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Toxicology sessions: beware of poisoning due to abortion… : Emergency medicine news

herbal abortifacient, abortion, Dobbs versus Jackson, poisoning, Roe versus Wade:

Clockwise from top left: pennyroyal, blue cohosh, black cohosh, mugwort, rue and cinchona (quinine).

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Online searches for DIY abortions using herbs skyrocketed after draft decision leaked in Dobbs v. Jackson Women’s Health Organizationthe Supreme Court case that has now overturned Roe vs. Wade. (New York Times. July 11, 2022; https://nyti.ms/3zkt6ls.) The #pennyroyaltea, #mugwort and other hashtags have become extremely popular, especially on TikTok.

Numerous TikTok videos promoting ancient herbal preparations as abortifacients have been taken down, but similar discussions can still be found online. We emergency physicians and medical toxicologists are likely to see more cases of exposure and overdose of traditional methods of pregnancy termination due to the Dobbs decision.

None of these methods consistently induce abortion, and some can cause significant morbidity and even death. But now seems like a good time to look at the toxicity of some of the more common herbal “abortifacients.”

Pouliot (Pulegium mint)

Think acetaminophen when you think pennyroyal. (Mnote mnemonic: pennyroyal ~ Tylenoyal.) Pennyroyal, like acetaminophen, is hepatotoxic, causing centrilobular necrosis in the liver. Like acetaminophen, its main toxic ingredient, pulegone, is converted to a more toxic metabolite, menthofuran, by the liver enzyme P450 CYP2E1. Liver damage occurs when liver stores of glutathione are depleted, which also occurs with acetaminophen.

Pennyroyal is a perennial bush in the mint family with distinctive purple flowers. It is native to the Mediterranean region but now widely distributed. It has been used since ancient times to induce abortion, treat headaches and excessive flatulence, and repel insects.

This herb is probably best known from the Nirvana song “Pennyroyal Tea”, in which Kurt Cobain sings: “Sit down and drink Pennyroyal tea / Distill the life that’s inside of me / Sit down and drink Pennyroyal tea / I’m anemic royalty”.

Early signs and symptoms of pennyroyal toxicity include nausea and vomiting, abdominal pain, and dizziness. Chemical hepatitis with elevated levels of AST and ALT begins within 24 hours of ingestion. This is followed by true liver dysfunction manifesting as coagulopathy, renal failure, seizures and, in rare cases, death on large exposures. The essential oil is much more concentrated and toxic than the leaves of the plant or the tea made from it.

Treatment for pennyroyal toxicity involves supportive care. Since pennyroyal produces effects similar to those of acetaminophen, administration NOT-Acetylcysteine ​​would be a reasonable intervention. Many adverse effects of pennyroyal are the result of P450 metabolism, and it is an intriguing but unresolved question whether the CYP2E1 inhibitor fomepizole would provide clinical benefit.

Blue Cohosh (Caulophyllum thalictroides)

This flowering plant with prominent blue berries is native to the eastern region of North America. It has long been used in Native American culture to induce labor and contains glycosides, which can promote contraction of the uterus, and methylcytisine, an alkaloid that acts as a nicotine agonist.

Exposure to blue cohosh can cause hypersalivation, nausea, vomiting, and seizures. A case has been reported in a 21-year-old woman who developed the typical nicotinic signs and symptoms of tachycardia, vomiting, abdominal distress, diaphoresis and muscle weakness with fasciculations after ingesting a tincture of black cohosh intended to induce an abortion. . (Vet Hum Toxicol. 2002;44[4]:221.) Evidence has also shown that blue cohosh can cause birth defects of the fetal cardiovascular system.

Mnemonic mnote: Blue cohosh → Camel Blue cigarettes → nicotine.

Black cohosh (Cimicifuga racemosa)

Black cohosh is a completely different genus with a different toxic profile than blue cohosh despite their similar names. It is sometimes recommended online as an abortifacient, but I have found no evidence that it is effective for this. Data on its adverse effects are also thin, but its use has been associated with hepatotoxicity and heart block with bradycardia.

Artemisia (Artemisia vulgaris)

This plant was named after Artemis, the Greek goddess of childbirth, points out John M. Riddle in his book, Eve’s Herbs: A History of Contraception and Abortion in the West. Recent animal studies have indicated that it impairs implantation. Mugwort contains thujone, the same chemical found in wormwood that is used to make wormwood. The herb can produce allergic reactions and has been reported to cause hallucinations.

Street (Ruta graveolens) and quinine (bark of cinchona trees)

Rue and quinine are also sometimes considered abortifacients. Small doses of rue are used in cooking, where its bitter taste has caused it to be associated with regret. Topical exposure to rue can cause phytotoxic blister contact dermatitis. Ingestion of large amounts of rue has been associated with liver and kidney damage.

Manifestations of quinine cinchonism include headache, nausea, hearing loss with tinnitus, dizziness, and gastrointestinal disturbances. Large doses of quinine can produce potentially fatal hematological and cardiovascular toxicity.

None of these herbs and plants have been shown to induce abortions consistently, and many of them can cause significant morbidity or mortality if taken in high doses. Using them as abortifacients is extremely dangerous. Unfortunately, we may be seeing more frequent cases of toxicity from these and other plants due to recent court rulings and state legislative actions. We should also note that these herbs are considered supplements, so it will be impossible to know exactly what they contain without extensive analytical testing.

Dr. Gussowis a volunteer attending physician at the John H. Stroger Hospital of Cook County in Chicago, assistant professor of emergency medicine at Rush Medical College, consultant at the Illinois Poison Center, and senior lecturer in emergency medicine at the University of the Illinois Medical Center in Chicago. Follow him on Twitter@poisonreview, and read his past columns onhttp://bit.ly/EMN-ToxRounds.