2 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 ………….”
3 IntroductionAlternative medicine use has increased dramatically over the past decadeMany health care providers are recommending its useMay have potentially more complex untoward side effects for the parturient as well as the fetus
4 Parameters Definition Popularity and recent trends Current cultural practices and variationsIssues related to herbal remediesBest available evidenceRecommendations
5 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 ailmentMay suggest the addition of certain edible plants to the diet, or may prescribe a medicinal preparationMay also recommend an essential oil, distilled from the plant.
6 History of herbal remedies Ayurverdic medicine practiced for > 5000 years, with > 1250 plants usedChinese medicine equally ancient1 AD, ‘Shen Nong’ recorded > 250 herbs of medicinal value and temp. + tasteCurrently up to 8000 plants being investigated
7 Why is complementary and alternative medicine on the rise? Desire for personal control over healthDissatisfaction with conventional treatment and it’s disregard for a holistic approachConcerns about side effects of western medicationsPerceived safetyEasy access to remediesAccess to information –free & easySafety profile grossly downplayed
9 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
10 Popularity and recent trends % reported use of herbal remedies in pregnancy85.4% of them did not consider them as medications46% did so on the recommendation of their health care provider
11 Popularity and recent trends 73.2% of certified nurse midwives recommended herbal remediesA 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 labourProducts commonly used blue cohosh, black cohosh, red raspberry leaf, castor oil and evening primrose oil.
12 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 vomitingIn later pregnancy and post delivery – for “general well-being”
13 New herbal trends Of recent concern : the creation of extracts with higher concentrations of certain active constituents
14 Current cultural practice and variations Literature review: the most commonly used herbal medicine products were garlic, aloe, chamomile, peppermint, ginseng, echinacea, and pumpkin seedsHowever, in the asian population, there is poor documentation
15 Herbs often used by Malaysians of Malay origin Kacip fatimahCekur (Kaempferia Galanga Linn)Senduduk (Melastoma malabathricum)Ikan haruanAnthemis vulgarisRhizoma leonticaEtc, etc
16 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 foundIn-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 cellsRecent studies (IMR) also show similarities to other estrogens such as estrone and estriol
17 Kacip fatimahpreliminary 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!!
18 Kacip fatimahStudy 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 RATSW. M. EFFENDY, J. SITI-NURTAHIRAH, Z. M. HUSSIN (KUSTEM.) ZAMRI-SAAD (UPM)Journal of Sustain. Sci & Mngt., 2006 Vol. 1(1): 40-46
19 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.
20 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 causesAntinociceptive activity of the methanolic extract of Kaempferia galanga Linn. in experimental animals. J Ridtitid et al. Ethnopharmacol Jul 23;118(2): Epub 2008 Apr 11.
21 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.
22 At all concentrations tested, the extract was found to exhibit significant (P < 0.05) antinociceptive, anti-inflammatory, 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 Dec;84(12):Senduduk
23 Ikan haruan Channa striatus Ophiocephalus wrahl; Ophiocephalus chena; Ophicephalus planiceps; Ophicephalus sowarah Common name: Chevron Snakehead Sang YeeTraditional valueScientific evidence
24 Herbs often used by Malaysians of Chinese origin PregnancyRadix AstragaliZhong Zhai Pai Wen Dang ShenSouth DatesHeart shaped DatesZhong Ning Gou LiMany othersPost-partumGinsengDong quai
28 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 effectAlso contains ferulic acid, a pain reliever and muscle relaxer, but strangely, before it relaxes the uterus, it stimulates the uterus brieflyAn in vitro investigation of herbs traditionally used for kidney and urinary system disorders: Potential therapeutic and toxic effects. Woicikowski K et al. Nephrology (Carlton) Sep 22.
29 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
30 Ginseng American ginseng (Panax quinquefolium) More sedative yin Korean ginseng (Panax ginseng)More stimulating yangSiberian ginsengMain active ingredients are the > 20 saponin triterpenoid glycosides called ginsenosides
31 GinsengA 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 consumptionSafety an efficacy of panax ginseng during pregnancy and lactation. Seely D et al. Can J Clin Pharmacol Winter;15(1):e Epub 2008 Jan 18.
32 GinsengIn 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.
33 Radix Astragali Dried root of Astragalus membranaceus Adjunctive therapy in treatment of colds and influenza. Enhances immune system, increases stamina and enduranceAlso in treatment of chronic diarrhoea, abnormal uterine bleeding, DM and as a cardiotonic agentUse supported by clinical data : NONENon-teratogenic effects – no data available, to be avoided in pregnancyEffects on the newborn- unknown to be avoided during lactationWHO monographs on selected medicinal plants 1999
34 Herbs often used by Malaysians of Indian origin CuminFennelCorianderGingerGarlicMargosa oil
35 GingerHas 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
36 GarlicCase report spontaneous epidural haematoma due to excessive garlic intakeSpontaneous spinal epidural haematoma with associated platelet dysfunction from excessive garlic ingestion: a case report. Neurosurgery 1990;26:880-2
37 CuminKnown medicinal properties and mentioned in the works of HippocratesStimulant, antispasmodic, carminativeNo clinical data availableAdverse effects ?
38 Coriander Mentioned in Sanskrit texts, 7000 years ago Also mentioned in the bibleReduces flatulence and good for increasing appetiteEvidence ?
39 Western herbsCommonly used herbal preparations for labor stimulation include blue cohosh, black cohosh, red raspberry leaf, castor oil and evening primrose oil
40 Issues related to herbal remedies There are thousands of herbs currently in useWho’s prescribing?There is a dearth of original research related to their safetyWhat information that exists is extremely contradictoryUnrecognised effects on pregnancy or labourHave interactions with prescribed medicationsPotentially serious complications to fetus
41 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 effects7% of herbal remedies sold in California retail herbal stores contained undeclared pharmaceuticals, with ephedrine being among the most common undeclared ingredient
42 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
44 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 effectsWhere clinical data exists, for herbs commonly used in the west
45 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
46 Best available evidence - Clinical trials of safety Raspberry leafRetrosp. Study (n=51) suggested decreased likelihood of premature or overdue labour and of medical intervention in labourHowever, 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.
47 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 factorginseng has an antiplatelet componentTherefore 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:
48 Local dataCase 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- 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 Nov;38(6):1150-7
51 Why is evidence difficult? Not looking for overt effectsExample: herb that increases risk of spontaneous miscarriage from 6 to 7%, a sample size of > women required!Furthermore, particular herbs may have many active constituentsRequires expertise and funding
52 Herb and drug safety chart 1. Herbs to be completely avoided during pregnancy(can be bad)eg: black Cohosh, blue Cohosh, Dong QuaiBest avoided (safety has not yet been established)eg: evening primrose oil, GingkoHerbs to use only in moderation in pregnancy(may be used in limited amounts – as herbs, not products)eg: gingerSafe – Raspberry leaf teaHowever, the information made available is rarely evidence based and oftencontradictory
53 So doctor, what do you think ? Should I take these herbs?
55 Conclusion Little overall evidence to guide Very few suggested to be safe, most unknownFuture research essential but difficultCommon herbs (garlic, ginger etc) may be safe as herbs, but not as supplementsSeek advice from the right sourceGenerally, until evidence emerges, best to avoid, especially in pregnancy and when breast-feeding
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