Blue Cohosh Adverse Effects

Cardiotoxic effects of Blue Cohosh on a fetus

A newborn infant whose mother took capsules of blue cohosh (Caulophyllum thalictroides) for several weeks as a preparation for birth was born with an acute myocardial infarction, congestive heart failure, and shock. The labor was also precipitous, coming on suddenly and lasting only one hour (Jones and Lawson). Some herbalists and midwives have responded to the case defensively, arguing that centuries of traditional use has never shown this effect before, and that the infant's problems cannot be attributed to blue cohosh on the basis of this single anecdote.

However, blue cohosh contains alcohol-soluble constituents with demonstrated effects on the heart (Jones and Lawson) and a similar case has appeared previously in the scientific literature (Gunn and Wright). One traditional herbal on women's health care warns that blue cohosh can cause precipitous labor when used alone, and that it can affect fetal heart tones during delivery (Weed), and another from 1869 says that the plant was only rarely used in the form of a powder (Cook). This article will examine the historical use of blue cohosh and will demonstrate that Native American use of the plant before the onset of labor was by no means universal; that the mother in the current study consumed a form and dose that were greatly in excess of traditional use by whites, and that blue cohosh was only rarely used alone as a partus preparator (preparation for childbirth).
Early references

The use of blue cohosh as a preparation for pregnancy appears to have entered the American medical literature in the works of medical botanist Constantine Rafinesque in 1828. He states that Native Americans employed ". . . constant use of tea 2-3 weeks prior to partruition," attributing this information to a commercial pamphlet published in 1813 in Cincinnati by an "Indian doctor" named Peter Smith who sold the herb commercially. Note that the term Indian doctor at that time did not necessarily refer to someone of Native American ancestry, and the doctor had not necessarily studied with Native Americans. It was a description of an herbalist who used the native North American plants, plants whose uses had for the most part not entered into regular medicine. Smith's statement cannot be accepted as a primary reference to native American use, although it was repeated in medical literature for the next hundred years on the strength of Rafinesque's reputation. Rafinesque himself only stated that the plant deserved further study.
Native American use

Three standard secondary sources for native American plants show only occasional use of the plant as a preparation for childbirth, although use during labor to promote delivery is more common (Erichsen-Brown, Moerman, Vogel). Vogel mentions use of the plant as emmenagogue, stomachic, aperient, deobstruent, febrifuge, sudorific, demuclent, antispasmodic, antirheumatic. It was also used for suppression of menstruation and for genitourinary complaints in either sex. He mentions its use for stalled labor, but his only reference to use as a partus preparator is a citation of Rafinesque. Erichsen-Brown describes the same uses and sources as Vogel, adding some Canadian sources which repeat the description of Rafinesque. Other than these, she does not describe any use specifically as partus preparator, although use for stalled labor is implied. Most of the tribes listed in Moerman's compendium of Native American plant uses did not reveal the use of blue cohosh as a childbirth aid. Of the ten tribes listed which used caulophyllum, only two ethnobotanical studies found caulophyllum used as a childbirth aid, and in these it is not clear whether they were used as preparation for childbirth or for stalled labor. Moerman's book contains the weaknesses of the field of ethnobotany in general, as there is no guarantee that the women of the tribes told the researchers what they used for childbirth. However, it seems that the use of caulophyllum for childbirth was by no means universal among the tribes within its range, and the major source for taking it as a partus preparator is from a single reference by Peter Smith in 1818, repeated in Rafinesque.
Thomsonian use

Thomsonian herbalism was the dominant system of herbalism, and in rural areas formed a dominant system of primary care medicine, between the 1820's and 1850s. Samuel Thomson himself did not appear to be aware of blue cohosh in his early writings, but by the 1830's the herb was used as a part of the Mother's Cordial formula (see Medical Herbalism volume 10, number 3, pages 18-19). The formula has probably been in continuous use as a preparation for childbirth in the United States from the time it was developed by Dr. P.F. Sweet on Connecticut in 1828 until the present day, and is available in tincture form from a variety of suppliers. Thomsonian Benjamin Colby does not record any use of blue cohosh as a single herb in preparation for birth in his text from 1846, and neither does Physiomedicalist William Cook in 1869. Cook states that the herb was used primarily in decoction, and only rarely as a powder. It is notable that the Thomsonians often used very large doses of herbs — as much as an ounce a day of the emetic lobelia for instance — yet used this herb conservatively in pregnancy, in small doses in decoction, and in conjunction with other herbs. This widespread historical use demonstrates safety of the herb in this form in most cases. Occasional fatal averse effects on the fetus could have been missed during this era of high infant mortality.

Other medical use` The other schools of medicine gradually adopted the use of blue cohosh from the Thomsonians, with the exception of Ellingwood in 1919, none of the Eclectics advocated use of blue cohosh alone as a preparation for pregnancy. Ellingwood used doses of 5-10 drops of the fluid extract as a preparation for pregnancy. It was commonly used by all the schools for stalled labor. The homeopaths used it as a partus preparator in homeopathic potency or in drop doses of the tincture for a few weeks before birth, and also to prevent miscarriage in certain cases (Hale). See Table 1 for a review of the historical forms and doses of blue cohosh as a childbirth aid.
Form and dose

The table on page 13 shows a summary of the historical forms and doses of blue cohosh as a childbirth aid in North American and British herbal literature. With only a few exceptions, it was not used alone as a preparation for childbirth, but was used with other herbs in the Mother's Cordial formula. Relatively large doses of the root or powder were used in decoction, but only very small doses of the tincture were used. Use of the powder undecocted as a preparation for childbirth is not recorded in these texts. The high-dose of decoction vs low-dose of tincture pattern suggests that the active properties of the plant are poorly soluble in water and very soluble in alcohol. Eclectic pharmacist John Uri Lloyd states in 1898: "Blue cohosh partially yields its virtues to hot water and glycerin, and fully to alcohol." Jones and Lawson suggested that the constituents responsible may have been the alkaloid methylcystine, which has vasoconstrictive effects, or the saponins caulosaponin and caulophyllosaponin, which are uterine stimulants and may also cause coronary vasoconstriction.
Use and side effects

If traditional use were followed, blue cohosh as a partus preparator would be used in relatively large dose as a decoction, in very small doses as a tincture, and would not be used alone or as powder or whole root. Among contemporary herbalists, Susun Weed states that blue cohosh should not be used alone, because it can cause precipitous labor. She also states that when using it in stalled labor "if fetal heart-tones are monitored, there may be noticeable elevation as the blue cohosh starts to work." Simon Mills states that it is "... probably unsafe to take in pregnancy until labor has commenced," and Sharol Tilgner states: "Overdose may cause nausea, vomiting, headache, thirst, dilated pupils, muscle weakness, incoordination, constriction of coronary blood vessels, cardiovascular collapse, and convulsions."
Conclusion

In the 1998 case reported by Jones and Lawson, the mother took 1 tablet of blue cohosh powder three times a day for three weeks before birth. Her midwife had instructed her to take 1 tablet per day. Blue cohosh powder contains all the alcohol-soluble constituents of the plant, and if used at all would require very low doses, 5-10 mg of the power for instance, and a dose of even 1 capsule would be an overdose by a factor of 30-60 times. The use of blue cohosh in this form is not supported by historical herbal use, and the precipitous labor and cardiotoxicity are consistent with pre-existing warnings in contemporary herbal literature.
Historical use of Caulophyllum thalactroides as a childbirth aid

Smith, 1813 Partus preparator

"Constant use of tea 2-3 weeks prior to parturition" attributed to Native women.
Colby, 1846

Partus preparator

1-6 grams per day as decoction, in 2-3 doses as component of Mother's Cordial. With Mitchella, Viburnum, Chamalirium. Decoction.
Williams, 1850?

Stalled labor

Unspecified dose
Gunn, 1861

Partus preparator

8 grams per day decocted in 2 doses.
Cook, 1869

Not alone in childbirth

6-8 grams daily as decoction, in 3 doses.

"Rarely used in powder" mostly in decoction.

Partus preparator

1-6 grams per day as decoction, in 2-3 doses. As component of Mother's Cordial. With Mitchella, Viburnum, Chamalirium.

Stalled labor

2-2.7 grams as decoction per half hour, with Cyprepedium, Trillium, Myrica.
Hale, 1878

Partus preparator

Homeopahtic dilutions of several drops of the tincture for a few weeks
Ellingwood, 1919

Partus preparator

5-10 drops fluid extract

Stalled labor

Same
Felter, Lloyd, 1898

Not specific as partus preparator

1-3 grams every 3-4 hours as decoction. 3-10 Drops Specific Caulophyllum (a concentrated pharmaceutical extract)
Fetter, 1922.

Partus preparator

6-12 grams per day as decoction, in 3 doses, as decoction, for a few weeks before birth, as component of Mother's Cordial. With Mitchella, Viburnum, Chamalirium.
Grieve, 1931

Stalled labor

3.5-7 grams root as decoction or 130-325 mg of powder.
Mausert, 1932

Emmenagogue

1.5-2.3 grams/day as decoction, as component of larger formula,
Lust, 1974

Stalled labor

1.3 grams as decoction each 2-3 hours "only under medical supervision"
Shook, 1978

Stalled labor

1.3-1.7 grams as decoction.
Priest, Priest, 1982

Stalled labor

Unspecified dose of tincture.
Mitehell, 1983

Stalled labor

30 drops tincture in two cups of water sipped throughout the day.
Weed, 1985

Partus preparator

5-10 drops tincture twice daily, with an equal amount of black cohosh, taken alone "Can cause precipitous labor"

Stalled labor

3-8 drop doses per half hour. "If fetal heart tones are monitored, there may be noticeable elevation as the blue cohosh starts to work"
Wren, 1988

Ambiguous references on childbirth.

0.3-2 g powder
Mills, 1991

Stalled labor

0.6-3 g powder "Probably unsafe to take in pregnancy until labor has commenced"
References

Colby, B. A Guide to Health, being an Exposition of the Principles of the Thomsonion System of Practice. Milford, N.H.: John Burns, 1846

http://chili.rt66.com/hrbmoore/ManualsOther/ManOther.html

Cook, W. The Physiomedicalist Dispensatory. Cincinnati: William Cook, 1869

Edmunds J. Blue cohosh and newborn myocardial infarction? Midwifery Today Int Midwife 1999 Winter;(52):34-5

Ellingwood, F. Eclectic medical Publications: Portland, Oregon, 1983 [Reprint of 1919 edition] American Materia Medico, Therapeutics, Pharmacognosy

Erichsen-Brown, C. Medicinal and Other Uses of North American Plants. New York: Dover Publications, 1979

Felter, H. and Lloyd, J.U, Kings American Dispensatory. Portland, Oregon, Eclectic Medical Publications, [original publication date, 1898]

Felter H. The Eclectic Materia Medico, Pharmacology, and Therapeutics. Portland, Oregon: Eclectic Medical Publications, 1985 [Reprint of 1922 original] http://chili.rt66.com/hrbmoore/FelterMM/Felters.html

Grieve, M. A Modern Herbal. New York: Dover, 1931

Gunn, J. New Domestic Physician or Home Book of Health. Cincinnati, Ohio: Moore, Wilstch, Keys, 1861

Hale, E. M. Special Therapeutics of the New Remedies. New Delhi: B. Jain Publishers, 1995 [Reprinted from 1875 original]

Gunn TR, Wright IM. The use of black and blue cohosh in labour. N Z Med J. 1996 Oct 25; 109(1032):410-1

Jones TK, Lawson BM. Profound neonatal congestive heart failure caused by maternal consumption of blue cohosh herbal medication J Pediatr 1998 Mar; 132(3 Pt 1):550-2

Lust, J. The Herb Book. New York: Bantam, 1974

Mausert, O. Herbs for Health. San Francisco, California: Otto Mausert, 1932.

http://chili.rt66.com/hrbmoore/ManualsOther/MausForm.txt

Mills, S. The Essential Book of Herbal Medicine. London: Pengiun Books, 1991

Mitchell, W. Naturopathic Applications of the Botanical Remedies. Seattle, Washington: William Mitchell, 1983

Moerman, D. Native American Ethnobotany. Portland, Oregon: Timber Press, 1998.

Priest and Priest, Herbal Medication. London: L.N. Fowler, 1982

Rafinesque, C.S. Medical Flora or Manual of Medical Botany in the United States. Volume 1. Philadelphia, Atkinson and Alexander, 1828

Shook, E. Advanced Treatise in Herbology. Beaumont, California: Trinity Center Press, 1978

Smith, P. Cited in Rafinesque, C.S. Medical Flora or Manual of Medical Botany in the United States. Volume 1. Philadelphia, Atkinson and Alexander, 1828

Tilgner, S. Herbal Medicine From the Heart of the Earth. Creswell, Oregon: Wise Acres Press, 1999

Vogel V. American Indian Medicine. Norman, Oklahoma: University of Oklahoma Press, 1970.

Weed, S. Wise Woman Herbal for the Childbearing Year. Woodstock, New York: Ash Tree Publishing, 1985

Williams, S. "Report on the Indigenous Medical Botany of Massachusetts." Transactions of the American Medical Association II, p 914. Cited in Vogel V. American Indian Medicine. Norman, Oklahoma: University of Oklahoma Press, 1970.

Wren, R.C. Potter's New Encyclopedia of Botanical Drugs and Applications. Saffron Walden, England: C.W. Daniel, 1988

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