later pregnancy and post delivery – for
“general well-being”
New herbal trends
Of recent concern :
the creation of extracts with higher
concentrations of certain active constituents
Current cultural practice and
variations
 Literature review: the most commonly used
herbal medicine products were garlic, aloe,
chamomile, peppermint, ginseng, echinacea,
and pumpkin seeds
 However, in the asian population, there is
poor documentation
Herbs often used by Malaysians
of Malay origin
 Kacip fatimah
 Cekur (Kaempferia
Galanga Linn)
 Senduduk (Melastoma
malabathricum)
 Ikan haruan
Anthemis vulgaris
Rhizoma leontica
Etc, etc
Kacip fatimah
(Labisia pumila)
 Has been used by many generations of
Malay women to induce and facilitate
childbirth as well as a post-partum medicine
(Burkill, 1935).
 Three varieties found
 In-vitro study using human endometrial
adenocarcinoma cells showed ethanolic
extract of the roots of L. pumila var. alata
exhibited a weak but specific estrogenic
effect on the cells
 Recent studies (IMR) also show similarities
to other estrogens such as estrone and estriol
Kacip fatimah
• preliminary data suggest that Kacip Fatimah does not
increase estrogen levels and but instead causes increase
free testosterone from the ovaries as it does not work
without ovaries.
• The increase in free testosterone may cause increase in
libido and sexuality in women.
• This could be the effect that the women taking Kacip
Fatimah are looking for!!
Kacip fatimah
• Study conducted to determine the side effects of
petroleum-ether extract on liver and kidney of white rats.
• Noted inflammatory lesions of the renal tubules
leading to Glomerulonephritis and nephrosis and
lesions in the liver.
• This abnormality in the liver and kidney tissue suggested
the presence of toxin compound from Kacip Fatimah.
THE SIDE EFFECTS OF KACIP FATIMAH EXTRACT ON LIVER AND KIDNEY OF WHITE RATS
W. M. EFFENDY, J. SITI-NURTAHIRAH, Z. M. HUSSIN (KUSTEM.) ZAMRI-SAAD (UPM)
Journal of Sustain. Sci & Mngt., 2006 Vol. 1(1): 40-46
Cekur
Kaempferia galangal Linn
• Chinese ginger, finger root, Lesser Galangale
(English), kencur (Indonesia), pro hom
(Thailand)
• Used as a rub to “warm the body” during a
woman’s confinement.
• Also used to treat “high blood pressure,
swellings, ulcers, sprains and asthma” and
widely used in the Malay herbal formulas of
jamu.
Cekur
Kaempferia galangal Linn
• Study investigated the antinociceptive activity in mice
and rats using acetic acid-induced writhing, formalin, hot
plate and tail-flick tests.
• Conclusion: the antinociceptive mechanisms appear to be
both peripherally and centrally mediated actions and the
opioid receptors are probably involved.
• Therefore supports the use in traditional medicine of
Kaempferia galanga against pain caused by various
causes
Antinociceptive activity of the methanolic extract of Kaempferia galanga Linn. in experimental animals. J
Ridtitid et al. Ethnopharmacol. 2008 Jul 23;118(2):225-30. Epub 2008 Apr 11.
Senduduk
(Melastoma malabathricum)
 Two varieties purple and white
flower.
 White flower is even more famous
since it is used by many traditional
medicine practitioners as a cure in
spiritually challenge environment.
 Traditional medicinal uses: Leaves
are used to treat diarrhoea and
dysentery (Malaysia, Indonesia);
wash for ulcers, to prevent scarring
from smallpox; and to treat piles.
At all concentrations tested, the extract
was found to exhibit significant (P <
0.05) antinociceptive, antiinflammatory, and antipyretic
activities in a concentration-independent
manner.
Findings supports previous claims on its
traditional uses to treat various ailments.
Antinociceptive, anti-inflammatory and antipyretic properties of Melastoma
malabathricum leaves aqueous extract in experimental animals. Zakaria et al.
Can J Physiol Pharmacol. 2006 Dec;84(12):1291-9.
Senduduk
Ikan haruan
Channa striatus
Ophiocephalus wrahl; Ophiocephalus chena; Ophicephalus
planiceps; Ophicephalus sowarah
Common name: Chevron Snakehead
Sang Yee
Traditional value
Scientific evidence
Herbs often used by Malaysians
of Chinese origin
Pregnancy
Post-partum
Radix Astragali
Zhong Zhai Pai Wen Dang
Shen
South Dates
Heart shaped Dates
Zhong Ning Gou Li
Many others
Ginseng
Dong quai
Dong quai (Dang Kwei)
Angelica sinensis
 Considered the "female ginseng" because of its balancing
effect on the female hormonal system.
 Demonstrated strong antioxidant effects in epithelial cells
and/or apoptotic effects on fibroblasts.
 Constituents include coumarin, prevents blood clotting
and some anti-inflammatory and antispasmodic effect
 Also contains ferulic acid, a pain reliever and muscle
relaxer, but strangely, before it relaxes the uterus, it
stimulates the uterus briefly
An in vitro investigation of herbs traditionally used for kidney and urinary system disorders: Potential
therapeutic and toxic effects. Woicikowski K et al. Nephrology (Carlton). 2008 Sep 22.
Dong quai (Dang Kwei)
Angelica sinensis
• Dong quai is not recommended during pregnancy due to
possible hormonal and anticoagulant/anti-platelet
properties.
• Animal research has noted conflicting effects on the
uterus, with reports of both stimulation and relaxation.
• Dong quai is traditionally viewed as increasing the risk of
abortion.
• There is insufficient evidence regarding the safety of
Dong quai during breastfeeding.
**Advice from the NHI US
Ginseng
 American ginseng (Panax quinquefolium)
More sedative  yin
 Korean ginseng (Panax ginseng)
More stimulating  yang
 Siberian ginseng
 Main active ingredients are the > 20
saponin triterpenoid glycosides called
ginsenosides
Ginseng
• A systematic review of literature for evidence on the use,
safety and pharmacology of Panax ginseng, focusing on
issues pertaining to pregnancy and lactation.
• Based on strong scientific evidence from a cohort study,
Panax ginseng was not associated with adverse effects
when used during pregnancy.
• In vitro evidence of teratogenicity with exposure to
ginsenosides; however, animal embryos and much higher
levels than achievable through normal consumption
Safety an efficacy of panax ginseng during pregnancy and lactation. Seely D et al. Can J Clin Pharmacol. 2008
Winter;15(1):e87-94. Epub 2008 Jan 18.
Ginseng
In lactation, there are no human studies on the
safety of Panax ginseng, only in vitro evidence
based on three animal studies reporting minimal
risk.
CONCLUSIONS: Panax ginseng should be
consumed with caution during pregnancy,
especially during the first trimester, and during
lactation.
Radix Astragali
 Dried root of Astragalus membranaceus
 Adjunctive therapy in treatment of colds and influenza.
Enhances immune system, increases stamina and
endurance
 Also in treatment of chronic diarrhoea, abnormal uterine
bleeding, DM and as a cardiotonic agent
 Use supported by clinical data : NONE
 Non-teratogenic effects – no data available, to be avoided
in pregnancy
 Effects on the newborn- unknown  to be avoided during
lactation
WHO monographs on selected medicinal plants 1999
Herbs often used by Malaysians
of Indian origin
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Cumin
Fennel
Coriander
Ginger
Garlic
Margosa oil
Ginger
Has been associated with mutagenesis in
culture of Escherichia coli*
Also may potentially inhibit fetal binding
of testosterone **
*Ginger treatment of hyperemesis gravidarum. Fischer-Rasmussen et al. Eur J Obstet Gynaecol
Reprod Biol 1991;38:19-24
** Ginger in preventing nausea and vomiting of pregnancy: a caveat due to its thromboxane synthetase
activity and effect on testosterone binding. Eur J Obstet Gynaecol Reprod Biol 1991;42:163-64
Garlic
Case report spontaneous epidural
haematoma due to excessive garlic intake
Spontaneous spinal epidural haematoma with associated platelet dysfunction from excessive garlic
ingestion: a case report. Neurosurgery 1990;26:880-2
Cumin
 Known medicinal properties and mentioned
in the works of Hippocrates
 Stimulant, antispasmodic, carminative
 No clinical data available
 Adverse effects ?
Coriander
 Mentioned in Sanskrit texts, 7000 years ago
 Also mentioned in the bible
 Reduces flatulence and good for increasing
appetite
 Evidence ?
Western herbs
Commonly used herbal preparations for
labor stimulation include blue cohosh, black
cohosh, red raspberry leaf, castor oil and
evening primrose oil
Issues related to herbal remedies
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There are thousands of herbs currently in use
Who’s prescribing?
There is a dearth of original research related to their safety
What information that exists is extremely contradictory
Unrecognised effects on pregnancy or labour
Have interactions with prescribed medications
Potentially serious complications to fetus
Issues related to herbal remedies
 The active ingredients of plant extracts are
chemicals that are similar to those in purified
medications, and they have the same potential to
cause serious adverse effects
 7% of herbal remedies sold in California retail
herbal stores contained undeclared
pharmaceuticals, with ephedrine being among
the most common undeclared ingredient
Issues related to herbal remedies
Herbal medicines are considered “dietary
supplements” by the Dietary Supplement Health
Education Act, and are neither governed by
federal regulations that establish criteria for purity,
identification and manufacturing, nor are they
subject to the same adverse reporting rules of the
food and drug administration
Best available evidence Clinical trials of safety
 There is a paucity of clinical trials of herbal
medicine products in pregnant women which
specifically report on adverse effects
 Where clinical data exists, for herbs commonly
used in the west
Best available evidence Clinical trials of safety
Exceptions:
Evening primrose oil on the length of pregnancy in low
risk nulliparous women (54/54). Oral admin. of EPO from
37 weeks onwards did not shorten gestation or decrease
duration of labour.
However, was associated with increased incidence of
prolonged rupture of membranes, oxytocin augmentation,
arrest of descent and increased frequency of vacuum
extraction
Best available evidence Clinical trials of safety
Raspberry leaf
 Retrosp. Study (n=51) suggested decreased likelihood of
premature or overdue labour and of medical intervention in
labour
 However, a CRT on 192 low risk nulliparous women
started from 32 weeks until labour.
 No adverse effects but did not shorten first stage of labour,
small shortening of second stage (10 mins) and less (19 vs
30%) forceps delivery in treatment group.
Best available evidence Clinical trials of safety
 Feverfew has been shown to inhibit platelet activity,
 garlic has been associated with decreased platelet
aggregation,
 ginger is a potent inhibitor of thromboxane synthetase,
gingko is a potent inhibitor of platelet-activating factor
 ginseng has an antiplatelet component
Therefore these substances may alter bleeding time, should
not be used concomitantly with certain other drugs
*Selected clinical considerations focusing on known or potential drug-herb interactions. Miller LG.
Arch Intern Med 1998;158:2200-11
Local data
Case controlled study showed that certain unidentified
‘orang asli’ herbs in the third trimester are protective
while the use of other unidentified herbs used in early
pregnancy associated with an increased risk perinatal
infant mortality
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The use of herbal medicines during pregnancy and perinatal mortality in
Tumpat district, Kelantan Malaysia. Ab Rahman et al. Southeast Asian J
Tropical Med Public Health. 2007 Nov;38(6):1150-7
Why is evidence difficult?
 Not looking for overt effects
 Example: herb that increases risk of
spontaneous miscarriage from 6 to 7%, a
sample size of > 19000 women required!
 Furthermore, particular herbs may have
many active constituents
 Requires expertise and funding
Herb and drug safety chart
1.
Herbs to be completely avoided during pregnancy
(can be bad)
eg: black Cohosh, blue Cohosh, Dong Quai
2.
Best avoided (safety has not yet been established)
eg: evening primrose oil, Gingko
3.
Herbs to use only in moderation in pregnancy
(may be used in limited amounts – as herbs, not products)
eg: ginger
4.
Safe – Raspberry leaf tea
However, the information made available is rarely evidence based and often
contradictory
So doctor, what do you think ? Should I
take these herbs?
Conclusion
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Little overall evidence to guide
Very few suggested to be safe, most unknown
Future research essential but difficult
Common herbs (garlic, ginger etc) may be safe
as herbs, but not as supplements
5. Seek advice from the right source
6. Generally, until evidence emerges, best to
avoid, especially in pregnancy and when breastfeeding
Thank you