Laxative
PREGNANCY RECOMMENDATION: Compatible
BREASTFEEDING RECOMMENDATION: Compatible
PREGNANCY SUMMARY
Senna, a naturally occurring laxative, contains the stereoisomeric glucosides, sennosides A and B. No reports of human teratogenicity or other fetal toxicity have been located.
FETAL RISK SUMMARY
Senna contains prodrug anthraquinone glucosides that are converted by bacterial enzymes in the colon to rhein-9-anthrone. This metabolite is then oxidized to rhein, the active cathartic agent of senna (1). Senna is not teratogenic in animals (2).
A 2009 population-based, case–control study examined the association of senna exposure during pregnancy with congenital anomalies (3). The population-based large data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities was used for the study. Most women were taking daily doses of 20 mg (range 10–30 mg). There were 22,843 cases with and 38,151 cases without congenital anomalies. In these groups, senna was used by 506 (2.2%) vs. 937 (2.5%), respectively, of the mothers. Compared with 500 matched controls, there was no higher risk for 23 different congenital anomalies groups in the 260 study mothers who were treated with senna during the second and/or third gestational months. The results indicated that senna treatment was not associated with a higher risk of congenital anomalies in offspring (3).
BREASTFEEDING SUMMARY
Sennosides A and B are not excreted into breast milk. A 1973 study using colorimetric analysis (sensitivity limit 0.34 mcg/mL) failed to detect the natural agents (4). The active metabolite, rhein, however, is excreted into milk in very small amounts (1). Lactating women administered 5 g of senna daily for 3 days excreted a mean 0.007% of the dose in their milk and no adverse effects were observed in the nursing infants. This is compatible with the fact that the anthraquinone laxatives are absorbed only slightly after oral administration (5).
In addition to the study above (1), use of the laxative during lactation has been reported in three other studies (4,6,7). Although diarrhea occurred in some of the infants, this was probably related to other causes, not to senna. In one study, mothers who ingested a single 100-mg dose of senna (containing 8.6 mg of sennosides A and B) and whose infants developed diarrhea were later given a double dose of the laxative (4). No diarrhea was observed in the infants after the higher dose. The American Academy of Pediatrics classifies senna as compatible with breastfeeding (8).
References
1.Faber P, Strenge-Hesse A. Relevance of rhein excretion into breast milk. Pharmacology 1988;36(Suppl 1):212–20.
2.Shepard TH. Catalog of Teratogenic Agents. 6th ed. Baltimore, MD: The Johns Hopkins University Press, 1989:574–5.
3.Acs N, Banhidy F, Puho EH, Czeizel AE. Senna treatment in pregnant women and congenital abnormalities in their offspring—a population-based case-control study. Reprod Toxicol 2009;28:100–4.
4.Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Col 1973;42:4–5.
5.American Hospital Formulary Service. Drug Information 1997. Bethesda, MD: American Society of Health-System Pharmacists, 1997:2236–8.
6.Baldwin WF. Clinical study of senna administration to nursing mothers: assessment of effects on infant bowel habits. Can Med Assoc J 1963;89:566–8.
7.Greenhalf JO, Leonard HSD. Laxatives in the treatment of constipation in pregnant and breast-feeding mothers. Practitioner 1973; 210:259–63.
8.Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108:776–89.