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Down the Primrose Path: Petechiae in a Neonate Exposed to Herbal Remedy for Parturition

2007; Elsevier BV; Volume: 152; Issue: 1 Linguagem: Inglês

10.1016/j.jpeds.2007.08.001

1097-6833

Kathy E. Wedig, Jeffrey A. Whitsett,

Medical History and Innovations

A 2855-g white female was born at 38 4/7 weeks gestation to a healthy 31-year-old primigravida woman by spontaneous vaginal delivery after labor that was augmented with pitocin. The mother’s pregnancy was uncomplicated. For the week before delivery, she had self medicated with raspberry leaf tea and a total of thirteen 500-mg capsules of evening primrose oil, vaginally and orally, in hopes of ripening her cervix to improve labor. The infant was born after 16 hours of labor, with Apgar scores of 9 and 9. The infant appeared well and was maintained with her mother. At 17 hours of age, the newborn female was noted to have diffuse ecchymoses and petechiae located on the trunk, extremities, and face (Figure). She was otherwise well. The result of the physical examination was otherwise unremarkable. There was no hepatosplenomegaly and minimal jaundice. There was no family history of hematologic abnormalities including Von Willebrand’s disease. The infant was transferred to the neonatal intensive care unit for observation. Laboratory study results were normal, and her platelet count was 370,000 to 390,000 (Table; available at www.jpeds.com). Head ultrasound scanning revealed no evidence of hemorrhage. Urine did not contain blood. The infant had no new ecchymoses develop and was discharged at 3 days of age. Purpura had resolved by 5 days of age, and the infant remains well.TableLaboratory values and normal ranges are shown at approximately 24 hours of ageLabValueNormalHematocrit4740-65Platelet count370,000-399,000140,000-375,000Bilirubin, total5.9 mg/dLCytomegalovirus, IgM0.4Negative <.89Blood cultureNegativeFibrinogen221 mg/dL170-410 mg/dLProtime12.3 sec10.8-13.2 secPTT35.4 sec31.3-54.3 secThrombin time15 sec10-16 secINR10.8-1.2IgM, Immunoglobulin M; PTT, partial thromboplastin time; INR, international normalized ratio. Open table in a new tab IgM, Immunoglobulin M; PTT, partial thromboplastin time; INR, international normalized ratio. This newborn infant experienced extensive petechiae and confluent purpuric cutaneous ecchymoses after recent in utero exposure to evening primrose oil and raspberry leaf tea. The treatment was recommended by her obstetrical care giver for reducing the duration of childbirth. Evening primrose oil and raspberry leaf tea are commonly recommended herbal remedies believed to improve the process of childbirth and minimize postpartum bleeding. Literature regarding both herbal remedies is retrospective, and clinical studies are uncontrolled. Possible adverse side effects have not been prospectively studied in the newborns, but the medications have been recommended in the literature.1Dove D. Johnson P. Oral evening primrose oil: its effect on length of pregnancy and selected intrapartum outcomes in low-risk nulliparous women.J Nurse Midwifery. 1999; 44: 320-324Crossref PubMed Scopus (53) Google Scholar Evening primrose oil contains approximately 9% gamma linolenic acid, an omega 6 essential fatty acid. Gamma linolenic acid and its metabolite, dihomo-gamma linolenic acid, may act as antithrombotic agents by their conversion to prostaglandin E12Fan Y.Y. Chapkin R.S. Importance of dietary gamma-linolenic acid in human health and nutrition.J Nutr. 1998; 128: 1411-1414PubMed Scopus (303) Google Scholar and by reduction of thromboxane B2, a potent platelet aggregator.3Guivernau M. Meza N. Baria P. Roman O. Clinical and experimental study on the long-term effect of dietary gamma-linolenic acid on plasma lipids, platelet aggregation, thromboxane formation and prostacyclin production.Prostaglandins Leukot Essent Fatty Acids. 1994; 51: 311-316Abstract Full Text PDF PubMed Scopus (53) Google Scholar Studies in human beings,3Guivernau M. Meza N. Baria P. Roman O. Clinical and experimental study on the long-term effect of dietary gamma-linolenic acid on plasma lipids, platelet aggregation, thromboxane formation and prostacyclin production.Prostaglandins Leukot Essent Fatty Acids. 1994; 51: 311-316Abstract Full Text PDF PubMed Scopus (53) Google Scholar, 4Sim A.K. McCraw A.P. The activity of gamma-linolenate and dihomo-gamma-linolenate methyl esters in vitro and in vivo on blood platelet function in non-human primates and in man.Thromb Res. 1977; 10: 385-397Abstract Full Text PDF PubMed Scopus (44) Google Scholar rats,3Guivernau M. Meza N. Baria P. Roman O. Clinical and experimental study on the long-term effect of dietary gamma-linolenic acid on plasma lipids, platelet aggregation, thromboxane formation and prostacyclin production.Prostaglandins Leukot Essent Fatty Acids. 1994; 51: 311-316Abstract Full Text PDF PubMed Scopus (53) Google Scholar rabbits,5De La Cruz J.P. Martín-Romero M. Carmona J.A. Villalobos M.A. Sánchez de la Cuesta F. Effect of evening primrose oil on platelet aggregation in rabbits fed an atherogenic diet.Throm Res. 1997; 87: 141-149Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar and baboons4Sim A.K. McCraw A.P. The activity of gamma-linolenate and dihomo-gamma-linolenate methyl esters in vitro and in vivo on blood platelet function in non-human primates and in man.Thromb Res. 1977; 10: 385-397Abstract Full Text PDF PubMed Scopus (44) Google Scholar showed that platelet aggregation was decreased after ingestion of evening primrose oil. Dihomo-gamma linolenic acid inhibited platelet aggregation in vitro.3Guivernau M. Meza N. Baria P. Roman O. Clinical and experimental study on the long-term effect of dietary gamma-linolenic acid on plasma lipids, platelet aggregation, thromboxane formation and prostacyclin production.Prostaglandins Leukot Essent Fatty Acids. 1994; 51: 311-316Abstract Full Text PDF PubMed Scopus (53) Google Scholar Although it is reasonable to optimize the process of childbirth, this case raises concerns regarding the safety of primrose oil in this clinical setting. In vitro and in vivo animal studies demonstrate that evening primrose oil inhibits platelet aggregation. This case supports the likelihood that primrose oil taken in late gestation inhibited platelet function (“thrombasthenia”) in the newborn infant, resulting in transient but extensive purpura and petechiae. Although herbal medicines are natural products, neither raspberry leaf tea nor primrose oil has been systemically shown to be either safe and effective. References available atwww.jpeds.com.