CHAPTER 15 Pregnancy: Third Trimester
CONSTIPATION DURING PREGNANCY
Constipation is defined as having bowel movements fewer than three times per week. The stools are typically hard, dry, small in size, and difficult to eliminate. Constipation may be accompanied by straining, pain, bloating, cramping, and the sensation of a full bowel. It is a bothersome common complaint of pregnancy, particularly in the second and third trimesters. Women who are habitually constipated may become more so during pregnancy. The prevalence of constipation in pregnancy is reported to be 11% to 38%.1 It has been generally accepted that decreased gastric motility in pregnancy is a result of increased circulating progesterone levels. More recent experimental evidence suggests that elevated estrogen concentrations are involved in delayed motility through an enhancement of nitric oxide release.1,2 Slow transit time of food through the intestinal tract leads to increased water absorption and thereby to constipation. Dietary factors, particularly inadequate fiber intake and lack of exercise, contribute to constipation, as does increased pressure of the growing uterus on the rectum as pregnancy becomes advanced.3 Ignoring the urge to have a bowel movement can also contribute to the problem. Iron-deficiency anemia can contribute to constipation, as can elemental iron supplements (see Chapter 16).
DIAGNOSIS
Constipation first presenting in pregnancy does not require an extensive evaluation, and is considered a normal pregnancy complaint.4 Constipation accompanied by other symptoms, for example, blood in the stools, or unresponsive to treatments requires further investigation to rule out possible pathology.
CONVENTIONAL TREATMENT OF CONSTIPATION
Most patients respond to simple dietary and lifestyle measures. Treatment during pregnancy is similar to that for the general population; however, special care must be taken to avoid medications that may be harmful to the fetus or disrupt the pregnancy.4
The first line of treatments for constipation include:
Fiber Supplementation: Bulk-Forming Laxatives
Fiber supplements, which are bulk-forming laxatives, are effective, safe, and without side effects when used in appropriate doses; however, limited studies are available on the use of laxatives in pregnancy.1 In addition to
softening the stool by keeping more fluid in the bowel lumen, the presence of the increased bulk is thought to stimulate intestinal peristalsis.5 Examples include wheat fiber (e.g., wheat bran), psyllium, flax seed, and pectin, to 25 g per day.6 Laxative effects may take 3 to 7 days to be noticeable. If side effects occur, switching to a different bulk laxative may help. Taken in excessive qualities they can lead to cramping, gas, diarrhea, and bloating.4,6 Bulk laxatives have a pregnancy B category (Table 15-1).4,6 Stool softeners are not recommended for use during pregnancy.
| CATEGORY | DESCRIPTION |
|---|---|
| A | Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. |
| B |
Adapted from Meadows M: Pregnancy and the drug dilemma, FDA Consum 35(3):16-20, 2001.
Osmotic Laxatives
Osmotic laxatives are indigestible sugars that work by increasing the amount of fluid that is retained in the bowel. Sorbitol, lactulose, and glycerin appear to be safe sources for use during pregnancy. Saline, phosphorus, and magnesium salt laxatives, including many prepackaged enemas, are not advisable during pregnancy because they can cause salt retention in the mother.7
Stimulant Laxatives
Stimulant laxatives are best used in pregnancy only after other measures have failed to relieve constipation. Examples of stimulant laxatives include senna, cascara sagrada, and aloes. Of these, only senna is considered safe (see senna discussion in the following) for use during pregnancy. Approved as an over-the-counter (OTC) medication, senna is an herb and is thus discussed in the following section with other botanicals. Stimulants are more likely to cause side effects of diarrhea and abdominal pain than are bulk laxatives.8
BOTANICAL TREATMENT FOR CONSTIPATION
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.
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.9 Commonly used herbs are listed in Table 15-2, 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.10 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.5 Rarely, allergic reactions have occurred.5 The preparation should not be taken by patients with swallowing difficulties because choking can occur.
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 15-2). 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.14 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.15 Two studies reported that human and animal data do not support concerns that senna laxatives pose a genotoxic risk to humans when taken properly. 16 17 18 A review article reported that senna appears to be the most appropriate stimulant laxative to use during pregnancy.19 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.15 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.10 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.
BOX 15-2 Formulas for Constipation
Formula 1: Laxative Tea (adapted from the German Standard Registration)5
| Senna leaf | (Cassia senna) | 15 g |
| Anise seed | (Pimpinella anisum) | 3 g |
| Chamomile blossoms | (Matricaria recutita) | 5 g |
| Spearmint leaf | (Mentha spicata) | 5 g |
| Total: 28 g (1 oz) | ||
Formula 2: Dandelion-Yellow Dock Syrup
| Yellow dock root | (Rumex crispus) | 14 g |
| Dandelion root | (Taraxacum officinale) | 14 g |
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.14 Limited maternal use has not been observed to cause any increase in fetal malformation or other harmful effects to the fetus.20 The use of yellow dock for constipation is illustrated in yellow dock dandelion root syrup, and in the case history in iron deficiency anemia.
Licorice Root
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.11 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.11 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 preterm (<37 weeks) delivery. In one study, the risk of preterm delivery was greater than double the risk of women not consuming licorice.12,13 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.
HYPERTENSION IN PREGNANCY
Hypertension is the most common medical problem of pregnancy, affecting 10% of all pregnant women.21 The condition can lead to devastating outcomes with significantly increased risks of placental abruption, disseminated intravascular coagulation (DIC), cerebral hemorrhage, hepatic failure, and acute renal failure.22 Hypertensive disorders of pregnancy are a significant cause of maternal and perinatal morbidity and mortality, and therefore require accurate diagnosis and proper medical management. CAM treatments for hypertensive disorders during pregnancy should always accompany proper medical management in conjunction with the care of an obstetrician.
Hypertension itself is defined as a sustained increase in blood pressure >140/90. Elevated blood pressure should be documented on at least two consecutive occasions greater than 6 hours apart, using the appropriate-size blood pressure cuff, to make a diagnosis of hypertension. Diastolic pressure should be considered the number at which the Phase V Korotkoff sound is auscultated. Patients should be told to avoid tobacco and caffeine for at least 30 minutes prior to a blood pressure reading, and should be encouraged to relax for 10 minutes prior to evaluation.22 The definition of hypertension as a 30 mm Hg systolic and/or 15 mm Hg rise over baseline is now considered invalid, as it is recognized that up to 73% of all women in their first pregnancies experience a diastolic rise of this magnitude at some point in the pregnancy with no subsequent development of pathology.23 Nonetheless, close observation of these women is recommended.21 Each type of hypertensive disorder of pregnancy has specific diagnostic criteria (Box 15-3).
BOX 15-3 Diagnosis of Hypertensive Disorders Complicating Pregnancy
Note that edema is no longer considered a diagnostic criterion of preeclampsia as it is found in many normal pregnancies and is not a reliable indicator.
Preeclampsia Superimposed on Chronic Hypertension
DESCRIPTIONS OF HYPERTENSIVE DISORDERS OF PREGNANCY BY CLASSIFICATION AND GENERAL CONVENTIONAL TREATMENT APPROACHES
Preeclampsia
Preeclampsia is a disease specific to pregnancy, with “cure” occurring only upon delivery of the placenta. The etiology of preeclampsia remains unknown, although there are numerous theories. It appears that it is a complex, multifactorial condition with genetic factors, immunologic factors, altered inflammatory pathways, insulin resistance (obesity, hyperlipidemia, glucose intolerance), endothelial dysfunction, macronutrient and micronutrient deficiencies, altered placental angiogenesis, and subclinical infections possibly participating in the risk of developing this condition.21,24 Advanced maternal age, first pregnancy, poor nutrition, residence at high altitudes, and lack of adequate prenatal care have also been associated with increased risk.24 There is a common thread in all cases: poor placental perfusion associated with maternal vasoconstriction and subsequent maternal multiorgan failure.21
Early identification of preeclampsia increases the likelihood of proper early management and reduction of poor prenatal outcome. Unfortunately, in spite of a great deal of investigation into serum markers that might help to identify women at risk of developing preeclampsia, no reliable markers have been found, nor is there a consistent standard for clinical identification of this potentially devastating condition.21 Similarly, no preventative measures for preeclampsia have been identified with any certainty. Current pharmacotherapy is able to reduce blood pressure and prevent the development of eclampia (preeclampsia with seizures), but it cannot stop the progression of the condition once it is established. Fetal intrauterine growth restriction is a major consequence of this disease. Initial ultrasound at 18 to 20 weeks gestation documents baseline fetal growth. When a woman is diagnosed with preeclampsia, serial ultrasounds at 28 to 32 weeks gestation and then monthly until term, are suggested for objective measurement. Fetal well-being tests such as non-stress tests (NST) and biophysical profile (BPP) are ordered in the third trimester. Fetal movement counts are helpful as a subjective measurement the woman can do at home. A variety of therapeutic strategies have been evaluated for the prevention and treatment of preeclampsia. These are discussed in the following.
Diuretics
Diuretics were once assumed to be a beneficial part of treatment of preeclampsia with its attendant hypertension and edema. However, women with preeclampsia are actually hypovolemic and hemoconcentrated; therefore, the use of diuretics may exacerbate the condition, and thus their use for this condition has been abandoned.21
Salt Restriction
There is no evidence that salt restriction is of any benefit in the prevention or treatment of preeclampsia.25,26
Antihypertensive Medication
Antihypertensive therapy for women with preeclampsia does not affect the underlying disease process or improve mother–baby outcome.26 Further, antihypertensive medications have been associated with adverse side effects, including total placental hypoperfusion; thus, their use is reserved for the treatment of chronic and severe hypertension.26
Aspirin
Data from randomized trials and meta-analysis have been conflicting on the prophylactic and therapeutic effects of low-dose aspirin for preeclampsia. The use of aspirin is predicated on the fact that widely disseminated endothelial dysfunction and platelet disturbances are associated with the etiology of this condition. Low-dose aspirin is thought to be effective because of its thromboxane synthesis inhibition, with consequent reduction in platelet aggregation, as well as its ability to inhibit free radical formation (lipid peroxides) and support of resistance to angiotensin II in pregnant women with increased susceptibility to this vasoconstriction substance.21,27,28 The most recent systematic review of all randomized trials to meet the reviewer’s inclusion criteria (39 trials with a total of 30,563 women) showed a positive safety profile with a moderate, but significant, reduction in the risk of preeclampsia regardless of weeks gestation at trial entry or dose of aspirin. A 15% reduction in incidence of preeclampsia was observed, with an 8% reduction in preterm birth and a 14% reduction in risk of perinatal death.29 In spite of disagreement of the value of aspirin for preeclampsia in earlier studies, all studies have demonstrated that aspirin use in recommended doses during pregnancy appears safe.21 Recent evidence suggests that the earlier in pregnancy that the aspirin is started, the greater the benefit. The recommended dosage range for optimal effects is between 80 and 150 mg per day, specifically to be taken at bedtime.30,31
Calcium
Studies on the efficacy of calcium supplementation for prophylaxis and treatment of preeclampsia have been equivocal. A recent, large, multicenter, randomized prospective trial of 2 g of elemental calcium vs. placebo given to healthy, nulliparous pregnant women beginning in their second trimester showed no differences in the incidence or severity of hypertensive disorders.32 However, a more recent trial demonstrated benefit for women who were at very high risk for developing preeclampsia.33 A proposed mechanism is via prevention of a compensatory rise in parathyroid hormone associated with low serum calcium, and consequently, smooth muscle contraction; however, this remains theoretical.21
Vitamins C and E
Oxidative stress has been proposed as a mechanism associated with the development of preeclampsia. Further, studies have demonstrated decreased levels of antioxidant levels in women with preeclampsia. This has prompted evaluation into the use of vitamin C and E supplements as possibly prophylaxis and therapy. The risk of developing preeclampsia was seen to be lower in high-risk women begun on supplementation at 16 to 20 weeks gestation compared with placebo.21 At this point, the role of antioxidants in this condition remains unclear. For women wishing to supplement vitamin C during pregnancy, it is recommended not to exceed 2000 mg per day to avoid the risk of sensitivity or neonatal rebound scurvy.
Chronic Hypertension
Chronic hypertension is defined as hypertension that predated pregnancy, or hypertension beginning prior to 20 weeks gestation. This diagnosis is not easy to establish in women who have not had care prior to pregnancy and because hypertension prior to 20 weeks gestation can also be indicative of preeclampsia that can occur early in pregnancy in a limited number of conditions.21 Blood pressure levels are less suggestive of poor maternal or fetal outcomes, including fetal growth retardation, prematurity, preeclampsia, placental abruption, and maternal or perinatal morbidity and mortality than are the onset of proteinuria and symptoms of preeclampsia.35,36 The health care professional may order electrocardiography, echocardiogram, ophthalmologic exam, and renal ultrasound. Women with mild hypertension (140 to 159 mm Hg systolic or 90 to 105 mm Hg diastolic) generally do well in pregnancy and, overall, do not need antihypertensive medication. In fact, women already taking antihypertensive medications may need to decrease the dose as some studies have shown decreased uteroplacental blood flow and fetal growth with medication.37 Tapering or stopping antihypertensive medications is done under close observation. Antihypertensive therapies are given to reduce the risk of maternal stroke and cardiovascular complication in women with a diastolic BP of >105 mm Hg. Recommendation of antihypertensive treatment is done when blood pressure levels reach or exceed 160 mm Hg systolic or 100 to 106 mm Hg diastolic, when abnormal laboratory values are found, and certainly with a combination of both abnormal factors. Oral antihypertensive medication with methyldopa or labetalol is typically recommended. Methyldopa does not appear to have negative effects on uteroplacental blood flow.38 Some women, however, do not tolerate it well because of drowsiness. Labetalol, a combined alpha- and beta-blocker, is another choice and can also be prescribed postpartum when breastfeeding. Ideally, women with chronic hypertension need to be evaluated before pregnancy for severity of the hypertension, modification of lifestyle habits and target organ damage (heart, kidney). Women with significant renal impairment (serum creatinine 71.4 mg/dL) may have further deterioration in pregnancy. Women with cardiac abnormalities may have underlying diseases in addition to chronic hypertension. Most women with mild chronic hypertension (140/90 mm Hg) have no end-organ involvement and can have uncomplicated pregnancies.
Gestational (Transient) Hypertension
Elevated blood pressure appearing after 20 weeks without proteinuria and with normal laboratory values in a previously normotensive woman generally results in a good outcome.21 However, gestational hypertension is considered a provisional term. Although most women will not develop subsequent problems, up to 25% will go on to develop symptoms of preeclampsia.39 Women with gestational hypertension appear to be at significantly increased risk of maternal and perinatal morbidity, with elevated rates of preterm delivery, small for gestational age infants, and abruptio placenta compared significantly higher than in the general obstetrical population, and similar to rates reported for women with severe preeclampsia.39 Thus, women with a diagnosis of gestational hypertension should be monitored closely, with weekly prenatal visits optimal. Ultrasound and fetal well-being tests are appropriate in the third trimester. If symptoms of preeclampsia develop, women are treated as is appropriate for that condition. If elevated blood pressure readings persist 12 weeks postpartum, a diagnosis of chronic hypertension is made retrospectively.
BOTANICAL TREATMENT OF HYPERTENSION IN PREGNANCY
Cramp Bark and Black Haw
Cramp bark and black haw have been used by midwives as part of herbal antihypertensive protocol for gestational hypertension. Traditionally, they have been used as musculoskeletal relaxants during pregnancy, and to treat irritable uterus, prevent premature labor, and relieve incoordinate uterine contractions.40,41 They are taken in tincture form, either alone or more typically with relaxing nervines and hawthorn, for this purpose in Table 15-3.
Garlic
Garlic has mild antihypertensive properties and inhibits platelet aggregation and inflammation. No studies have evaluated the efficacy or safety of garlic use for pregnancy hypertension. Garlic is a common food used during pregnancy worldwide, and in modest doses is not expected to cause any adverse effects. The German Commission E gives no contraindication to its use during pregnancy, nor does the Botanical Safety Handbook, which does however provide a caution about use during lactation because of active constituents passing through the breast milk. 42 43 44 (McKenna et al. note that the dose of constituents received through breast milk is actually quite small.)43 A randomized control study of 100 primigravid women given either 800 mg/day of garlic tablets or placebo during third trimester pregnancy to evaluate the effect of garlic supplementation on preeclampsia found that pregnancy outcomes were comparable in both groups. There were no reports of side effects in the garlic group other than garlic body odor, and nausea, nor reports of an incidence of adverse fetal outcomes or spontaneous abortion.45 Garlic odor was identifiable in the amniotic fluid of a small group of pregnant women taking garlic supplements.46 It is commonly recommended that because of its antithrombotic effects, garlic use should be discounted 7 days prior to surgery.43 A recent Cochrane review evaluating the effects of garlic on preeclampsia and its related complications concluded that there is insufficient evidence to recommend increased garlic intake for preventing preeclampsia and its complications, and that side effects have not been reported with its use in pregnancy.47 Although the actual risk of bleeding is uncertain, it is prudent to discontinue the medicinal use of garlic 3 weeks prior to the due date to minimize any increased risk of bleeding, as women with hypertensive disorders during pregnancy are more likely to enter labor early.
Hawthorn
Hawthorn has been used for treating a variety of cardiovascular conditions, and has noted antioxidant effects and antiplatelet aggregating effects, which may be of benefit in preventing pregnancy hypertension.42,43,48 Other noted actions are an increase in the integrity of blood vessel wall, improvement in coronary blood flow, and positive effects on oxygen use.43 There are no known contraindications or restrictions to the use of this herb during pregnancy or lactation. 42 43 44
Reishi
Although not classically used for the treatment of hypertension in pregnancy, it is worth mentioning that the medicinal mushroom Ganoderma lucidum has demonstrated positive results in research looking at its antihypertensive effects, as well as effects against diabetes and hyperlipidemia. 49 50 51 One interesting study looked at the effects of reishi on glomerular function, and found that it was able to improve hemodynamic flow in glomerular disease and reduce proteinuria. The beneficial effect of Ganoderma lucidum appears to be multifactorial, including the modulation of immunocirculatory balance, antilipid, vasodilator, antiplatelet, and improved hemodynamics. Together with vitamins C and E, this herb helped to neutralize oxidative stress and suppress the toxic effect to the glomerular endothelial function.52 Extracts of reishi polysaccharides have demonstrated significantly improved basal nitrous oxide (NO) release and endothelium-dependent relaxation but without affecting endogenous nitrous oxide synthase (NOS) activity. These results suggest that this herb has the potential to improve endothelium-dependent relaxation in mineralocorticoid hypertension.53 In a study evaluating the clinical effects of lyophilized G. lucidum extract, 53 patients were divided into two groups: Group I consisted of essential hypertensive patients, and Group II consisted of mild hypertensive or normotensive patients. The patients were instructed to take six tablets containing 240 mg of the extract per day. Biochemical and hematologic examination were performed for 21 test items, and the following results were obtained.1 In regard to hypertension, blood pressure significantly decreased in Group I, but did not in Group II, thus showing that G. lucidum has an ameliorating effect on hypertension.2 In regard to biochemical and hematologic effects, the oral intake did not result in any change in the values of any of the 21 test items beyond the normal range, except that total cholesterol decreased slightly and fibrinogen increased slightly. It was therefore concluded that G. lucidum has blood pressure lowering effect on patients with essential hypertension and will not have any side effects on patients with essential or border line hypertension during 6 months oral intake.54 No safety data on use during pregnancy was identified.55 Reishi may be taken alone or in combination with other herbs, and may be taken as a liquid extract or in solid (pill) form (Box 15-4).
BOX 15-4 Protocol for Chronic or Gestational Hypertension
Tincture Formula for Cardiovascular Support
| Hawthorn | Crataegus oxyacantha | 40 mL |
| Cramp bark or black haw | Viburnum spp. | 30 mL |
| Passion flower | Passiflora incarnata | 30 mL |
| Total: 100 mL |
ADDITIONAL THERAPIES
Nutritional Considerations
A diet rich in calcium, magnesium, and potassium may lessen cardiovascular risk. A diet rich in fruits, vegetables, whole grains, legumes, nuts, good-quality oils, and low-fat foods is associated with decreased hypertension and may be especially beneficial for women with chronic hypertension. Essential fatty acids may be beneficial in the prevention of pregnancy hypertension. Vascular sensitivity to angiotensin II was determined in the midtrimester of pregnancy in women after taking a diet with supplemented essential fatty acids and vitamins. The essential fatty acids linoleic and dihomo-gamma-linolenic acid were administered as evening primrose oil capsules (Efamol) for 1 week prior to the study. Vascular sensitivity was then determined in response to 4, 8, and 16 ng kg-1 min-1 angiotensin II. Vitamin supplements (Efavit) were given with the Efamol capsules. Seven women have been studied, and their vascular sensitivity compared with controls on normal diet. The vascular sensitivity was significantly reduced in all the patients on essential fatty acid supplements, and all values fell below the mean of the control group.56
GROUP B STREP (GBS) INFECTION IN PREGNANCY
In the 1970s, Group B Streptococcus (GBS), infection with Streptococcus agalactiae, emerged as a leading cause of pneumonia, sepsis, and meningitis in newborns.57 GBS is a normal inhabitant of the intestinal tract and colonizes the vaginal tracts of many women; it can be demonstrated by culture of combined rectal and vaginal swabs in 15% to 40% of pregnant women on random sampling. Most bacterial transmission to the neonate occurs during birth via passage of the baby through the birth canal, or via ascendant bacteria during labor with ruptured membranes. Premature babies and babies of mothers with premature or prolonged rupture of membranes (PROM) are at higher risk of infection. GBS can also cross the membranes, so cesarean section is not protective and carries additional surgical risks to the mother. Infection is categorized as either early or late onset. Early-onset disease symptoms manifest within a few hours, and up to a week after birth. Antibiotic prophylaxis administered to the mother during labor, as is discussed in the following, is used to prevent early-onset infection in the neonate. Late-onset disease develops through contact with hospital nursery personnel and usually manifests in the first 3 months after birth. Up to 45% of health care workers carry the bacteria on their skin, and may transmit the infection to newborns.58 Meticulous hand-washing practices in the hospital are essential for reduction of nosocomial disease transmission.
