Effects of cinnamon on perineal pain and healing of episiotomy: a randomized placebo-controlled trial

Acute pain management after vaginal delivery with perineal tears or episiotomy

BACKGROUND

A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.

OBJECTIVE

The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.

EVIDENCE REVIEW

MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.

FINDINGS

Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.

CONCLUSIONS

Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.

The effect of probiotic supplementation on episiotomy wound healing among primiparous women: a triple-blind randomized clinical trial

BACKGROUND

Probiotics increase the defense power of immune system and accelerate the wound healing process by anti-inflammatory mechanisms at the wound site. The present study aimed at evaluating the effect of Lactobacillus casei oral supplementation on episiotomy wound healing among primiparous women.

METHODS

This triple-blind randomized clinical trial was performed on 74 primiparous women delivered in Alzahra Hospital, Tabriz, Iran. Participants with mediolateral episiotomy (incision length equal to and less than 5 cm) were randomly assigned to the probiotic and placebo groups. The probiotic group received Lactobacillus casei 431 with 1.5 * 10⁹ colony-forming unit /capsule once a day from the day after birth to 14 days. Wound healing as a primary outcome was measured by Redness, Edema, Ecchymosis, Discharge, Approximation and pain as a secondary outcome by the Visual Analogue Scale before discharge, 5 ± 1 and 15 ± 1 days after birth. The data were analyzed using independent t-test and repeated measures one way analysis of variance.

RESULTS

The mean (standard deviation: SD) score of wound healing in the probiotic group altered from 4.91(1.86) before discharge to 1.55 (0.99) during 5 ± 1 days after birth and reached to 0.95 (0.27) during 15 ± 1 days after birth. Further, the mean (SD) score of wound healing in the placebo group altered from 4.62 (1.99) before discharge to 2.80 (1.20) during 5 ± 1 days after birth and reached to 1.45(0.71) during 15 ± 1 days after birth (adjusted mean difference: -0.50, confidence interval 95%: -0.96 to -0.05, P = 0.03).

CONCLUSION

Lactobacillus casei oral supplementation is effective in healing episiotomy wounds. It is suggested to evaluate the effect of topical use of Lactobacillus casei on episiotomy repair and pain in further studies.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20170506033834N7. Date of registration: 11/08/2021.

Cinnamaldehyde-Based Self-Nanoemulsion (CA-SNEDDS) Accelerates Wound Healing and Exerts Antimicrobial, Antioxidant, and Anti-Inflammatory Effects in Rats’ Skin Burn Model

Cinnamaldehyde, the main phytoconstituent of the cinnamon oil, has been reported for its potential wound healing activity, associated to its antimicrobial and anti-inflammatory effects. In this study, we are reporting on the cinnamaldehyde-based self-nanoemulsifying drug delivery system (CA-SNEDDS), which was prepared and evaluated for its antimicrobial, antioxidant, anti-inflammatory, and wound healing potential using the rat third-degree skin injury model. The parameters, i.e., skin healing, proinflammatory, and oxidative/antioxidant markers, were evaluated after 3 weeks of treatment regimens with CA-SNEDDS. Twenty rats were divided randomly into negative control (untreated), SNEDDS control, silver sulfadiazine cream positive control (SS), and CA-SNEDDS groups. An aluminum cylinder (120 °C, 10-s duration) was used to induce 3rd-degree skin burns (1-inch square diameter each) on the rat’s dorsum. At the end of the experiment, skin biopsies were collected for biochemical analysis. The significantly reduced wound size in CA-SNEDDS compared to the negative group was observed. CA-SNEDDS-treated and SS-treated groups demonstrated significantly increased antioxidant biomarkers, i.e., superoxide dismutase (SOD) and catalase (CAT), and a significant reduction in the inflammatory marker, i.e., NAP-3, compared to the negative group. Compared to SNEDDS, CA-SNEDDS exhibited a substantial antimicrobial activity against all the tested organisms at the given dosage of 20 µL/disc. Among all the tested microorganisms, MRSA and S. typhimurium were the most susceptible bacteria, with an inhibition zone diameter (IZD) of 17.0 ± 0.3 mm and 19.0 ± 0.9 mm, respectively. CA-SNEDDS also exhibited strong antifungal activity against C. albicans and A. niger, with IZD of 35.0 ± 0.5 mm and 34.0 ± 0.5 mm, respectively. MIC and MBC of CA-SNEDDS for the tested bacteria ranged from 3.125 to 6.25 µL/mL and 6.25 to 12.5 µL/mL, respectively, while the MIC and MBC for C. albicans and A. niger were 1.56 µL/mL and 3.125 µL/mL, respectively. The MBIC and MBEC of CA-SNEDDS were also very significant for the tested bacteria and ranged from 6.25 to 12.5 µL/mL and 12.5 to 25.0 µL/mL, respectively, while the MBIC and MBEC for C. albicans and A. niger were 3.125 µL/mL and 6.25 µL/mL, respectively. Thus, the results indicated that CA-SNEDDS exhibited significant wound healing properties, which appeared to be attributed to the formulation’s antimicrobial, antioxidant, and anti-inflammatory effects.

The Use of Complementary Medicine During Childbearing Years: A Multi-Country Study of Women From the Middle East اس نه الطب التكميلي خلال سنوات الإنجاب: دراسة متعددة البلدان لنساء من الشرق الأوسط

The prevalence of self-prescribed complementary medicine (CM) use is an area of concern across the Middle East. We conducted a descriptive qualitative study to describe women’s use of CM during their childbearing years in Egypt, Jordan, Saudi Arabia and Iran. The study conducted using face to face audio-recorded interviews with 70 participants. Our findings showed that women used several herbal plants to ease pain and discomfort during menstruation and/or during pregnancy and in postpartum care. Acupuncture, meditation, and massage were less likely to be used by women. The impact of CM was often described in relation to perceived usefulness and safety of herbs. Cultural beliefs and roles of women contributed to the use of herbs among women. Given the high use of herbal medicine, there is a need for discussion about the potential of adverse effects of some plants or their metabolites following self-medication during the childbearing years.

The effectiveness and safety of complementary health approaches to managing postpartum pain: A systematic review and meta-analysis

Background

Women experience pain from a number of causes during the postpartum period. Although pharmacological pain relief has shown to be effective, the efficacy of non-pharmacological methods of pain relief will be of interest to breastfeeding women. The aim of this systematic review was to examine the efficacy and safety of complementary approaches to manage postpartum pain.

Methods

A search of English language databases from their inception to 2020 was undertaken for randomised controlled trials and included primiparous and multiparous women who experienced postpartum pain up to two weeks post birth. The primary outcome was pain. The risk of bias was assessed using the Cochrane risk of bias tool.

Results

Thirty trials were included in the review, 25 trials (2,413 women) were included in the meta-analysis. Two trials of massage found a reduction in pain following caesarean birth within the first 24 h post birth (MD -2.64, 95–2.82 to -2.46, 184 women, I² 0%), and at seven days postpartum (MD -1.91, 95%CI -2.42 to -1.40, 2 trials, 120 women I² 37%). Two trials conducted with women receiving an episiotomy found reduction in perineal pain from herbal ointments within 24 h (MD -1.33, 95% CI -.96 to -0.70, 221 women) and at 14 days postpartum (MD -0.74, 95% CI -1.02 to -0.47, 4 trials). Few trials reported on safety, few trials were at an overall low risk of bias, and overall the quality of evidence was very low.

Conclusion

Further high quality trials are needed to determine the safety and effectiveness of herbal ointment and massage during the early postpartum period.

Topical application of Cinnamomum hydroethanolic extract improves wound healing by enhancing re-epithelialization and keratin biosynthesis in streptozotocin-induced diabetic mice

Context: Cinnamomum verum J. Presl. (Lauraceae) has a high number of polyphenols with insulin-like activity, increases glucose utilization in animal muscle, and might be beneficial for diabetic patients.Objective: This study evaluated the effectiveness of an ointment prepared from Cinnamomum verum hydroethanolic extract on wound healing in diabetic mice.Materials and methods: A total of 54 male BALB/c mice were divided into three groups: (1) diabetic non-treated group mice that were treated with soft yellow paraffin, (2 and 3) mice that were treated with 5 and 10% C. verum. Two circular full-thickness excisional wounds were created in each mouse, and the trial lasted for 16 d following induction of the wound. Further evaluation was made on the wound contraction ratio, histopathology parameters and mRNA levels of cyclin D1, insulin-like growth factor 1 (IGF-1), glucose transporter-1 (GLUT-1), total antioxidant capacity, and malondialdehyde of granulation tissue contents. HPLC apparatus was utilized to identify the compounds.Results: The HPLC data for cinnamon hydroethanolic extract identified cinnamaldehyde (11.26%) and 2-hydroxyl cinnamaldehyde (6.7%) as the major components. A significant increase was observed in wound contraction ratio, fibroblast proliferation, collagen deposition, re-epithelialization and keratin biosynthesis in the C. verum-treated groups in comparison to the diabetic non-treated group (p < 0.05). The expression level of cyclin D1, IGF1, GLUT 1 and antioxidant capacity increased in the C. verum-treated groups in comparison to the diabetic non-treated group (p < 0.05).Conclusions: Topical administration of C. verum accelerated wound healing and can possibly be employed in treating the wounds of diabetic patients.

Porous electrospun poly(ε-caprolactone)/gelatin nanofibrous mat containing cinnamon for wound healing application: in vitro and in vivo study

In this study, cinnamon (cin) was loaded into poly(ε-caprolactone)/gelatin (PCL/Gel) nanofibrous matrices in order to fabricate an appropriate mat to improve wound healing. Mats were fabricated from PCL/COLL [1:1 (w/w)] solution with 1, 5 and 25% (w/v) of cinnamon. Prepared mats were characterized with regard to their microstructure, mechanical properties, porosity, surface wettability, water-uptake capacity, water vapor permeability, blood compatibility, microbial penetration and cellular response. The fabricated mats with and without cinnamon were used to treat the full-thickness excisional wounds in Wistar rats. The results indicated that the amount of cinnamon had a direct effect on porosity, mechanical properties, water uptake capacity, water contact angle, water vapor transmission rate and cell proliferation. In addition, the results of in vivo study indicated that after 14 days, the wounds which were treated with PCL/Gel 5%cin had better wound closure (98%) among other groups. Our results suggest that the cinnamon can be used as a suitable material for wound healing.

[Evidence-Based Practices in Episiotomy Care]

AIM

The aim of this study was to systematically evaluate the research associated with wound healing process in episiotomy care.

METHOD

The search for this study was conducted through the international databases of Cochrane, Science Direct, Medline, Medine Complete, CIHANL, Scopus, AcademicSearch Complete, Complementary Index and ULAKBIM medical database among the National Databases between May 1 and July 17, 2017. "Episiotomy care" and "episiotomy wound healing" were used as key words during the search. A total of 23 publications compliant with the inclusion criteria were included in the study and were evaluated in terms of comparisons, restrictions, and results.

RESULTS

Studies about episiotomy care were evaluated under four headings such as the use of antiseptic solutions, use of dry/wet and hot and cold applications, laser and light therapy, and the use of aromatic oils and phytotherapy in episiotomy care. Among the 23 studies included in this study, 17 were designed as experimental and 6 as half-experimental and a total of 2.408 puerperal women participated in this study.

CONCLUSION

The results of this literature review revealed a limited number of research findings on the care of episiotomy wounds and a necessity of performance of new studies on this subject was established.

Cinnamaldehyde accelerates wound healing by promoting angiogenesis via up-regulation of PI3K and MAPK signaling pathways

The bark of Cinnamomum cassia (C. cassia) has been used for the management of coronary heart disease (CHD) and diabetes mellitus. C. cassia may target the vasculature, as it stimulates angiogenesis, promotes blood circulation and wound healing. However, the active components and working mechanisms of C. cassia are not fully elucidated. The Shexiang Baoxin pill (SBP), which consists of seven medicinal materials, including C. cassia etc., is widely used as a traditional Chinese patent medicine for the treatment of CHD. Here, 22 single effective components of SBP were evaluated against the human umbilical vein endothelial cells (HUVECs). We demonstrated that in HUVECs, cinnamaldehyde (CA) stimulated proliferation, migration, and tube formation. CA also activated the phosphatidylinositol 3-kinase (PI3K) and mitogen-activated protein kinase (MAPK) pathways. Furthermore, the secretion of vascular endothelial growth factor (VEGF) from HUVECs was increased by CA. In vivo, CA partially restored intersegmental vessels in zebrafish pretreated with PTK787, which is a selective inhibitor for vascular endothelial growth factor receptor (VEGFR). CA also showed pro-angiogenic efficacy in the Matrigel plug assay. Additionally, CA attenuated wound sizes in a cutaneous wound model, and elevated VEGF protein and CD31-positive vascular density at the margin of these wounds. These results illustrate that CA accelerates wound healing by inducing angiogenesis in the wound area. The potential mechanism involves activation of the PI3K/AKT and MAPK signaling pathways. Such a small non-peptide molecule may have clinical applications for promoting therapeutic angiogenesis in chronic diabetic wounds and myocardial infarction.

The use of medicinal herbs in gynecological and pregnancy-related disorders by Jordanian women: a review of folkloric practice vs. evidence-based pharmacology

Context National statistical reports in Jordan indicate a decrease in the total fertility rate along with a parallel increase in contraceptive use. The folkloric use of medicinal herbs in gynecological disorders has been growing in Jordan, despite of deficient reports on the evidence-based safety and efficacy of these practices. Objective The aim of this comprehensive article is to review medicinal plants with claimed ethnonpharmacological usage in various gynecological and pregnancy-related issues in Jordan, and to assess their evidence-based pharmacological studies as well as their phytochemistry. Methods The published literature was surveyed using Google Scholar entering the terms "ethnopharmacology AND Jordan AND infertility AND gynecology OR gestation". We included ethnopharmacological surveys in Jordan with available full-text. Results Twelve articles were reviewed. Plant species which are commonly used for female gynecological issues such as Artemisia monosperma Del. and A. herba-alba Asso. (Asteraceae) have been found to exert an antifertility effect. Ricinus communis L. (Euphorbiaceae) and Citrullus colocynthis (L.) Schrad. (Cucurbitaceae) had antifertility effects in male rats, but Nigella sativa oil L. (Ranunculaceae) and Cinnamon zeylanicum J. Presl (Lauraceae) were found to enhance it. Conclusion Using plants for gynecological disorders is a common practice in Jordan. Many of them, whether utilised for gynecological or non-gynecological conditions equally, were found to have detrimental effects on female or male fertility. Thus, couples planning pregnancy should be discouraged from the consumption of these herbs. Further local studies are warranted to confirm the appreciable beneficial pharmacological effects and safety of these plants.

The effect of equisetum arvense (horse tail) ointment on wound healing and pain intensity after episiotomy: a randomized placebo-controlled trial

Background:

Episiotomy, a common surgical practice in midwifery, is accompanied with high levels of pain and discomfort for mothers. The importance of medicinal herbs and traditional medicine in wound healing cannot be neglected.

Objectives:

Considering the positive effects and easy accessibility of Equisetum arvense, this study examined the effectiveness of topical application of Equisetum arvense ointment in wound healing, reduction of inflammation and pain relief after episiotomy in nulliparous mothers.

Patients and Methods:

This double-blind clinical trial was performed on 108 postpartum nulliparous mothers (54 women in horsetail group and 54 women in placebo group) in Alzahra Educational-Medical Center (Tabriz, Iran). About 5 ± 1 and 10 ± 1 days after the childbirth, the primary outcomes of episiotomy, i.e. wound healing and pain intensity, were assessed based on redness, edema, ecchymosis, discharge and approximation of the edges (REEDA) scale and a visual analogue scale (VAS), respectively. The secondary outcomes evaluated in the current research were the number of used painkillers and the adverse events during the 10-day period of the study. Data was analyzed using independent t and Mann-Whitney U tests.

Results:

The case and control groups had no significant differences in for the mean wound healing score (5.0 ± 1.6 vs. 4.1 ± 1.6) and mean pain intensity (5.7 ± 2.4 vs. 5.3 ± 2.2) at baseline. During both follow-up sessions (5 ± 1 and 10 ± 1days after delivery), the mean scores were significantly lower in the case group than the control group. The adjusted pain score difference (MD) after 5 ± 1 and 10 ± 1 days was -2.3 (95% CI: -3.2 to -1.3) and 3.8 (95% CI: -4.7 to -3.0), respectively. The mean numbers of acetaminophen pills used in the control and case groups during the 10-day period of the study were 6.8 ± 4.4 and 11.6 ± 7.1, respectively (P < 0.001).

Conclusions:

According to our findings, 3% Equisetum arvense ointment promoted wound healing and relieved pain during the 10-day period after episiotomy. Since this study was the first to assess the effects of Equisetum arvense ointment on wound healing and pain intensity following episiotomy in humans, further research is warranted to fully clarify the beneficial effects of prepared ointment.