Anaesthesia

Review and Intensive Care

Anaesthesia and Intensive Care
2019, Vol. 47(3) 226–234
Herbal medicines and pregnancy: ! The Author(s) 2019
Article reuse guidelines:
A narrative review and anaesthetic sagepub.com/journals-permissions
DOI: 10.1177/0310057X19845786
considerations journals.sagepub.com/home/aic

Peter CA Kam1,2, Denise WY Barnett2 and Ian D Douglas2

Abstract
The use of herbal medicines by pregnant women varies among different countries, ranging from 4.3% in Sweden to 69%
in Russia. The aim of this narrative review is to evaluate the benefits and safety of common herbal medicines used during
pregnancy. A systematic literature search (from 1995 to February 2018) was performed using a variety of electronic
databases. The levels of evidence of the clinical studies were graded using the Oxford Centre for Evidence-Based
Medicine levels of evidence guidelines. From the 736 articles retrieved, 69 articles were used for this review. Ginger
has been investigated extensively and has been consistently found to decrease nausea and vomiting associated with
pregnancy (Level 2). There is insufficient evidence concerning the efficacy of other herbal medicines such as garlic,
cranberry and raspberry in pregnancy (Level 3–4). Much of the literature is based on case reports with limited phar-
macodynamic/kinetic studies. There are no clear data on the adverse herb–drug interactions during anaesthesia. As the
risks of these interactions are unknown, it would be prudent for anaesthetists to explicitly ask their patients about their
use of herbal medicines before surgery and prior to labour and birth. The European Society of Anaesthesiology and
American Society of Anesthesiologists recommend that patients cease taking herbal medicines two weeks
before surgery.

Keywords
Herbs, parturient, anaesthesia, herbal medicine

There is much diversity in the use and roles of tradi-
tional, complementary and alternative medicine as a
result of cultural practices and beliefs. The consump-
tion of herbal medicines has increased worldwide.1–3
Many consumers believe herbal medicines are of
“natural” origin and therefore are safer alternatives
to conventional medicines.1,2
Herbal medications have been associated with harm-
ful effects as a result of direct toxicity, herb–drug inter-
actions, toxic constituents, contamination or
adulteration with toxic metals or even undisclosed con-
ventional drugs (e.g. steroids, non-steroidal anti-
inflammatory drugs (NSAIDs)).4 In a cross-sectional
study of 947 patients in Israel, Levy et al. reported
that an adverse event occurred in 3.7% of patients
who consumed dietary and herbal supplements.5 In a
cohort study of 601 general surgical patients consum-
ing traditional Chinese herbal medicines (TCHM), Lee
et al. reported that patients who had been prescribed
TCHM were twice as likely to experience
hypokalaemia and impaired haemostasis (as measured
by prolonged International Normalized Ratio (INR) or
activated partial thromboplastin time (aPTT))
preoperatively.6
Parturients are apprehensive about the potential
adverse effects of conventional medicines consumed
during pregnancy, and so they take herbal products
instead because they are believed to be harmless.7
However, the belief of their efficacy and safety in preg-
nancy is not evidence-based.
1
Discipline of Anaesthetics, Faculty of Medicine and Health, University of
Sydney, Sydney, Australia
2
Department of Anaesthetics, Royal Prince Alfred Hospital,
Camperdown, Australia
Corresponding author:
Peter CA Kam, Department of Anaesthetics, Royal Prince Alfred
Hospital, Camperdown, New South Wales 2050, Australia.
Email: pkam@usyd.edu.au
Kam et al. 227

The aim of this narrative review is to evaluate the
evidence on the efficacy and adverse effects of the
common herbs used in the peripartum period and
perioperative anaesthetic considerations.
Search strategy
A systematic literature search was performed on
MEDLINE, PubMed, CINAHL and AMED (Allied
and Complementary Medicine Database) databases
from 1995 to February 2018 using the following key
words: herbs, herbal medicine and supplements, com-
plementary medicine, alternative medicine, Chinese
herbal medicine, Ayurvedic medicine, pregnancy,
labour, obstetrics, and midwifery. The search was lim-
ited to articles published in the English language and
human studies. Data from studies involving acupunc-
ture, transcutaneous electrical nerve stimulation, mas-
sage therapy, reflexology, aromatherapy, hypnosis,
vitamin supplements or animal and in vitro studies
were excluded. The search results were imported into
“Endnote”, a bibliographic management program, and
duplicate items were removed. The bibliographies of
the retrieved articles were examined for additional rel-
evant articles. From a total of 736 articles retrieved, 69
articles were included in this review. The levels of evi-
dence of the clinical studies were graded using the
Oxford Centre for Evidence-Based Medicine levels of
evidence guidelines8 (Table 1).
Prevalence
The prevalence of the consumption of herbal medicines
by pregnant women ranged from 4.3% in Sweden up to
69% in Russia.9 The prevalence was 52%–58% in
Australia,10 40%–48% in Norway and Italy,11–13
6%–9% in Canada and USA,14,15 58% in Malaysia16
and 43%–45% in China.17 Several surveys in Western
countries have reported that consumption of herbal
products was most frequent in parturients in the 41-
to 50-year age group, and with higher education and
income levels.18,19 In contrast, there is an inverse asso-
ciation between income and herbal consumption in
China and Hong Kong.17 This is attributed to the
lower cost of herbal medicines in these countries
making them more affordable to mothers with low
family income. Other factors associated with consump-
tion of herbal products include habitual or previous use
of complementary medicine, primiparity, non-smoking
and the desire for a natural birth.20
In a survey in the United Kingdom, almost half of
pregnant women were prescribed conventional medi-
cines and almost half of these patients used herbal med-
icines. This raises concerns of potential drug–herb
interactions. In early pregnancy, the herbal medicines
most commonly used were ginger (35.6%), chamomile
(23.2%) and raspberry (20.5%), whereas in late preg-
nancy the herbal medicines used were raspberry
(42.5%), cranberry (26.7%), ginger (23.7%) and cham-
omile (11.8%). More than half of the parturients used
more than one herbal product.21 In Eastern countries,
the types of herbs are more varied; Angelica sinensis
(dong quai) is most popular among Chinese mothers
as it ‘enriches’ the blood and circulation; and white
atractylodes rhizome, Glycyrrhizae radix (liquorice
root) and Ginseng radix are popular with
Korean mothers.22
Indications
Several complementary and alternative medicine
approaches for nausea/vomiting, pain management,
preconception, pregnancy or induction of labour have
been used.23 Several studies have described the use of
herbal medicines for relief of stress and pregnancy-
related symptoms, postpartum care, preparation for
labour and for general health.20 Other studies exam-
ined the efficacy of herbal medicines for nausea24 and
low back pain during pregnancy.25

Table 1. Levels of evidence and grades of recommendation according to Oxford Centre for Evidence-Based Medicine 2011.

Level of evidence

1 Systematic review of all RCTs or n ¼ 1 RCT

2 At least one randomized trial or observational study with dramatic effect
3 Non-randomized controlled cohort/follow-up study (observational)
4 Case-series, case-control studies or historically controlled studies
5 Mechanism-based reasoning (expert opinion, physiology, animal or laboratory-based studies)
Grades of recommendation
A Consistent with level 1 studies
B Consistent with level 2 or 3 studies or extrapolation from level 1 studies
C Level 4 studies or extrapolation from level 2 to 3 studies
D Level 5 evidence or inconsistent/nonconclusive studies of any level
RCT: randomized controlled trials.
228
Preconception
The prevalence of the consumption of herbal drugs to
enhance fertility is reported to be 8.3%–29% of
patients attending infertility clinics in Australia.26
Stankiewicz et al. found that green tea (27%, as an
antioxidant), chamomile (13%), echinacea (8%), pep-
permint (7%), chaste tree berry, astragalus (5%), gin-
seng (4.2%) and horseradish (4%) were the herbal
remedies used because it was believed that they
enhanced fertility.27
Herbal drugs used during pregnancy
Herbal supplements are taken to reduce or treat minor
symptoms such as nausea and vomiting, indigestion/
dyspepsia, backache, bladder/urinary symptoms, anxi-
ety and to ‘boost’ the immune system.7 The choice and
incidence of herbal medicine use varies during the dif-
ferent phases of pregnancy. Maats and Crowther28
found that commonly used herbal medicines were
ginger (42%) and chamomile (9%) in the first trimester,
chamomile (13.6%) and ginger (9%) in the second tri-
mester, and raspberry leaf tea (8%) and chamomile
(6%) in the third trimester. Ginger is the most popular
herb used to reduce or treat nausea and/or vomiting.
Other antiemetics included wild yam (Dioscorea villosa)
and red raspberry (Rubus idaeus) (Table 2).
Cervical ripening
Evening primrose oil is used by some midwives to trig-
ger cervical ripening and therefore help initiate labour.
In a retrospective study, evening primrose oil increased
the incidence of prolonged rupture of membranes,
Table 2. Common herbs used during pregnancy.
Herb Indication
Ginger (Zingiber spp.) Prevents nausea
Treatment of ‘morning sickness’
Indigestion
Peppermint Nausea
Morning sickness
Indigestion
Cranberry Prevention of urinary tract infections
Treatment of urinary tract and vaginal infections
Chamomile Anxiolytic
Mild hypnotic
Valerian (Valeriana officinalis) Anxiolytic
Mild hypnotic
Raspberry ‘Strengthens’ uterus
Prepares uterus for labour
Echinacea Enhances immunity
Prevents upper respiratory tract infections
Motherwort Analgesia
Anaesthesia and Intensive Care 47(3)
oxytocin augmentation and vacuum extraction of the
infant, shortening neither gestation nor duration of
labour.29 Other herbs used for cervical ripening include
Lobelia inflata and Gossypium herbaceum (cotton root)
(Table 3).
Herbs used for induction of labour
Raspberry (usually taken as a tea), blue cohosh and
castor oil are used in traditional midwifery either to
‘prepare’ the uterus for labour or stimulate the
uterus. The mechanism of action of these herbal med-
icines in uterine stimulation is uncertain, although it
has been proposed that they may have either a spas-
molytic or stimulatory effect on the uterus. Although
castor oil is commonly used as a laxative, midwives and
parturients use it to initiate labour. Castor oil stimu-
lates uterine contraction by increasing the production
of prostaglandin F2 alpha in the uterus.30 The mecha-
nism of action of blue cohosh is mediated by glycosides
(caulosaponin, caulophyllosaponin) and sparteine,
which induce uterine contraction. However, they are
not recommended as they have been associated with
coronary vasospasm resulting in myocardial ischaemia
in the fetus.31
Herbs used to relieve anxiety and pain during labour
A combination of herbs that have anxiolytic properties
is commonly recommended (Table 2). A variety of
herbs are used as anxiolytics to facilitate a pleasant
experience in labour.32 Valerian, passionflower and
chamomile are used for their calming and relaxation
properties.33
Level of evidence
1
3
3
3
3
3
3
4
Kam et al. 229

Table 3. Herbs used prior to labour.

Level of
Herb Actions and uses Adverse events and contraindications evidence

Black cohosh Oestrogen effect Headache, gastric discomfort 4

(Cimicifuga racemosa)
Blue cohosh
(Caulophyllum thalictroides)
Black haw
(Viburnum prunifolium),
cramp bark (Viburnum opulus)
Cotton root
(Gossypium herbaceum)
Lobelia (Lobelia inflata)
*observational event – low quality evidence.
*Decreases labour duration, promotes if large doses used
uterine contractions
Maintains uterine contraction
after delivery
Antispasmodic and uterine stimulant *Coronary vasoconstriction and 4
Induction of labour and cardiac ischaemia
augmentation of labour Case report of myocardial infarction
*Prevent miscarriages in infant born to a woman
taking blue cohosh
Relieve false labour pains and afterpains Postural hypotension 4
by antispasmodic effects
*Antispasmodic properties
Enhances endogenous oxytocin Side-effects are those of oxytocin 4
Aids cervical ripening
Initiates or augments labour
Facilitates cervical dilation Contraindicated in presence 4
of hypertension

In the USA, independent midwives promoted the
use of herbal remedies for the relief of labour pain
and discomfort. In addition to massage therapy, hydro-
therapy, breathing and relaxation techniques, they pro-
moted herbal mixtures consisting of motherwort, wild
ginger, lobelia, wild yam, blessed thistle, blue cohosh,
squawvine, false unicorn and bayberry root to provide
analgesia and relaxation. Most of the herbs either had
anxiolytic effects or reduced dysfunctional labour by
mild uterine stimulating effects. Labour pain was fre-
quently treated with motherwort.1
Herbs used in the postpartum period
Herbal medicines used to treat some of the symptoms
during pregnancy may be continued into the postpar-
tum period. Lavender oil is used to relieve perineal
discomfort after vaginal delivery. A double-blind ran-
domized clinical study failed to show any reduction in
postnatal perineal discomfort.34
There are different dietary practices in the postpar-
tum period among different cultures. In Chinese cul-
ture, ‘ginger–vinegar soup’ is ingested to “enrich blood
and strengthen internal organs”. The soup contains
ginger, sweet vinegar, dates, chicken and pig trotters.35
Large quantities of ginger may be consumed in the first
month after delivery if this soup is consumed, which
predisposes to the potential adverse effects of ginger.
St John’s wort is advocated for postnatal depres-
sion.36,37 In a prospective, observational cohort study
in 33 breastfeeding women receiving St John’s wort for
postnatal depression no significant adverse effects asso-
ciated with lactation or breastfeeding were found.38
Most studied herbal medicines
Ginger
Ginger is a popular herbal drug in many Asian coun-
tries. It has been used in Chinese and Ayurvedic (Indian)
traditional medicine for thousands of years to stimulate
digestion and for its antiemetic, antitussive and anti-
inflammatory properties. During pregnancy it is
mainly used as an antiemetic in the first trimester. The
use of ginger during pregnancy has been extensively
studied in 10 randomized controlled trials (RCTs)
(Level 1; grade B recommendation) (Table 4).
Out of the 10 RCTs that evaluated the antiemetic
effects of ginger, five RCTs39–43 reported that ginger was
superior in reducing nausea and vomiting compared with
a placebo, whereas five44-48 found ginger equally effective
when compared with dimenhydrinate or vitamin B6.
There were no increased adverse events or risks to the
fetus.49,50 The recommended daily dose of ginger for the
treatment of nausea and vomiting is 1000 mg. It is pro-
posed that the antiemetic properties of ginger are mediat-
ed by serotonin antagonism in the gut and the central
nervous system (CNS). When the maximum daily dose
of 4 g is exceeded, several adverse effects such as cardiac
arrhythmias, CNS depression and coagulopathy may
occur.51 Coagulopathy is caused by antiplatelet effects
due to inhibition of thromboxane synthetase.52
230 Anaesthesia and Intensive Care 47(3)

Table 4. Randomized controlled trials using ginger for nausea and vomiting.

Study design n Ginger dose Outcome Reference

39
Double-blind RCT 120 5 g/day Nausea & retching: better than placebo
Ginger vs placebo T ¼ 60 Vomiting: equal to placebo
P ¼ 60
40
Double-blind RCT 70 1 g/day Nausea & vomiting: better than placebo
Ginger vs placebo T ¼ 32
P ¼ 38
41
Single-blind RCT 67 1 g/day Nausea & vomiting: better than placebo
Ginger vs placebo T ¼ 32
P ¼ 35
42
Double-blind RCT 26 1 g/day Nausea & vomiting better than placebo
Ginger vs placebo T ¼ 14
P ¼ 12
43
Double-blind cross over RCT 30 250 mg/day Nausea & vomiting better than placebo
T ¼ 15
Lactose ¼ 15
44
Double-blind RCT 70 1g/day or vit B6 Equal to vit B6
Ginger vs vit B6 Ginger ¼ 36 40 mg/day
B6 ¼ 34
45
Double-blind RCT 291 1.05 g/day Equal to vit B6
Ginger vs vit B6 Vit B6 75 mg/day
46
Double-blind RCT 170 1 g/day or Equal to dimenhydrinate
Ginger vs dimenhydrinate T ¼ 85 dimenhydrinate
D ¼ 85 100 mg/day
47
Double-blind RCT 128 1.5 g/day or vit Equal to vit B6
Ginger vs vit B6 T ¼ 64 B6 30 mg/day
B6 ¼ 54
48
Double-blind RCT 126 650 mg/day or vit Equal to vit B6
Ginger vs vit B6 T ¼ 63 B6 25 mg/day
B6 ¼ 63
RCT: randomized controlled trial; T: trial drug; P: placebo; D: dimenhydrinate.

Consequently, large doses of ginger should not be admin-
istered with antiplatelet drugs or warfarin.53 Ginger
should be used with caution in gestational diabetes
because it has been reported to potentiate hypoglycaemia
with insulin and the oral hypoglycaemic drugs.51
Cranberry
The main indication for taking cranberry during
pregnancy is to prevent or treat urinary tract infec-
tion. The mechanism by which cranberry prevents
urinary tract infection is mediated by two compounds
in the fruit, fructose and proanthocyanidin, that pre-
vent Escherichia coli from adhering to the urethral
epithelial lining. In an RCT, Wing et al. investigated
the efficacy of cranberry extract with placebo in pre-
vention of urinary tract infection in pregnant women
and reported multiple daily dosing reduced frequency
of asymptomatic bacteriuria (57%) and urinary tract
infection (41%).54 However, the study was underpow-
ered because 38.8% of subjects withdrew, most for
gastrointestinal symptoms. The authors concluded
that cranberry may have a protective effect against
urinary tract infection during pregnancy but further
larger studies are required (Level 3; grade C
recommendation).
Raspberry
Since the 6th century, raspberry has been taken during
pregnancy to shorten labour by augmenting uterine
contractions and to reduce uterine bleeding. In an
RCT, Simpson et al. reported that raspberry ingestion
did not shorten the first stage of labour but reduced
the rate of forceps delivery (19.3% versus 30.4%)
and the duration of the second stage of labour (mean
difference 9.5 min) (Level 3; grade C recommenda-
tion).55 It is not associated with any maternal or fetal
adverse effects.
Garlic
The traditional indication for garlic is to prevent colds,
influenza and gastroenteritis56 (Level 3; grade C recom-
mendation). It has been suggested that it inhibits
Kam et al. 231

Table 5. Examples of Chinese herbal medicines used in pregnancy.

Herbal medicine Ingredients Level of evidence

‘An-Tai-Yin’ Fritillaria, Zingiber, Angelica, Radix liguistici, Paeonia, 5

Astragali, Notopterygium, Magnoliae, Schizonepeta,
Artenisiae, Citri immaturus, Argyi folium, Semen cuscutae
‘Huanglian’ Coptidis rhizome 5
Ginseng Ginseng radix 5
‘Szu-Wu-Tang’ Rehmanniae radix, Paeoniae radix, Angelica sinensis, 5
Chuanxiong rhizoma
‘Sheng-Hua-Tang’ Angelica radix, Ligustici rhizome, Semen persica, 5
Zingiberis rhizome, Glycyrrhizea radix

platelet aggregation and oxidative stress. This led to the
hypothesis that garlic may be beneficial in pre-
eclampsia. However, one RCT showed that it was not
efficacious in reducing the incidence of hypertension or
pre-eclampsia.57 Consumption of large doses of garlic
is associated with platelet dysfunction.58
Blue cohosh
Blue cohosh is used as a uterine stimulant to induce
and augment labour59 in the late stages of pregnancy
(Level 4; grade C recommendation). However, animal
studies have reported serious coronary vasoconstric-
tion resulting in myocardial ischaemia. Myocardial
infarction in an infant born to a mother who had
been taking blue cohosh during the last month of preg-
nancy has been reported.54
Black cohosh
Black cohosh, which has oestrogen-like properties, is
used in the last few weeks of pregnancy to promote
rhythmic uterine contractions and maintain a con-
tracted uterus after delivery59 (Level 4; grade C recom-
mendation). Unlike blue cohosh, no adverse effects
have been reported.
Castor oil
Castor oil is used to initiate labour. A prospective
study by Garry et al. showed a significant increase in
the rate of initiation/induction of labour60 (Level 4;
grade D recommendation). However, Boel et al.
showed that it increased nausea and could not demon-
strate any effect on initiation of labour.61
Echinacea
Echinacea is used to promote the immune system to
protect against upper respiratory tract infections. In a
prospective cohort study of 206 pregnant women who
used echinacea during the first trimester for upper
respiratory tract ailments, respiratory symptoms in
the treated group improved compared with the non-
treated group (Level 3; grade C recommendation).62
There were no fetal malformations. Prolonged con-
sumption of echinacea (>8 weeks) can cause liver
dysfunction.63
Chinese herbal medicines
Chinese herbal medicines usually contain either raw or
processed ingredients from one or more plants. Animal
or inorganic substances are sometimes added to the
herbs. In some instances, conventional drugs such as
steroids and NSAIDs are added but not disclosed.3 The
common Chinese herbal products include An-Tai-Yin,
Pearl power, Huanglian, Szu-Wu-Tang and Ginseng
during pregnancy, and Sheng-Hua-Tang and Szu-Wu-
Tang in the postpartum period.64 Dong quai (Angelica
sinensis) is taken as a powder contained in capsules by
Chinese women for postpartum weakness and uterine
hypotonia (Table 5). There are no good-quality studies
on the safety and efficacy of the use of TCHMs
(Level 5; grade D recommendation). Green tea
(Melissa officinalis) can induce early maternal hypothy-
roidism, as the isoflavanoids inhibit thyroperoxidase
and deiodinases resulting in low T3 levels.65
Hypotension and delayed recovery from general anaes-
thesia may result from this unexpected hypothyroidism
(Level 4 evidence).
Anaesthetic considerations
There are currently no clear data on the specific adverse
interactions between herbal medicines and anaesthetic
drugs. The available data on the risks and probable
herb–anaesthetic drug interactions is based on case
reports and limited pharmacodynamic/kinetic studies.
Self-prescription of herbal medicines is common.
A high proportion of pregnant women (76%) fail to
disclose to their midwife or obstetrician that they are
taking herbal medicines.11 A common reason for this
lack of disclosure is simply because the women are not
asked by their care providers.66
232
As regional anaesthesia is advocated in obstetrics,
the potential for coagulopathy and haemodynamic
instability are major concerns. Large doses of garlic,
ginseng and ginger impair platelet function by inhibit-
ing thromboxane synthetase. Coagulopathy is only a
concern when large doses of garlic, ginseng and
ginger are consumed in the peripartum period
(Level 4). Caution should be undertaken when manag-
ing postpartum Chinese women, as they may take large
doses of ginger (>4 g) in the ‘ginger–vinegar soup’. In a
study investigating the incidence and risk of perioper-
ative events among surgical patients taking TCHMs,
Lee et al. found that ginger consumption was not asso-
ciated with prolonged aPTT or INR.6 They found no
spinal or epidural haematomas in 133 patients who
were taking TCHMs and who underwent regional
anaesthesia. This supports the recommendations of
the American Society of Regional Anesthesia
Consensus on Neuraxial Anesthesia and
Antithrombotic Therapy, which states that “herbal
drugs, by themselves, appear to represent no significant
risk for the development of spinal hematoma in
patients having epidural or spinal anesthesia”.67
When pregnant women take traditional Chinese or
Ayurvedic medicines, the potential for adverse effects
of contamination or undeclared added metals, steroids
or NSAIDs should be considered. Lead and arsenic
added to these traditional medicines can cause bone
marrow depression, and the addition of NSAIDs can
cause excessive bleeding.
Limitations of review
There are several limitations of this narrative review.
As it was restricted to English language publications,
issues related to publication bias arise especially as dif-
ferent cultures use different herbal medicines.
Moreover, some medicinal plants are used as food
and not as medicines. Much of the evidence comes
from case reports and low-quality studies. The active
constituents of the herbal medicines may vary in con-
centration and composition as they are not regulated.
Conclusion
Despite the popularity and widespread use of herbal
medicines during pregnancy, there are very few good-
quality studies of these drugs and their adverse effects.
No definitive recommendations concerning the periop-
erative safety of these herbal medicines can be made
because randomized double-blind placebo-controlled
studies are not available. The American Society of
Anesthesiologists68 and the European Society of
Anaesthesiology69 guidelines on preoperative evalua-
tion of adults undergoing elective non-cardiac surgery
Anaesthesia and Intensive Care 47(3)
suggest that herbal medicines are stopped two weeks
prior to surgery and that patients should be explicitly
asked about their intake of herbal drugs (e.g. ginger,
ginseng, garlic and gingko) that may impair coagula-
tion. There is no evidence to postpone elective surgery,
but for obstetric surgical procedures associated with
massive haemorrhage it may be prudent to perform
preoperative coagulation screening tests and use intra-
operative point-of-care coagulation monitoring.
Further research and longitudinal observational studies
are required to provide clear data on the safety of
herbal medicines in regard to anaesthesia.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Allaire AD. Complementary and alternative medicine in
the labor and delivery suite. Clin Obstet Gynecol 2001;
44: 681–691.
2. Hodges PJ and Kam PC. The peri-operative implications
of herbal medicines. Anaesthesia 2002; 57: 889–899.
3. Kam PC and Liew S. Traditional Chinese herbal medi-
cine and anaesthesia. Anaesthesia 2002; 57: 1083–1089.
4. Saper RB, Kales SN, Paquin J, et al. Heavy metal content
of ayurvedic herbal medicine products. JAMA 2004;
292: 2868–2873.
5. Levy I, Attias S, Ben-Ayre E, et al. Adverse events asso-
ciated with interactions with dietary and herbal supple-
ments among inpatients. Br J Clin Pharmacol 2017;
83: 836–846.
6. Lee A, Chui PT, Aun CST, et al. Incidence and risk of
adverse perioperative events among surgical patients
taking traditional Chinese herbal medicines.
Anesthesiology 2006; 105: 454–461.
7. Hall HG, Griffiths DL and McKenna LG. The use of
complementary and alternative medicine by pregnant
women: a systematic review. Midwifery 2011;
27: 817–824.
8. Howick J, Chalmers I, Glasziou P, et al. Explanation
of the 2011 Oxford Centre for Evidence-based
Medicine levels of evidence (background document)
http://www.cebm.net/index.aspx?oþ5623 (accessed 6
November 2018).
9. Kennedy A, Lupatelli A, Koren G, et al. Herbal medicine
use in pregnancy: results of a multinational study.
BMC Complement Altern Med 2013; 13: 355. http:/
www.biomedcentral.com./1472-6882/13/355 (accessed 20
July 2018).
Kam et al.
10. Frawley J, Adams J, Sibbritt D, et al. Prevalence and
determinants of complementary and alternative medicine
use from a nationally representative sample of Australian
pregnant women. Aust N Z J Obstet Gynaecol 2013;
53: 347–352.
11. Holst L, Wright D, Haavik S, et al. Safety and efficacy of
herbal remedies in obstetrics: review and clinical implica-
tions. Midwifery 2011; 27: 80–86.
12. Nordeng H, Bayne K, Havnen GC, et al. Use of herbal
drugs. Complement Ther Clin Pract 2011; 17: 147–151.
13. Lapi F, Vannacci A, Moschini M, et al. Use, attitudes
and knowledge of complementary and alternative drugs
(CAS) among pregnant women: a preliminary survey in
Tuscany. Evid Based Complement Alternat Med 2010;
7: 477–486.
14. Mousally K, Oriachi D and Bérard A. Herbal products
use during pregnancy: prevalence and predictors.
Pharmacoepidemiol Drug Saf 2009; 18: 454–461.
15. Louik C, Gardiner P, Kelley K, et al. Use of herbal treat-
ments in pregnancy. Am J Obstet Gynecol 2010;
202: e431–e410.
16. Yusof J, Mahdy ZA and Noor RM. Use of complemen-
tary and alternative medicine in pregnancy and its impact
on outcome. Complement Ther Clin Pract 2016;
25: 155–163.
17. Tang L, Lee AH, Binns CW, et al. Consumption of
Chinese herbal medicines during pregnancy and postpar-
tum: a prospective cohort study in China. Midwifery
2016; 34: 205–210.
18. Dante G, Pedrielli G, Annessi E, et al. Herb remedies
during pregnancy: a systematic review of controlled clin-
ical trials. J Matern Fetal Neonatal Med 2013; 26: 306–312.
19. Hepner DL, Harnett M, Segal S, et al. Herbal use in
parturients. Anesth Analg 2003; 94: 690–693.
20. Adams J, Lui CW, Sibbritt D, et al. Women’s use of
complementary and alternative medicine during pregnan-
cy: A critical review of the literature. Birth 2009;
36: 237–245.
21. McLay JS, Izzah N, Pailvalapila AR, et al. Pregnancy,
prescription medicines and the potential risk of herb-drug
interactions: A cross sectional survey. BMC Complement
Altern Med 2017; 17: 543.
22. Jo J, Lee SH, Lee JM, et al. Use and safety of Korean
herbal medicine during pregnancy: a Korean medicine
literature review. Eur J Integr Med 2016; 8: 4–11.
23. Mathews AR, Haas D, O’Mathuna P, et al. Interventions
for nausea and vomiting in early pregnancy. Cochrane
Database of Systematic Reviews 2014; 3: CD007575.
24. Hollyer T, Boon H, Geogousis A, et al. The use of CAM
by women suffering from nausea and vomiting during
pregnancy. BMC Complement Alternat Med 2002; 2: 5.
http://www.biomedcentral.com/1472-6882/2/5.
25. Wang SM, DeZinno P, Fermo I, et al. Complementary
and alternative medicine for low-back pain in pregnancy:
A cross-sectional survey. J Altern Complement Med 2005;
30: 138–143.
26. Charaf S, Wardle JL, Sibbritt DW, et al. Women’s use of
herbal and alternative medicines for preconception care.
Aust N Z J Obstet Gynaecol 2015; 55: 222–226.
233
27. Stankiewicz M, Smith C, Alvino H, et al. The use of
complementary medicines and therapy by patients
attending a reproductive medicine unit in South
Australia: A prospective survey. Aust N Z J Obstet
Gynaecol 2007; 47: 145–149.
28. Maats FH and Crowther CA. Patterns of vitamin, min-
eral and herbal supplement use prior to and during preg-
nancy. Aust N Z J Obstet Gynaecol 2002; 42: 494–496.
29. Dove D and Johnson P. Oral evening primrose oil: its
effect on the length of pregnancy and selected intrapar-
tum outcomes in low risk nulliparous women. J Nurse
Midwifery 1999; 44: 320–324.
30. Garry D, Figueroa R, Guillaume J, et al. Use of castor oil in
pregnancies at term. Altern Ther Health Med 2000; 6: 77–79.
31. Jones TK and Lawson BM. Profound neonatal conges-
tive heart failure caused by maternal consumption of
blue cohosh herbal medication. J Pediatr 1998;
132: 550–552.
32. Gentz BA. Alternative therapies for the management of
pain in labour and delivery. Clin Obstet Gynaecol 2001;
44: 704–732.
33. Bruno LO, Simoes RS, Simoes MD, et al. Pregnancy and
herbal medicines: an unnecessary risk for women’s
health: a narrative review. Phytother Res 2018;
32: 796–810.
34. Dale A and Cornwell S. The role of lavender oil in reliev-
ing perineal discomfort following childbirth. J Adv Nurs
1994; 19: 89–96.
35. Chan SM, Nelson EAS, Leung SSF, et al. Special post-
partum dietary practices of Hong Kong Chinese women.
Eur J Clin Nutr 2000; 54: 797–802.
36. Moretti ME, Maxson A, Hanna F, et al. Evaluating the
safety of St John’s wort in human pregnancy.
Reproductive Toxicol 2009; 28: 96–99.
37. Grush LR, Nierenberg A, Keefe B, et al. St John’s wort
during pregnancy. JAMA 1998; 280: 1566.
38. Lee A, Minhas R, Lam M, et al. The safety of St John’s
wort (Hypericum perforatum) during breast feeding.
J Clin Psychiatry 2003; 64: 966–968.
39. Willetts KE, Ekangaki A and Eden JA. Effect of a ginger
extract on pregnancy induced nausea: a randomized con-
trolled trial. Aust NZ J Obstet Gynaecol 2003;
43: 139–144.
40. Vutyavanich T, Kraisarin T and Ruangsri R. Ginger for
nausea and vomiting in pregnancy: randomized, double-
masked, placebo controlled trial. Obstet Gynecol 2001;
97: 577–582.
41. Ozogoli G, Goli M and Simbar M. Effects of ginger
capsules on pregnancy, nausea and vomiting. J Altern
Complement Med 2009; 15: 243–246.
42. Keating A and Chez RA. Ginger syrup as an antiemetic
in early pregnancy. Alternative Therapies Health and
Medicine 2002; 8: 89–91.
43. Fischer-Rasmussen W, Kjaer SK, Dahl C, et al. Ginger
treatment of hyperemesis gravidarum. Eur J Obstet
Gynaecol Reprod Biol 1991; 38: 19–24.
44. Ensiyeh J and Sakineh MA. Comparing ginger and vita-
min B6 for the treatment of nausea and vomiting in preg-
nancy. Midwifery 2009; 25: 649–653.
234
45. Smith C, Crowther C, Willson K, et al. A randomized
controlled trial of ginger to treat nausea and vomiting in
pregnancy. Obstet Gynecol 2004; 103: 639–645.
46. Pongrojpow, Somprasit C and Chanthasenanont A. A
randomized comparison of ginger and dimenhydrate in
the treatment of nausea and vomiting in pregnancy.
J Med Thai Assoc 2007; 90: 1703–1709.
47. Sripramote M and Lekhyananda N. A randomized com-
parison of ginger and Vitamin B6 in the treatment of
nausea and vomiting in pregnancy. J Med Assoc Thai
2003; 86: 846–853.
48. Chittumma P, Kaewkiattkun K and Wiriyasiriwach B.
Comparison of the effectiveness of ginger and Vitamin
B6 for treatment of nausea and vomiting in early preg-
nancy: A randomised double blind controlled trial. J Med
Assoc Thai 2007; 90: 15–20.
49. Portnoi G, Chng LA, Karimi-Tabesh L, et al. Prospective
comparative study of the safety and effectiveness of
ginger for the treatment of nausea and vomiting in preg-
nancy. Am J Obstet Gynecol 2003; 189: 1374–1377.
50. Heitman K, Nordeng H and Holst L. Safety of ginger use
in pregnancy: results from a large population cohort
study. Eur J Clin Pharmacol 2013; 69: 269–277.
51. Ding M, Leach M and Bradley H. The effectiveness and
safety of ginger for pregnancy-induced nausea and vom-
iting: A systematic review. Women Birth 2013;
26: e26–e30.
52. Backon J. Ginger as an antiemetic: possible side effects
due to its thromboxane synthetase activity. Anaesthesia
1991; 46: 705–706.
53. Smith C, Crowther C, Wilson K, et al. A randomized
controlled trial of ginger to treat nausea and vomiting
in pregnancy. Obstet Gynecol 2004; 103: 639–645.
54. Wing DA, Rumney PJ, Preslicka CW, et al. Daily cran-
berry juice for the prevention of asymptomatic bacteri-
uria in pregnancy: A randomized controlled pilot study.
J Urol 2008; 180: 1367–1372.
55. Simpson M, Parsons M, Greenwood J, et al. Raspberry
leaf in pregnancy: its safety and efficacy in labour.
J Midwifery Womens Health 2001; 46: 51–59.
56. Lissiman E, Bhasale AL and Cohen M. Garlic for the
common cold. Cochrane Database Syst Rev 2012;
3: C006206.
57. Ziaer S, Hantoshzadeh S, Rezasoltani P, et al. The effect
of garlic tablet on plasma lipids and platelet aggregation
Anaesthesia and Intensive Care 47(3)
in nulliparous pregnancy at high risk of preeclampsia.
Eur J Obstet Gynecol Reprod Biol 2001; 99: 201–206.
58. Rose K, Crossaint PD and Parliament CF. Spontaneous
spinal epidural hematoma with associated platelet dys-
function from excessive garlic ingestion: a case report.
Neurosurgery 1990; 26: 880–882.
59. Wright I. Neonatal effects of maternal consumption of
blue cohosh. J Pediatr 1999; 134: 384–385.
60. Garry D, Figuera R, Guillaume J, et al. Use of castor oil
in pregnancies at term. Altern Ther Health Med 2000;
6: 77–79.
61. Boel ME, Lee SJ, Rijken MJ, et al. Castor oil for induc-
tion of labour: not harmful, not helpful. Aust NZ J
Obstet Gynaecol 2009: 49; 499–503.
62. Gallo M, Sarkar M, Au W, et al. Pregnancy outcome
following gestational exposure to Echinacea. Arch
Intern Med 2000; 160: 3141–3143.
63. Miller LG. Selected clinical considerations focusing on
known or potential drug-herb interactions. Arch Intern
Med 1998; 158: 2200–2211.
64. Chuang CH, Chang PJ, Hsieh WS, et al. Chinese Herbal
medicine use in Taiwan during pregnancy and the post-
partum period: a population-based cohort study. Int J
Nurs Stud 2009; 46: 787–795.
65. Roman GC. Autism: Transient in utero hypothyroxine-
mia related to maternal flavoid ingestion during pregnan-
cy and other environmental antithyroid agents. J Neurol
Sci 2007; 262: 15–26.
66. Harrigan JT. Patient disclosure of their use of comple-
mentary and alternative medicine to their obstetrician/
gynaecologist. J Obstet Gynaecol 2011; 31: 59–61.
67. Horlocker TT, Wedel DJ, Benson H, et al. Regional
anesthesia in the anticoagulated patient: defining the
risks (the second ASA Consensus Conference on
Neuraxial Anesthesia and Anticoagulation). Reg Anesth
Pain Med 2003; 28: 172–197.
68. Leak JA. Perioperative considerations in the manage-
ment of patients taking herbal medicines. Curr Opin
Anaesthesiol 2000; 13: 667–669.
69. De Hart S, Staender S, Fritsch G, et al. Preoperative
evaluation of adults undergoing elective non-cardiac sur-
gery: updated guideline from the European Society of
Anaesthesiologists. Eur J Anaesthesiol 2018; 35: 407–465.