Garbhini Vyapad - Chhardi, Pandu, Kikkis Emesis, anaemia, eclampsia, pre eclampsia

1. Garbhini Vyapad
Dr Jasmine Gujarathi

2. • Garbhini Vyapad
• Garbhini Vikar
• Garbha Upadrava

3. •
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•
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5. Garbhini Chhardi
• Emesis gravidarum – Morning Sickness, Simple vomiting – as a
symptom of pregnancy
• Hyperemesis gravidarum - severe type of vomiting during pregnancy
which has deleterious effect on health of mother and hamper her day
to day activities

6. Emesis gravidarum
• Limited to first trimester of pregnancy
• Nausea, vomiting, giddiness in morning, can occur at other time also
• Vomitus is small- clear or bile stained
• Does not produce any other impairment
• Disappears without treatment also
• Causes – High levels of HCG, Progesterone, neurogenic factor
• Management – Assurance, dry toast or biscuit in morning, avoiding spicy
food,
• Supplementation of Vitamin B1
• Doxylamine succinate and pyridoxine

7. Hyperemesis gravidarum
• Incidence – 1 in 1000, fall in incidence because of family planning methods
and availability of potent drugs
• Etiology
1. First trimester but can be seen throughout pregnancy
2. Primigravida – can repeat in subsequent pregnancies
3. Unplanned pregnancy
4. Younger age
5. Multiple pregnancy / hydatiform mole
6. Family history – mother, sister
7. History of motion sickness

8. Hyperemesis gravidarum
• Theories
• Hormonal 1. Progesterone 2. HCG
• Psychogenic – Surroundings, unplanned, primigravida
• Dietetic deficiency – Carbohydrate reserve, low body mass, overnight
fasting, vitamin B6, B1 deficiency
• Allergic – histamine
• Immunologic

11. Carbohydrate
starvation
KetoacidosisVomiting

12. Clinical features
• Mild – 45% , Morning, provoked by travelling, emotional stress,
overnight accumulation of gastric secretions
• Moderate – 5% - At any time of day, dehydrated, acidosis in urine
• Severe – 2 in 1000 – increased dehydration and ketoacidosis

13. Symptoms
• Early – patient looks well, no pathology in blood or urine
• Late – increased vomiting in amount and frequency
• Nausea persists
• Coffee ground colour or even blood
• Urine quantity decreased – oliguria
• Epigastric pain
• Confined to bed
• Retinal detachment / haemorrhage – blindness
• Restlessness, sleeplessness, loss of memory of recent events

14. Signs
• Emaciation, loss of weight
• Anxious look
• Eyes sunken
• Skin lusterless
• Tongue dry, thickly coated
• Breath – acetone smell
• Pulse – rapid
• BP – hypotension
• Temp – 100 or more

15. Complications
Neurogenic –
• Wernicke’s encephalopathy
• Korsakoff’s psychosis
• Thiamine deficiency
• Peripheral neuritis
Stress ulcer
Jaundice
Convulsions and coma
Renal failure

16. Complications
Maternal
•Neurologic
•Ulcer
•Hepatic failure
•Convulsions
•Renal failure
Fetal
•Low birth weight
•IUGR
•Preterm
•Unaffected

17. Investigations
• Confirmation of pregnancy
• Urine – quantity less, colour – dark concentrated, acetone present
• Presence of bile pigments rarely and protein
• Increased blood urea and uric acid
• Decreased serum electrolytes
• Ophthalmoscopic examination – retinal hemorrhage, detachment

18. Management
• Maintenance of hydration
• Control vomiting
• Correct electrolytes and fluids
• Correct metabolic disturbances
• Prevent serious complications
• Care of pregnancy

19. • Hospitalization
• Fluids – IV – total 3 litres (1.5 Dextrose 5% and 1.5 RL) + equal
amount of vomitus and urine
• No oral for 24 hours
• Drugs – Antiemetic – Promethazine (Phenargan) 25mg
• Stemetil 5 mg
• Doxylamine succinate and pyridoxine – anti histaminic

21. Garbhini Chhardi
• Vata nimittaja – due to pathology
• Dauhrida avamanan janya – 4th month
• Garbha nimittaja – morning sickness
Management Principles
Relieve vata
Madhura sheeta dravya
Desirable Hridya anna

22. General principles of Treatment

23. General principles of Treatment

24. Utmost care of Garbhini

25. Garbhini Chhardi
• Bhunimba kala with sugar
• Yavasaktu with sunthi and bilva
• Dhanyaka with tandulodaka
• Bilva majja with laja
• Matulunga swarasa with kola majja
• Dadima sharkara with madhu

26. Doshanusara (Ka.Khi.10/121-122)
• Vatika chhardi
• Matulunga swarasa, laja, kola majja, anjana, dadimasara, sugar
and honey
• Pittaja Chhardi
• Laja churna with sugar and honey+chaturjataka
• Laja peya with sugar and honey
• Sleshmaja Chhardi
• Amra, jambu leaves kashaya with sugar and honey
• Mudga yusha with dadima and salt

27. Practical Treatment
• Frequent small meals
• More carbohydrates – less fat
• Bland diet
• Dadima, Nimbu, Dhanyaka, Sharkara
• Chhardiripu vati – Shati – controls vomiting, increases appetite
• Vomiteb syrup
• Madiphala rasayana
• Assurance, Psychological counselling
• Hydration

29. Researches

30. Further reading…

31. • Vomiteb Syrup contains Anethum Sowa, Carum Copticum, Caryophyllus
Aromaticus, Cinnamomum Cassia, Citrus Limonum, Elettaria Cardamomum, Embelia
Ribes, Emblica Officinalis, Hedychium Spicatum, Myristica Fragrans, Piper
Longum and Zingiber Officinale
• Madiphala rasayana
• Mathulunga (Citrus medica)
Shunti (Zingiber officinale)
Maricha (Piper nigrum)
Pippali (Piper longum)
Chitraka (Plumbago zeylanica)
Saindhava lavana (Rock salt)
Sharkara (Sugar)

32. Garbhini Pandu
Anaemia in Pregnancy
• 40% maternal mortality during pregnancy
• 50-80% of pregnant women in India are anaemic
• Total iron loss during pregnancy – 1230 mg
• Conserved iron due to amenorrhoea – 410 mg
• Criteria for diagnosis of anaemia :
Hb < 11gm % (10 gm% in India)
PCV < 33% (30% in India )

33. Cause for increased prevalence
• Faulty dietary habits
• Faulty absorption mechanism
• Iron loss – Repeated pregnancies, sweating, excessive
menstruation, hook worm, piles, chronic malaria
• Pre pregnant health status
• Diminished intake of iron

35. Classification according
to Severity
Mild anaemia -------- 9 -10.9 gm /dl
Moderate anaemia--- 7-8.9 gm /dl
Sever anaemia-------- < 6.5gm /dl
Very sever anaemia-- < 4gm/dl

36. Classification
• Physiological
Haemodilution
Maternal Plasma volume increase – 40-50%
RBC volume increase – 20%
Negative iron balance
Fall in Haematocrit and Haemoglobin concentration

37. HAEMOTOLOGY CHANGES
1.Blood volume – 30 – 40%
2.Plasma volume – 40 – 50%
3.RBC – 20-30%
4.Hb – 18-20%
Fall in haemoglobin concentration
Haemodilution
Advantages – Decreased blood viscosity –
optimum gaseous exchange
Protection against blood loss

39. Classification
• Pathological
1. Deficiency anaemia
Iron – microcytic hypochromic
Folic acid – macrocytic normochromic
Vitamin B12 – do-
Protein

43. Classification
2. Haemorrhagic Anaemia
Hook worm infestation
Bleeding piles
Ante partum haemorrhage
3. Haemolytic Anaemia
Malaria
Sickle cell
Thalassemias

44. Clinical
features of
Anaemia
Symptoms Signs
Weakness Pallor
Lassitude, tiredness,
fatigue
Glossitis
Indigestion Stomatitis
Loss of appetite Oedema
Palpitation Hypoprotenemia
Breathlessness Soft systolic murmur in
mitral area
Giddiness / dizziness Pale nails
Swelling on feet / eye lids

46. Complications of Severe anaemia
• Pre eclampsia
• Infection
• Heart failure
• Pre term labour
During
Pregnancy
• Uterine inertia
• PPH
• Cardiac failure
• Shock
During Labour
• Sepsis
• Subinvolution
• Failing lactation
• Thrombosis
Puerperium

47. Management
• Prophylactic – iron supplementation
200 mg of ferrous sulphate (60 mg
elemental iron with 1 gm of folic acid)
Prevention – 3 years of gap between
successive pregnancies
Proper nourishment / Planned pregnancy
Management depends upon
1. Severity of anaemia
2. Gestation age
3. Associated complications

49. Management
• Moderate anaemia
• > 32 weeks pregnancy - IM
• Iron Sorbitol
• Iron Dextran
• Iron Sucrose
• Severe Anaemia – Near term
• Blood transfusion

51. Food supplements
• Dates
• Grapes
• Spinach
• Green leafy vegetables
• Jaggery
• Lentils
• Pomegranate, Banana

54. Classical preparations
Punarnava
Mandur
Dhatri
loha
Tapyadi
Loha
Navayas
Loha
Dadimadi
Ghrita
Mandur
Vataka
Darvyadi
leha

55. Patent preparations
• Limiron Granules
• Limiron tablets
• Raktda syrup
• Ranger syrup

56. Research

57. Research

58. Pregnancy and skin
• Hormonal changes during pregnancy:
• Reason for glow on face: High level of Progesterone and
Oestrogen
• Melasma (also known as chloasma faciei, or the mask of
pregnancy when present in pregnant women) is a tan or dark skin
discoloration. Although it can affect anyone, melasma is
particularly common in women, especially pregnant women and
those who are taking oral or patch contraceptives or hormone
replacement therapy (HRT) medications.

59. Chloasma / Melasma
• The symptoms of melasma are dark,
irregular well demarcated hyper pigmented
macules to patches commonly found on the
upper cheek, nose, lips, upper lip, and
forehead. These patches often develop
gradually over time. Melasma does not
cause any other symptoms beyond the
cosmetic discoloration.
• Melasma is also common in pre-menopausal
women

60. Linea nigra
• Linea nigra (Latin for "black line") is a dark
vertical line that appears on the abdomen
in about three quarters of
all pregnancies.
• The brownish streak is usually about a
centimeter in width. The line runs
vertically along the midline of
the abdomen from the pubis to
the umbilicus, but can also run from the
pubis to the top of the abdomen.

61. Linea Nigra
Linea nigra is due to
increased melanocyte stimulating
hormone made by the placenta, which
also causes melasma and
darkened nipples.

62. Striae
Striae Gravidarum Striae Albicuns

63. Stria Gravidarum
• Occurs in 90% of women due to skin stretching and effect of
adrenocortical steroid, Oestrogen and relaxin on skin elastic
fibres
• Striae, or "stretch marks", begin as reddish or purple lesions,
which can appear anywhere on the body, but are most likely to
appear in places where larger amounts of fat are stored; the
most common places are the abdomen (especially near
the naval), breasts, upper arms, thighs (both inner and
outer), hips and buttocks. Over time, they tend to atrophy and
lose pigmentation. The affected areas appear empty, and are
soft to the touch

64. Striae gravidarum
• Stretch marks are caused by tearing of the dermis.
This is often from the rapid stretching of the skin
associated with rapid growth or rapid weight
changes.
• Stretch marks may also be influenced by
hormonal changes associated with
puberty, bodybuilding, or hormone replacement
therapy.

65. • Collagen and elastic fibers in the reticular region provider Strength,
Extensibility and Elasticity to the skin
↓
• When the skin is stretched beyond it’s capacity.
↓
The underlying tissue tears
↓
The body responds by forming scar tissue
↓
The fresh striae look pink, red brown or purple
↓
Overtime the colour fades
↓
The striae becomes a shimmering silver line
↓
The scar is permanent

66. Kikkisa
•
•

67. •
•
•
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68. Treatment
• Paste of chandana and Mrinala
• Churna of Sirisha, Dhataki, Sarshapa and madhuka
• Kalka of Kutaja, Musta, haridra
• Kalka of nimba, Kola, surasa and manjistha
• Gentle massage with oil boiled with karavira patra
• Pariseka with kwath of malati and madhuka
• Thesis – kutaja, tulsi, haridra, Chandana. Ushira, nimba – ointment with
badar kwath

69. PATHYA-APATHYA
• Aharaj :
Diet should be sweet and capable of suppressing
vata (Ch. Sha. 8/32, A.S. Sha. 3/10)
With little quantity of fat and salt (Ch. Sha. 8/32, A.S. Sha.
3/10).
Light and sweet (A.H. Sha. 1/50)
Diet should be taken repeatedly in small amount (A.S. Sha.
3/10).
Use of little quantity of water as anupana. (Cha. Sha. 8/32,
A.S. Sha. 3/10)

70. PATHYA-APATHYA
•Viharaj:
•One should not scratch (inspite of urge for itching) to
avoid disfigurement or skin stretching.

71. Hypertensive disorders of Pregnancy
Pregnancy induced hypertension (PIH)
• Gestational Hypertension – Rise in BP returns normal 12 weeks post
partum
• Pre – eclampsia – HTN + Proteinuria +oedema
• Eclampsia – Seizure in pregnancy without any neurological
pathology
• Chronic hypertension – HTN diagnosed before 20 weeks and persists
after 12 weeks post partum

72. Pre eclampsia
• Multisystemic disorder
• Rise in BP >140/90 mm Hg after 20 weeks
• Systolic > 30 mmHg
• Diastolic > 15 mmHg
• Proteinuria or oedema or both
• Proteinuria > 300mg / 24 hours

73. Risk factors
• Elderly primigravida
• Family history
• Placental abnormalities
• Obesity BMI > 35
• Existing vascular disease
• Multiple pregnancy
• Metabolic disorers
• Family history
• Maternal age > 35
• Weight gain > 500 gm / week or 2.5 kg / month

75. Pathophysiology
• Generalized Vasospasm
• Imbalance in Prostacyclin and Thromboxane
• Thromboxane – increases (released from platelets ) – vasoconstrictor
• Prostacyclin – decreases (vascular endothelium) – vasodilator
• Nitric oxide – decreases
Thromboxane A2 > Prostacyclin, NO
Oedema – Endothelial cell breakdown – exudation of plasma proteins
into extra vascular spaces
Proteinuria – Decreased GFR due to hypovolaemia, increased capillary
permeability – increased leakage of proteins

77. pathophysiology

79. convulsion

81. Organs affected
• Uterus – Decreased utero placental blood flow – IUGR
• Kidneys – Decreased GFR – damage – anoxia – bilateral renal cortical
necrosis
• Liver – Thrombosis of arterioles – necrosis of liver – HELLP syndrome
• Brain – Cerebral oedema – capillary thrombosis – disturbed EEG

82. Mild pre eclampsia Severe Pre eclampsia
DBP > 90 but < 110 SBP > 160 mmHg
DBP > 20 mmHg above
normal reading
DBP > 110 on two occasions
Proteinuria may be
absent / > 300 mg in 24
hour
Proteinuria 5gm / 24 hour , oliguria
Oedema in non
dependent parts
Cerebral / visual disturbances
Headache and epigastric pain
Elevated liver enzymes

83. Clinical features
Symptoms
• > 20 weeks
• Slight swelling on ankles, tightening of ring
• Oedema extended to face, abdominal wall and vulva
• Headache
• Disturbed sleep
• Diminished urinary output < 500 ml / 24 hrs
• Epigastric pain (coffee ground vomiting )
• Blurring and dimness of vision

84. Clinical Features
• Signs
• Abnormal weight gain >2 kg / month
or > 1 kg/week
• Rise in blood pressure
• Oedema - visible oedema on ankles after rest
• Scanty liquor
• Growth retardation
• Rapid weight gain – Visible Oedema / Hypertension – Proteinuria

85. Maternal Complications
During pregnancy During labour Puerperium
Eclampsia Eclampsia Eclampsia (48 hrs)
Accidental haemorrhage PPH Shock
Oliguria and Anuria Sepsis
Vision disturbances
Preterm labour
HELLP

86. • Remote complication
• Residual hypertension
• Recurrent pre eclampsia
• Chronic nephritis

87. Fetal Complications
IUGR Chronic placental insufficiency
IUD Accidental haemorrhage / infarction
Asphyxia Preterm labour or preterm induction
Prematurity Preterm labour or preterm induction

88. Prevention
• Identifying risk factors
• Regular antenatal check up
• Diet rich in protein
• Salt restriction
• Rest in left lateral position

89. Management
• Rest – improves circulation – improves renal function – improves
placental function – reduces blood pressure
• Diet – Protein rich (100 gm/day) Extra salt in diet to be restricted
• Sedative – to relieve anxiety
• Diuretics – in acute condition – to decrease fluid retention – may
harm fetus by decreasing placental perfusion and electrolyte
imbalance
• Antihypertensive – Sedative and rest may be sufficient. Persistent
may require – Labetelol
• Low dose aspirin – improve circulation

90. Termination of pregnancy
• > 37 weeks – Induction or CS without delay
• < 37 weeks- Fetal wellbeing
No Fetal
compromise
Continue till 37
weeks
Fetal Distress
Fetal lung maturity
Termination

91. Ayurveda – Adjuvant management
• Gokshur Churna Kshirpaka
• Punarnava
• Bramhi Vati
• Sarpagandha ghan vati
• Sutshekhar rasa
• Chandraprabha vati (without guggulu)
• Shilajit vati
• Lasuna Kshirpaka ?
• Planned pregnancy
• Follow Do’s and Don’ts

92. Classical references
• Sopha on face and vulva – Asadhya Lakshana according to
Vagbhat
• Arishta lakshana – Kashyap – Shotha
• External application – Yogratnakar
Chandana, Madhuka, Ushira, Ajashringi, Manjistha Tila ,
Punarnava
• Kwath of punarnava mula with devadaru and murva or
bhadradaru kwath with honey
• Virechana strictly contraindicated

93. Eclampsia
Flash of lightening
Pre eclampsia complicated with Convulsions or
Coma (Epileptic)
Convulsions can occur antepartum, intrapartum
and postpartum (within 48 hours of delivery)
Cause of convulsions – Anoxia, cerebral oedema

95. • Onset of convulsions
1. Antepartum – 50%
2. Intrapartum – 30%
3. Postpartum – 20% (48 to 72 hours)

96. Clinical features
1. Premonitory stage – Unconscious, twitching of face muscles, tongue
and limbs. Eyeballs rolls to one side and fixed. Lasts for 30 seconds
2. Tonic stage – Tonic spasm. Limbs flexed and hands clenched.
Respiration ceases. Tongue protrudes between teeth. Cyanosis
appears. Lasts for 30 seconds
3. Clonic stage – Voluntary muscles undergo alternate contraction and
relaxation. Whole body involved in convulsion. Biting of tongue.
Frothy discharge from mouth. Cyanosis disappears. 1 to 4 minute
4. Stage of coma – does not remember the happenings.
Status eclampticus

97. • After convulsion
Rise in temperature
Tachycardia
Rise in respiration rate
Hypertension
Urine output diminished
Uric acid levels increases

98. Complications
• Injuries
• Aspiration pneumonia
• Exhaustion
• Acute left ventricular failure
• Cerebral hemorrhage
• DIC
• Sepsis
• Psychosis
• Eye complications

99. Prognosis
• Depends on duration between onset of treatment and convulsions
• > 10 convulsions
• Coma in between convulsions
• Temperature rise > 102 F, pulse > 120 bpm,
• Systolic > 200 mmHg
• Oliguria < 400 ml / 24 hour , platelet <1,00,000
• Hepatic complications
• Non responsive to treatment

100. Mortality
Maternal Fetal
Cardiac failure Prematurity
Pulmonary oedema Asphyxia
Aspiration pneumonia Iatrogenic
Anuria Trauma during delivery
Postpartum shock
Puerperial sepsis

101. Management
• Aim – stabilize patient and deliver baby
1. To relieve generalized vasospasm – permit better blood flow to
uterus, brain, kidneys and liver
2. Decrease sensitivity to brain to external stimuli
3. Reduce hypertension
4. Elimination of retained water
5. To deliver baby within 6 to 8 hours after adequate oxygenation

102. • Principles
1. Resuscitation
2. Oxygen administration
3. Arrest convulsion
4. Ventilatory support
5. IV fluid replacement to prevent hypovolemia
6. Prevent injury

103. • Hospitalization
• Examination – FHS
• Investigation – proteinuria, output
• Fluid balance – not more than 2 litres in 2 hours
• Antibiotic – Taxim 1 gm IV 12 hourly
• Ampicillin – 500 mg IM or IV 6 hourly

109. Management
• Magnesium sulphate
Decreases neuromuscular irritability
Cerebral vasodilation
Dilates uterine arteries
Increases production of prostacyclin
Dose 4 gm (20%) IV loading dose through infusion pump over 5 to 10
min
5 gm IM (50%) in each buttock

110. • Hyrdralazine 5 mg ----- 20 min ----- 10 mg----- 20 min------ 20 mg
• Labetalol 20 mg IV ------ 10-15 min------ 40 mg----- 10-15 min---- 80 mg
------10-15 min-

114. Ayurveda
• Asadhya Lakshana

115. Care Through Ayurveda
• Planned Pregnancy
• Observance of Garbhini Paricharya
• Role of Surroundings and Family
• Health attitude
• Herbal cure
• Pathya Apathya