Is senna (anthraquinone laxative) safe during pregnancy?

From the Guidelines

Senna should be avoided in pregnancy due to conflicting safety data and the availability of safer alternatives. When considering the management of constipation in pregnant individuals, it is essential to prioritize treatments with a more established safety profile. According to the most recent guidelines, including the 2024 expert review published in Gastroenterology 1, the best practice advice for constipation in pregnant persons includes dietary fiber, lactulose, and polyethylene glycol–based laxatives. Key points to consider in the management of constipation during pregnancy include:

• Increasing dietary fiber intake to the recommended daily amount of approximately 30 g/d to promote regular bowel movements and prevent constipation
• Consuming an adequate amount of fluids, particularly water, to help soften stools and ease bowel movements
• The use of bulk-forming agents, such as psyllium husk or methylcellulose, which are safe to administer in pregnancy due to the lack of systemic absorption
• The administration of osmotic laxatives, such as polyethylene glycol or lactulose, which can also be safely used during pregnancy Stimulant laxatives, including senna, should be avoided because safety data on these medications are conflicting, as noted in the expert review 1. Therefore, the focus should be on using safer, evidence-backed treatments for constipation in pregnancy.

From the FDA Drug Label

Ask a doctor before use if you have ... are pregnant or breast feeding The FDA drug label advises to ask a doctor before use if pregnant, which implies that senna may not be safe in pregnancy without medical supervision.

• The label does not provide explicit information on the safety of senna in pregnancy.
• It is recommended to consult a doctor before using senna during pregnancy 2.

From the Research

Senna Safety in Pregnancy

• The safety of senna in pregnancy has been studied in a population-based case-control study, which found no higher risk of congenital abnormalities (CAs) in the offspring of pregnant women with constipation who used senna treatment 3.
• The study compared cases with CAs and their matched controls without CAs, and found that the adjusted OR with 95% CI was 1.0.9-1.1, indicating no significant association between senna treatment and CAs.
• The study also found that gestational age at delivery was somewhat longer and the rate of preterm birth was lower in newborn infants without CA born to mothers with senna treatment compared with babies born to mothers without senna treatment.

Comparison with Other Studies

• A study on the use of senna-based laxatives in children found that senna is a safe treatment option for constipation in children, with rare side effects such as perineal blistering 4.
• Another study on opioid-induced constipation found that sennosides have equal efficacy and side effect profiles compared to PEG in the management of OIC in adults, but noted that further research is strongly encouraged 5.
• Studies on preterm labor have found that diarrhea is a warning sign associated with preterm labor, but not with spontaneous preterm delivery 6, and that tocolytic agents have significant maternal and fetal side-effects associated with their use 7.

Key Findings

• Senna treatment does not associate with a higher risk of CAs in the offspring of pregnant women with constipation 3.
• Senna is a safe treatment option for constipation in children, with rare side effects such as perineal blistering 4.
• Further research is needed to fully understand the safety and efficacy of senna in pregnancy and other populations.