JBRA Assist. Reprod. 2016;20 (4):257-258
CASE REPORT
doi: 10.5935/1518-0557.20160050
1Department of Obstetrics and Gynecology, Reproductive Endocrine and Infertility Medicine Department, King
Fahad Medical City (KFMC), Riyadh, Saudi Arabia
2Research Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
CONFLICT OF INTERESTS
No conflict of interest have been declared.
ABSTRACT
Recurrent miscarriage places a huge psychological burden on a woman who
is trying to conceive. Meanwhile, the use of traditional medicine still
plays an important role within the Saudi Arabian culture, where many
patients still seek alternative forms of therapy. However, this
traditional way of treatment might expose patients to many hazards. We
present a case of a 32-year-old pregnant woman with a history of
infertility and recurrent miscarriages. She used large amounts of myrrh
herbs for 2 months, since a traditional healer told her that her
current pregnancy would progress safely by its use. However, her
pregnancy was complicated with an acute abdominal pain. Her symptom was
relieved as soon as she stopped taking myrrh. We assume that myrrh
acted as a uterine stimulant causing acute abdominal pain. Scientific
studies should be carried out to evaluate the safety of Myrrh intake
during pregnancy.
Keywords: Pregnancy, myrrh, recurrent pregnancy loss, Saudi Arabia, herbal medicine, commiphora.
INTRODUCTION
Traditional medicine in Saudi Arabia, based on herbal remedies and
spiritual healing, still plays a prime role within the local Saudi
culture. Some people strongly believe in the essential role of herbs
for the treatment of medical conditions, including recurrent
miscarriages, which are difficult to be treated in any way. One of the
most used herbs in the Arabian Peninsula is called Myrrh,
scientifically known as Commiphora Myrrh (El Ashry et al., 2003).
The Myrrh genus, Commiphora, contains approximately 190 species of
shrubs and trees, which is distributed throughout the sub-tropical
regions of Africa, the western Indian Ocean islands, the Arabian
Peninsula, India, Vietnam, and South America (Nomicos, 2007). It may also be known as Murrah, Abyssinian Myrrh found in Ethiopia and Arabian Myrrh (El Ashry et al., 2003).
The composition of Myrrh includes a volatile essential oil,
sesquiterpenes, which is an alcohol-soluble resin containing
commiphoric acids and a water-soluble gum (Mills & Bone, 2005).
According to the Encyclopedia of Islamic Herbal Medicine (Goodier, 2012)
“The Messenger of Allah stated: ‘Fumigate your houses with al-shih,
murr, and sa’tar’”. The author claims that this use of the word “murr”
refers specifically to Commiphora myrrha.
A study carried out by
Chinese researchers, also found that resins from myrrh extracts might
be effective against human gynecologic cancer cells (Su et al., 2011). Some women use myrrh oil during childbirth in order to lessen labor pain, an old practice that was exclusive for royalty (Hillson, 1988). The appropriate dose depends on several factors, such as the user’s age, health, and several other conditions (El Ashry et al., 2003).
Large doses may be unsafe; amounts greater than 2-4 grams can cause kidney irritation and heart rate changes (El Ashry et al., 2003). There is not enough scientific information to establish an appropriate dose range for myrrh (El Ashry et al., 2003).
In terms of pregnancy and lactation, taking myrrh orally during
pregnancy is unsafe and should be avoided. Myrrh can stimulate the
uterus and might cause miscarriage or preterm labor; nevertheless,
there isn’t enough information to rate the safety of using myrrh
locally on skin during pregnancy (Al Awadi & Gumaa, 1987). Breast-feeding women should also avoid using myrrh, since the safety of using it when breast-feeding is still unknown (Al Awadi & Gumaa, 1987).
Myrrh also stimulates uterine bleeding, which is why it is used by some
women to enhance blood flow during the early days of their periods (El Ashry et al., 2003). Taking Myrrh with Warfarin, an anticoagulant agent, decreases its action and increases the chance of blood clotting (Ernst, 2002).
CASE REPORT
We present a case of a 32 years old pregnant Saudi woman, a current IVF
pregnancy, with gestational age of 9 weeks. She had had a history of
infertility for 10 years and a history of 4 previous spontaneous
miscarriages despite thromboprophylaxis. The patient presented to the
Emergency Room complaining of severe lower abdominal pain, worse on the
right lower quadrant radiating to the right groin. It was associated
with nausea and vomiting for 2 days. Upon examination, the patient was
in pain, but vitally stable. Abdominal examination showed generalized
lower abdominal tenderness, with positive rebound tenderness and
positive renal angle tenderness over the right side as well.
Investigations included initial blood tests: complete blood count,
renal function test, electrolytes, liver function test and serology,
midstream specimen urine (MSU) analysis and all were found to be
normal. Gynecological US confirmed the pregnancy by visualizing an
intrauterine single viable embryo at gestational age of 8 weeks and 6
days, consistent with the Embryo Transfer (ET) date. The right ovary
measured 89x47x61 mm with about 15 follicles, and the largest was 22x20
mm and the left ovary measured 68x45x52 mm with about 10 follicles,
with the largest being 22x20 mm. Small volume of free fluid was seen in
the pelvis. Ultrasound of the kidney, urethra, bladder, liver and
biliary tract were normal.
After an initial denial of any history of herbal medicine intake, the
patient later stated having 2 cups of myrrh a day. The Myrrh resin was
dissolved in a 500 ml water bottle after consulting a traditional
healer. The traditional healer advised the intake of myrrh to avoid
pregnancy loss, which the patient complied with as soon as she
discovered her pregnancy. In the hospital, after admission, the patient
was advised to stop taking myrrh immediately and continue on enoxaparin
60 mg subcutaneous once a day. One day after doing so, the patient was
discharged home as she was in a stable clinical condition, with no
active complaints. She was followed throughout her pregnancy and
delivered a normal healthy baby at 38 weeks of gestation. Patient’s
consent was taken for reporting her case and ethics’ committee’s
approval was obtained through the Institutional Review Board to issue
this case report.
DISCUSSION
The C. molmol extract (myrrh) carries analgesic, anti-inflammatory and anti-hyperlipidemic effects (Chevallier, 1996).
The main Myrrh components are: volatile oil (primarily sesquiterpenes),
triterpenes, and gum resin with reported actions as analgesic,
antifungal, antiseptic, astringent, carminative, emmenagogue,
expectorant, antispasmodic, disinfectant, immune stimulant, circulatory
stimulant, stomachic, tonic, and vulnerary (Chevallier, 1996).
The oily gum resin of Commiphora increases the number of leucocytes and
stimulates phagocytosis and thus Myrrh is used for the treatment of the
female reproductive tract disorders mainly as a disinfectant, and as an
astringent (Chevallier, 1996, Saeed & Sabir, 2004).
This resin is the Myrrh component that acts as a uterine stimulant and emmenagogue (Saeed & Sabir, 2004). Despite its widespread usage, Myrrh is not recommended for pregnant women because of its effects as a uterine irritant (Chevallier, 1996, Saeed & Sabir, 2004).
This is in agreement with to what has possibly happened to our patient,
who had been admitted with acute abdominal pain, and whose symptoms
were relieved as she stopped taking Myrrh.
Despite several reports
on the effective usage of Myrrh, more evidence is needed to rate its
actions, especially during pregnancy.
CONCLUSION
While traditional
healers would claim their curing abilities, the safety of herbal
remedies has been always a subject for debate. Further scientific
studies should be conducted to evaluate the safety of commonly used
local herbal remedies, especially during pregnancy.
Until such conclusive results are available in the literature, the huge
task of healthcare professionals is to educate the population and the
healthcare professionals in order to gradually shift community beliefs
from relying on spiritual healers with their herbal treatment of
unknown safety to well recognized contemporary medications.
Acknowledgements
Joza Al-Dohaim for informing me about the existence of such an important herb.
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