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| Natural Medicines Used During Pregnancy and Lactation |
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Natural Medicines Used for Pregnancy-related Conditions |
Natural Medicines Used for Lactation-related Conditions |
Caffeine Use During Pregnancy and Lactation
The Bottom Line |
References
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As many as 60% of pregnant and breast-feeding women use alternative therapies, including natural medicines such as herbals, vitamins and minerals, and other supplements.16017
These women use natural medicines for a variety of reasons. In many cases, the natural medicines are used for everyday non-pregnancy or non-lactation related conditions such as insomnia, depression, diabetes, and general health. But natural medicines are also often used specifically for pregnancy- and lactation-related conditions such as morning sickness or stimulating breast milk production.
Pregnant and lactating women often use these products on the advice of friends or family, rather than health professionals such as obstetricians or gynecologists. In fact, OB/GYN practitioners rarely recommend natural medicines (other than prenatal vitamins, of course) for their patients. Only about 8% of pregnant women who use natural medicines are doing so based on the advice of a physician or pharmacist.16017
However, other practitioners often recommend natural medicines for pregnant and lactating women. More than 90% of nurse midwives report recommending alternative therapies for their patients, often including natural medicines.16016
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Question #1 | | Which of the following natural medicines is correctly matched with its Pregnancy Safety Rating? | | | | | | | | |
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| | Natural Medicines Used for Pregnancy-related Conditions |  | |
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Natural medicines are commonly used by patients specifically for pregnancy-related conditions. Morning sickness is one of the most common reasons pregnant women turn to natural medicines, but these products are used for a variety of other conditions as well.
Morning Sickness
Ginger is the best known natural medicine used for pregnancy-related nausea and vomiting..."morning sickness." It's also one of the best studied. Several small clinical trials show that taking a supplement of ginger 250 mg four times daily reduces pregnancy-related nausea and vomiting better than placebo.721,1922,5343,11346,13071
Although ginger appears to be helpful for morning sickness, the safety of its use during pregnancy is not entirely clear. Some research suggests that ginger could potentially affect fetal sex hormones.7083 There is also a case report of spontaneous abortion during week 12 of pregnancy in a patient who used ginger for morning sickness.721
However, clinical research in pregnant women suggest that ginger can be used safely for morning sickness without harm to the fetus. The risk for major malformations in infants of women taking ginger does not appear to be higher than the baseline rate of 1% to 3%.721,1922,5343,11346,13071,13080 As with any medication given during pregnancy, the potential benefit to risk must be weighed.
Pyridoxine (vitamin B6) is also commonly used for morning sickness. In fact, the American College of Obstetrics and Gynecology (ACOG) considers pyridoxine a first line treatment.14446 Taking 25 mg every 8 hours significantly reduces pregnancy-related nausea and vomiting compared to placebo.6168 Lower doses also help for nausea, but might not work as well for preventing vomiting.6167 Doxylamine is often added when patients don't respond to pyridoxine alone.
German chamomile and raspberry leaf are also tried for morning sickness, but there is no reliable evidence that they are effective for this use. Additionally, the safety of German chamomile during pregnancy is not known. Raspberry leaf has been safely used around the time of delivery;6481,9796 however, the safety of raspberry leaf in the first trimester when morning sickness typically occurs, is not known.
Peppermint oil or tea is also commonly tried for morning sickness. There is evidence that it can help for "soothing" the digestive tract and for upset stomach. But there is no reliable evidence that it works for pregnancy-related nausea and vomiting. There is also no reliable information about the safety of peppermint during pregnancy.
Leg Cramps
Leg cramps can be a troubling problem for many pregnant women. The most common approach to treating them is taking magnesium. Taking 240 mg in the morning and 440 mg in the evening seems to significantly reduce cramping.1194,14331
Calcium is also tried for leg cramps. Preliminary clinical research shows that taking elemental calcium 1 gram twice daily can reduce the occurrence of leg cramps in the second and third trimester.2567
Some people also try vitamin E. There is contradictory evidence about whether it works for nocturnal leg cramps; however, there is no reliable research that it is effective for pregnancy-related leg cramps.
Edema
Swelling in the hands, feet, and ankles is a common complaint of pregnant women; however, there are few treatment options.
| Alternative System of Medicine: Reflexology is an alternative treatment modality that some women are trying for edema. Reflexology involves applying pressure to specific points on the feet, hands, and ears. It's believed that applying pressure at these points will stimulate specific areas, tissues, or organs of the body resulting in improved outcomes. Preliminary research suggests that reflexology can improve feelings of well-being and reduce stress, tension, discomfort, and pain. However, it does not seem to reduce edema.15839 |
Pre-eclampsia
It is theorized that oxidative stress might play a role in the development of pre-eclampsia. As a result there has been a lot of interest in using antioxidant supplements to prevent pre-eclampsia.
A combination of vitamin C and vitamin E has been used in several clinical trials. Some clinical research shows that the combination might help prevent pre-eclampsia in high-risk patients.3236 However, other research has not been positive. An analysis of these antioxidant studies shows that, overall, taking vitamin C and vitamin E does NOT significantly reduce the risk of developing pre-eclampsia.16018
Calcium also seems to play a role in the development of pre-eclampsia. Clinical research shows that taking an elemental calcium 1-2 grams daily decreases the risk of pregnancy-related hypertension and pre-eclampsia by about 50% compared to placebo. The effect seems to be greatest in high-risk women and women with low calcium levels.971,973,1833,1834,8828,15029
Advise pregnant women to ensure that they are taking the recommended amount of calcium, which is 1000 mg/day. Explain that not all prenatal vitamins contain this amount. Some do, but others contain much less.
Labor Facilitation and Induction
Nurse midwives commonly use a variety of natural medicines to help facilitate or induce labor.
Raspberry leaf is one of the most common natural medicines used for this purpose. Raspberry leaf might have some effects on uterine smooth muscle. Low doses are thought to stimulate contractions, whereas higher doses are thought to have spasmolytic effects.1096,1122 Very little clinical research has evaluated the use of raspberry leaf for facilitating or inducing labor. One clinical trial shows that raspberry leaf does not reduce time in labor or decrease the need for analgesics in the perinatal time.9796
Black cohosh is used by as many as 45% of nurse midwives to induce labor.1122 However, there is no reliable evidence that it is safe or effective for this use.
Blue cohosh is also often used to induce labor. Although the name sounds similar, it is not related to black cohosh. Blue cohosh does have uterine stimulate activity and might stimulate labor;12047 however, the effectiveness of blue cohosh for this use has not been evaluated in clinical research.
Blue cohosh is considered UNSAFE to use during pregnancy. Several blue cohosh constituents are potentially teratogenic. Use of blue cohosh near term can cause life-threatening toxicity in the newborn infant.1207,9492,9493,12047 Blue cohosh should be avoided at all stages of pregnancy.
Castor oil is routinely used by midwives for stimulating labor. Castor oil is thought to cause hyperemia in the gastrointestinal tract, resulting in a reflex stimulation of the uterus. It might also increase prostaglandin production, resulting in uterine stimulation. Some clinical research shows that giving a dose of 60 mL of castor oil results in labor within 24 hours in about 50% or more women who are at term. Although there is not much data available regarding safety, there is no evidence suggesting harm to the fetus or mother.7191
Advise patients that, if they are not at term, they should not take castor oil or any other natural medicine that might have uterine-stimulating effects. Taking these products could potentially cause premature labor.
Labor Pain
Motherwort is sometimes used by midwives for labor pain. It's thought to have mild sedative and spasmolytic effects. It might also increase uterine tone. However, there is no reliable evidence that it is safe or effective for reducing labor pain.
Post-partum Hemorrhage
Shepherd's purse is thought to have antihemorrhagic properties. Therefore, some midwives recommend it for post-partum bleeding. However, there is no reliable information about the effectiveness of shepherd's purse for this use.
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*At term or immediately post-partum
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| | | | View brands containing: | | - | Ginger |
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Question #2 | | Which of the following has been show to reduce pregnancy-related nausea and vomiting more than placebo? | | | | | | | | |
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Question #3 | | Which of the following is considered a first line option for treating pregnancy-related nausea and vomiting? | | | | | | | | |
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Question #4 | | Which of the following has been shown to reduce pregnancy-related leg cramping? | | | | | | | | |
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Question #5 | | Which of the following has been shown to reduce the risk of pre-eclampsia? | | | | | | | | |
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Question #6 | | Which of the following has been shown in clinical research to be effective for inducing labor in pregnant women at term? | | | | | | | | |
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Question #7 | | Which of the following contains potential teratogens and has been associated with toxicity in newborn infants? | | | | | | | | |
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Question #8 | | Why shouldn't a pregnant woman take castor oil in her second trimester? | | | | | | | | |
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| | Natural Medicines Used for Lactation-related Conditions | | |
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Most natural medicines that women use related to lactation are those that are thought to stimulate or increase milk production. Agents that increase milk production are referred to as "galactagogues."
There are many purported natural galactagogues...alfalfa, blessed thistle, caraway, chasteberry, fennel, goat's rue, and others. But none of these have reliable clinical evidence that they work for this purpose.
Fenugreek is especially popular for this use. Although many swear by it for increasing milk production, there is no reliable research demonstrating this effect. Fenugreek should not be used during pregnancy because it can stimulate the uterus.12531 The safety of fenugreek after pregnancy and during breast-feeding is not known, however, there are no known reports of adverse events in the nursing baby. Fenugreek can cause body odor that smells like maple syrup. This can occur in the mother as well as the nursing infant.
Breast Engorgement
For breast engorgement, some women use cabbage leaves. Chilled cabbage leaves provide relief similar to applying chilled gel packs.6781,6784
A cream containing cabbage leaf extract has also been tried; however, it doesn't reduce symptoms better than placebo.6783
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Question #9 | | Which of the following has been shown to improve milk production in lactating women? | | | | | | | | |
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Question #10 | | Which of the following is TRUE about fenugreek? | | | | | | | | |
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| | Caffeine Use During Pregnancy and Lactation | | |
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The safety of using caffeinated products, and how much is acceptable, is a common question pregnant and breast-feeding women have. Many women drink coffee, tea, or caffeinated soda on a regular basis, and therefore experience some caffeine-related dependence. When they become pregnant, discontinuing or cutting back caffeine intake substantially can be a challenge.
Caffeine crosses the placenta, but it's not considered a teratogen. Fetal blood and tissue levels are similar to maternal concentrations.4260 The use of caffeine during pregnancy is controversial; however, moderate consumption of less than 200 mg/day has not been associated with clinically important adverse fetal effects.2708,2709,2710,2711,9606,11733,16014,16015 Consuming over 200 mg/day is associated with a significant increased risk of miscarriage.16014 High maternal doses of caffeine throughout pregnancy have also resulted in symptoms of caffeine withdrawal in newborn infants.9891 Advise mothers to keep caffeine consumption below 200 mg/day. This is similar to the amount of caffeine in about 2 cups of coffee or tea.
There is less concern about the mother consuming caffeine during breast-feeding, but caution is still warranted. Drinking 1-2 caffeine-containing beverages per day during lactation is not associated with unacceptable levels of caffeine in human milk.11734 Consuming large amounts of caffeine can cause wakefulness or irritability in breast-fed infants. It can also cause feeding intolerance and gastrointestinal irritation in infants.6026
Remind pregnant women that caffeine can show up in many unexpected places. Supplements containing green tea extracts, guarana, cola nut, and mate can contain significant amounts of caffeine.
| Caffeine Content of Various Caffeinated Beverages |
| Beverage or Food |
Caffeine Content |
| Espresso, 1 oz. |
64 mg |
| Instant coffee, 8 oz. |
27-173 mg |
| Brewed coffee, 8 oz. |
95-300 mg |
| Brewed black tea, 8 oz. |
40-120 mg |
| Brewed green tea, 8 oz. |
15-60 mg |
| Hot cocoa, 12 oz. |
8-12 mg |
| Chocolate milk, 8 oz. |
5-14 mg |
| Soft drinks, 12 oz. |
Approx 20-80 mg |
| Sports/Energy drinks, 8 oz. |
48-300 mg |
| Starbucks café latte, 16 oz. |
150 mg |
| Hershey's Special Dark chocolate bar, 1.45 oz. |
18 mg |
| Hershey's chocolate bar, 1.55 oz. |
9 mg |
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*Note: Caffeine content can vary considerably depending on how coffee, tea, or other beverages are prepared.
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| | | | The Bottom Line | | |
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Our understanding of the safety of conventional drugs during pregnancy and lactation is very limited due to a lack of research done in this area. For natural medicines, the amount of research is even less. As a result, there is a major shortage of reliable information about the effects of these products in pregnant or lactating women.
Despite the general lack of information in this area, there are a few natural medicines that are worth considering. For morning sickness, pyridoxine and possibly ginger are worth a try. For leg cramps, magnesium can be effective for many women.
Antioxidants should not be recommended for preventing pre-eclampsia, but women should be advised to ensure adequate intake of calcium, at least 1000 mg/day.
For facilitating or inducing labor, castor oil seems to work for many women without evidence of adverse events.
Although many natural medicines are used for stimulating milk production, evidence supporting these uses is lacking. However, chilled cabbage leaves seem to be beneficial for relieving breast engorgement.
As with conventional drugs, careful consideration of the risk vs. benefit should be done before recommending natural medicines for pregnant or lactating women. Products without clear benefit and safety should be avoided.
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| References
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Neonatal effects of maternal consumption of blue cohosh. J Pediatr 1999;134:384-5. | | 1833 | Crowther CA, Hiller JE, Pridmore B, et al. Calcium supplementation in nulliparous women for the prevention of pregnancy-induced hypertension, preeclampsia and preterm birth: an Australian randomized trial. FRACOG and the ACT Study Group. Aust N Z J Obstet Gynaecol 1999;39:12-8. | | 1834 | Power ML, Heaney RP, Kalkwarf HJ, et al. The role of calcium in health and disease. Am J Obstet Gynecol 1999;181:1560-9. | | 1922 | Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2000;(2):CD000145. | | 2567 | Hammar M, Larsson L, Tegler L. Calcium treatment of leg cramps in pregnancy. Effect on clinical symptoms and total serum and ionized serum calcium concentrations. Acta Obstet Gynecol Scand 1981;60:345-7. | | 2708 | The National Toxicology Program (NTP). Caffeine. Center for the Evaluation of Risks to Human Reproduction (CERHR). Available at: http://cerhr.niehs.nih.gov/common/caffeine.html. | | 2709 | Klebanoff MA, Levine RJ, DerSimonian R, et al. Maternal serum paraxanthine, a caffeine metabolite, and the risk of spontaneous abortion. N Engl J Med 1999;341:1639-44. | | 2710 | Eskenazi B. Caffeine—filtering the facts. N Engl J Med 1999;341:1688-9. | | 2711 | Fernandes O, Sabharwal M, Smiley T, et al. Moderate to heavy caffeine consumption during pregnancy and relationship to spontaneous abortion and abnormal fetal growth: a meta-analysis. Reprod Toxicol 1998;12:435-44. | | 3236 | Chappell LC, Seed PT, Briley AL, et al. Effect of antioxidants on the occurrence of pre-eclampsia in women at increased risk: a randomized trial. Lancet 1999;354:810-6. | | 4260 | Briggs GB, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1998. | | 5343 | Vutyavanich T, Kraisarin T, Ruangsri R. 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BMC Comp Altern Med 2002;2:5. | | 16018 | Rumbold A, Duley L, Crowther C, Haslam R. Antioxidants for preventing pre-eclampsia. Cochrane Database Syst Rev 2008;(1):CD004227. |
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