Ayurvedic Medicine in Maternal and Foetal Health - Essay Example

Ayurvedic Medicine in Maternal and Foetal Health: An Evaluation of the Safety and Efficacy of Zingiber Officinale (ginger) as an Ingredient in Ayurvedic Preparations Ayurvedic medicine has long recognized the importance of treating conditions pertaining to obstetrics, gynecology, and paediatrics. These specialties, the kaumarabhryta, were identified as one of the eight original clinical specialties according to the Ashtanga Ayurveda. As such, emphasis has been placed on ensuring the health and well being of the expectant mother, as this will facilitate the health and well being of the unborn child. While pregnancy can be a joyous experience for a woman, pregnancy can bring about unpleasant physical changes making the pregnancy a period of distinct discomfort, and at times, a danger to the health of the mother and the unborn baby. One of the most common physical sequelae of pregnancy is nausea and vomiting. While exact figures vary, most research indicates that anywhere from 70 to 85 percent of pregnant women have nausea and/or vomiting during pregnancy (Flake et al., 2004; Wilkinson, 1999). Quinlan and Hill (2003) indicate that generally nausea and vomiting begin between the fourth and seventh week after a woman's last menstrual period, and resolves by the 20th gestational week for 90% of women; Wilkinson (1999) notes simply that "morning sickness usually starts early in the pregnancy with symptoms peaking at 8-9 weeks and then disappearing by about the 14th week." Meltzer (2000) wisely notes "Studies of nausea and vomiting in pregnancy are often made more challenging because of the subjective nature of the symptom of nausea versus the objective sign of vomiting." One indisputable danger from uncontrolled nausea and vomiting is development of hyperemesis gravidarum. Hyperemesis gravidarum, defined as, "persistent vomiting that is serious enough to cause fluid and electrolyte disturbance" (Jewell, 2003a) often necessitates hospitalization to rehydrate the woman and ameliorate electrolyte imbalances. Though the prevalence of hyperemesis gravidarum is estimated at only .3% (Fisher-Rasmussen, 1990) to 3% (Hollyer et al., 2002), its consequences can be tragic if untreated. Nausea and vomiting during pregnancy (NVP) impacts more than only the pregnant woman. Hollyer et al. (2002) report study findings where almost 50% of employed women reported reduced work efficiency due to pregnancy-related nausea and vomiting, 25-66% reported having to take time off from work, with almost 50% reporting that the nausea and vomiting negatively affected their relationship with their partner including having an adverse effect on the partner's [italics added] day-to-day life. Clearly, finding a treatment to lessen NVP is long overdue, but fraught with risks. Since the 1960's thalidomide tragedy, research on medications used for pregnant women has been limited. Ethical concerns preclude "experimentation" of medications or treatments for a pregnant woman, thus much research relies on that which is known to date or is discovered spuriously. Treatments for NVP span both "traditional" (Western) and "complementary" (Eastern) medicine. A lengthy discussion of these treatment alternatives is beyond the scope of this paper, though Jewell (2003b) provides a concise summary in Clinical Evidence. This paper focuses on one particular treatment for NVP, the use of Zingiber officinale (ginger). As will be noted, ginger can be found in varying forms (syrup, tea, capsules, food products) and this variation may confound the inter-study correlations. Zingiber officinale (ginger), as noted in the Alternative Medicine Review (2003), has a long history of medicinal use, primarily in India and China, dating back 2,500 years. Though the reasons for its anti-emetic effect are not well defined, it is thought, "the aromatic, spasmolytic, carminative, and absorbent properties of ginger suggest it has direct effects on the gastrointestinal tract (Alternative Medical Review, 2003). Combining the known benefits of ginger in Ayurvedic and "Eastern" medicine, with the increased interest in complementary and alternative medicine (CAM) in "Western" countries, it is not surprising to find between five and ten studies focusing primarily on ginger's use for treating NVP. Boone and Shields (2005) provide an outstanding review of the literature pertaining to the use of ginger in NVP. As stated in their objective, "To review literature assessing the safety and efficacy of the use of ginger to treat nausea and vomiting in pregnancy," they conducted a comprehensive literature search spanning international publications and tapping the MEDLINE database using the following keywords: ginger, nausea, vomiting, emesis, and pregnancy, and restricted the search to English-language publications. Unfortunately, the authors did not document the authors or title of each study, simply describing a series of studies, which rendered the review difficult to follow. However, uniformly the studies under review - while acknowledging methodological concerns in each of them - clearly pointed to reductions in NVP without statistically significant differences in birth defects, abortions, or major malformations. The authors conclude "There is evidence suggesting that ginger is effective in reducing nausea and vomiting experienced during pregnancy." They continue, "Without more stringent product quality regulations and large-scale trials confirming safety and efficacy, ginger should not be universally recommendedHowever current data do indicate that ginger is low risk and probably effective in the management of nausea and vomiting in the first trimester of pregnancy and may be a good option for patients not responding to non-pharmacologic interventions. Ernst and Pittler (2000) conducted a study on the efficacy of ginger for nausea and vomiting, but not specifically for pregnancy-related nausea and vomiting. Only one of the studies reviewed (Fischer-Rasmussen et al., 1990) evaluated ginger for NVP, and their study will be discussed further in this paper. Ernst and Pittler did conclude, "that ginger is a promising antiemetic herbal remedy, but clinical data to date are insufficient to draw firm conclusions." Their findings are in line with those of Portnoi et al. (2003) who conducted a prospective, but very uncontrolled, study on the safety and effectiveness of ginger in treating NVP. Their study involved women who called the Motherisk Program (a counseling service for pregnant and post-partum women). When women called asking about the use of ginger in pregnancy, specifically in the first trimester, the women were asked if they would be willing to participate in the study and have follow-up contact after pregnancy outcome. The authors were able to follow 187 women through to pregnancy outcome and found no statistically significant differences between the control and experimental group when considering: live births, spontaneous abortions, major malformations, or gestational age. The only statistical difference was fewer low birth weight babies in the ginger group as compared to the control group. However, the study was rife with methodological flaws. The two groups were divided according to whether they used ginger or no anti-emetic medication. The authors clearly state, though, that the women taking ginger were often taking other anti-emetics. This also invalidated any findings on the women's perceived efficacy of ginger, as there was no way of determining if the ginger was taken alone or in combination with other treatments. The statement of Portnoi et al. (2003), "In summary, in this cohort of women exposed to ginger during pregnancy, all of whom used it during the first trimester, the results do not suggest that there is a higher risk for major malformations above the baseline rate of 1% to 3%. The results also suggest that ginger is somewhat helpful in alleviating the symptoms of NVP, more so with capsules that any other preparation" should be interpreted with caution. Conversely, Vutyanvanich et al. (2001) conducted a well-controlled, randomized, double-masked study, using a placebo, to determine the effectiveness of ginger in treating NVP. It is noteworthy, given the problem of attrition during a study, that all 32 of the women beginning the study in the experimental/ginger group completed it, while 3 of the 38 in the placebo group chose not to. While the study was short, 4 days on treatment/placebo, and a follow-up 7 days later, the findings were impressive. Of the ginger-treated group, 87.5% (28/32) reported that their symptoms improved, while only 28.6% (10/35) reported improvement in the placebo group. The study was meticulously conducted, including pill counts for each group and assessing other anti-emetic use. They also followed the women through to pregnancy outcome, with three spontaneous abortions in the placebo group and one in the ginger group. None of the infants were reported to have any congenital abnormalities and all were released from the hospital in good condition. The authors note that they chose a short study period (4 days) as it had been previously shown that ginger's effect was evident within several days of treatment and a longer trial period risked high attrition rates. Ginger's rapid effectiveness is another benefit of its apparent successful use. In one of the few studies assessing ginger's safety and effectiveness in treating hyperemesis gravidarum, Fischer-Rasmussen et al. (1990) also reported reductions in nausea and vomiting for women treated with ginger. In a double-blind, placebo-controlled study, 27 women received ginger or placebo for 4 days, were washed-out for 2 days, and were then crossed over to the other treatment method. The authors report that 70% of the women stated a preference for the ginger treatment, while 14.8 had no preference. The women also reported a significant reduction in the severity of nausea and vomiting with no side effects. No other anti-emetic medication was used, though the women continued to received intravenous fluid. The women were followed to pregnancy outcome, 1 reported a spontaneous miscarriage at 12 weeks, 1 electively terminated, with the remaining women delivering healthy babies near or at term. A study reporting similarly positive findings, though markedly less enthusiastic, is that conducted by Willetts et al. (2002). While their conclusion reads "Ginger can be considered as a useful treatment option for women suffering from morning sickness," their findings appear to counter this: There was no significant difference between ginger extract and placebo groups for any of the vomiting symptoms For retching symptoms, the ginger extract group was shown to have significantly lower symptom scores than the placebo group for the first days only. They do provide regression analyses to demonstrate some positive effects of ginger, but their discussion is less than encouraging, "This study confirms the presence of the placebo effect in the relief of nausea but still detects some benefit of ginger in improving morning sickness. It is important to note, however, the subject were given ginger in the form of 125mg ginger extract. As such, it is not surprising that four subjects in the ginger group withdrew because of reflux and heartburn. This is not inconsistent with the findings of Hollyer et al. (2002) in their survey of women who used complementary and alternative medicine in alleviating their NVP. They found that the two most common reported adverse experiences when using alternative medicines (of all types) were wrist irritation from those who used acupressure wrist bands, and the intolerability of the strong flavor of ginger. This underlies the need to carefully monitor the method in which the ginger is given to subjects in a study. A discussion of the safety and efficacy of ginger for NVP would not be complete without mention of Backon's (1991) letter, "Ginger in preventing nausea and vomiting of pregnancy: a caveat due to its thromboxane sythesase activity and effect on testosterone binding." While only writing as a "caveat," this one article is consistently cited as a limitation in the use of ginger in treating NVP, yet no studies have ever demonstrated the concerns cited and indeed, consistently indicate that ginger can be used safely in pregnancy. However, Backon's letter seems to resurrect in the "Limitations" section of virtually ever paper assessing the safety and effectiveness of ginger, even though it is now 15 years old and never substantiated. Upon reviewing the findings of methodologically sound studies on the safety and effectiveness of ginger, it appears that ginger does provide some relief for women with NVP, with minimal effects on the unborn child. While most literature discussing the various applications of ginger for health purposes (PDRhealth, NutraSanus) continue to note that ginger is not recommended in pregnancy, this may be a function of few large-scale clinical trials and concern that until ginger is "proven" safe, it is best for pregnant women to be conservative. However, in conjunction with an appropriately trained clinician, whether trained in Ayurvedic medicine, or more traditional western medicine, the literature consistently points to ginger as a safe and low-risk remedy for pregnancy-related nausea and vomiting. References Backer, J. 1991. 'Ginger in preventing nausea and vomiting of pregnancy; a caveat due to its thromboxane synthetase activity and effect on testosterone binding [letter]', European Journal of Obstetrics, Gynecology, and Reproductive Biology, Vol. 42, pp. 163-164 Boone, S.A. & Shields, K.M. 2005. 'Treating pregnancy-related nausea and vomiting with ginger', The Annals of Pharmacotherapy, Vol. 39, pp. 1710-1713. Ernst, E. & Pittler, M. H. 2000. 'Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials', British Journal of Anesthesia, Vol. 84, No. 3, pp. 367-371. Fischer-Rasmussen, W., Kjaer, S.K., Dahl, C. & Asping, U. 1990. 'Ginger treatment of hyperemesis gravidarum', Journal of Obstetrics and Gynecology and Reproductive Biology, Vol. 38, pp. 19-24. Flake, Z.A., Scalley, R.D, & Bailey, Austin, G. 2004. 'Practical selection of antiemetics', American Family Physician, pp. 1169-1174, Accessed 17 April 2006, http://www.aafp.org/afp "Ginger" 2004. NutraSanus, Accessed 23 April 2006, http://www.nutrasanus.com/ginger.html "Ginger Root" 2005. PDRhealth, Thompson Healthcare, Accessed 23 April 2006, http://www.pdrhealth.com/drug_info/nmdrugprofiles/herbaldrugs/101230.shtml Hollyer, T., Boon, H., Georgousis, A., Smith, M., & Einarson, A. 2002. 'The use of CAM by women suffering from nausea and vomiting during pregnancy', BMC Complementary and Alternative Medicine, Vol. 2, No.5, Accessed 18 April 2006, http://www.biomedcentral.com/1472-6882/2/5 Jewell, D. 2003a. 'Nausea and Vomiting in Early Pregnancy', American Family Physician, Vol. 68, no. 1, Accessed 20 April 2006, http://aafp.org/afp/20030701/british.html Jewell, D. 2003b. 'Nausea and vomiting in early pregnancy', Clinical Evidence, Vol. 9, pp. 1561-1570. Meltzer, D. I. 2000. 'Selections from Current Literature: Complementary therapies for nausea and vomiting in early pregnancy", Family Practice, Vol. 17, pp. 570-573. Portnoi, G., Chng, L., Karimi-Tabesh, L., Koren, G., Tan, M.P., Einarson, A. 2003. 'Prospective comparative study of the safety and effectiveness of ginger for the treatment of nausea and vomiting', American Journal of Obstetrics and Gynecology, Vol. 189, pp. 1374-1377. Quinlan, J.D. & Hill, D.A. 2003. 'Nausea and vomiting of pregnancy', American Family Physician, Vol. 68, no. 1, Accessed 17 April 2006, http://www.aafp.org/afp Vutyavanich, T., Kraisarin, T., & Ruangsri, R. 2001. 'Ginger for nausea and vomiting in pregnancy: Randomized, double-masked, placebo-controlled trial', Obstetrics and Gynecology, Vol. 97, No 4, pp. 577-582. Wilkinson, J.M. 1999. 'What do we know about herbal morning sickness treatments A literature survey', Midwifery, Vol. 16, pp. 224-227. Willetts, K.E., Ekangaki, A., & Eden, J. A. 2003. 'Effect of ginger extract on pregnancy-induced nausea: A randomised controlled trial', Australian and New Zeland Journal of Obstetrics and Gynecology', Vol. 43, 139-144. "Zingiber officinale" (Monograph), Alternative Medicine Review, Vol. 8, No. 3, pp. 331-335. Read More