Discussion and conclusion:
In Uganda, medicinal plants are widely used by indigenous ethnic groups, both as food vegetables and culinary herbs and in traditional medicine. In a study conducted in western Uganda, 75 plants commonly used to induce labor have been identified; most of them possess uterotonic properties and, at unspecified high doses, their toxicity may be life-threatening for both the mother and the fetus [14].
In northern Uganda, two plants are commonly used to induce labor, i.e. the Commelina Africana , also known as wandering jew” (Figure 1), and the Vernonia amygdalina , also known as“bitter leaf” (Figure 2). The uterotonic properties of these herbs have been already tested and confirmed [15]. Commelina Africana ( Wandering jew”; “Lototo” in Acholi language and “Otoro” in Luo language), is known to have hypoglycemic effects [10], as well as uterotonic activity; in fact, it can increase both the force of contractions and their frequency, with a dose-response curve [15]. To induce abortion, the stem of the plant is normally broken in small pieces and inserted in the vagina, adjacent to the cervix, to induce it to dilate [14]. The severe complications due to the use of this herb, as reported in Case 1, seem to be due to its insertion in the vagina under unsterile conditions, which allow the ascension of pathogens to the pelvic cavity passing through the cervix, the uterus and the fallopian tubes, causing massive pelvic abscesses, severe peritonitis, and septic shock. In our case, this condition required multiple surgical interventions with extensive abdominal lavage, as well as the use of reserve antibiotics.
Vernonia amygdalina (“Bitter leaf”; “Labwori” in the Acholi language and “Olusia” in Luo language) is an indigenous shrub that grows in most parts of sub-Saharan Africa and may be found growing wild along the edges of agricultural fields. It grows to a height of 1-2 m, with elliptical leaves up to 20 cm long. It is commonly called “bitter leaf” in English because of its bitter taste. As reported by Echemet al.[16], Vernonia amygdalina plays a big role in the diet of indigenous people throughout equatorial Africa because of the presence of vitamins and mineral salts [15]. For numerous African ethnic groups, it is also considered a very strong medicine in the treatment of malarial fever, schistosomiasis, amoebic dysentery, and several other intestinal parasites and stomach aches; extracts thereof have been also used traditionally in the treatment of sexually transmitted diseases, cough, constipation, and hypertension. Its ability to contract the uterus, thereby inducing abortion, has been validated [15]. Vernonia species contain phytochemical principles, which include bitter sesquiterpene lactones, vernolepin, vernodalin, vernomygdin, and steroid glucosides, from which its biological properties were derived [17]. Vernonia amygdalina,especially those grown along heavy traffic routes, can concentrate high levels of heavy metals such as Iron (Fe), Manganese (Mn), Lead (Pb), chromium (Cr), Zinc (Zn) and Cadmium (Cd) ; which have the potential to act as biological poisons even at parts per billion levels, [16]. The concentration of these metals is highest in the leaves, which are commonly used for decoctions.
In case 2, the use of Vernonia amygdalina led to complications requiring admission to the hospital; the patient presented with reduced GCS due to hepatic encephalopathy, associated with other signs of acute renal and liver failure. Typical laboratory findings were hypoglycemia, leucocytosis, and elevated liver enzymes, associated with elevated creatinine and urea values. The course of the disease was deadly.
In conclusion, we reported two cases describing the unusual severe toxicity of two herbal medicines that are frequently used to induce abortion in northern Uganda. In particular, the use of Commelina Africana may be associated with pyometra and/or pyoperitoneum and sepsis, while Vernonia amygdalina may lead to acute liver and renal failure, which can be fatal.
The ingestion of medicinal plants to induce abortion involves the risk of severe maternal morbidity and mortality; patients should be informed that the use of these medicinal plants as abortifacients can be life-treating. Active policy to improve knowledge of contraception and family planning is required.
Moreover, further field and laboratory research is needed to identify the active principles contained in such herbal medicines and their biological properties, to achieve a better understanding of their pathophysiology, dosage levels, and toxicity. This would help in the treatment of the associated complications and the development of possible antidotes.