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 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? 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, 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. 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 Radix Astragali Zhong Zhai Pai Wen Dang Shen South Dates Heart shaped Dates Zhong Ning Gou Li Many others Post-partum 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 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 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 - 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 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 Seek advice from the right source Generally, until evidence emerges, best to avoid, especially in pregnancy and when breast-feeding

Thank you