1. GARBHA VYAPAD
Dr Jasmine Gujarathi
Prof & Head
Dept of Prasuti tantra and Stri roga
G J Patel Institute of Ayurveda Studies and Research
New Vallabh Vidyanagar
Anand, Gujarat
11.
Psychological stress, fear, strain with physical or any external trauma can
cause death
This description is given in Mritagarbha
12. 1. Abnormalities in the factors responsible for proper
growth and development of fetus – can cause IUD or
preterm labour
2.After fourth month of pregnancy –
Anger, grief, jealousy, fear, excessive coitus, exercise,
irritation, supression of natural urges, sitting – standing
and sleeping on uneven place, abnormal postures,
suppression of thirst and hunger, use of stale food and
bleeding per vagina.
13. 3. According to sushrut, etiology of mudhagarbha and
garbhastrava pata are same
Coitus, travelling, riding on horse, falling from height,
trauma, suppresssion of natural urges, hot or
pungent diet, grief, diarrhoea, excessive use of kshara,
emetics and purgatives, indigestion and use of
abortificient drugs.
Krimi, vata and aghata – example of fruit
As it gets detached in the similar way fetus gets detached
due to above factors.
14. 4. Vagbhatta – Due to excessive
accumulation of doshas, non avoidance
of contraindicated articles, due to
diseases or deeds of previous life of
either mother or fetus
16. ABORTION
Definition:
Termination of pregnancy before 20-22-24 weeks of
gestation
Or if the fetus weight < 500g
If > 24 w & > 500 g ➔ ~ premature labour
Abortus
17. Abortion occurring without medical or
mechanical means to empty the uterus is
referred to as spontaneous
Another widely used term is miscarriage
32. Pathology
Hemorrhage into the decidua basalis, followed by
necrosis of tissues adjacent to the bleeding
If early, the ovum detaches, stimulating uterine
contractions that result in its ovulation
Gestational sac is opened , fluid surrounding a small
macerated fetus or alternatively no fetus is visible
→ blighted ovum
35. Threatened abortion
Definition
The process of abortion has started but has not progressed to state from which
the recovery is impossible.
Bleeding is frequently slight, but may persist for days or weeks
Frequency
Extremely common (one out of four or five pregnant women)
Symptoms
Usually bleeding begins first, brisk, brownish or bright red in colour
Dull abdominal pain follows a few hours to several days later, backache
Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
Categories of spontaneous abortion
36. Threatened abortion
Examination
P/s – Bleeding through external os, bright red
P/v – closed os
Uterus – soft, size corresponds to period of amenorrhoea
Investigations
USG / TVS
Blood grouping
Serum progesterone - > 25 ng/ml
Treatment
Bed rest
Progesterone (IM)
Rh-negative women with threatened abortion
should receive anti-D immunoglobulin
Categories of spontaneous abortion
37. Threatened abortion
Treatment :
Vaginal sonography
Serial serum quantitative hCG
Serum progesterone
→ can help ascertain if the fetus is alive & its location
Gestational sac(+) & hCG < 1000mIU/ml
→ gestation is not likely to survive
→ If any doubt(+), check the serum hCG level at intervals of
48hrs
→ if not increase more than 65%, almost always hopeless
Serum progesterone value < 5 ng/ml
→ dead conceptus
Categories of spontaneous abortion
39. Inevitable abortion
Definition : The changes of abortion have
progressed to a state from which the continuation
of pregnancy is impossible.
Clinical features : Threatened abortion +
Increased vaginal bleeding
Aggravation of pain - colicky
General condition detoriates with increased
bleeding
P/v Examination - Internal examination reveals
dilated os through which the product of conceptus
are felt
Categories of spontaneous abortion
41. Management –
Improve general condition
Accelerate process of expulsion
Maintain asepsis
Before 12 weeks – D&C
After 12 weeks – Oxytocin – accelerate uterine
Contraction (10 units in 500 ml RL or NS 40-60 drops
per minute)
43. Follow up
Iron supplementation
Contraceptive
Investigations
44. Complete abortion
Following complete detachment & expulsion of the
conceptus
Clinical features
Subsidence of abdominal pain
No bleeding
P/v examination –
Uterus firm, smaller than period of amenorrhoea
The internal cervical os closes
USG – empty uterus
Treatment : Hematinics, Anti D, Antibiotics
Categories of spontaneous abortion
45. Incomplete abortion
Expulsion of some but not all of the products of conception
during 1st half of pregnancy
The internal cervical os remains open & allows passage of
blood
Clinical features
1. Continuation of pain and bleeding
Examination
P/s – Uterus is smaller than period of amenorrhoea
Cervix dilated
The mass expelled is incomplete
46. Management
Resuscitation IV fluids
Evacuation under analgesia or anesthesia D&E
Tab Misoprost 200
Hematinics
Anti D
Antibiotics
47. Missed abortion
Retention of dead fetus inside the uterus for variable
period.
Pathology – Macerated or mummified, liquor absorbs –
after 12 weeks
Before 12 weeks – Carneous mole / Fleshy mole
Repeated haemorrhages in choriodecidual space disrupt
the villi from attachments.
Clotted blood is collected called as mole.
Categories of spontaneous abortion
48. Missed abortion
Clinical features
Persistence of brownish vaginal discharge
Subsidence of pregnancy symptoms
Retrogression of breast changes
Cessation of uterine growth
Examination –
P/s Cervix feels firm, uterus firm smaller then Amenorrhoea
No FHS on doppler
49. Management
< 12 weeks
Medical management – Misoprost 800 Microgram vaginally
– repeat after 24 hours
Suction evacuation
> 12 weeks
Prostaglandin
Oxytocin – 10- 20 units in 500 ml RL or NS 30 drops / min
52. Septic Abortion
Definition – Any abortion associated with clinical evidences of
infection of the uterus and its contents is called septic abortion.
Clinical criteria of septic abortion
1. Rise in temperature - 100.4 F
2. Offensive and purulent vaginal discharge
3. Lower abdominal pain and tenderness
4. Malaise
53. Causes
Endogenous cause – Infection elsewhere,
decreased immunity
Anaerobic, Aerobic
Exogenous or mixed – from outside – Antiseptic
and aseptic precautions not taken, incomplete
evacuation
54. Clinical features
Temperature with chills and rigors
Tachycardia
Abdominal or chest pain
Diarrhoea, vomiting
P/s and P/v – Tenderness +++, purulent discharge
55. Clinical grading
Grade I – Localized in uterus
Grade II – Adnexal structures – parametrium, ovaries,
tubes, pelvic peritoneum
Grade III – Generalized peritonitis, endotoxic shock,
jaundice, renal failure
56. Investigations
Cervical or vaginal swabs for culture
Blood tests with coagulation profile
Urine analysis
USG
57. Prevention and Management
Prevention
Contraceptive use
Legalized abortion
Aseptic precautions during induction and management
58. Management of septic abortion
Hospitalization
Grade I
Antibiotics
Prophylactic antigas gangrene serum and antitetanus serum
Analgesics and sedatives
Evacuation 24 hours after antibiotics
Grade II
Antibiotics & supportive treatment
Colpotomy wit suction evacuation
Grade III
Antibiotics
ICU
Laparotomy / Hysterectomy
63. Definitions . . .
Induced Abortion: intentional medical or surgical termination
of a pregnancy
Elective: if performed for a woman’s desires
Therapeutic: if performed for reasons of maintaining
health of the mother
64. In India the abortion was legalized by
Medical Termination of Pregnancy Act – 1971., enforced in
April 1972 revised in 1975…….
MEDICAL TERMINATION OF PREGNANCY REGULATIONS, 2003
Done by registered medical practitioner
65. Indications
1.Continuation of pregnancy would involve
serious risk of life or grave injury to the
physical and mental health of pregnant
woman.
2. Risk of child being born with serious
physical and mental abnormalities
3. When the pregnancy is caused by rape,
both in cases of minor or major girl and in
mentally imbalanced woman.
4. Failure of contraceptive
66. First Trimester Abortion
Early Uterine Evacuation (EUE), Minisuction, Menstrual
Regulation
Suction Abortion, Vacuum Curettage
Medical Abortion
68. Minisuction
Requires early recognition of
pregnancy.
Performs abortions up to 7-8
weeks from LMP
Cervical dilation not required, 6
mm diameter cannula used
Simplest, safest, least expensive
examine aspirated tissue is
essential
71. Medical Abortion
Mifepristone (RU486)
analogue of progestin
strong affinity for the progesterone receptor
acting as an antagonist
a single oral dose given to women 5 weeks or less produces
abortion in 85% of cases
72. Mifepristone protocol
Women less than 49 days LMP with confirmed b-hCG
600mg mifepristone on day 1
On day three, return for prostaglandin, Misoprost 400 mcg
orally
Patient remain in clinic four hours, during which time
expulsion of
pregnancy usually occurs
74. MEDICAL ABORTIONS
The advantages
The procedure is non-invasive; no surgical instruments
are used.
Anesthesia is not required.
Drugs are administered either orally or by injection.
The procedure resembles a natural miscarriage
75. Disadvantages
The effectiveness decreases after the seventh week.
The procedure may require multiple visits to the doctor.
Bleeding after the abortion lasts longer
than after a surgical abortion.
The woman may see the contents of her womb as it is expelled
76. Side effects
Excessive bleeding
Nausea
Vomiting
Headache
Diarrhoea
Backache
Abdominal pain
Anxiety
Loss of appetite
Incomplete abortion
77. Dilatation and curettage (D&C)
Removal of
pregnancy contents by
some mechanical
means
Vacuum most commonly
used
12-13 weeks is the
upper limit of
gestational age
78. D&C (vacuum curettage)
The cervix must be dilated
to permit larger diameter
suction curettes
Premedication with
NSAID
Local (paracervical block),
spinal, conscious sedation,
or general anesthesia
88. Intrauterine injection of
abortificient
Prostaglandin, hypertonic saline, hypertonic urea are introduced by
amniocentesis
Fetus and placenta are aborted vaginally
Osmotic dilators are used to decrease time to delivery and decrease
complications
95. Pain in uterus, sacral, groin region and over the
urinary bladder along with bleeding (Su.sa.10)
This pain is due to vitiation of vayu and bleeding
Is due to expulsion of ‘ama garbha’ and opening of
orifices of ‘artava vaha srotas’
97. Shotha
Apatanaka
Arsha
Vedana
Pain with or without bleeding
Excessive bleeding
Retention of urine
Burning sensation etc.
98. Treatment
Before 3 months – Ajatsara / Ama garbha /
Virrudhaupakrama
(if bleeding starts due to faulty dietary habits of
mother, it will be difficult to cure)
After 4th month – Garbha sthapana chikitsa
99. Treatment of abortion of ama-garbha
Before expulsion
1. Ruksha and shita treatment
2. After observing fast, decoction made from
duralabha, amrita, ushira, parpataka
chandana, ativisha, bala, dhanyaka
3. Trina dhanya and Sali or shastika rice in the form
of peya or solid diet.
100. 4. Yusha prepared from mudga etc for digestion of ama
After digestion of ama – Snigdha, shita karma
After expulsion
1. Madhya pana –
for complete evacuation of uterus and relief of pain
101. 2. Langhupanchamula siddha ruksha peya (without Sneha)
3. Amadhyapa – Yavagu made from Tila and uddalaka, with
Pachaka dravyas, salt and fat free.
4. Peya made from Brihata panchamula with panchakola kalka
(2 months = 2 days)
102. In case of incomplete expulsion of ama garbha
Tikshna dravyas are used till complete Expulsion
➢ For treatment of abdominal pain after garbha pata – use
of Arishta
103. After complete expulsion of ama garbha
1 Snehapana
2. Basti
3. Diet consisting of appetizing, digestive,
jivaniya, sweet and vatahara dravyas
104. Treatment of threatened abortion
External medications
1. Yoni pichu – Ghee + Yashtimadhu, Kshir
2. Lepa – shatdhauta ghrita / sahastra dhaut below umbillicus
3. Parisechan – Below umbillicus by
Decoction of Yashtimadhu or nagrodhadhi gana or cow’s milk
105. 4. Avagahan – cold water
5. Nyagrodhadhi gana – siddha taila pichu
6. Root of kantaki – tie around waist
7. Abhyanga by lakshadi oil
106. Internal medications
1. Garbhasthapana gana
2. Pumsavana karma
3. Nyagrodhadi gana – Shunga + Kshir sarpi
4. Jeevaniya gana sadhita kshir or shasti shali
5.
107. Monthwise treatment of
abortion
First month
Madhuka, Shakabija, Payasya, Surdaru
Second month
Ashmantak, Krishna tila, Tamravalli,(Manjistha) Shatavari
Third month
Vrikshadani, payasya, Priyangu, Utpal, Sariva
112. Garbha Shosha / Vatabhipanna garbha
Dalhan
Garbha Nadi – Alpa rasa vahan and Akala bhojana – Chirena
Apyayate
113. Treatment
1. Ruksha to be avoided
2. Brimhaniya drugs, milk and meat soup
3. Milk treated with Madhuyashti, sariva, Kashmari
4. Meat soup of carnivorous animals with brimhaniya drugs
5. Use of milk
115. ◼ Foetal growth restriction
◼ Small for gestational age (SGA)
◼ 'wasted' and 'stunted'
Intra Uterine Growth Retardation
◼ Intra Uterine Growth Restriction
116. Definition
Birth weight less than 10th percentile of those
born at same GA
◼ Low birth weight (LBW) means a baby
with a birth weight of less than 2500Gms,
which could be due to IUGR or Prematurity
119. < 1 Kg ELBW
< 1.5 Kg VLBW
< 2.5 Kg LBW
< 10th Percentile – SGA
10th to 90th Percentile – AGA
> 90th Percentile – LGA
120. Normal Fetal Growth
1st phase – 4th week to 20th week
Hyperplasia – 5gms / day
2nd Phase – 20 to 28th week
Hyperplasia and Hypertrophy – 15-20gms / day
3rd Phase – 28 to 40th week
Hypertrophy + accumulation of fat
32 to 34 weeks – 30-35 gm / day
121. Fetal growth has been
divided into three phases. 1-cellular hyperplasia
2- hyperplasy &
hypertrophy
3- hypertrophy
cell size
fat deposition
fetal weight as much as
200 G.r. per week.
122. Classification/ Types of IUGR
•Small and healthy
•PI Normal, No riskSGA
•Symmetrical
•Assymetrical
True/
Pathological
IUGR
123. Pondrel index : Widely used measurement of infants
relative thickness or fatness in relation with height or
length.
PI = Est Ft Wt / FL3
8.3 normal
Rohrer’s Pondrel Index = BW X 100/ Height3
124. Symmetrical (Type I) 20-30% Asymmetrical (Type II) 70-80%
Early exposure Late exposure (> 28 weeks)
TORCH, Chromosomal abnormalities,
Chemical exposure
Placental insufficiency – PIH,
abruption, pre eclampsia
Decrease in number of cell Cell size decreases
Uniformly small fetus
Ratio normal
HC > AC
PI – normal PI – abnormal
Poor prognosis Good prognosis
125. Type III
Symmetrical + Asymmetrical
Initially symmetrical and later assymetrical
Associated with Hypertension and vascular disease
Worst prognosis
Other Classification
Early Onset – before 32 weeks
Late Onset – after 32 weeks
Intrinsic
Extrinsic
Combined
Idiopathic
126. Classification
Symmetrical Asymmetrical
baby's brain is abnormally
large when compared to the
liver.
may occur when the foetus
experiences a problem
during later development
the baby's head and body
are proportionately small.
may occur when the
foetus experiences a
problem during early
development.
In a normal infant, the brain weighs about three times more than the liver. In
asymmetrical IUGR, the brain can weigh five or six times more than the liver.
127. Normal growth
Availability of nutrients – Maternal nourishment
Transfer of nutrients – Placenta and cord
Utilization of nutrients – Fetal
133. Diagnosis – Antenatal
Poor maternal weight
gain
< 2kg weight gain /
month in second half of
pregnancy
Abdominal girth less (at
um)
Fundal height lag in < 4
weeks suggestive of
moderate IUGR
Fundal height lag in > 4
weeks suggestive of
severe IUGR
Detailed serial Ultrasound – AC,
HC Doppler velocimetry –
Umbillical artery resistance,
placental infarction, placental
morphology
Amniotic fluid Index
TORCH
Amniocentesis, Karyotyping
FH increase 1 cm / week between 14-32 weeks
Gravidogram
Abdominal girth – 1 inch / week after 30 weeks
30 inch at 30 weeks
134. Diagnosis –At birth
Weight
HC
Dry wrinkled skin “old man
look”
Thin umbilical cord
Plantar creases well defined
Baby alert
Eyes open
Reflexes normal
148. Samprapti
Vagbhat – upavishtaka and upasushka
Use of contraindicated articles causes bleeding per
vaginum – leads to aggravation of vata –
withholding pitta and sleshma
compresses rasa vaha nadi – obstruction of
nourishment to fetus – fetus does not grow
properly – eg of paddy.
149. Kuksi does not increase in size
Continues sphurana – quickening
151. Etiology
Observing fast
Eating stale food
Does not take fat
Use of vata vitiating diet
Dalhana – this occurs before 3 months of pregnancy
Sushruta – Naigmesha
153. Types of Upashushka and Upavishtaka
Vata, pitta and kapha dominated symptoms in
Upavishtaka and upasushka
154. Time of delivery
The fetus grow slowly through the teja of maternal diet.
When they attain proper maturity they are
delivered.
She may even deliver after years
Because of prolonged stay – it delivers with teeth and hair
(INDU)
155. Treatment
As described in Lina garbha
Dhanyakuttana
Diet – Vatahara, brimhana, madhura
Followed by -
Yana vahan
Jrumbha
Kshobha
159. Lina garbha
Due to abnormalities of srotas caused by
complications of vayu, the fetus becomes
lina – adhered, this remains in the uterus
For a very long time and gets various
Complications.
Dalhana – death after prolong intra uterine
Stay
Absence of spandana - Vagbhat
160. Lina garbha Treatment
Mridu Vaman, Virechana, Mridhu swedana snehana
Yavaguu prepared with mamsa rasa (sea hawk)
Kula masha tila bilva unripe (bilva shalatu) with wine
(madhvika ) for 7 days
Massage of Kati frequently
Mamsa of Bahira, Sikhi (peacock) fish with ghee
Masha and Mulaka swarasa with ghee
Dhanya kuttana, yanavahana
162. Etiological factors
Vagbhatt
Common causative factors of abortionand IUFD.
Excessive accumulation of Doshas, the garbha is detached
like the fruit from its tree
Deeds of previous life
Nirahara
163. Causes (Ch. Sa. 8)
1. Excessive accumulation of doshas
2. Excessive use of pungent and hot
substances
3. Suppression of natural urges – defaecation,
micturition
4. Sitting, sleeping or standing at abnormal
or uneven surface
5. Compression or injury over abdomen
6. Anger, sorrow, jealousy, fear, excessive courage
167. Treatment
Garbhashalya should either be treated with suppressive measures
As mentioned in treatment of retained placenta or with the use of
hymns mentioned in atharvaveda or should be extracted by
Experienced surgeon
168. After Shalya Karma
For Garbhashaya shuddhi and Praharsha – Madhyapana
Brimhana, Santarpana
Sneha rahit yavagu
Dipaniya, Jivaniya, Madhura Vatahara
169. Intra Uterine Fetal Demise (IUFD)
Baby with no signs of life beyond 20 weeks, 24 weeks,
28 weeks weighing more than 500 gm
Death at any time during pregnancy
Still birth – no signs of life after 28th week
WHO definition : Death prior to complete expulsion or
extraction of fetus during any week of pregnancy
Types
1. Early – 20-28 weeks
2. Late - > 28 weeks
170. Still birth
Still born infant which is viable
No signs of life
Types of Still birth
1. Macerated
2. Fresh
171. Morbid pathology of IUFD
A dead fetus undergoes an aseptic destructive process called
maceration. The epiderm is the first structure to undergo
the process, whereby blistering and peeling off of the skin
occur. It appears between 12-24 hours after death.
The foetus becomes swollen and looks dusky red. Gradually
aseptic autolysis of the ligamentous structure and
liquefaction of the brain matter and other viscera take place.
172. Etiological factors
Main cause is chronic placental insufficiency
Pregnancy complications, Maternal illness, Fetal causes,
Iatrogenic, Idiopathic
1. Pregnancy complications
Pre – eclampsia
Eclampsia
APH
Chorioamnionitis
176. Diagnosis
Symptoms- Absence of foetal movements
Signs- Retrogression of the positive breast changes.
Per-abdomen-
- Gradual retrogression of the height of the uterus
- Uterine tone is diminished
- Foetal movement are not felt during palpation.
- Foetal heart sound is not audible
177. Investigations-
- Straight- X-ray abdomen
- Spalding sign: Over laping of skull bones because of liquefaction of
brain matter
- It usually appears 7 days after I.U.F.D.
- Hyperflexion of the spine – Ball’s sign
because of loss of tone of neck muscles
- Appearance of gas shadow (Robert’s sign) : 12 hours
179. Diagnosis (contd…)
Sonography :
(a) Lack of all foetal motions (including cardiac)
(b) Oligohydramnios and collapsed cranial bones
Haematological examination: Rh-typing, VDRL, Blood sugar
and urea
Postmortem studies
Cytogenetic study: In cases of congenital malformation of
IUGR
180. Maternal Complications
Disseminated Intravascular Coagulopathy
Decreased platelets
Decreased fibrinogen
Increased PT/PTT (Clotting times)
Clinical bleeding / oozing from all sites
Depression, Anxiety, Psychosocial
Anxiety with future pregnancies
May have repeat losses (depending on causes)
Bleeding ---> can lead to DIC but may only require blood
product replacement
Pain, Infection (similar to any other delivery)
181. Management
If expectant management is planned:
Await spontaneous onset of labour during the next four weeks
Reassure the woman that in 90% of cases the fetus is
spontaneously expelled during the waiting period with
no complicatons.
If platelets are decreasing, four weeks have
passed without spontaneous labour, fibrinogen
levels are low or the woman request it,consider
active management (induction of labour)
182. Management (contd…)
If induction of labour is planned, assess the
cervix
If the cervix is favourable (soft, thin, partly dilated) labour using oxytocin.
If the cervix is unfavourable(firm, thick, closed) ripen the cervix.
If spontaneous labor does not occur within four weeks,
platelets are decreasing and the cervix is unfavourable,
ripen the cervix.
184. Induction
Prostaglandins vaginal (Misoprost)
Oxytocin 5 – 10 units in 500 ml of 5% Dextrose 15-20 drops
/ min
Caesarean section
Bromocriptine 2.5 mg BD for 10 days