Ayurvedic Management of Recurrent Abortions due to Uterine Fibroid.

Uterine fibroids are present in 30-70% of women of reproductive age. Uterine fibroids distort the uterine cavity. Therefore there is consensus of a negative impact on both the clinical pregnancy and delivery rates.[2] In addition, studies have also reported an increased risk of spontaneous miscarriage with submucosal fibroids. In biomedicine, myomectomy is considered the treatment of choice and Assisted Reproductive Technology is advised to overcome infertility. In Hārita Saṃhitā treatment is given for recurrent abortion (Garbhasrāvī). In this study, considering pitta doṣa and altered uterine receptivity (kṣetra duṣṭi) as causative factors, purgation (virecana karma) was done, enema (yoga basti) was given after post purgation protocol (saṃsarjana karma). After body purification (śodhana), garbhasthāpaka drugs were given to the patient for one month. Patient conceived in the second month with this treatment. In Antenatal Care, haematinics and calcium supplements and month wise Ayurvedic medication (Māsānumāsika kaṣāya) were given for nine months. Elective caesarean section ắs done after GA 38 weeks (USG) followed by inj. Wymesone 8 mg. The procedure uneventful. Thus proving Ayurvedic management of recurrent abortion due to uterine fibroid. It is cost effective and improves and normalises uterine receptive environment.

Introduction

Uterine fibroids are present in 30-70% of women of reproductive age.[1] Hārita has defined infertility as failure to achieve child birth rather than failure to conceive, because he has included recurrent pregnancy loss (Garbhasrāvī) and still birth (mṛta garbha) under the classification of infertility.[3] In biomedicine uterine fibroids are responsible for infertility. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcomes. The two questions that have to be addressed are: which are fibroids that have to be treated, and how to treat them? Submucosal fibroids are associated with a 70% reduction in delivery rate. Furthermore, uterine fibroids are associated with an increased risk of spontaneous miscarriage. Studies have also shown that fibroids can contribute to adverse obstetric outcomes, such as preterm labour and delivery, placenta previa, intrauterine growth retardation, increased rate of caesarean section and postpartum haemorrhage.[12]

The altered endometrial receptivity, glandular atrophy in the endometrium overlying the fibroid are the most commonly observed histological alterations associated with fibroids.[45] This is in addition to abnormal vascularization, chronic inflammation and abnormal hormonal milieu.[67] Existing evidence indicates that these effects are directly dependent on the proximity of the fibroid to the endometrium.[8] Furthermore, histologic changes have been noted on the endometrial surface opposite the fibroid, which might be attributed to the mechanical pressure exerted by the fibroid.[9] More recently, experiments of Rackow and Taylor have demonstrated that the presence of submucosal and intramural fibroids results in a global reduction in endometrial HOX gene expression, which is not limited to the focal area overlying the fibroid.[10]

Considering the significant health burden fibroids pose to women, development of appropriate evidence-based management strategies for uterine fibroids, addressing both efficacy and safety, is of crucial importance.

Case Report

A 37-year old lady (G4P1A3L1) (G-gravida, P-parity, A-abortion, L-live children) came for consultation and treatment for Secondary Infertility and recurrent abortion in Obstetrics and Gynaecology (Striroga– Prasutitantra) Department OPD of Vasantdada Patil Ayurvedic College, Sangli, Maharashtra. Past Obstetric History revealed one Full Term Caesarean Section – Female Child nine year age. The indication for caesarean section was foetal distress, three spontaneous first trimester abortions first – four and half year ago, second – three year ago and third – one and half year ago. Per vaginal examination revealed bulky uterus size around twelve weeks.

Pelvic USG – anterior wall submucosal uterine fibroid size 40 × 36 × 30 mm.

TFT (Thyroid Function Test) – within normal range.

LFT (Liver Function Test) – within normal range.

Hormonal profile – within normal range.

BSL (Blood Sugar Level) – within normal range.

BUL (Blood Urea Level) – within normal range.

TORCH (Toxoplasma, Rubella, Cytomegalo Virus) – Negative,

IGg/IGm – within normal range.

AFPA (Anti Phospholipid Antibody) – within normal range.

Blood group – B Rh positive.

Provisional Ayurvedic Diagnosis – Garbhasrāvī vandhyātva (recurrent abortion)

Purgation (Virecana) was done after oral administration of medicated ghee (snehapāna) using Phalaghṛta[35] in doses of 30, 65, 85, 100, 120 ml for five days and daily oleation (Sarvāṅgasnehana) using Dhānvantaratailam and sudation (Svedana) with Bāṣpasveda for five days. On the sixth day 40 ml of Trivṛtsneha[36] was given with 200 ml of milk at 9.40 am, the purgation which followed was uneventful. Proper post purgation protocol (Saṃsarjana krama) was followed. Enema (Yogabasti krama) using 1 lit. of decoction of Śatapuṣpa (Anethum sowa) (nirūha basti) and Nārāyaṇa tailam 50 ml (matrā basti) was done to bring the female reproductive organs back to normal (avyāpanna yoni). Syp.-Aśokāriṣṭa 10 ml thrice a day and Cap– ODC two twice a day (August Bio Pharma) was recommended for two months. Patient conceived in the second month, pregnancy was confirmed using Urine Pregnancy Test (UPT) and Ultrasonography (USG). In antenatal care, in the first trimester, (i) Tab– Folinext (folic acid) 5 mg once a day was given along with Aśvagandhā (Withania somnifera) and Śatāvarī (Asparagus racemosus) powder medicated milk 50 ml thrice a day (Aśvagandhā- Śatāvarī cūrṇa-siddha milk) (ii) one Cap-Autrin (Ferrous sulphate iron supplement) once a day, (iii) one Tab- Calcimax 500 mg (calcium supplement) once a day were prescribed. Specific monthly medicine (Māsānumāsika kaṣāya) were given for nine months, two doses of inj. - T.T. 0.5 ml I.M. were given. Obstetric USG ắs done on 3rd, 5th, 7th and 9th months. Considering advanced maternal age and large uterine fibroid, patient was posted for elective caesarean section after GA 38 weeks (USG) followed by inj. Wymesone (Dexamethasone) 8 mg. Operative and post-operative period was uneventful. Full term male child of weight 2.90 kg, APGAR good, all reflexes were positive with no visible external congenital anomaly.

Discussion

Many Ayurvedic texts have mentioned unequivocally that pregnancy occurs only in healthy reproductive organs.[111213] General line of treatment for Pitta vṛddhi (increase in pitta) was adopted. After snehana, svedana, virecana, basti–sthāpana and anuvāsana in consecutive order, women conceive and deliver normally.[14] Kaśyapa says that infertility gets cured by use of virecana.[15] In Bhela Saṃhitā medicated decoction enema (nirūha basti) `is claimed to be nectar to an infertile woman.[16]

Medicated milk (with Aśvagandhā –Śatāvarī powder 3 g) is advised in Suśrutasaṃhitā and is useful to retain normal development of foetus due to madhura rasa and rejuvenative (rasāyana) properties. Ethyl acetate and acetone extract of the root of Asparagus racemosus blocked spontaneous motility of virgin rat uterus, inhibited contraction induced by spasmogens such as acetylcholine, barium chloride and 5- hydroxyl tryptamine whereas alcoholic extract was found to produce a specific block of pitocin induced contraction.[32] A glycoside, Shatavarin 1, isolated from the roots of Asparagus racemosus has been found to be responsible for the competitive block of oxytocin induced contraction of rat, guinea pig and rabbit uteri, in vitro as well as in vivo.[3334] Researchers from Banaras Hindu University in Varanasi, India, have discovered that some of the chemicals within Aśvagandhā are powerful antioxidants. They tested these compounds for their effects on rat brain and found an increase in the levels of three natural antioxidants, superoxide dismutase, catalyse and glutathione peroxidase. They conclude by saying that their findings are consistent with the therapeutic use of W. somnifera as a rasāyana (health promoter). The antioxidant effect of active principles of W. somnifera may explain, at least in part, the reported anti-stress, cognition facilitating, anti-inflammatory and anti ageing effects produced by them in experimental animals and in clinical situations.

In this case, for śodhana, purgation (virecana karma) was preferred because pitta doṣa being predominant and leading to excessive bleeding (rakta-atipravṛtti) and recurrent abortions (Asraja yonivyāpat). For snehapāna, phala ghṛta was given because ghṛta normalizes pitta. Phala ghṛta is the most recommended ghṛta in the treatment of infertility and recurrent abortions.[17181920] For abhyaṅga, Dhānvantaram tailam was used because it normalizes channels (srotases). Yogabasti krama was administered to normalize vātadoṣa. Basti is the best treatment for all types of infertility (vandhyātva). Cap-ODC was given to correct ovarian function and initiate ovulation. Syp. Aśokāriṣṭa when administered to the patients through oral route, may act as follows: Aśoka (Saraca indica), Śuṇṭhi (Zingiber officinale), Harītakī (Terminalia chebula), Vāsā (Adhatoda vasica), and Candana (Santalum album) strengthen the heart (hṛdya) and endow power (Balya) and act as rejuvenatives (rasāyana) and strengthen body (Dhātupuṣṭi).These are given to enhance endometrial receptivity to avoid abortion.[3031] Monthly Ayurvedic medicine (Māsānumāsika kaṣāyas) were given to avoid pregnancy complications and for better foetal growth. Garbhapāla rasa kalpa was used to avoid pregnancy loss.

It is clear that uterine fibroids have adverse effects on fertility and pregnancy outcomes. The detrimental effect of sub mucosal fibroids (i.e., cavity distorting fibroids) is well established. Furthermore, recent evidence suggests that intramural fibroids, even in the absence of cavity distortion, may have a negative impact on fertility.[21222329] Although alternative treatments with a good safety and efficacy profile have become available for the management of symptomatic fibroids for indications other than infertility, myomectomy remains the treatment of choice for women seeking fertility treatment.[242526] The rising numbers of women who have delayed childbearing for personal reasons, together with the observed increase in the prevalence of fibroids with increasing age have led to an increased prevalence of uterine fibroids in women.[2728]

Conclusion

A good result was obtained in this case. An informed consent was taken from the patient for this study. Results obtained in this case demonstrate that the management of recurrent abortion due to uterine fibroids with Pancakarma and Ayurvedic drugs offers a good approach to manage recurrent abortion due to uterine fibroids. This approach may be useful for clinical practices and for further studies in treating recurrent abortions due to uterine fibroids.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.