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Ginger: a Cautionary Alternative Therapy for Nausea and Vomiting during PregnancyChloe Clark Trent University NURS 3550H-FANovember 12th, 2014Tiran, D. (2012). Ginger to reduce nausea and vomiting during pregnancy: Evidence of effectiveness is not the same as proof of safety. Complimentary Therapies in ClinicalPractice, 18, 22-25. doi:10.1016/j.ctcp.2011.08.007.This article discusses the current research evidence available for ginger (Zingiber officinale) and its uses for decreasing nausea and vomiting in pregnant woman. The article focuses on the safety of ginger and emphasizes that it is not a universal remedy for nausea and vomiting during pregnancy, but instead should be used with caution. There are clear uncertainties about effective and safe doses with America stating a max dose of 2g/day, while China uses up to 9g/day. This warrants a need for more research on therapeutic and toxic levels. The research compiled evidence that indicated the anti-emetic effects of ginger are not fully understood. One agent, gingerol, is thought to be responsible for the anti-emetic effect, while shogaol and galanoactone are thought to work on serotonin receptors. A checklist of contraindications and cautions was created that consisted of effects, obstetrics, pathology, and interactive medications. The findings that were contained within Table 1 were well organized and will be useful for practitioners who deal with pregnant women, allowing them to point out if the individual will benefit from the use of ginger. It was stated that there is a lot of contradictory information from research which indicates that there is a need for a better understanding of how ginger effects women during pregnancy. Evidence shows that it has anticoagulation effects, can cause heartburn, and lower blood pressure. While ginger has obvious useful effects for reducing nausea and vomiting, it is clear that it must be taken as a serious medication that has many effects on the body and interactions with other medications. It was stated that there were no conflicts of interest declared, therefore this was taken into account during their research and we can accept the findings with this in mind. Ozgoli, G., Goli, M. & Simbar, M. (2009). Effects of ginger capsules on pregnancy, nausea andvomiting. The Journal of Alternative and Complementary Medicine, 15(3), 243-46. doi:10.1089/acm.2008.0406.This article discusses a clinical trial that studied ginger as a means of reducing nausea and vomiting during pregnancy. There were 67 pregnant women, < 20 week’s gestation, who participated in this single-blind controlled clinical trial. The participants were randomly split into an experimental or control group. Prior to treatment, participants filled out a questionnaire about demographics and rated their nausea and vomiting on a scale of 1-10 for the last 24 hours. The experimental group was given 250mg ginger capsules, taken 4 times a day, while the control group received capsules filled with lactose, taken at the same intervals; both groups took their capsules for 4 consecutive days . Participants were asked to complete a questionnaire daily, recording their nausea intensity and vomiting, at noon and at bedtime. A statistically significant difference was seen between the two groups with the experimental group seeing a 50% decrease in the incidences of vomiting, while only a 9% decrease for women in the control group. Intensity of nausea improved for 84% of the experimental group, compared to 56% in the control group. Limitations include the small study size, the short assessment period of the research design, and the use of lactose for the control— as this could cause nausea in women with lactose sensitivities. A study strength is the validity and reliability of the questionnaires being confirmed by a pilot study. No adverse effects occurred, however it was not explicitly stated how they identified adverse effects. The methods section was clearly stated and precisely identifying the experimental design. Overall, the results showed that 1000mg of ginger daily will decrease nausea and vomiting for pregnant women in Iran. Their findings were congruent with previous studies findings therefore increasing the validity of their findings.Ensiyeh, J., & Sakineh, M. A. C. (2009). Comparing ginger and vitamin B6 for the treatment ofnausea and vomiting in pregnancy: a randomised controlled trial. Midwifery, 25(6), 649-653. doi:10.1016/j.midw.2007.10.013.This article discusses a double-blinded clinical trial comparing the use of ginger and vitamin B6 in reducing nausea and vomiting during pregnancy. The participants included 69 women, 17 weeks gestation or less, from the antenatal clinic at Fattemieh University Hospital. The participants were randomly divided into two groups, ginger and vitamin B6. The women in the ginger group were given 500mg ginger capsules to be take twice daily, while the vitamin B6 group received 20mg vitamin B6 capsules taken twice daily; both groups complied with treatment for 4 days. Two scales were used to rate nausea intensity for the women, a visual analogue scale and a Likert scale. Baseline scores were recorded prior to treatment, then they were asked to record nausea intensity three times daily over the course of the treatment, as well as incidences of vomiting. The results showed a significantly greater reduction of nausea intensity for women taking ginger capsules (p = 0.024) compared to the vitamin B6 group. There was no significant difference between the groups for reduction in incidences of vomiting. According to the Likert scale results taken at a 1 week follow-up, 82.8% of the ginger group reported improved symptoms compared to 67.6% of the vitamin B6 group. A strength in this study was the use of two different reliable and validated scales for determining nausea intensity. A limitation to the study would be that there were possible dietary confounding factors not taken into consideration during the treatment. The methods of the study described each scale meticulously. In conclusion, the findings of the study were that ginger is more effective at reducing nausea than vitamin B6 during pregnancy, and just as effective in reducing the incidence of vomiting. Similar studies have come to the same conclusions. Background: Ginger (Zingiber officinale)Based on the information found from Ensiyeh and Sakineh (2009), Ozgoli, Goli, and Simbar (2009), and Tiran (2012), I believe ginger is an effective alternative therapy for reducing nausea and vomiting when taken appropriately, however I feel there is still too much unknown about its effects that deem it cautionary to pregnant women until further research has proved what qualifies a safe therapeutic dose. It is clear that ginger (Zingiber officinale) is a spice that has more uses than just within the kitchen, although it is not treated with the same respect that pharmaceutical medications are given. For centuries, Asian and Thai cultures have used ginger for cooking (Tiran, 2012 and Ozgoli et al., 2009). Indian, Chinese, and other eastern cultures have used ginger as an alternative medicine for its therapeutic effects as an anti-emetic (Tiran, 2012 and Ozgoli et al., 2009). It appears to be a newer practice within Western medicine to use ginger for its anti-emetic actions. Although it has been used as an anti-emetic for a very long time, therapeutic and toxic doses are widely disagreed upon throughout the world, therefore it is important to be cautious when taking ginger before consulting a physician. I found these articles extremely informative for myself as I plan to direct my career path towards maternal and infant healthcare, specifically within Labour and Delivery. The issue of alternative therapies, such as ginger, lacking an abundant amount of research increases my awareness of how difficult choosing the right therapies during pregnancy must be. Understanding how alternative therapies and medications affect a fetus is important for myself because I would like to take on a large role in educating pregnant women about safe and effective alternative medications. Knowing the mechanisms, actions, indications, interactions, and contraindications of alternative therapies will aid nurses in understanding if a medication is right for a specific individual. Tiran (2012) points out that countries such as Germany and Finland have ginger listed as unsafe during pregnancy. The 3 articles contradict each other in many ways which I believe decreased their reliability. Role of GingerPeople of all ages use ginger as an anti-emetic. Ensiyeh and Sakineh (2009), Ozgoli et al. (2009), and Tiran (2012) showed us that women use ginger to reduce nausea and vomiting during pregnancy. Ginger acts on many areas of the body using different mechanisms of action. It is frequently used in tea as a soothing agent for an upset stomach (Tiran, 2012). Tiran (2012) stated that there are many forms in which ginger can be taken— dried root, crystalized ginger, tea, or ginger ale/beer. She went on to explain that in many ways the therapeutic dose of ginger is not met with some types of ginger consumption and the relief from an upset stomach could be due to a placebo effect or a rise in blood sugar. It is important to focus on where pregnant women find information on alternative therapies that they plan to use during their pregnancy. According to Tiran (2012), there is an abundant supply of information available for pregnant women, however very little of it is backed by proper evidence. This is very alarming because of the possible dangers that accompany the use of alternative therapies. As a student in university, I have been equipped with the ability to critically analyse information given to me. I have found that it has taken me 4 ? years of university to fully understand how to dissect an article and be able to understand its implications for the real world. Not all individuals are able to read information with a critical eye and decipher whether or not the information is valid, reliable, and rigorous. Knowing that there is a large amount of uncredited information available for pregnant women, who may not be able to see the lack of evidence behind the statements presented, is a cue for nurses, and nursing students, to educate others in how they can understand the true implications of what they read. Providing evidence-based information is a key practice for all nurses when educating their patients. Mechanisms of Action Ginger’s mechanisms of action are not fully understood, therefore it is possible that interactions, adverse effects, and contraindications other than those listed within this paper may occur. According to Tiran (2012) gingerol is thought to be responsible for the anti-emetic effect, while shogaol, galanolactone, and zingiberene act as serotonin 5-HT receptor antagonists within the ileum. Prescription medication anti-emetics use the same mechanism of action (Tiran, 2012). Ozgoli (2009) also believes that shogaol and gingtol are the effective anti-emetic substances that cause a localized effect on the gastric system which reduces the feelings of nausea, but did not mention its effects on serotonin 5-HT receptors. Tiran (2012) found evidence that says ginger can suppress vasopressin, reduce tachygastric activity, and be weakly cholinergic which is contradictory with Ozgoli’s et al. (2009) indication of ginger acting only locally. As we can see, the mechanisms of action are not quite agreed upon at this point in time. The lack of coordination between two peer-reviewed articles further convinces me that ginger should be cautioned against for long-term use in pregnancy. Adverse Effects Many adverse effects were mentioned within the 3 studies. Hypotension, anti-coagulation, heartburn, decreased iron absorption, increased bile secretion, hypoglycemia, and effects on the GI tract all presented as effects with the use of ginger. These effects pose a wide range of problems for women who are pregnant and further explain why I believe ginger should be cautioned during pregnancy. Many women suffer from acid reflex, also known as heartburn, during pregnancy due to their organs shifting to make room for the growing fetus. There is less space for the stomach therefore increasing the likelihood of gastric juices entering the esophagus causing pain. Ginger would increase the effects of heartburn as it is a stomach irritant. Secondly, women can experience bleeding during their pregnancy, which when taking ginger can cause complications such as spontaneous abortion or miscarriage. Their risks also increase for perinatal and post-partum bleeding if they take an anti-coagulate such as ginger because their ability to form clots would be hindered. When someone is unaware of gingers anti-coagulant effects they may not know to stop taking it when nearing their due date, or there may be greater complications if the child is unexpectedly premature. The effects of hypotension, such as dizziness and confusion, can also be an issue during pregnancy. Their risk for falling increases which could cause serious harm to the mother and fetus. The GI tract is also effected by ginger, with Tiran (2012) stating that it has caused intestinal blockages when dried ginger root was not chewed fully. This is a serious issue that can occur and only further be complicated by pregnancy. Ginger is also capable of causing an increase in bile secretion which would lead to hypoglycemia if not monitored. This is a further issue if a woman is already diabetic, which can occur during pregnancy as a phenomenon known as gestational diabetes. Tiran (2012) explains that there is also a decreased ability to absorb iron when taking ginger. During the development of a baby, their only source of nutrients is supplied by the mother. Furthermore, babies rely on their iron stores for the first 6 months of life. If a mother’s ability to absorb iron is hindered during pregnancy, both her and the fetus will have insufficient amounts of iron. Serotonin is found within the central nervous system and is also associated with depression. Inhibiting this during pregnancy could lead to an increased risk of post-partum depression. Finally, based on the three articles, I was unable to determine whether ginger is known to cross the placental barrier or not. If it is able to cross the placental barrier and enter into the developing fetus, I can infer that these adverse effects would also be present within the fetus. Interactions There were a number of drug-drug interactions listed within the three articles. Medications that would cause a negative effect if taken with ginger include: blood thinners, barbiturates, benzodiazepines, beta blockers, and other herbs such as gingko biloba. Benzodiazepines are already contraindicated for use during pregnancy because of their ability to cross the placental barrier. Both benzodiazepines and ginger are CNS depressants, if taken together an additive effect would occur. Taking ginger together with any type of anticoagulant such as aspirin, warfarin, or enoxaparin would cause an increased risk of bleeding do to a lack of clotting factors within the blood. Because ginger is also thought to reduce blood pressure, taking it with a beta blocker would increase the risk for hypotension. Inadequate blood pressure would result in insufficient levels of oxygen circulating the body which in turn would negatively affect a growing fetus. In addition to all of the listed medications that could cause an interaction with ginger, I also believe that other alternative therapies should be consulted with a physician before taking alongside ginger. We do not fully understand the effects ginger has on the body and therefore should not take it with other over-the-counter medications as well. Contraindications Based on the adverse effects that were listed within the three articles, there are a number of contraindications for the use of ginger. People with hypotension would further have a decrease in blood pressure if taking ginger (Tiran, 2012). GI tract issues such as irritable bowel disease or acid reflex can be exacerbated when taking ginger as it can be a stomach irritant (Tiran, 2012). As mentioned above, people with a blood clotting disorder or on any type of blood thinner such as warfarin, heparin, or aspirin should avoid ginger due to its anti-coagulant effects, including anyone who has a previous miscarriage or spontaneous abortion (Tiran, 2012). Clinical TrialsThe two clinical trials looked at the effectiveness of ginger as an anti-emetic and anti-nausea medication. Ensiyeh and Sakineh’s (2009) study compared ginger and vitamin B6 as effective alternative therapies. Their findings suggested that ginger reduced nausea and vomiting better than vitamin B6. The dose of 1000mg/day did not show any adverse effects, however as Ensiyeh and Sakineh (2009) stated, their sample was too small to conclude that no adverse effects could occur at this dose. Ozgoli et al. (2009) studied the effectiveness of ginger capsules in reducing nausea and vomiting, and found that 1000mg/day was an effective dose that caused no adverse effects. Their sample size consisted of 70 participants which is also too small to conclude that no adverse effects could occur at this dose. Although both study’s showed promising results, the doses were only taken for the duration of 4 days. From these articles, we are unable to conclude the effects of long-term ginger use during pregnancy and therefore I continue to advise that ginger not be used during pregnancy without closely monitoring the presence of adverse effects.ConclusionIt is clear from the three articles discussed that there needs to be more research into the effects ginger has on the human body. Whether ginger is safe for pregnant women to use will be determined when safe therapeutic doses are agreed upon and its mechanism of action and adverse effects are better understood. Long term use was not addressed within the studies and due to the lengthy duration of a pregnancy, I would not advise using ginger for relief of nausea or vomiting. ReferencesEnsiyeh, J., & Sakineh, M. A. C. (2009). Comparing ginger and vitamin B6 for the treatment ofnausea and vomiting in pregnancy: a randomised controlled trial. Midwifery, 25(6), 649-653. doi:10.1016/j.midw.2007.10.013.Ozgoli, G., Goli, M. & Simbar, M. (2009). Effects of ginger capsules on pregnancy, nausea andvomiting. The Journal of Alternative and Complementary Medicine, 15(3), 243-46. doi:10.1089/acm.2008.0406.Tiran, D. (2012). Ginger to reduce nausea and vomiting during pregnancy: Evidence of effectiveness is not the same as proof of safety. Complimentary Therapies in ClinicalPractice, 18, 22-25. doi:10.1016/j.ctcp.2011.08.007. ................
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