Review Article Received: 30 September 2014,

Revised: 26 November 2014,

Accepted: 26 November 2014

Published online in Wiley Online Library: 7 February 2015

(wileyonlinelibrary.com) DOI 10.1002/jat.3108

Safety of Chinese herbal medicines during pregnancy Bo Lianga, Lu Lia, Ling Yin Tanga, Qi Wub, Xiao Ke Wub and Chi Chiu Wanga* ABSTRACT: Miscarriage and infertility have long been public concerns due to the mental and physical suffering they bring to potential parents. There is a strong need for effective and affordable treatments. Chinese herbal medicines (CHMs) have been shown to be effective for preventing miscarriage and treating infertility; however, due to the limited knowledge of their pharmacological mechanisms and unknown potential toxicity, their use has been restricted. This paper reviews 24 clinical trials of CHMs to prevent miscarriage and treat infertility. Most of these studies did not meet the requirements of randomized controlled trials. Even when using quality assessments based on the Newcastle–Ottawa Scale to assess the quality of non-randomized studies, most studies did not meet the requirements. The reviewed papers were evaluated for maternal and embryonic adverse effects, including those in animal experiments. Slight maternal effects were noted, with some reports of severe toxic effects of CHMs for preventing miscarriage and severe adverse maternal effects of CHMs used for infertility. Owing to the poor quality of the randomized controlled clinical trials and the limited number of studies, it is not possible to draw a conclusion. From animal studies, for all three gestational periods, growth delay and congenital anomalies were the most commonly recorded adverse effects. However, baseline toxicological data and detailed mechanisms are still lacking. To gain a better understanding of the potential toxic effects of CHMs, additional high-quality randomized controlled trials should be conducted, and high-throughput in vitro screening method for baseline data should be considered. Copyright © 2015 John Wiley & Sons, Ltd. Keywords: Chinese herbal medicines; pregnancy; safety; clinical studies; experimental studies; reproductive toxicity

Introduction Pregnant women are recognized as a vulnerable population with regard to drug safety, and many governments have special rules in place assessing drug safety for this population. In an effort to avoid potential side effects from Western drugs, pregnant women in Asian countries often use Chinese herbal medicines (CHMs; Wang et al., 2012). Although the use of CHMs has been increasing over the past 20 years in Western countries, CHMs remain distinct from Western drugs, and are often treated in government regulations as a distinct category, like dietary supplements in the United States. One of the most important factors currently preventing more widespread use of CHMs is that their safety, including reproductive toxicology, has not been fully studied (Gallo et al., 2003). Compared with Western medicines, CHMs seem to have better efficacy in preventing miscarriage and treating infertility (Ried and Stuart 2011). However, CHMs are not recommended by most Western physicians due, in part, to their lack of toxicological data (Angell and Kassirer, 1998). In this review, we provide a brief summary of the toxicity of the CHMs used to prevent miscarriage and treat infertility. Data from clinical trials and animal experiments are reviewed to evaluate the safety of CHMs used for pregnancy.

Chinese Medicines for Pregnancy

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Traditional Chinese Medicine and Chinese Herbal Medicines Traditional Chinese medicine (TCM) has been practiced to maintain health and treat diseases for more than 5000 years. Diagnosis and treatment are guided by unique theories, the yin-yang and the Five Phase, which is also known as the FiveElements theory or “Wu Xing” in Chinese (Lin and Cai, 2012; Zheng and He, 2011). In these theories, yin and yang are considered two types of energy that maintain a homeostatic status in the human body and in the universe. As two opposite energies, if the homeostasis of yin and yang is broken, the human body will become weak or ill. According to the Five Phase theory, “Wu” refers to the composition of the human body and the whole universe, which are made of Wood, Fire, Earth, Metal and Water, and “XING” refers to special relationships of the *Correspondence to: Chi Chiu Wang, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, c/o 1st Floor, Special Block E, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. E-mail: [email protected] a Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong b

Department of Obstetrics and Gynecology, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China

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For millennia, CHMs have been widely accepted as effective treatments of fertility and pregnancy-related issues. Most CHMs are considered safe (Gori and Campbell, 1998), though the use of some CHMs has been restricted during pregnancy (Fig. 1).

However, these recommendations and restrictions are based on clinical observations, and have not undergone formal testing of the potential toxicity of CHMs using modern methodology and technology.

B. Liang et al.

Figure 1. Summary of Chinese herbal medicines for pregnancy.

“Wu” elements, which are in constant motion and change. The basic relationships include generation and restriction. In the Five Phase theory, the human organs correspond to different elements, where liver, stomach, spleen, lung and kidney correspond to wood, fire, earth, metal and water respectively. The kinetic balance among each of these elements and its corresponding organ affects human health (Ma et al., 2014; Zheng and He, 2011). CHMs, which are also known as Chinese Materia Medica, are an integral part of TCM. CHMs are used to regulate the balance between yin and yang and to maintain their homeostasis. According to the yin-yang and Five Phase theories, objects in the universe all contain yin-yang energy and correspond to one or more elements of the Five Phase. CHMs also contain yin-yang energy and belong to different elements. Origin (Chen et al., 2013), pretreatment (Ji et al., 2014), preparation (Zhang et al., 2014) and storage have great impact on the energy and elements in CHMs, including the proportion and quantity of their effective and toxic constituents. Most CHMs are made from plants, but some CHMs are produced from animals and minerals. Compared with Western medicines, which are often single entity drugs, CHMs are extracted from natural resources and contain hundreds of components. The quality of CHMs is a critical factor that affects the constituents in different compositions. Historically, the qualities of CHMs were assessed by experienced practitioners of Chinese medicine according to their shape, smell, color and taste. Currently, highperformance liquid chromatography, liquid chromatography– mass spectrometry and other standardized methods are used to assess the quality of CHMs. The standardized quality control procedures for CHMs make the quality and ingredients of each composition easier to control. The most common way to prepare CHM for human use is decoction, prepared by boiling the herbs in water. The yield of a given decoction may vary considerably from batch to batch because of various factors, including boiling container, heater temperature, quality of water, among other issues (Li et al., 2014). Currently, extracting and purifying the effective constituents by an accredited pharmaceutical manufacturer is a new approach to standardize the quality and improve the stability of CHMs for human use (Xie et al., 2006).

processing procedure (Chan, 2003; Chan and Critchley, 1996). Therefore, many pregnant women prefer to use herbal medicines rather than Western medicines. In China, people also view CHMs as being safe and having fewer side effects when used properly, although there may be side effects if the CHMs are taken inappropriately (Cheng et al., 2012; Pang et al., 2009). According to previous literature, some CHMs, such as Semen Strychni, are restricted for use during pregnancy. Perceived safety and fewer side effects are not the only reasons why CHMs have become popular worldwide. Recent reviews have shown that CHMs have unique properties for treating some pregnancy-related conditions such as infertility and threatened miscarriage (Fig. 2, Li et al., 2011; Ried and Stuart, 2011). Miscarriage is one of the most common complications during pregnancy, with approximately 15% of all pregnancies ending in miscarriage (Herbert et al., 2009). In more than 50% of cases, a miscarriage can be associated with chromosomal abnormality (Vorsanova et al., 2005). Other associated factors include maternal age (de la Rochebrochard and Thonneau, 2002) and health conditions such as menstrual disorders (Homburg, 2006), maternal lifestyle factors such as use of coffee, alcohol and tobacco (Rasch, 2003), and a history of miscarriage (Sugiura-Ogasawara et al., 2009). Although many factors have been found to be associated with miscarriage, in many cases, the causes of miscarriage are unclear (Robertson et al., 2006). In some ways, infertility shares factors with miscarriage. A previous study reported that approximately 33% of infertility is due to sperm defects or dysfunction, whereas 25% is due to ovulation failure (Hull et al., 1985). Age and lifestyle are also critical factors for infertility (Homan et al., 2007). Advanced age and smoking reduce the fertility rate by approximately 20% and 15%, respectively (Bunting and Boivin, 2008). In vitro fertilization has been used for more than 30 years and has proven that infertility can be treated by medical technology. An increasing number of babies are being conceived by in vitro fertilization. However, a recent survey reported that only approximately 20% of patients using this technology eventually became pregnant (Sullivan et al., 2010). Owing to the unclear causes of infertility and miscarriage, there are no effective ways to treat or prevent them (Wahabi et al., 2011). One of the most practical ways to prevent miscarriage and treat infertility is to avoid the risk factors. CHMs offer

Chinese Herbal Medicines for Pregnancy

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In most Asian countries, people consider herbal medicines to be safe and non-toxic natural remedies because of their source and

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Figure 2. Clinical applications of Chinese herbal medicines for pregnancy. CHMs: Chinese herbal medicines.

Copyright © 2015 John Wiley & Sons, Ltd.

J. Appl. Toxicol. 2015; 35: 447–458

Safety of Chinese herbal medicines during pregnancy a variety of alternative methods to approach these reproductive health issues (Li et al., 2012). To treat threatened miscarriage, the most commonly used CHM formula is Shou Tai Wan. As described in our previous review, CHMs, including Shou Tai Wan and other formulas, when used with western medicines, were more effective than Western medicines alone for treating threatened miscarriage (Li et al., 2012). Based on clinical trials and experimental results, Shou Tai Wan is also effective for treating recurrent miscarriages (Li and Song, 1995; Tan et al., 2013a, b). In addition to Shou Tai Wan, other types of CHMs have been found effective for threatened and recurrent miscarriage when used with or without Western medicines (Du, 2009; He et al., 2009; Luo et al., 2009; Zhang et al., 2011). Male infertility is primarily driven by low sperm counts and weak sperm motility. In TCM, the kidney is considered the major organ responsible for sperm quality, and kidney function quality influences sperm quality. Based on this theory, some CHMs can be used to regulate kidney function and refill the yang energy in the human body (Gong and Dou, 2013; Zhou, 2011). Female infertility is driven by complications such as polycystic ovary syndrome and endometriosis, and in Chinese medicine, these complications are considered different dysfunctions. In Chinese medicine, polycystic ovary syndrome and endometriosis are both seen as dysfunctions or weaknesses of the kidney. However, polycystic ovary syndrome is caused by yang deficiency of the kidney (Lu et al., 2012; Yu and Xu, 2011), whereas blood stasis is the major cause of endometriosis (Wu et al., 2012). Based on their different causes, a variety of formulas will be applied to treat each of these conditions (Chao et al., 2003; Guo and Yu, 2013). Owing to the therapeutic effects of CHMs, they are being increasingly used to treat threatened miscarriage and infertility, particularly in Asian countries (Zhou and Qu, 2009). However, their growing use brings concerns about their safety. Accurate toxicological data are needed to determine whether these CHMs are safe for parental health and fetal development because the perceptions of patients that these are safe and have fewer side effects are not based on experimental data.

Safety Issues of Chinese Herbal Medicines for Pregnancy Adverse Outcomes in Animal Studies

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Although CHMs are an important means to treat complications and symptoms of pregnancy in Asian countries (Li et al., 2012), they are regulated by Western countries in a diverse and complex way, because most often they do no provide with information on reproductive toxicology. One of the most important factors that limit the use of CHMs is the lack of systemic evaluation of their potential risk. Unlike Western medicines, most CHMs have not been carefully studied and have no or limited toxicological data available, particularly those classified as contraindicated, not recommended and precautions CHMs in Pharmacopeia of the People’s Republic of China (Table 1). Less than half have clear scientific evidence to support their potential reproductive toxicity. As shown in Table 1, Rhizoma Sparganii (Sun et al., 2011), Rhizoma Curcumae (Xing et al., 2013), Radix Phytolaccae (Li et al., 2003), Scolopendra subspinipes (Yu et al., 1994), Radix Achyranthis Bidentatae (Liu et al., 2006) and Rhizoma Pinelliae (Xu et al., 2013) were found to have a toxic effect on embryo development.

Reproductive toxicity of CHMs was also reported, such as maternal toxic effect (Mao et al., 1998; Yang et al., 2002) and male reproductive effect (Xiao et al., 2000). However, when comparing LD50 with recommended clinical dosage in Pharmacopeia of the People’s Republic of China, the LD50 doses of most CHMs were hundreds or thousands time higher than the recommended dosage, except Mylabris, the LD50 dose is only two times higher than recommend dosage (Zhou et al., 2002). Although there are increasing toxicological studies of CHMs, there is still not enough evidence to draw a conclusion regarding the safety of CHMs. These unknown risks are important because improper use may lead to adverse outcomes. Currently, the only method to test CHMs in humans is a clinical trial. However, before the clinical trials, the potential pharmacological mechanism and toxicological mechanism should be studied in mammals such as rats, mice and rabbits (Ososki and Kennelly, 2003). For Western single entity drugs, the toxicological data regarding the chemical’s toxic effect and effective mechanism can usually be translated from the mammalian model and identified in humans. Therefore, going from an in vivo model to clinical trial is an efficient method for testing Western drugs. However, for CHMs, which typically use several plant extracts as components of a complex formula, the chemical components in the decoction may number in the hundreds or even thousands. Drug–drug interactions complicate the underlying pharmacological and toxicological mechanisms of the CHM study (Cheng et al., 2010). Additionally, different formulas may contain different types or different amounts of plants. It is impossible to isolate and analyze each component from every CHMs formula or even a single CHM. Thus, in most cases, the whole extract of CHM will be assessed for toxicity. Using animal models, the toxic compound(s) can be identified and subsequently quantified in further analyses of the herbal remedies. Recently commonly used CHMs for pregnancy have been screened (Wang et al., 2012). As shown in Table 2, most of the growth delay or stunting was detected when animals were exposed to these CHMs in early and late gestational stages. However, if a high dose was applied, fetal resorption or perinatal mortality occurred. In the mid-gestational stage, congenital anomalies were recorded even in animals exposed to low doses of these CHMs, and this phenomena may relate to the sensitive developmental window during organogenesis in midgestation (Ellington, 1980). Weight loss only occurred when animals were exposed to a high dose of a specific CHM during a particular gestational stage, such as liquorice root and Eucommia bark. For most CHMs studied, only long-term exposure increased the maternal mortality rate (Table 2). Although the study was performed in only one species and the maximum sample size was small as pointed out by a re-evaluation study (Wiebrecht et al., 2014), the study did raise potential safety concern of CHMs in pregnancy. Direct dose-dependent relationship in the in vivo study is not expected as in vivo settings involve complicated bioavailability and metabolism, which is controlled in in vitro settings. On the other hand, susceptibility of adverse outcomes may vary in different gestational periods due to massive dynamic changes of physiological, biochemical and pharmacological parameters during pregnancy. To obtain more reproductive toxicological data regarding CHMs, it will be important to have well characterized extracts, standardizing their processing procedures, including the origin, collection methods, processing method and storage method. Because the components in a single CHM are complex, the method used for final quality assessment should be able to

Table 1. Recent toxicological studies of Chinese herbal medicines on animals

Latin

English name

450

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Copyright © 2015 John Wiley & Sons, Ltd.

Resina Ferulae Radix Euphorbiae Pekinensis

Flos Genkwa

Whitmania pigra Whitman

Pharbitis seed Semen Pharbitidis Xedoray rhizome Rhizoma Curcumae

Lilac daphne flower bud Chinese asafetida Peking eu phorbia root

Prepared common monkshood mother root Leech

Eupolyphaga seu Steleophage Radix Aconiti Preparata

– Water extract Water extract

M Wistar rats

– Water extract Water extract

Water extract Water extract Water extract

MI Mice MI Mice – Kunming mice – – – ICR mice – Kunming mice – – A Wistar rats

Water extract

Water extract

Mice

AF Kunming mice

–

–

Water extract

Reproductive toxicity MI Kunming mice – –

Exposed species and strain

Ground beetle

Extraction Water extract

Dose range

ICR mice

–1

– 1.4, 2.8, 5.6 –1 g kg

– – –

–1

–1

150 mg kg –1 75 mg kg –

3 g kg

–

–

3, 9, 15 g kg

100, 200, 400 –1 mg kg

Exposure route ðdaily; unless specificÞ

A

ig

– ig

– – –

ig ig –

ig

–

–

ig

ig

Exposed period ðdays; unless specifiedÞ –

–

–

–

Heart, craniofacial, vertebrae defect in offspring Miscarriage

–

E6–E19

E6–E19

–

– – –

– – –

(Yang et al., 2002) –

(Mao et al., 1998)

–

(Miao et al., 2005) –

(Sun et al., 2011)

–

– – Neurodevelopmental (Xing et al., delays 2013)

– – –

5 days before Low pregnant pregnant rate, smaller little size E6–E9 Miscarriage E6–E9 Miscarriage – –

E0–E9

E7.5–E21

–

Adverse pregnancy outcomes

–

References

–

– –

– 36.9 160.3

30.4

–

–

30.78

–

– (Li et al., 2013) (Zhang et al., 2013) – –

(Dai 2012)

–

–

(Zhang et al., 2005)

–

–

–

–

–

–

–

LD50 g kg1 Þ

–

References

–

3–6 g 6–9 g

1–1.5 g 1.5–3 g

1.5–3 g

1.5–3 g

1.5–3 g

3–9 g

4.5–9 g

3–6 g

RD

–

– –

– 861–1722 3740.3–7480

709.3–1418.6

–

–

718.2–1436

–

–

–

–

LD50 =RD

Contraindicated Obtuselef Caulis Erycibes erycibe stem Common Rhizoma buried Sparganii rubber

B. Liang et al.

Chinese name

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Moschus Calomelas

Semen

Musk Calomel

Fructus

451

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Realgar

Not recommended Snow lotus Herba Saussureae Involucratae Precautious Jack-in-the Rhizoma pulpit tuber Arisaematis Trichosanthes Radix Trichosathis kirilowii

Rabiagar

Crotonis Pulveratum Birthwort fruit Fructus Aristolochia Gansui root Radix Euphorbiae Kansui Caper euphorbia Caulis seed Erycibes Sheep loitered Rhododendri azalea Mollis Strychnos seed Semen Strychni Blister beetle Mylabris

crotonis

Centipede

Radix Phytolaccae Scolopendra subspinipes

Pokeberry root

Mice

–

AB Human

–

M Sprague– Dawley rat MP New Zealand rabbits

Kunming mice AFA Kunming mice

–

–

–

Kunming mice Mice

– –

Mice

– Kunming mice Kunming mice

–

–

– –

Petroleum ether extract Water extract

–

Water extract

Water extract

–

Alcoholic extract Water extract

Water extract

Water extract

– Water extract

Water extract

Water extract

A

Kunming mice MA Kunming mice

Water extract

AF Mice

im

–

– 24 mg per person

–

ig

ig

ig

–

–

–

–

–

External use

– –

ig

ig

ig

–

125, 250, –1 550 mg kg 31.3, 62.5, 1 125 mg kg

0.03, 0.06 –1 g kg

–

–

–

–

–

–

– –

1, 5, 10, –1 20 g kg 500, 1000 –1 m g kg

1.4, 2.8, –1 5.6 g kg

–

–

–

–

–

–

– –

–

–

–

–

–

–

Low bodyweight gain, teratogenesis, stillbirth, resorption – –

–

–

–

–

–

–

– –

(Zhou et al., 2013) (Zhao et al., 2009) (Li et al., 2003) (Yu et al., 1994)

23.6 Week

–

–

Abortion

–

–

(Yao and Li 2008)

–

–

5 days before Low pregnant rate, (Xiao et al., pregnant–E19 high mutation rate, 2000) low sperm count E6–E15 Anorexia, maternal (Gu et al., death, 2013) E6–E18 Anorexia, maternal death, low live fetus rate, high late fetus loss rate

E7–E11

E12–E17

–

Low food intake, low birth weight Low birth rate, miscarriage Embryo mutation

(Wang et al., 2008) (Li et al., 2010) (Liang et al., 2011) –

– (Zhou and Liu 2013) (Pan et al., 2011)

(Jin and Zhang 2000) –

–

42.53

–

–

(Tang et al., 2012) –

–

–

(Gong et al., 2007) 0.00184 (Zhou et al., 2002)

– 0.1442

912

113.64

200

0.38

– 0.41

–

6.53

–

– 143.5–287

–

50.8–152.4

10–15 g

3–9 g

3–6 g

0.05–1 g

0.03– 0.06 g

0.3–0.6 g

0.6–1.5 g

0.5–1 g

0.5–1.5 g

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(Continues)

–

330.8–992.4

–

–

2.14–4.29

16.8–33.6

–

63840–127680

5303–15909

0.06–0.6 g 23333–233333

–

0.03–0.1 g 0.1–0.2 g

3–5 g

3–9 g

Safety of Chinese herbal medicines during pregnancy

Exposed species and strain

Reproductive toxicity

Latin

English name

452

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Chinese name

Copyright © 2015 John Wiley & Sons, Ltd.

Rhizoma Pinelliae

MG ICR mice

ICR mice

Water extract

n-butyl alcohol extract

–

P

–

–

–

Water extract

–

–

–

AF Wister rats

–

–

–

30 g kg

–1

250, 300 –1 mg kg 0.5, 2.0, –1 4.0 g kg

–

–

–

–

ig

ig

ig

–

–

–

–

– –

E6–E15

15 Days before

E1–E10

–

–

–

–

– –

Resorption

Low pregnant rate

–

–

–

–

Low bodyweight gain (male) – –

(Liu et al., 2006) (Bu et al., 2006)

–

–

–

–

(Hu et al., 2006) – –

15.83

–

–

–

–

– 121.7

2.72

(Yang and Zhang 2005)

–

–

–

(Hu et al., 2006) – (Bai et al., 2009) –

4.5–9 g

3–9 g

3–15 g

2–6 g

1–1.5 g

6–12 g 1–1.2 g

0.15–0.3 g

123.1–246.2

–

–

–

–

– 7099–8519

634–1269

Low Bodyweight (Xu et al., 397.24 (Zhang et al., 3–9 g 3089–9268.9 gain, Growth 2013) 2005) retardation A, congenital anomalies; AB, abortion; AF, antifertility; G, growth delay/stunting; M, maternal mortality; MI, miscarriage; P, fetal resorption/intrauterine death/perinatal mortality; RD, Recommend dosage by China Pharmacopoeia 2010; W, weight loss.

Not specific Pinellia ternata

Monkshood branched root Sodium sulfate powder Achyranthes bidentata

Semen Nigellae Radix Aconiti Lateralis Preparata Natrii Sulfas Exsiccatus Radix Achyranthis Bidentatae

–

–

–

Extraction

Mice

Dose range

– –

Exposure route ðdaily; unless specificÞ

Sodium sulfate Kusnezoff monkshood leaf Chinese honeylocust abnormal fruit Love-in-a-mist

Exposed period ðdays; unless specifiedÞ –

Adverse pregnancy outcomes

ig

References

0.34, 0.68, –1 1.36 g kg – –

LD50 g kg1 Þ

Dispersed suspension – –

References

AF ICR mice

RD

Borneol

LD50 =RD

Natrii Sulfas Folium Aconiti Kusnezoffii Fructus Gleditsiae Abnormalis

Table 1. (Continued)

B. Liang et al.

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Safety of Chinese herbal medicines during pregnancy Table 2. Adverse outcomes of animal studies of commonly used Chinese medicines for pregnancy

A, congenital anomalies; G, growth delay/stunting; M, maternal mortality; P, fetal resorption/intrauterine death/perinatal mortality; W, weight loss.

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Figure 3. Three in vitro models suitable for embryotoxicity assessment of Chinese herbal medicines.

Qualitative assessment of clinical trials Although clinical trials could be used to evaluate the effectiveness and safety of CHM in humans, information from clinical trials is not always reliable. One of the critical factors that affect their reliability is the quality of the clinical trial design, which may be influenced by selection, performance, detection and attrition bias (Bornhoft et al., 2006). Additionally, the high risk of clinical trials decreases their reliability. Most of the randomized controlled studies of CHMs for the treatment of miscarriage clearly classified and compared covariates such as age and symptoms between each group of participants, and found no significant differences (He and Che, 2007; Li et al., 2006; Song and Zhu, 2007; Teng and Wu, 2008; Yue et al., 2009; Zhang et al., 2000; Zhang et al., 2005; Zhao et al., 2008, 2010; Zhou, 2006). However, the ways in which participants were divided into different groups were not described, and the

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resolve and identify as many components as possible. One method being more widely employed for botanical chemical characterization is high-performance liquid chromatography. Besides the quality control of CHMs, a proper appropriate model is important for toxicity assessment of CHMs. Except for the typical animal models for the acute or chronic toxicity of CHMs, when considering the embryotoxicity of CHMs, a good model of embryo development is necessary (Kennelly et al., 1999). Because CHMs are administered over a short period, when using in vivo models as a target, a precise window to mimic the maternal administration for testing should be determined, which is more specific than simply exposing the pregnant animal during the whole period of embryo development. It is difficult to set timing as each CHM could have different effects on development, and therefore the period of susceptibility would be different. Consequently, the in vivo model would have to be adjusted for each herbal remedy. Alternatively, to assess the toxicological effects and mechanisms of as many CHMs as possible, in vitro models may be more suitable than an in vivo approach for the toxicological pre-assessment. Therefore, a suitable in vitro model should also be incorporated (Fig. 3). With consideration of the varied toxic effects of different CHMs in developmental stages, and the advancement in toxicological methods, embryonic stem cell tests, whole embryo culture and micromass, which cover different stages of embryo development, could be recommended for assessment of CHMs toxicity. Embryonic stem cell testing focuses on the toxic effect during pre-implantation (Doetschman et al. 1985; Seiler and Spielmann, 2011), so this method is more sensitive to the potential toxicity occurring in early embryo developmental stages. The whole embryo culture focuses on effects after implantation, making this method more suitable for the study of early organogenesis toxicity (New, 1978). Micromass focuses on the potential toxicity on fetal growth, in particular skeleton development, which is the most common congenital anomaly occurring during pregnancy (Genschow et al., 2002; Paulsen and Solursh, 1988). However, there is still no systemic evaluation of these in vitro embryotoxicity tests for CHMs.

B. Liang et al. methods used for allocation concealment and blinding were not clearly described (Gong and Chen, 1993; Li et al., 2006; Song and Zhu, 2007; Zhang et al., 2000; Zhou, 2006). In some studies, the outcome data were adequately addressed. There are limited best quality trials for the treatment of miscarriage, such as two by Li and Zhang (Li et al., 2006; Zhang et al., 2000); however, their methods of allocation concealment and blinding were unknown. This limited information is not sufficiently reliable to draw a solid conclusion regarding the safety or effectiveness of CHMs for pregnancy. Most of the clinical trials of infertility have a low risk of bias due to adequate sequence generation; the methods of dividing participants into different groups were clearly described. Although some trials noted the methods for blinding, many had unclear descriptions of blinding and allocation concealment. Among these studies, the one with the lowest risk of bias was performed by Wu et al. (2006). In that study, although the risk of selective reporting is unknown, all other biases were clearly described and of low risk. Newcastle–Ottawa Scale assessment for clinical trials Owing to their poor assessments of the risk of bias, studies of both miscarriage and infertility do not fully meet the

requirements of randomized controlled trials, particularly for allocation concealment and blinding. To assess further the quality of these trials using a more reliable platform, assessment tools for non-randomized controlled trials have been applied. As shown in Table 3, the studies were considered non-randomized controlled trials and their quality were assessed using the Newcastle–Ottawa Scale. All of the clinical trials of miscarriage met the four requirements: adequate definition of miscarriage, comparability of design or analysis, use of the same method to ascertain cases and controls and an equal non-response rate for both groups (Table 3). For the remaining requirements, among the trials of miscarriage, only Yang’s (1992) study satisfied the selections of controls. The 12 trials of infertility are nearly the same as the trials of miscarriage. All those examined satisfied the requirements of adequate definition, comparability of design or analysis, use of the same method of ascertainment for cases and controls and equal non-response rate. Only Wu et al.’s (2006) study met the requirement of representativeness of cases. Four of the 12 infertility trials met the requirement of ascertainment of exposure, but none satisfied the selection and definitions of controls. Even when the studies were considered non-randomized controlled trials and quality assessments were performed using the Newcastle–Ottawa

Table 3. Risk of bias and quality assessment of clinical trials of Chinese medicines for pregnancy

454

+: presence; : absence; ?, unknown; 0, score 0; 1, score 1; AC, allocation concealment; AD, adequate definition; AE, ascertainment of exposure; ASG, adequate sequence generation; CODA, comparability on design or analysis; DC, definitions of controls; FB, free of other bias; FSR, free of selective reporting; IODA, incomplete outcome data addressed; NOS, Newcastle–Ottawa Scale; NRR, non-response rate; RAC, representativeness of cases; SC, selections of controls; SMAFCC, same method of ascertainment for cases and controls; TS, total score.

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J. Appl. Toxicol. 2015; 35: 447–458

455

J. Appl. Toxicol. 2015; 35: 447–458

RCT RCT RCT RCT RCT RCT RCT RCT RCT

Zhao et al., 2010

Yue et al., 2009 Teng and Wu, 2008 Zhao et al., 2008

He and Che, 2007 Li et al., 2006 Zhang et al., 2005

Zhang et al., 2000 Yang, 1992

Design

–

–

– – Gastrointestinal symptoms – –

No

–

Adverse effects and toxicity

Song and Zhu, 2007 Zhou, 2006 Gong and Chen, 1993

Quasi-RCT Controlled trial Controlled trial

– – Toxicity

No

– – – Adverse effects

– –

– – –

Inevitable abortion – – –

Intervention failure

–

– –

Preterm labor Diabetes, preterm –

Stillbirth

No

Preterm labor

Adverse pregnancy outcomes

Copyright © 2015 John Wiley & Sons, Ltd.

– – – –

– – – – – – –

No Neurodevelopmental morbidity No Neonatal death – Others

– Fetal expansion of lateral ventricle No No –

No

No

Adverse perinatal outcomes

– Preterm labor – Adverse maternal and prenatal outcomes Infertility trials Ren, 2002 RCT – – – Hua et al., 2003 RCT – – – Liao, 2004 RCT – – – Shao et al., 2004 RCT – – – Xia et al., 2004 RCT – – – Zhang and Wang, 2004 RCT – – – Ge and Ying, 2006 RCT – – – Wu et al., 2006 RCT – – Liver toxicity Acne oligomenorrhea Li et al., 2007 RCT – – – Ye et al., 2007 RCT – – – Liang et al., 2008 RCT – OHSS & LUFS* Miscarriage Ma et al., 2009 RCT – – – –, not determined; No, not identified; RCT, randomized controlled trials. *Ovarian hyperstimulation syndrome and luteinized unruptured follicle syndrome

Miscarriage trails

Study

Table 4. Adverse outcomes of clinical trials of Chinese medicines for pregnancy

Safety of Chinese herbal medicines during pregnancy

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B. Liang et al. Scale, the quality was not sufficient to draw a conclusion. Higher quality trials should be conducted to assess the safety of CHMs. Adverse Outcomes in Clinical Trials For clinical trials of miscarriage, the adverse outcomes of CHMs can be classified into the following four groups: adverse effects and toxicity; intervention failure; adverse pregnancy outcomes; and adverse perinatal outcomes (Table 4). For adverse effects and toxicity, slight gastrointestinal symptoms were recorded in one study (Zhang et al., 2005). Inevitable abortion was recorded in Zhao et al.’s (2010) study, but the exact prevalence was unclear. Some severe adverse pregnancy outcomes such as stillbirth occurred, but no obvious causes for these outcomes were recorded (Zhao et al., 2008). Other adverse pregnancy outcomes reported were preterm labor (He and Che, 2007; Zhao et al., 2008, 2010) and diabetes (Li et al., 2006). Drug side effects may affect the development of embryos and may have an influence on neonates. Lateral ventriculomegaly, neurodevelopmental morbidity and neonatal death were found in some cases (Yang, 1992; Zhao et al., 2008; Zhou, 2006). Whether adverse outcomes were directly associated with the use of CHMs is unknown. For clinical trials of infertility, adverse effects of CHMs included adverse maternal and prenatal outcomes among others (Table 4). Most of the selected trials did not report adverse outcomes. The adverse outcomes of ovarian hyperstimulation syndrome and luteinized unruptured follicle syndrome occurred (Liang et al., 2008). For adverse maternal and prenatal outcomes, liver toxicity, oligomenorrhea and miscarriage were found (Liang et al., 2008; Wu et al., 2006). Acne was reported in Wu et al.’s (2006) study.

Future Directions

456

Owing to their wide use and limited safety information, there is a great need for safety testing of CHMs, particularly those for the treatment of infertility and the prevention of miscarriage because they are used by women of child-bearing age and pregnant women. Manufacturers of CHMs are also requesting safety data about CHMs. For Western drugs, the structural, toxicological and clinical data of the drug is required as part of the safety profile before marketing the drug in most countries. However, most CHMs lack systematic evaluation, which is a major reason why CHMs are not sold as drugs in most Western countries, but are used as complementary and alternative medicine, such as botanical dietary supplements in the United States. Considerable safety and efficacy data would need to be presented in order for CHMs to be approved for sale by the US Food and Drug Administration. Safety testing of CHMs is required both for government regulation, as well as for greater consumer confidence in these medicines. Although Chinese medicines in China have achieved remarkable success with standardization (Chinese Pharmacopoeia Commission of PRC, 2010), additional efforts are needed to provide more detailed information on the ingredients and proper preparation of CHMs. The use of CHMs during pregnancy is a major public health concern. However, there is no high-throughput screening platform available with which to assess the adverse pregnancy outcomes associated with using CHMs. A comprehensive internet platform should be established to provide general and in-depth information regarding the safety concerns of CHMs during pregnancy for both the general public and professionals such as clinicians and researchers and workers in

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community, industry and government settings (Wang, 2014). Based on the great need for evaluating CHMs regarding the timing of their use, in vitro methods could greatly assist the rapid screening of safety testing of CHMs before the use of expensive in vivo studies. Therefore, refining in vitro assessment methods should be a high priority in this field of botanical research.

Conclusions Drug safety concern is a major public health concern. Although CHMs have been widely used in many Asian countries, the limited safety profiles are a major constraint for wider clinical application. Current available clinical and animal data are very limited and still unable to draw a conclusion regarding the safety issue of CHMs, including single CHM or formula. To acquire better assessment of CHM, quality controls of CHMs, more relevant and efficient test models, and better quality studies are necessary.

Conflict of Interest The authors did not report any conflict of interest.

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