|Year : 2017 | Volume
| Issue : 4 | Page : 247-251
|Sleep disturbances and memory impairment among pregnant women consuming khat: An under-recognized problem
Md. Dilshad Manzar1, Mohammed Salahuddin2, Peter Sony1, Tarekegn Tesfaye Maru2, Seithikurippu R Pandi-Perumal3, Adam Moscovitch4, Ahmed S Bahammam3
1 Department of Biomedical Sciences, College of Health Sciences, Mizan-Tepi University, (Mizan Campus), Mizan Teferi, Ethiopia
2 Department of Pharmacy, College of Health Sciences, Mizan-Tepi University, (Mizan Campus), Mizan Teferi, Ethiopia
3 University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh; National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
4 Sleep and Fatigue Institute, The University of Calgary, Calgary, Canada
|Date of Submission||19-Jan-2017|
|Date of Acceptance||24-Feb-2017|
|Date of Web Publication||10-Oct-2017|
Ahmed S Bahammam
University Sleep Disorders Center, King Saud University, Riyadh
| Abstract|| |
Khat (Catha edulis) is a evergreen flowering shrub that is cultivated at high altitudes, especially in East Africa and the southwest of the Arabian Peninsula. The plant contains alkaloids, of which cathinone and cathine have structural similarity and pharmacological action similar to amphetamines. The leaves are, therefore, consumed in some regions as a psychoactive stimulant due to cultural beliefs and misperceptions on the health benefits of khat consumption. This resulted in a growing prevalence of khat consumption among pregnant women. The myriad of physiological changes associated with pregnancy impairs sleep and memory. Moreover, khat has also been shown to have adverse effects on memory and sleep. Therefore, its use during pregnancy may further aggravate those impairments. The purpose of this mini-review is to summarize the changes in sleep and memory during pregnancy and the evidence supporting a relationship between khat consumption and neurocognitive deficits and sleep dysfunctions. The misperceptions of beneficial effects of khat, the high prevalence of consumption among pregnant women, and the possibility of under-reporting of khat abuse do necessitate the development of alternative methodologies to identify cases of unreported khat abuse in pregnant women. It is proposed that screening for sleep problems and memory deficits may help identify under-reported cases of khat abuse in pregnant women.
Keywords: Catha edulis, chat, neurocognitive, memory, pregnancy, sleep, khat
|How to cite this article:|
Manzar MD, Salahuddin M, Sony P, Maru TT, Pandi-Perumal SR, Moscovitch A, Bahammam AS. Sleep disturbances and memory impairment among pregnant women consuming khat: An under-recognized problem. Ann Thorac Med 2017;12:247-51
|How to cite this URL:|
Manzar MD, Salahuddin M, Sony P, Maru TT, Pandi-Perumal SR, Moscovitch A, Bahammam AS. Sleep disturbances and memory impairment among pregnant women consuming khat: An under-recognized problem. Ann Thorac Med [serial online] 2017 [cited 2017 Oct 24];12:247-51. Available from: http://www.thoracicmedicine.org/text.asp?2017/12/4/247/216292
Khat (Catha edulis) is an evergreen flowering shrub that grows at high altitudes. It is cultivated especially in East Africa and the southwest of the Arabian Peninsula. The young tender leaves are used as a psychoactive stimulant. The major active compounds are alkaloids, of which cathinone and cathine are the most active ones. These are similar in structure and pharmacological activity to amphetamines and stimulate the central nervous system. The global consumption is continually increasing, with new parts of the world reporting and documenting this social habit. This is mainly because migrants from the khat-growing regions are settling in Europe, America, and Australia., Khat use is greatly prevalent in Afro-Asian countries.,,, The social burden can be grossly estimated from the prevalence of khat use being as high as 90% in some regions. Khat use by women is increasing.,, Unfortunately, khat use is common in women even during pregnancy. High prevalence of khat consumption (as high as 60% in general women and 40.7% in pregnant women) has been reported.
The cultural beliefs that khat consumption has health benefits such as relief of a headache, weight loss and assistance in birth, and delivery may account for the risky practice. Under-reporting of khat consumption (due to social desirability bias) makes it difficult for the gynecological and antenatal health-care systems to provide a timely intervention. It is therefore very important to identify potential clinical markers of complications related to khat consumption in pregnant women. Such markers may help identify cases of khat abuse in pregnant women.
Both memory deficits and sleep problems are associated with pregnancy.,, This mini-review summarizes the evidence supporting a relationship between khat consumption and memory deficits and sleep problems in pregnancy. [Figure 1] demonstrates a schematic representation of the relationship between khat consumption, sleep problems, pregnancy, and memory deficit.
|Figure 1: Schematic representation of the relationship between pregnancy, khat consumption, sleep problems, and memory deficit|
Click here to view
| Sleep and Memory|| |
One of the important functional roles of sleep is facilitation and consolidation of learning and memory., The effects of disturbed sleep on memory are summarized in [Table 1]. Chronic sleep deprivation has a detrimental effect on cognitive functioning during pregnancy., Moreover, partial sleep deprivation is associated with reduced cognitive performance in pregnant women. Insufficient sleep has a negative effect on cognitive performance including problem-solving, language, forward planning, and attention. Sleep deficits the night before decrease memory and concentration tasks. The performance of memory and concentration tasks in postpartum women is significantly predicted by the amount of sleep they had the preceding night. Further, the causal implication of sleep disturbances and deprivation on memory is supported by the finding that declarative memory significantly improved after sleep in healthy adolescents.
| Sleep in Pregnancy|| |
The multifaceted physiological changes during pregnancy manifest as irregularities in sleep [Table 2]., The effects of pregnancy on sleep are summarized in [Table 2]. Insomnia,, poor sleep efficiency, and short sleep duration  are usually prevalent in pregnant women. Poor sleep usually improves after delivery and subsequently improves steadily., Sleep irregularities are dynamic and gradually change during pregnancy.,, Increased daytime sleepiness, increased nocturnal insomnia, increased total sleep time (regular naps), and decreased stage N3 sleep are usually seen in in the first trimester., The second trimester is characterized by increased sleep latency, increased awakenings,, fewer hours of night sleep, decreased sleep efficiency, decreased stages N3, and rapid eye movement (REM) sleep. Decreased total sleep time, increased insomnia, increased daytime sleepiness, increased stage N1 sleep, increased waking after sleep onset, decreased stage N3 sleep, and decreased REM sleep are seen in the third trimester. Sleep problems during pregnancy have been found to adversely affect maternal and fetal outcomes (i.e., cesarean section rates; longer, preterm, and discomfortable labor; and increased perception of pain).,
The effects of pregnancy and its associated medical conditions on memory are summarized in [Table 3]. Cognition is impaired during pregnancy and this manifests as poor memory performance during the three trimesters. Pregnancy affects long-term memory (both implicit and explicit) and short-term/working memory. There is a substantial evidence indicating that pregnancy has a negative influence on declarative memory. The results are more conclusive regarding the recall memory but not recognition. The physiology behind this impairment is not clear with several proposed mechanisms., Crawley et al. reported perceived impairments in verbal memory in pregnant women. Sleep disturbance (e.g., fragmentation and deprivation) have been linked to lower scores on tasks of immediate memory, complex mental functions (e.g., problem-solving), and overall daytime function during the immediate postpartum period.,,
| Khat and Pregnancy|| |
The khat has been found to have detrimental effects on both pregnant women and babies [Table 4]. It has been implicated in impaired liver and kidney function, hormonal profiles and fetal outcomes, teratogenicity, anorexia, appetite changes, and fatigue., The khat use during pregnancy is associated with the increase in parameters such as heart rate, diastolic blood pressure, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, creatinine, blood urea, estrogen, postimplantation losses, and increased risk of dysmature infants.
Further, khat consumption and cathinone level in pregnancy have been related to low birth weight,,,, decreased uteri-placental blood flow,, decreased maternal myometrial blood flow, decreased maternal milk production, reduced fetal growth and development,,, low plasma albumin and sodium, low maternal weight, and decreased lipid. Chest pain, sinus tachycardia, and hypertension were reported in a pregnant woman after khat chewing in a case report. Therefore, it is very important to closely monitor pregnant women with history of khat consumption.
| Khat and Sleep|| |
Khat has been found to affect sleep and to be associated with sleep problems [Table 5].,, The prevalence of sleep problems was very high in khat users (65%), with 31% reporting moderate to severe level of disturbances. Sleep disturbance,,, insomnia,,, and nightmares  have been commonly reported in khat users. After a khat session, the user usually experiences depressed mood, irritability, anorexia, and difficulty to sleep. Lethargy and a sleepy state follow the next morning. In chronic khat users, sudden discontinuation results in withdrawal symptoms during the 1st day, such as sleeping disturbances, depression, and intense cravings. This diabolic situation of depression with continued use as well as depression on discontinuation of khat can be very challenging for the antenatal care system., Since depression  and sleep deprivation  are common in pregnant women, khat consumption may further aggravate both symptoms. Sleep gradually improves on discontinuation of khat., This further establishes the contributory relationship between sleep problems and khat consumption.
| Khat and Memory|| |
Multiple areas of neurocognitive deficit have been identified in chronic users of psychostimulants, such as amphetamines and methamphetamines.,, Effects of khat consumption on memory are summarized in [Table 6]. Khat has been shown to result in long-term memory deficits (both implicit and explicit) in different populations., Khat users had been found to have attentional impairment, impaired inhibitory control, impairments in cognitive flexibility and monitoring of information in working memory, and impaired spatial learning and memory. Moreover, khat abuse may impair working memory, perceptual-visual memory, and decision speed cognitive functions.,, Concurrent use of khat and tobacco impairs verbal learning, working memory, and delayed recall deficits., Khat abuse is pregnant women may adversely affect neonate's cognitive health. Mild problems in cognition, attention, and neuromotor functioning are associated with the low birth weight in neonates.
| Conclusions|| |
Complex physiological changes occur during pregnancy and result in impairment of sleep and memory. The adverse effects of khat on memory and sleep may further aggravate those impairments. Impaired cognitive function may put the pregnant women and her fetus at risk. Impairment of explicit memory may interfere with adherence to prescribed medicine. This may expose pregnant women to the risk of underdose or overdose. Moreover, khat-chewing pregnant women with impaired implicit memory may have problems in skills, tasks, and planning-related activities. In such a situation, the daily routine of a pregnant woman will be chaos. The misperceptions of beneficial effects of khat (e.g., relief of a headache, weight loss and assistance in birth, and delivery), the high prevalence of consumption among pregnant women, and the possibility of under-reporting of khat abuse  do necessitate the development of alternative methodologies to identify cases of unreported khat abuse in pregnant women. It is proposed that screening sleep and memory in pregnant women may provide an additional tool to identify unreported khat abuse. This will help provide timely intervention and decrease the potential risk of complications in pregnant women with a history of khat consumption.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hoffman R, Al'absi M. Concurrent use of khat and tobacco is associated with verbal learning and delayed recall deficits. Addiction 2013;108:1855-62.
Nakajima M, Hoffman R, Al'Absi M. Poor working memory and reduced blood pressure levels in concurrent users of khat and tobacco. Nicotine Tob Res 2014;16:279-87.
Nakajima M, al'Absi M, Dokam A, Alsoofi M, Khalil NS, Al Habori M. Gender differences in patterns and correlates of khat and tobacco use. Nicotine Tob Res 2013;15:1130-5.
Khawaja M, Al-Nsour M, Saad G. Khat (Catha edulis
) chewing during pregnancy in Yemen: Findings from a national population survey. Matern Child Health J 2008;12:308-12.
Stevenson M, Fitzgerald J, Banwell C. Chewing as a social act: Cultural displacement and khat consumption in the East African communities of Melbourne. Drug Alcohol Rev 1996;15:73-82.
Mahfouz MS, Alsanosy RM, Gaffar AM. The role of family background on adolescent khat chewing behavior in Jazan Region. Ann Gen Psychiatry 2013;12:16.
Insana SP, Stacom EE, Montgomery-Downs HE. Actual and perceived sleep: Associations with daytime functioning among postpartum women. Physiol Behav 2011;102:234-8.
Santiago JR, Nolledo MS, Kinzler W, Santiago TV. Sleep and sleep disorders in pregnancy. Ann Intern Med 2001;134:396-408.
Mickes L, Wixted JT, Shapiro A, Scarff JM. The effects of pregnancy on memory: Recall is worse but recognition is not. J Clin Exp Neuropsychol 2009;31:754-61.
Abel T, Havekes R, Saletin JM, Walker MP. Sleep, plasticity and memory from molecules to whole-brain networks. Curr Biol 2013;23:R774-88.
Dudai Y, Karni A, Born J. The consolidation and transformation of memory. Neuron 2015;88:20-32.
Miller MA, Wright H, Hough J, Cappuccio FP. Sleep and cognition. In: Idzikowski C, editor. Sleep and its Disorders Affect Society. Croatia: InTech; 2014. p. 3-28.
Swain AM, O'Hara MW, Starr KR, Gorman LL. A prospective study of sleep, mood, and cognitive function in postpartum and nonpostpartum women. Obstet Gynecol 1997;90:381-6.
Chang JJ, Pien GW, Duntley SP, Macones GA. Sleep deprivation during pregnancy and maternal and fetal outcomes: Is there a relationship? Sleep Med Rev 2010;14:107-14.
Kempler L, Sharpe L, Bartlett D. Sleep education during pregnancy for new mothers. BMC Pregnancy Childbirth 2012;12:155.
Gais S, Lucas B, Born J. Sleep after learning aids memory recall. Learn Mem 2006;13:259-62.
Potkin KT, Bunney WE Jr. Sleep improves memory: The effect of sleep on long term memory in early adolescence. PLoS One 2012;7:e42191.
Palagini L, Gemignani A, Banti S, Manconi M, Mauri M, Riemann D. Chronic sleep loss during pregnancy as a determinant of stress: Impact on pregnancy outcome. Sleep Med 2014;15:853-9.
Montgomery-Downs HE, Insana SP, Clegg-Kraynok MM, Mancini LM. Normative longitudinal maternal sleep: The first 4 postpartum months. Am J Obstet Gynecol 2010;203:465.e1-7.
Matthey S, Ross-Hamid C. The validity of DSM symptoms for depression and anxiety disorders during pregnancy. J Affect Disord 2011;133:546-52.
Hashmi AM, Bhatia SK, Bhatia SK, Khawaja IS. Insomnia during pregnancy: Diagnosis and Rational Interventions. Pak J Med Sci 2016;32:1030-7.
Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol 2004;191:2041-6.
Insana SP, Williams KB, Montgomery-Downs HE. Sleep disturbance and neurobehavioral performance among postpartum women. Sleep 2013;36:73-81.
Crawley RA, Dennison K, Carter C. Cognition in pregnancy and the first year post-partum. Psychol Psychother 2003;76(Pt 1):69-84.
de Groot RH, Vuurman EF, Hornstra G, Jolles J. Differences in cognitive performance during pregnancy and early motherhood. Psychol Med 2006;36:1023-32.
Eidelman AI, Hoffmann NW, Kaitz M. Cognitive deficits in women after childbirth. Obstet Gynecol 1993;81(5 (Pt 1)):764-7.
Muema EK. Biochemical, Hormonal and Toxicological Effects of Catha edulis
(Khat) on Pregnancy and Fetal Development in Olive Baboons (Papio anubis
) (PhD Thesis) [PhD]. Nairobi, Kenya: University of Nairobi; 2015.
Gashaw A, Getachew T. The Chemistry of khat and adverse effect of khat chewing. Am Sci Res J Eng Technol Sci 2014;9:33-46.
Favrod-Coune T, Broers B. The health effect of psychostimulants: A literature review. Pharmaceuticals (Basel) 2010;3:2333-61.
Getahun W, Gedif T, Tesfaye F. Regular khat (Catha edulis
) chewing is associated with elevated diastolic blood pressure among adults in Butajira, Ethiopia: A comparative study. BMC Public Health 2010;10:390.
Toennes SW, Harder S, Schramm M, Niess C, Kauert GF. Pharmacokinetics of cathinone, cathine and norephedrine after the chewing of khat leaves. Br J Clin Pharmacol 2003;56:125-30.
Wabe NT. Chemistry, pharmacology, and toxicology of khat (Catha edulis
forsk): A review. Addict Health 2011;3:137-49.
Kuczkowski KM. Herbal ecstasy: Cardiovascular complications of khat chewing in pregnancy. Acta Anaesthesiol Belg 2005;56:19-21.
Basker GV. A review on hazards of khat chewing. Int J Pharm Pharm Sci 2013;5:74-7.
Al-Motarreb A, Baker K, Broadley KJ. Khat: Pharmacological and medical aspects and its social use in Yemen. Phytother Res 2002;16:403-13.
Al-Ghamdi SS. The reproductive and thyroid hormonal profile of khat (Catha edulis
) chewers. Pharmacol Pharm 2012;3:447-52.
Al-Habori M. The potential adverse effects of habitual use of Catha edulis
(khat). Expert Opin Drug Saf 2005;4:1145-54.
Hassan NA, Gunaid AA, Murray-Lyon IM. Khat (Catha edulis
): Health aspects of khat chewing. East Mediterr Health J 2007;13:706-18.
Belew M, Kebede D, Kassaye M, Enquoselassie F. The magnitude of khat use and its association with health, nutrition and socio-economic status. Ethiop Med J 2000;38:11-26.
Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice. Curr Opin Psychiatry 2012;25:141-8.
Patel NB. Mechanism of action of cathinone: The active ingredient of khat (Catha edulis
). East Afr Med J 2000;77:329-32.
Kimani ST, Patel NB, Kioy PG. Memory deficits associated with khat (Catha edulis
) use in rodents. Metab Brain Dis 2016;31:45-52.
Hoffman R, Al'Absi M. Khat use and neurobehavioral functions: Suggestions for future studies. J Ethnopharmacol 2010;132:554-63.
Colzato LS, Ruiz MJ, van den Wildenberg WP, Hommel B. Khat use is associated with impaired working memory and cognitive flexibility. PLoS One 2011;6:e20602.
Colzato LS, Ruiz MJ, van den Wildenberg WP, Bajo MT, Hommel B. Long-term effects of chronic khat use: Impaired inhibitory control. Front Psychol 2011;1:219.
Khattab NY, Amer G. Undetected neuropsychophysiological sequelae of khat chewing in standard aviation medical examination. Aviat Space Environ Med 1995;66:739-44.
Kimani ST, Nyongesa AW. Effects of single daily khat (Catha edulis
) extract on spatial learning and memory in CBA mice. Behav Brain Res 2008;195:192-7.
Henry JF, Sherwin BB. Hormones and cognitive functioning during late pregnancy and postpartum: A longitudinal study. Behav Neurosci 2012;126:73-85.
Henry JD, Rendell PG. A review of the impact of pregnancy on memory function. J Clin Exp Neuropsychol 2007;29:793-803.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]