Is licorice root extract safe to use during pregnancy?

Licorice Root Extract During Pregnancy: Safety Concerns

Licorice root extract should be avoided during pregnancy due to its association with increased risk of preterm birth, hypertension, and potential stillbirth.

Safety Concerns with Licorice During Pregnancy

Maternal Risks

• Hypertension and electrolyte disturbances: Licorice contains glycyrrhizin which has mineralocorticoid effects that can cause:

  • Elevated blood pressure 1
  • Hypokalemia (low potassium) 2
  • Pseudohyperaldosteronism (a syndrome mimicking excess aldosterone) 2

• Drug interactions: Licorice is known to interact with several medications including:

  • Spironolactone 3
  • Cyclosporine and other immunosuppressants 3
  • Antihypertensive medications 1

Fetal/Neonatal Risks

• Preterm birth: Heavy licorice consumption (≥500 mg/week of glycyrrhizin) is associated with:

  • 2-fold increased risk of preterm delivery (<37 weeks) 4
  • 3.07-fold increased risk of early preterm birth (<34 weeks) 4

• Potential increased risk of stillbirth: Some research suggests a marginally higher rate of stillbirths among women who consumed licorice during pregnancy (OR = 7.9; 95% CI 0.9-71.5) 5

Evidence from Guidelines and Research

The Ramadan Fasting and Liver Diseases guideline specifically states that licorice juice "needs special attention because of its mineralocorticoid and drug-drug interaction activities" 3. While this guideline focuses on patients with liver disease, the concern about mineralocorticoid effects applies to pregnant women as well.

The American College of Cardiology identifies licorice as a substance that can elevate blood pressure, particularly in patients with pre-existing hypertension and individuals on antihypertensive medications 1. This is especially concerning during pregnancy when blood pressure management is critical.

A Danish prospective cohort study found that 11.1% of pregnant women consumed ginger supplements and 87.1% reported consumption of licorice, with 7.1% reporting daily consumption. Notably, licorice consumption was associated with increased blood pressure in these pregnant women 6.

Recommendations for Clinical Practice

1. Advise against use: Counsel pregnant women to avoid licorice root extract and products containing glycyrrhizin during pregnancy.

2. Screening questions: When taking medication and supplement histories from pregnant patients, specifically ask about licorice consumption, as many women may not consider it a medication or supplement.

3. For patients already consuming licorice:

   • Recommend immediate discontinuation
   • Monitor blood pressure and serum potassium levels
   • Assess for signs of preterm labor if in later stages of pregnancy

4. Patient education: Inform patients that "natural" or "herbal" does not necessarily mean safe during pregnancy. Many herbal products lack sufficient safety data for use during pregnancy.

Common Pitfalls and Caveats

• Confusion about forms: Patients may not recognize licorice in various forms (candy, tea, supplements, traditional medicines)
• Misconception of safety: Many patients believe herbal products are inherently safe because they are "natural"
• Inconsistent labeling: Some products may contain licorice without clearly stating the amount of glycyrrhizin
• Cultural considerations: Licorice is used in various traditional medicine practices and may be deeply ingrained in some cultural dietary habits

In conclusion, while licorice root extract is not considered a major teratogen 5, its association with preterm birth 4, hypertension 1, 6, and potential increased risk of stillbirth 5 warrants caution. The safest approach is to avoid licorice consumption during pregnancy until more robust safety data becomes available 7.