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To the Editor.— With St John's wort (Hypericum perforatum) gaining popularity as a nonprescription, herbal treatment for depression we are concerned that women may assume that it is safe to take during pregnancy.
Review of MEDLINE and Reproductive Toxicity Review using the search terms St John's wort, Hypericum perforatum, hypericin, and Johanneskraut (German) revealed scant information. Increased uterine tonicity has been reported in animals,1 suggesting that use of this agent should be avoided during pregnancy.2 However, a study of toxic effects in rats and dogs at oral doses of 900 and 2700 mg/kg showed no reproductive effects.3 Also, a study of the mutagenic potential of hypericum extract on mammalian cells showed no effects.4 To date, there are no published cases, to our knowledge, of human antenatal exposure or lactation effects.
A 38-year-old woman experienced a recurrence of major depressive disorder during her first trimester of pregnancy. At 24 weeks she started taking 900 mg/d of St John's wort, taking her last dose 24 hours prior to delivery. The pregnancy was unremarkable except for late onset of thrombocytopenia (platelet count, 88 000).
She gave birth at term to a healthy 7 lb, 8 oz female infant with Apgar scores of 9 at 1 and 5 minutes. Physical examination and laboratory results were normal. She discontinued taking St John's wort postpartum and initiated breast-feeding. The neonate developed jaundice on day 5, requiring brief phototherapy. On day 20, the woman resumed St John's wort at 300 mg/d but continued breast-feeding. Behavioral assessment of the neonate at 4 and 33 days was within the normal range.
A 43-year-old woman with a history of treatment-refractory, recurrent major depressive disorder successfully treated with fluoxetine hydrochloride and methylphenidate hydrochloride conceived unexpectedly. Concerned about potential harmful effects to the fetus, she discontinued taking her antidepressants and started taking 900 mg/d of St John's wort.
Both women initiated treatment without medical consultation, assuming that St John's wort was safer than conventional antidepressants. In addition, patient 2 discontinued an effective pharmacologic treatment, placing herself at risk for relapse of refractory depression while pregnant. We caution against the use of St John's wort during pregnancy and emphasize the need for a complete medication history in pregnant women. Until the efficacy of St John's wort for the treatment of major depressive disorder is firmly established and its reproductive safety is evaluated more thoroughly, the tricyclic antidepressants and fluoxetine appear to be safer pharmacologic alternatives.5
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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