Botanical treatment for constipation relies on a combination of the practical dietary and lifestyle changes presented on the preceding page, and gentle herbs that increase bulk and moisture in the bowel, or gently stimulate bowel activity. These herbs may be used singly, or in combination, and are combined with a carminative herb — one that relieves gas and griping — to prevent side effects sometimes associated with laxatives. Examples of carminatives that can be safely used for short durations during pregnancy include ginger root and anise seed. Stimulant laxatives are used only for short durations (up to 2 weeks) to avoid dependence. When using herbal bulking laxatives, it is important to make sure the patient is drinking plenty of water, because the bulk laxative will absorb large amounts of water from the colon. There have been few studies evaluating the safety or efficacy of natural laxatives in pregnancy. A number of herbal preparations available in health food and grocery stores contain herbs that are not appropriate or safe for use in pregnancy, including cascara sagrada, aloe, and buckthorn (see Case History 1). Aloe may be teratogenic, whereas the other herbs are associated with increased uterine activity. Practitioners should inquire of their pregnant patients whether they are using preparations containing these herbs if constipation is a problem and direct them to safer food-based, lifestyle, and herbal alternatives.
Botanical Treatment Strategies for Heartburn
|Therapeutic Goal||Therapeutic Activity||Botanical Name||Common Name|
|Relieve constipation||Bulk laxatives||Linum usitatissimum||Flax (Linseed)|
|Plantago psyIlium, P. ovata||Psyllium|
|Lubricating laxatives||Clycyrrhiza glabra||Licorice|
|Stimulating laxatives (aperients)||Cassia senna; Cassia angustifolia||Senna|
|Rumex crispus||Yellow dock root|
Foods and food agents commonly used to relieve constipation include wheat bran, which is a high-fiber source, prunes (soaked in water or apple juice until soft and plump), and fruits high in sorbitol, including apples, pears, apricots, and cherries. Molasses is both high in iron and a gentle laxative, and therefore excellent for constipation associated with anemia. Commonly used herbs are listed in Table Botanical Treatment Strategies for Heartburn, and discussed below. In traditional Chinese medicine constipation is considered a symptom of blood deficiency, and may be treated with Dong Quai and Peony formula, discussed under iron deficiency anemia.
Discussion of Botanicals for Constipation during Pregnancy
Psyllium Seed and Husk
Psyllium seeds, as well as Ispaghula seeds, which have comparable activity, are bulk laxative agents. Psyllium seeds shorten bowel transit time by increasing the intestinal contents and stimulating stretch receptors and thereby peristalsis. The whole seeds or husks are soaked in water or apple juice for several hours and then they are taken with a large amount of liquid. Bowel movements are usually achieved within 6 to 12 hours after taking the preparation. Rarely, allergic reactions have occurred. The preparation should not be taken by patients with swallowing difficulties because choking can occur.
Commonly Used Botanical Laxatives That Are Contraindicated during Pregnancy
|Castor oil||(Ricinus communis)|
|Chinese rhubarb||(Rheum palmatum)|
Senna Leaf and Pod
Senna, a quick-acting, reliable stimulating laxative generally, is taken as a tea. Its mechanism of action is primarily via anthracoids (sennoside A and B), or anthraquinone glycosides. Senna is considered appropriate for use in acute cases, and is not considered an herb to be used regularly. When used alone it can elicit loose stool with significant griping, and is therefore traditionally combined with a small amount of ginger root, anise seed, fennel seed, spearmint, or peppermint for their carminative action (see Formula 1 in Box Formulas for Constipation). There is significant disagreement in the literature regarding the safety of senna use during pregnancy. Modern herbalists have tended to consider it contraindicated for use during pregnancy, with the supposition that the markedly increased bowel peristalsis stimulated by the herb might lead to reflex uterine activity and thus may have indirect emmenagogic effects. The herb is commonly found on lists of herbs contraindicated during pregnancy. The Botanical Safety Handbook classifies senna as a Class 2b herb, not to be used during pregnancy or lactation unless otherwise directed by an expert qualified in the appropriate use of this substance. According to the European Scientific Cooperative on Phytotherapy (ESCOP) there no reports of undesirable or damaging effects during pregnancy or on the fetus when senna is used in accordance with the recommended dosing and use schedule. However, because of experimental data concerning a genotoxic risk from several anthracoids (emodin and aloe-emodin), the herb should be avoided during the first trimester or taken only under medical supervision. Two studies reported that human and animal data do not support concerns that senna laxatives pose a genotoxic risk to humans when taken properly. A review article reported that senna appears to be the most appropriate stimulant laxative to use during pregnancy. Small amounts of active metabolites are excreted in the breast milk, and though these do not appear to have a laxative effect in the newborn, its use is not recommended during lactation. The dose recommended by ESCOP is individualized to the smallest possible dose that produces a comfortable, soft, formed stool. Weiss states that small doses of 1 to 2 g soften the stools within 5 to 7 hours. It is recommended that the herb be used only short-term for occasional constipation. Senna preparations are typically taken at bed time to produce a bowel movement the following morning.
Formulas for Constipation
Formula 1: Laxative Tea (adapted from the German Standard Registration)
Senna leaf (Cassia senna) 15 g Anise seed (Pimpinella anisum) 3g Chamomile blossoms (Matrkaria recutita) 5g Spearmint leaf (Mentha spicata) 5g
Total: 28 g (1 oz)
Directions: Prepare 1 to 2 teaspoons as an infusion. Steep for 10 minutes. Take 1 cup each evening.
Formula 2: Dandelion-Yellow Dock Syrup
Yellow dock root (Rumex crispus) 14 g Dandelion root (Taraxacum officinale) 14 g
Directions: Prepare a decoction by simmering both herbs (1 oz / 28 g total) in 4 cups of water, uncovered, until reduced to 1 cup. Strain the liquid thoroughly (discard the herb material) and add ¼ cup blackstrap molasses, mixing until blended. Cool to room temperature. Keep refrigerated. The product will keep for up to 2 weeks refrigerated.
Dose: 1 to 2 tablespoons, up to twice daily.
Yellow Dock Root
Yellow dock is sometimes contraindicated during pregnancy because of its anthraquinone glycoside contents. Clinically, it is widely used by midwives as a gentle stimulating laxative because it is effective yet much milder than senna, which is generally avoided when possible. According to the Botanical Safety Handbook, this herb contains only a small amount of anthraquinone glycosides and has a mild laxative effect. Limited maternal use has not been observed to cause any increase in fetal malformation or other harmful effects to the fetus. The use of yellow dock for constipation is illustrated in yellow dock dandelion root syrup, and in the case history in iron deficiency anemia.
Herbalists favor the use of licorice root for its intestinal moistening abilities. According to Wichtl et al., licorice root is included in laxative herbal tea formulas because it potentiates the activity of anthraquinone-containing herbs (e.g., senna), lowering the required dose of the anthraquinone laxative. Because of its effects on glucorticoids, excessive doses (>50 g per day) over a prolonged period can result in hypokalemia, hypernatremia, edema, hypertension, and cardiac disorders, and in extreme cases, pseudoaldosteronism. Symptoms disappear within days of discontinuation of the herb. Two recent reports on high-dose licorice consumption, in the form of licorice candy containing actual glycyrrhizin-containing licorice, during pregnancy, demonstrated no increase in maternal hypertension or low birth weight; however, both studies, demonstrated a significant increased in pre-term (<37 weeks) delivery. In one study, the risk of pre-term delivery was greater than double the risk of women not consuming licorice. No studies demonstrate harm or adverse outcomes with short-term use of modest doses of licorice. It is recommended that licorice not be used in excessive doses or for prolonged periods during pregnancy, rather, as with senna, it be used for acute use for up to several days at a time.