Toxicology Rounds: Look Out for Poisonings from ‘Abortifacients’ : Emergency Medicine News

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Toxicology Rounds

Toxicology Rounds

Look Out for Poisonings from ‘Abortifacients’

Gussow, Leon MD

Emergency Medicine News 44(9):p 4, September 2022. | DOI: 10.1097/01.EEM.0000874664.87554.d0
    FU1-5
    herbal abortifacient, abortion, Dobbs v. Jackson, poisoning, Roe v. Wade:
    Clockwise from top left: pennyroyal, blue cohosh, black cohosh, mugwort, rue, and Cinchona (quinine).
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    Figure

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

    Many of the 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 to and overdose from folk methods for terminating pregnancies because of the Dobbs decision.

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

    Pennyroyal (Mentha pulegium)

    Think of acetaminophen when you think of pennyroyal. (Mnemonic Mnote: 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 hepatic P450 enzyme CYP2E1. Liver damage occurs when hepatic glutathione stores are depleted, which is what 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 headache and excessive flatulence, and repel insects.

    This herb is probably best known from the Nirvana song “Pennyroyal Tea,” in which Kurt Cobain sings: “Sit and drink Pennyroyal tea / Distill the life that's inside of me / Sit 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 starts within 24 hours of ingestion. This is followed by true liver dysfunction manifested as coagulopathy, renal failure, seizures, and, in rare cases, death in significant exposures. The essential oil is much more concentrated and toxic than the leaves of the plant or the tea made from them.

    Treatment of pennyroyal toxicity involves supportive care. Because pennyroyal causes effects similar to those of acetaminophen, administrating N-acetylcysteine would be a reasonable intervention. Many of the adverse effects of pennyroyal are the result of P450 metabolism, and it is a fascinating but unresolved question whether the CYP2E1 inhibitor fomepizole would provide any 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 nicotinic agonist.

    Exposure to blue cohosh can cause hypersalivation, nausea and vomiting, and seizures. One case was reported of 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 blue cohosh in an attempt to bring on 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 from that of blue cohosh despite the similarity in their names. It is occasionally recommended online as an abortifacient, but I could not find any evidence that it is effective for that. Data on its adverse effects are also slim, but its use has been associated with hepatoxicity and heart block with bradycardia.

    Mugwort (Artemisia vulgaris)

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

    Rue (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 led to it being associated with regret. Topical exposure to rue can cause phytotoxic blistering contact dermatitis. Ingestion of large amounts of rue have been associated with liver and kidney damage.

    Manifestations of cinchonism from quinine include headache, nausea, hearing loss with tinnitus, dizziness, and gastrointestinal distress. Large doses of quinine can produce life-threatening hematologic and cardiovascular toxicity.

    None of these herbs and plants has been shown to induce abortions consistently, and many of them can cause significant morbidity or mortality if taken in large doses. Using them as abortifacients is extremely dangerous. Unfortunately, we may be seeing more frequent cases of toxicity from these plants and others because of recent court decisions 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 voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Follow him on Twitter@poisonreview, and read his past columns athttp://bit.ly/EMN-ToxRounds.

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