प्रसूति िन्त्र

&
स्त्रीरोग
Paper I
PART A
 CHAPTER I: Introduction

 Prasuti Tantra & Obstetrics

 Prasuti Tantra
Prasuti = Labour
Tantra = Knowledge / Science
Prasuti Tantra is branch of medical science which deals with the process of labour.

Prasuti Tantra covers various topics from pre-conception to neonatal care. It is a

surgical field which provides knowledge about anatomy and physiology of the
female reproductive system as well.
Taking care of mother and child is the goal of Prasuti Tantra.

 Obstetrics:
Obstetrics is the field of study which focuses on pregnancy, childbirth and the
postpartum period.
As a medical specialty, obstetrics is combined with gynaecology under the
discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

 Stree
 Nirukti:
स्त्रायिे गर्ाा ि् इति स्त्री ।
The one who bears Garbha is called Stree.

स्त्यायिः शुक्रशोतििे अस्ाां सा स्त्री ।

In Stree, the union of Shukra and Shonita takes place.

 Paryaya:
Yoshita, Abala, Yosha, Nari, Simantina, Vadhu, Pratipadarshani, Vama, Vanita,
Mahila

 Mahatva:
Woman is the root cause of progeny and so she should be protected.
Righteousness, wealth, abundance and all creation depend on women.
A woman procreates and nurtures a family, in turn the society, thereby she
perpetuates this universe. Hence, health of a family / society / universe revolves
around a woman. Therefore, her health is vital to sustain.

 Female: A female is an individual of or denoting the sex that can bear offspring or
produce eggs, distinguished biologically by the production of gametes (ova) which
can be fertilized by male gametes.
 CHAPTER Ii: Stree shareera vijnana /
Anatomy of female reproductive
system

 Organs of the Female Reproductive System

 External
The external genitalia are the accessory structures of the female reproductive
system that are external to the vagina. They are also referred to as the vulva or
pudendum. The external genitalia include:
- Mons pubis
- Labia majora
- Labia minora
- Clitoris
- Vestibule
- Bartholin glands / Vestibular glands
- Hymen
- Vaginal orifice

Accessory: Breasts

 Internal
Internal reproductive organs include:
- Vagina
- Uterus
- Fallopian tubes
- Ovaries

 Bhaga
Bhaga is the classical term for vulva.
Length = 12 Angula
It extends from the upper border of mons / symphysis pubis to the end of perineum.
 Yoni
The term Yoni can be understood in two ways:
a) Entire female reproductive system (E.g.: Yonivyapat)
b) Vagina (E.g.: Yonikandu)

 Yoni Akriti: (Shape of Yoni)

Yoni resembles Shankha-Nabhi (hollow portion of conch shell).
It has three Avarta = Trayavarta (3 Envelopes or circles)

a) Entire female reproductive system:

1) Prathama Avarta = External genital area, vagina
2) Dvitiya Avarta = Cervix, external OS
3) Tritiya Avarta = Uterus, internal OS, fallopian tubes, ovaries
(including adnexa = surrounding connective tissue)

b) Vagina:
1) Prathama Avarta = Mucous membrane of vagina
2) Dvitiya Avarta = Muscular layer of vagina
3) Tritiya Avarta = Connective fibrous tissue

 Yoni Nadi: - 3
1) Smirana
2) Chandramukhi
3) Gauri

1) Smirana
It is situated at Madana patra (clitoris).
Shukra falling over it becomes useless.

2) Chandramukhi
It is situated at Kandarapageha (mid-vaginal canal).
Shukra falling over it will bring a female child.

3) Gauri
It is situated at Upastha garbha (deep vaginal canal).
Shukra falling over it will bring a male child.
 Artavavaha Srotani
Acharya Sushruta has mentioned Artavavaha Srotas.

आिा ववहे द्वे ियोर्ूा लां गर्ाा शयािा ववतहन्यश्च धर्न्यः ॥ (सु - शा - ९)
Mulasthana = Garbhashaya, Artavavaha Dhamani

Structures can be included as part of Artavavaha Srotas if the following three criteria are
applicable:

i) They are 2 in number.

ii) They are closely related to Garbhashaya and Artavavaha Dhamani.
iii) Injury to the structure produces Vandhyatva (infertility), Maithuna-asahishnuta
(dyspareunia), Artavanasha (amenorrhoea).

As per modern anatomy, following structures can be included under Artavavaha Srotas:

- Uterus, Uterine arteries & veins, Ovarian arteries & veins (Mulasthana)
- Ovaries (all 3 criteria are applicable)

- Fallopian Tubes
If the fallopian tubes are seen as a separate organ, they cannot be included under
Artavavaha Srotas since all 3 criteria are not fulfilled; injury to fallopian tubes does not
cause Artavanasha.

शुक्रशोतििजीवसांयोगे िु खलु कुतिगिे गर्ा सांज्ञा र्वति ॥ (च - शा - ४ / ५)

According to Acharya Charaka, Garbha (zygote) is the conjunction of Shukra (sperm),
Shonita (ovum) and Jeeva (Atma) which takes places in Kukshigata (Garbhashaya).
As per modern science, sperm and ovum meet in fallopian tube to form zygote.
So, fallopian tube can be seen as part of Garbhashaya.

शुक्रशोतििां गर्ाा शयस्थर्ात्मप्रकृतितवकारसांर्ूर्च्छािां गर्ा इत्यु च्यिे ॥ (सु - शा – ५ / ३)

According to Acharya Sushruta, Shukra, Shonita and Atma come together in Garbhashaya
to form Garbha along with its Prakriti and Vikriti.
The word Garbhashaya is composed of two words:
Garbha = Zygote / Embryo / Foetus
Ashaya = Shelter
Garbhashaya is the shelter of the zygote. Once sperm and ovum meet in fallopian tube to
form the zygote, the fallopian tube becomes the shelter for Garbha.

Therefore, fallopian tubes can be considered as part of Garbhashaya and are part of
Artavavaha Srotas.
 Garbhashaya
Garbhashaya is the shelter or seat of the foetus. It is generally correlated to the uterus in
modern anatomy. However, the fallopian tubes can also be considered as part of
Garbhashaya as previously described.
Garbhashaya is the one additional 8th Ashaya in females.
It is Mulasthana of Artavavaha Srotas along with Artavavaha Dhamani.

 Paryaya: Kukshi, Kukshigata, Garbhakosha, Yoni, Dhara

 Sthana:
1) It is situated between Pittashaya & Pakvashaya (in case of pregnancy).
2) It is situated posteriorly to Basti (Basti parshva).
3) It is situated and attached to Tritiya Avarta of Yoni.
4) It is situated anteriorly to the Kundala of Vipula Srotas (multiple coils of
intestine) which is covered by Jarayu (peritoneum).

 Akriti:
1) Garbhashaya is similar in shape and size as the mouth of Rohita Matsya.
2) Garbhashaya is triangular in shape, broad at the fundus, narrow at the cervix.

 Stana & Stanyavaha Srotani

Due to Vaya Parinama (transformation / development in age) in Bala-avastha, there is
development of Stana.
A woman who has never conceived and in Bala-avastha, Stana gata Dhamanis are
constricted, hence Doshas are unable to reach the breasts and they will not be afflicted
by diseases.
In pregnant and puerperal women, dilatation of Stana gata Dhamanis make the breasts
vulnerable to Stanaroga.

 Stana Peshi:
There are 5 Peshi in each Stana which develop during Yauvana-avastha; together
they constitute 10 of the 20 extra Peshi in females.

 Stana Sampat:
Acharya Charaka mentions best qualities of breast as neither too high/elevated nor
to elongated, large or emaciated. They should have appropriate size of nipple so
that the child can easily be fed.

 Stanyavaha Srotani:
According to Acharya Ganekara, Stanyavaha Srotas are two in number and their
Mulasthana are in both Stanas (breasts). Injury to Stanyavaha Srotas may lead to
absence of Stanya (breastmilk), delayed lactation or breastmilk mixed with blood.
 Peshi
Peshi is a part of Mamsa Dhatu.
Vayu enters into Mamsa and divided it into Peshi.
Peshi is important for strength & stability.
Peshi covers Asthi, Sandhi, Snayu and gives strength to the body.

 Paryaya: Pishita, Tarasa, Palala, Kravaya, Amisha

 Bheda: - 12
िासाां बहलपे लवस्थू लािु पृथुवृत्तह्रस्वदीर्ा र्च्स्थरर्ृ दुश्लक्ष्िककाशर्ावाः ॥
1) Bahala (Thick / Dense)
2) Pelava (Thin / Delicate)
3) Sthula (Large)
4) Anu (Small)
5) Prithu (Broad)
6) Vritta (Round)
7) Hrasva (Short)
8) Deergha (Long)
9) Sthira (Stable)
10) Mridu (Soft)
11) Shlakshna (Smooth)
12) Karkasha (Rough)

 Sankhya: - 500

Anga Sankhya
Shakha 400 (100 x 4)
Madhya Shareera 66
Shira 34
--- 500

 Stree Peshi:
There are 20 extra Peshi present in females which develop during adolescence.

- 5 in each Stana (breast) = 10

- 4 in Apatyapatha =4
(Antah prasrite = 2)
(Bahya Mukhasrite = 2)
- Garbha chidra =3
- Shukra/Artava praveshini = 3
 External Female Reproductive Organs

 Mons Pubis:
Synonyms: Mons, Mons veneris
It is the fatty tissue over the symphysis pubis covered with skin which becomes
hairy and prominent during puberty under the influence of hormones. It becomes
less prominent after menopause.

 Labia Majora:
It is homologous to scrotum in males. Labia majora are the two longitudinal,
prominent cutaneous folds extending from mons pubis to the perineum.
The connective fold of skin between the posterior ends of labia majora is called
posterior commissure. Labia majora includes the pudendal cleft which is formed
anteriorly where the labia majora meet at the mons pubis.
Labia majora becomes prominent in puberty and is covered with hair.

 Labia Minora:
It is enclosed by labia majora with the inner surface lying in contact with each
other. Anteriorly it divides and encloses the clitoris, thereby uniting with each other
in front to form prepuce and behind forming frenulum. Posteriorly labia minora
unite to form a thin ridge at the midline called fourchette.
 Clitoris:
It is an erectile structure / organ homologous to penis in males.
It consists of Glans, Body and Crus.

 Hymen:
It is an incomplete membrane covering the vagina. After delivery, the tissue
remnants of the hymen form nodules called myrtiform caruncles / carunculae
myrtiformes.

 Vestibule:
It is a cleft enclosed between labia minora where the vaginal orifice, urethra and
bartholin’s duct open. Generally, it is a triangular area between the vaginal orifice
and clitoris in which the urethra opens.

 Bartholin’s Glands / Vestibular Glands:

They are bilateral pea sized oval shaped glands lying on the posterio-lateral side of
the vagina with its ducts opening at the junction of the hymen and labium minus.
The glands provide lubrication during coitus by secreting mucous.
 Vagina
 Synonym: Kolpos

 Introduction:
Vagina is the lowest segment of internal genitalia. It is a musculo-membranous
canal which serves as birth canal, coital canal and as a menstrual passage.
The mucous membrane has a horizontal rugae which allows dilatation of vagina
during coitus and child birth.

 Location: It lies between urinary bladder and urethra (in front), rectum and anal
canal (behind).

 Walls:
1) Anterior
2) Posterior

 Layers:
1) Fibrous layer (outer most)
2) Muscle layer
3) Submucous layer
4) Mucous layer (inner most)

 Secretion:
- Colour = Whitish / Yellowish white
- pH = 4-4.5
Acid pH provides protection against infection. The vaginal pH is 7 (alkaline) in
menopausal women and children, hence they are more prone to infections.

 Blood supply:
1) Cervico-vaginal branch of uterine artery (upper third of vagina)
2) Vaginal branch of internal iliac artery (middle third of vagina)
3) Mid-rectal & Internal pudendal artery (lower third of vagina)

 Venous drainage: Vaginal veins drain into the internal iliac vein

 Nerve supply: Perineal branch of pudendal nerve and pelvic plexus.

- Sympathetic: T11 – L1
- Parasympathetic: S2 – S4
 Uterus
 Synonym: Hysteria, Womb

 Introduction: It is the primary organ for growth & development of the foetus and
menstruation.

 Location: At the centre of the pelvic cavity between the urinary bladder and
rectum.

 Shape: Pear / Pyriform

 Weight: 45-55 gm
 Dimension:
- Length = 7.5 cm
- Width = 5 cm
- Thickness = 2.5 cm

 Colour: Pinkish-grey

 Layers:
1) Perimetrium (outer, serous layer)
2) Myometrium (middle, muscle layer)
3) Endometrium (inner, mucous)

The foetus is connected to the mother by the attachment of the umbilical cord
to the myometrium, which is the thickest layer of the uterus.

 Parts:
1) Fundus (upper part, fertilized zygote is implanted on the posterior wall)
2) Corpus (middle part)
3) Cervix (lower part; it has 2 walls: Supra-vaginal, Vaginal)
+
4) Isthmus

The isthmus is the indermediate portion between corpus and cervix at the
level of internal OS. It should be considered as a physiological entity rather
than an anatomical one. Its obstetrical significance is that during labour it is
essential to the formation of lower uterine segment. It increases to about
25mm, becomes soft and compressible.
Hegar’s sign is a non-sensitive indication of pregnancy in women - its absence
does not exclude pregnancy. It pertains to the features of the cervix and the
uterine isthmus. It is demonstrated as a softening in the consistency of the
uterus, and the uterus and cervix seem to be two separate regions.
 Blood supply:
1) Uterine artery
2) Ovarian artery

 Venous drainage:
1) Uterine vein
2) Ovarian vein

 Nerve supply:
- Sympathetic: T10 – L1
- Parasympathetic: S2 – S4
 Support of Uterus and Cervix:
Ligaments: - 5 pairs
1) Broad ligament
2) Round ligament
3) Ovarian ligament
4) Transverse ligament
5) Suspensory ligament
1,2 & 3 are attached to the uterus.
4 & 5 are attached to the cervix.

1) Broad ligament
- No: 2
- It is the double fold of the peritoneum.
- It extends from the lateral walls of the uterus to the pelvic sidewalls.
- Each broad ligament contains a fallopian tube, uterine & ovarian arteries,
veins & nerves.
- Parts: 4 i) Infundibulo-pelvic ligament (from infundibulum of fallopian
tube to the lateral pelvic wall)
ii) Mesovarium (it is a fold of the peritoeneum posterior of the
broad ligament to which the ovary attaches)
iii) Mesosalpinx
iv) Mesometrium

2) Round ligament
- No.: 2
- Length: 10-12 cm
- One end is attached to the cornu of the uterus (entry point of fallopian tube)
and the other end terminates in the anterior third of the labium majus.

3) Ovarian ligament
- No.: 2
- Length: 2.5 cm
- Each one is a fibromuscular cord-like structure which attaches to the uterus
posteriorly below the level of attachment of the fallopian tube.

4) Transverse / Cardinal / Mackenrodt’s ligament

- No.: 2
- It extends in a fan-shaped manner from the supra-vaginal cervix to the lateral
pelvic wall.

5) Suspensory / Latero-sacral ligament

- No.: 2
- It extends from the postero-lateral surface of the cervix at the level of
internal OS to the sacrum.
 Fallopian Tube
 Synonym: Salpinx, Uterine tube

 Introduction: It is the primary site for fertilization. It transports gametes, facilitates

formation of zygote and supports the zygote through its secretion.

 Location: Lateral to uterus at the upper margin of the broad ligament.

 No.: - 2
 Diameter: 3 mm
 Openings: - 2
1) Uterine
2) Pelvic

 Diameter: 3 mm
 Length: 10 cm
 Parts: - 4
1) Intramural / Interstitial (1.25 cm)
2) Isthmus (2.5 cm)
3) Ampulla (5 cm)
4) Infundibulum (1.25 cm)

8-10 finger-like structures are present at the end of the infundibulum. They are
called ovarian fimbriae. 1 is longer than the others.
The ampulla is the actual site of fertilization.

 Structures: - 3
1) Serous coat
2) Muscular coat
3) Mucous coat

 Blood supply:
1) Uterine artery
2) Ovarian artery

 Venous drainage:
1) Uterine vein
2) Ovarian vein

 Nerve supply:
- Sympathetic: T11 – L1
- Parasympathetic: S2 – S4
 Ovary
 Introduction: Ovaries are paired almond-shaped female sex gonads producing
ovum and sex hormones.

 No.: - 2

 Shape: Oval / Almond

 Colour: Pinkish-grey
 Dimension:
- Length = 3 cm
- Width = 2 cm
- Thickness = 1 cm

 Ends: - 2
1) Tubal
2) Uterine

 Borders: - 2
1) Mesovarium
2) Free posterior

 Surfaces: - 2
1) Medial
2) Lateral

 Attachments: - 3
1) Broad ligament by mesovarium ligament
2) Lateral pelvic wall by infundibular pelvic ligament
3) Uterus by ovarian ligament

 Blood supply:
1) Ovarian artery
2) Uterine artery

 Venous drainage:
1) Ovarian vein
2) Uterine vein

 Nerve supply:
- Sympathetic: T10 – T12
- Parasympathetic: S2 – S4
 Breast
 Introduction:
- Breast is an accessory reproductive organ.
- It is a modified sweat gland.

 Location:
- Vertically = 2nd – 6th rib
- Horizontally = Lateral border of sternum to mid-axillary line

 Structures:
- The breast consists of 15-20 lobes.
- Lobes -> Nodules -> Lactiferous duct -> Lactiferous sinus -> Nipple
- Pectoralis major
- Suspensory ligament /
Ligament of Cooper
- Lymph nodes:

 Quadrants:
1) Upper outer
2) Upper inner
3) Lower outer
4) Lower inner

 Developmental changes:
- At birth = only ducts are present, no alveoli
- Puberty = Breast growth, alveolar cells, maturation of breast components
- Pregnancy = Development of mammary function
- Menopause = Inhibition of lactation, glandular tissue in breasts shrinks

 Breast examination:
- Monthly examination after menstruation.
Self-examination or examination by the physician.
i) Inspection -> Lump, swelling, pulled in nipple, skin changes, redness, rash,
dripping, dimpling
ii) Palpation with index-, middle- and ring finger -> Up & down, circular, wedge;
palpation of axillary and supraclavicular lymph nodes
 Stree Shroni / Female Pelvis

 Varieties: - 4
1) Gyneacoid pelvis (normal)
2) Platypelloid pelvis (flat)
3) Android pelvis (male-like)
4) Anthropoid pelvis (monkey-like)

 Gyneacoid pelvis
- Normal female pelvis
- 50% of female have gyneacoid pelvis.
- The chance for normal delivery is much higher.

 Bones: - 4
1) Right Hip bone
2) Left Hip bone
3) Sacrum
4) Coccyx

Bones of the pelvis are कपाल अर्च्स्थ (flat bones).

 Joints: - 4
1) Right Sacro-iliac joint
2) Left Sacro-iliac joint
3) Sacro-coccygeal joint
4) Symphysis pubis

Joints of the pelvis are सर्ु द्ग सर्च्ि (box-shaped joints).

  Divisions: - 2
1) False pelvis
2) True pelvis
i. Inlet / Brim
ii. Cavity
iii. Outlet

1) False pelvis
- It is the area above the brim.
- It plays no active role in labour.
- It provides support to uterus.
- Boundaries: Anterior = Abdominal wall
Posterior = Lumbar vertebra
Lateral = Rt. & Lt. Iliac fossa

2) True pelvis
- It is the actual passage of foetus.
- Shape = Almost round
- Boundaries: Anterior = Upper border of symphysis pubis
Posterior = Sacral promontory
Lateral = Rt. & Lt. Ilio-pectineal line

- Sub-divisions:
i. Inlet / Brim
ii. Cavity
iii. Outlet

- Diameters:
AC = Anatomical Conjugate
TC = True Conjugate
OC = Obstetric Conjugate
DC = Diagonal Conjugate
AO = Anatomical Outlet
OO = Obstetric Outlet

ANTERIOR-POSTERIOR (AP) OBLIQUE (O) TRANSVERSE (T)

INLET AC / TC = 11 cm 12 cm 13 cm
OC = 10 cm
DC = 12 cm

CAVITY 12 cm 12 cm 12 cm

OUTLET AO = 13 cm --- AO = 11 cm
OO = 11 cm OO = 10.5 cm
i. Inlet
 Anterior-Posterior Diameter
o AC = Anatomical Conjugate = TC = True Conjugate = 11 cm
Distance between mid-point of sacral promontory & inner surface of
upper border of symphysis pubis.

o OC = Obstetric Conjugate = 10 cm
Distance between mid-point of sacral promontory & bony projection
of inner surface of symphysis pubis.

o DC = Diagonal Conjugate = 12 cm
Distance between mid-point of sacral promontory & lower border of
symphysis pubis.

 Examination of DC:
- Only to be performed at onset of labour, otherwise uterine
contractions may get initiated and premature labour may
result.
- Patient is in lithotomy position.
- PV-examination, try to touch sacral promontory.
- If sacral promontory can be touched, keep the hand at
symphysis pubis and make a mark on the hand directly at
vaginal opening.
- Measure from tip of finger to mark = DC.
- DC – 2 cm = AC (approximately)
- If sacral promontory cannot be touched, diameter is wide
enough for labour.
  Oblique Diameter = 12 cm
Distance between sacro-iliac joint & ilio-pubic eminences.
No. 2 = Rt. & Lt.

 Transverse Diameter = 13 cm
Distance between the two farthest points of right & left ilio-pectineal lines.

ii. Cavity
 Middle potion of pelvis
 Shape = Round
 Boundaries: Anterior = Inlet
Posterior = Outlet

 Diameters: AP = 12 cm
O = 12 cm
T = 12 cm

iii. Outlet
 Varieties: - 2 a) Obstetrical Outlet
b) Anatomical Outlet

a) Obstetrical Outlet
- Slightly narrower due to ischial spines.
- Shape = Oval
- Boundaries: Anterior = Lower border of symphysis pubis
Posterior = Tip of sacrum
Lateral = Rt. & Lt. ischial spine

- Diameters: AP = 11 cm – Distance between lower border of

symphysis pubis & tip of sacrum.

O = ---

T = 10.5 cm – Distance between right & left ischial spine.

The transverse obstetrical diameter of outlet is also
called bi-spinous diameter.
 b) Anatomical Outlet
- Shape = Diamond
- Boundaries: Anterior = Lower border of symphysis pubis
Posterior = Tip of coccyx
Lateral = Rt. & Lt. ischial tuberosity

- Diameters: AP = 13 cm – Distance between lower border of

symphysis pubis & tip of coccyx.

O = ---

T = 11 cm – Distance between right & left ischial

tuberosity.
TDO = Transverse Diameter of Outlet

Normally, coccyx is bent towards pelvic cavity.

The Anterior-Posterior Diameter is 13 cm long if the coccyx is pushed
backwards by 2 cm due to presence of foetal head.
In older age, flexibility of coccygeal joints becomes less and therefore the
anterior-posterior diameter decreases which is less favourable for the
delivery.

 Diagnosis of contracted / normal pelvis:

1) Inlet Examination
- History taking: ▪ Previous easy vaginal delivery indicates towards normal
pelvis.
▪ Previous difficult vaginal delivery may indicate abnormal
pelvis.

- Height of patient: ▪ ≥ 150 cm indicates towards normal pelvis.

▪ ≤ 150 cm indicates towards small / abnormal pelvis.

- Examination of pelvic diameters:

▪ If foetal head is deeply engaged, the bi-parietal diameter of
foetal head passed the inlet, which indicates normal pelvis.
Engagement occurs after 8 months of pregnancy.
▪ If head is not deeply engaged, the Diagonal Conjugate has to
be examined (see above) to diagnose pelvic diameter.
2) Outlet Examination
a) Pubic arch examination:
- Completely extended & spread index finger & thumb are placed on mons-pubis of
the patient. If the fingers fall on the boundaries of pubic arch, pelvic outlet is
normal.
- If the boundaries of pubic arch are narrower, pubic outlet is small / abnormal.

b) Ischial spine examination through vaginal route:

- PV-examination, examine the lateral walls of pelvis to detect bony projections –
ischial spine. Usually, the ischial spine is only a mild projection in female. If it is
prominent, the anatomical transverse diameter of outlet is decreased and not
favourable for delivery.

c) Ischial spine examination through anal route:

- Patient is in supine position with flexed thighs.
- Enclose the thumb of one hand with fingers and form a fist.
- Press the anus. If the fist goes inside, the anatomical transverse diameter of outlet
is normal and favourable for delivery.
 CHAPTER Iii: rajo vijnana

 Raja & Artava

 Paribhasha:
स्त्रीिाां र्ातस र्ातस योति तिःसृि रक्तर्् ।
The blood which is expelled every month from the Yoni of women is known as Raja.

रजः स्त्रीिाां र्ातस र्ातस त्र्यहां स्रवेि् ।

Raja is the monthly discharge occurring in women for days.

ऋिौ र्वति इति आिा वर्् ।

Artava is the ovum, produced in Ritu (Ritukala = Ovulation period).

 Utpatti:
Raja is the Upadhatu of Rasa Dhatu. The blood collected in Garbhashaya during the
whole month by the 2 Dhamanis is slightly black in colour and of characteristic
odour. It is expelled by Vayu through Yonimukha.

 Paryaya: Artava, Raja, Shonita, Puspa, Beeja

 Sthana: Artavavaha Srota - Moola = Garbhashaya & Artavaha Dhamani

 Pramana: 4 Anjali

 Shuddha Raja:
- Monthly periodic flow
- Colour is same as that of Shashaka Rakta (rabbit blood) / Laksha rasa /
Rakta Gunja Phala / Padma / Indragupta
- Devoid of Picchila, Daha, Arti (pain)
- Neither heavy nor scanty
- Does not stain the cloth

 Raja / Artava Guna:

- Artava is Agneya due to predominance of Tejo Mahabhuta.
- It has all the characteristics of Rakta and is responsible for the formation of
Garbha.
- A. Chakrapani says that during the formation of Artava, it is Somya as it is formed
from Rasa Dhatu. However, after some time it changes to Agneya. This changei s
brought about by the action of Doshas in the same way as a solid matter is changed
into fumes due to the action of fire or sugarcane juice becomes wine after the
process of fermentation.
  Differences between Raja and Artava:

Feature Raja Artava

Definition रजः स्त्रीिाां र्ातस र्ातस त्र्यहां स्रवेि् । ऋिौ र्वति इति आिा वर्् ।

Raja = Menstrual fluid Artava = Ovum

Formation & Rajah Srava Kala Ritukala

Secretion
Cell debris of endometrium Mature ovum
Components Blood
Degenerated ova
Ovum Dead Alive & active

Function Cleansing of the body Garbhotpada

Pramana 4 Anjali 1 Beeja

 Prathama Rajodarshana (Menarche)

- Acharya Sushruta mentions 12 years as the age of menarche and 50 years as the age of
menopause.
After a certain age due to time, there are changes in a child which indicate the
commencement of puberty. In a female, these changes can be seen as pubic & axillary
hair, breast development and the onset of menses (menarche).
- Acharya Vagbhata mentions 12 years as the age of menarche. Acharya Arundatta
clarifies that this is the probable age; it may occur earlier or later.
Acharya Vagbhata explains that just as a very old or too young flower and fruit of a tree
does not possess the natural fragrance, similarly a woman younger than 12 and older
than 50 years does not have Rajas, Stanya, etc.
- Acharya Chakrapani say that Artava is only explicit after 12 years of age, but it is
present since foetal life.
- Acharya Kashyapa mentions 16 years as the age of menarche. He further adds that it
depends on the nutritional status and health of an individual.
 Ritu Chakra
The duration of Rituchakra (menstrual cycle) is 1 month (Chandramasa – 28 days).
It is divided into 3 phases:

1) Rajah Srava Kala (Menstrual phase) 3-5 days

2) Ritukala (Proliferative phase + Ovulation) 12 / 16 days
3) Rituvyatita Kala (Secretory phase) 9 / 13 days

1) Rajah Srava Kala (Menstrual phase)

- Periodic expulsion of Raja from Yoni.
- This phase is Vata dominant.
- Duration of Rajah Srava:
A. Charaka = 5 days
A. Vagbhata = 3 days
A. Harita = 7 days
A. Bhavamishra
Excessive flow = 3 days
Mediocre flow = 5 days
Scanty flow = 16 days

- Rajah / Artava Utpatti:

Raja is the Upadhatu of Rasa Dhatu. The blood collected in Garbhashaya during the
whole month by the 2 Dhamanis is slightly black in colour and of characteristic odour.
It is expelled by Vayu through Yonimukha.

2) Ritukala / Nisheka Kala (Proliferative phase + Ovulation)

- It is the appropriate time for conception. It is the ovulation period.
- This phase is Kapha dominant.
- Beeja deposited during Ritukala will surely bear fruits.
- After Rajodarshana (menstruation), Ritukala persists for 12 days. It can even last for a
whole month if Yoni, Garbhashaya and Artava are healthy. Ritukala may even occur if
Rajodarshana is absent.

- The psychological state of the mind of the couple during Ritukala influences the
Manasika prakriti of the child.
If the couple is happy and content, the child will be Sativka.
If the couple is worried or anxious, the child will be Rajasika.
If the couple is depressed or sorrowful, the child will be Tamasika.

3) Rituvyatita Kala (Secretory phase)

- It is the post-ovulatory phase in which Artava becomes Agneya.
- This phase is Pitta dominant.
- Cervical mucous forms a plug causing Yoni samvarana (closing of Yoni) which prevents
entry of Shukra.
 Rajasvala Charya (Regimen during menstruation)
A) According to Acharya Charaka:
From the onset of menses until 3 days and nights, the woman must observe chastity, eat
in a broken vessel which is held in the hand, and should not wash herself, take bath or
clean her body.

B) According to Acharya Sushruta:

From the first day of onset of menstruation, a woman should follow Brahmacharya and
avoid Divasvapna, Anjana, Ashrupatana (crying), Snana, Lepana, Abhyanga,
Nakhachedana, running, laughing, talking too much, listening to various topics, combing
the hair, exposure to wind and exercise. She must sleep on a bed made of Darbha, eat
meal prepared with Ghrita, Shali and Dugdha. It should be served in hand or palm or
utensil made of clay, leaves, etc.

C) According to Acharya Vagbhata:

A Rajasvala must follow Brahmacharya, avoid bath & ornaments, sleep on a bed made of
Darbha for 3 nights, should eat in Sharava (bowl) made of leaves, should take Dugdha
and Yava when hungry. She should avoid Ushna, Katu and Lavana Ahara.

- If the woman does not avoid the restricted acts due to ignorance or greed, the vitiated
Doshas lead to the following abnormalities in the foetus:
Rajasvala Striya Varyja Garbha Vikriti
Divasvapna Svapasheela (sleepiness)
Anjana Andha (congenital blindness)
Ashrupatana / Rudana Vikritadrishti (visual disorders)
Snana & Lepana Dukhasheela (gloominess)
Abhyanga Kustha (skin disorders)
Nakhachedana / Nakhakartana Kunakhi (nail deformity)
Pradhavana (running) Chanchala (fickle minded)
Hasana (laughing) Shyava Danta-Ostha-Talu-Jihva (blackish
teeth, lips, pakate, tongue)
Atikathana (talking too much) Pralapa (garrulous)
Atishabda Shravana (listening too much) Badhira (deafness)
Avalekhana (combin) Khalita (baldness)
Maruta Ayasa (exposure to wind) Unmada (insanity)
Bhumi khanana (scrapping or digging the Falling / tripping while walking
earth)
Nasya Artavadusti (Menstrual abnormalities)

- Consequences of coitus during menstruation:

Acharya Sushruta says that coitus on the first day of menstruation shortens the life span
of the husband and the child would die immediately after delivery.
The same happens if coitus is done on the second day.
Coitus on the third day leads to a child with short life span or deficient body parts.
Coitus on the fourth day will result in a child with all body parts and longevity.
 Ritumati Lakshana
A) According to Acharya Charaka:
After expulsion of old Raja and formation of new Raja, the woman after bath possessing
healthy Yoni, Garbhashaya & Shonita, is termed as Ritumati.

B) According to Acharya Sushruta & Vagbhata:

A female looks bright, healthy, with moistened lips and teeth. She is eager to hear love
stories and have sexual relations. She is passionate, happy, excited and quivers at arms,
breasts, umbilicus, thighs and hips. All these reveal the physiological state of a woman
who is termed as Ritumati.

 Ritumaticharya
A) According to Acharya Charaka:
After menstruation, on the fourth day, the woman should take head bath after
Abhyanga/Lepana and wear white clothes, garlands and flowers. With a pleasant state of
mind and passion, she should indulge in cohabitation.

B) According to Acharya Sushruta:

On the fourth day (the day after menstruation), the woman must take a bath, wear new
white clothes, ornaments, garlands, flowers, etc. After chanting Mantras, she should see
her husband first.

C) According to Acharya Vagbhata:

On the fourth day of menses, the woman should take a bath, wear white clothes,
ornaments, flowers, garlands, chant mantras and should see her husband first.

-> After onset of menstruation on the fourth day, whomever the woman sees first, so will
be the child. Hence, she must look at her husband first or she can also see God, cows,
Brahmana, Guru, elders, Acharya, Satvika or good hearted people.

 Concept of Stree Shukra

- Shukra is present throughout the Shareera just as Ghrita in Ksheera, Taila in Tila beeja,
Ikshurasa in Guda, but the specific location/seat of Shukra is Majja, Mushka
(scrotum/vagina) and Stana.

- Acharya Vagbhata says that the woman secretes Shukra during coitus with men, but it
does not play any role in conception.
Acharya Arundatta clarifies that during coitus, woman secretes Retas, but this secretion
may occur even without coitus by mere memory, touch or sight of the desired man. This
Retas has no role in conception.

- Acharya Sushruta says that if two hypersexual women indulge in coitus, they secret
Shukra which results in a boneless foetus.
 Developmental changes in a Female
 Childhood (Bala)
- Genitalia are present but not fully developed. Primordial follicles are present in
ovaries since childhood though they are not functional.
- Ratio of uterine body to cervix is 1:1.
- Vaginal and vulval ski are delicate, thin and with poor resistance. They are more
prone to infections due to lack of oestrogen and alkaline pH (7) of vagina.
- Hypothalamus is under inhibitory state and insensitive until puberty.

 Puberty/Adolescence (Kumari/Rajasvala)
- Puberty/Adolescence is the physiological transition from childhood to adulthood
in which the reproductive potential is attained.
The term puberty includes physiological changes with reference to development of
adult reproductive capacity.
The term adolescence is related to psychological, social and cognitive changes
leading to development of an identity as an adult individual.
- WHO defines adolescence as the progression from appearance of secondary
sexual character to sexual and reproductive maturity and development of adult
mental process.

- The first visible sign of puberty in girls is the breast bud (thelarche) at 10-11 years
of age followed by pubarche (axillary & pubic hair), and then by menarche (onset of
menses) at around the age of 13.
- Appearance of secondary sexual character before 8 years and menstruation
before 10 years of age is termed as precocious puberty.
- If secondary sexual characters do not appear at the age of 14 and menarche is
unattained by the age of 16, it is termed as delayed puberty.

- Physiological changes in puberty according to Tanner and Marshall’s classification:

Stage Physiological Changes Pubic hair Breast growth
I Overall physical growth No pubic hair Elevation of papilla
II Development of secondary sexual Sparse, medial of Elevation of breast
organs majora tissue & papilla,
enlargement of
areola
III Pubic & axillary hair growth Darkening & curling Further enlargement
of hair, extending of breast & areola
upward and laterally
IV Development of ovaries & genital Adult consistency Projection of areola
organs hair, limited to mons & papilla forming
secondary mound
V Growth spurt & menarche Hair spreading to Adult breast contour
the thighs appears with
disappearance of
secondary mound
  Adult female (Stree)
- Deposition of fat at mons pubis, labia majora develops further.
- Vaginal pH is 4.5 and therefore more resistant to infections.
- Ratio of uterine body to cervix is 2:1 or 3:1.
- Primordial follicles start growing into graafian follicles (functional unit of ovaries)
under the influence of hypothalamic and gonadotrophin stimuli.
- Though graafian follicles mature, ovulation may be delayed by 1-2 years.
- Closure of epiphyses.

 Menarche
Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans.
From both social and medical perspectives, it is often considered the central event of
female puberty, as it signals the possibility of fertility.
Girls experience menarche at different ages. The timing of menarche is influenced by
female biology, as well as genetic and environmental factors, especially nutritional
factors. The worldwide average age of menarche is very difficult to estimate accurately,
and it varies significantly by geographical region, race, ethnicity and other characteristics.
Various estimates have placed it at 13. There is a later age of onset in Asian populations
compared to the West.
Menarche is the culmination of a series of physiological and anatomic processes of
puberty:

 Attainment of a sufficient body mass (typically 17% body fat).

 Disinhibition of the GnRH pulse generator in the arcuate nucleus of the
hypothalamus.
 Secretion of estrogen by the ovaries in response to pituitary hormones.
 Over an interval of about 2 to 3 years, estrogen stimulates growth of the uterus (as
well as height growth, breast growth, widening of the pelvis, and increased regional
adipose tissue).
 Estrogen stimulates growth and vascularity of the endometrium, the lining of the
uterus.
 Fluctuations of hormone levels can result in changes of adequacy of blood supply to
parts of the endometrium.
 Death of some of the endometrial tissue from these hormone or blood supply
fluctuations leads to deciduation, a sloughing of part of the lining with some blood
flow from the vagina.

No specific hormonal signal for menarche is known; menarche as a discrete event is

thought to be the relatively chance result of the gradual thickening of the
endometrium induced by rising but fluctuating pubertal estrogen.

The menstruum, or flow, consists of a combination of fresh and clotted blood with
endometrial tissue. The initial flow of menarche is usually brighter than mature
menstrual flow. It is often scanty in amount and may be very brief, even a single
instance of "spotting." Like other menses, menarche may be accompanied by
abdominal cramping.
 Menstrual Cycle & Ovulation
Menstruation is the physiological periodic shedding of oestrogen and progesterone
primed endometrium following withdrawal of the hormones. In normalcy, it occurs at
regular intervals (once in 28 days) during the whole reproductive period except in
pregnancy and lactation. Menstruation usually lasts for 3-5 days.

Ovulation is the release of ovum from a mature ruptured graafian follicle. Ovulation may
occasionally be accompanied with pelvic pain called “mittelschmerz.” Ovulation usually
occurs between 13th – 17th day of 28 days of the menstrual cycle.
The life span of the released ovum is about 24 hours. The life span of sperm is 36-48
hours. Hence, for fertilization to occur, it is vital that sperms are deposited during the
ovulation period. Ovulation may occur even if menstruation is absent, commonly seen in
lactational amenorrhoea.

The physiology of menstruation includes:

1) Cyclic changes in the endometrium -> Endometrial / Uterine cycle
2) Cyclic changes in the ovaries -> Ovarian cycle

1) Endometrial / Uterine Cycle:

These are the cyclical changes occurring in the endometrium under the influence of
ovarian hormones, starting with the onset of menses which ends with the
commencement of next menstrual cycle.

i) Proliferative phase:
- It lasts from 6th – 14th day of menstrual cycle.
- Proliferation of glandular epithelium with progressive miotic growth of
endometrium under the influence of rising oestrogen level.
- Endometrial glands become long tortuous.

ii) Secretory phase:

- It starts after ovulation under the influence of progesterone.
- It lasts from 15th – 25th day of menstrual cycle.
- Endometrial glands become more tortuous.
- Stroma cells become oedematous and prominent.
- Leucocytic infiltration occurs.
- Three distinct layers of the endometrium can be recognized:
a) Superficial compact layer
b) Intermediate spongy layer
c) Deepest basal layer

The basal layer shows no changes during the menstrual cycle and is responsible for
regeneration of the endometrium. Superficial compact and intermediate spongy
layers are shed periodically during menstruation.
 iii) Menstrual phase:
Absence of fertilization and regression of corpus luteum along with withdrawal of
oestrogen and progesterone causes spiral artery spasms leading to endometrial
hypoxia/ischemia. There is lysis and shedding of endometrium which is known as
menstruation.

After a short period of resting phase, the basal epithelium starts regenerating and
causes proliferative changes in the endometrium following oestrogen stimulation
from the new follicles.

2) Ovarian Cycle:
These are the cyclical changes occurring in ovaries under the influence of pituitary
hormones.

i) Graafian follicular phase:

Among a few primordial follicles, only one undergoes maturation and development
under the influence of FSH (follicle stimulating hormone). The rest of them undergo
atresia (degeneration). The mature graafian follicle (GF) secretes oestrogen. The
release of ovum from a mature graafian follicle is known as ovulation and generally
occurs on the 14th day of 28 days of menstrual cycle.

ii) Corpus luteal phase:

A mature graafian follicle after ovulation under the influence of LH (luteinizing
hormone) forms or becomes yellow body or corpus luteum. There is rise in
progesterone level during this phase. The stage of maturity of corpus luteum persists
from 22nd – 26th day of 28 days of menstrual cycle, after which it regresses in the
absence of fertilization becoming white body or corpus albicans.

On the other hand, in case of fertilization, corpus luteum continues to secrete

progesterone until 12 weeks of pregnancy under the stimulus of hCG (human
chorionic gonadotrophin).
 CHAPTER IV: Garbha vijnana

कुतिस्थस् प्रातििः गर्ा इति ।

िस् तवज्ञािां गर्ा तवज्ञािर्् ॥
The living organism in the womb is called Garbha. The study / science / knowledge of
Garbha is known as Garbha Vijnana.

Garbha Shad-Dhatu = Panchamahabhuta + Chetana

शुक्रशोतििजीवसांयोगे िु खलु कुतिगिे गर्ा सांज्ञा र्वति ॥ (च - शा - ४ / ५)

शुक्रशोतििां गर्ाा शयस्थर्ात्मप्रकृतितवकारसांर्ूर्च्छािां गर्ा इत्यु च्यिे ॥ (सु - शा – ५ / ३)

 Garbha Sambhava Samagri

(Essential factors for conception)

 According to Acharya Charaka:

Conception of Garbha is only successful in the presence of unimpaired Shukra,
Artava, Garbhashaya and by following Garbhadhana Purvakarma.
While observing the advised diet and regimen, when a female & male of physical &
mental maturity & health copulate, the unvitiated Shukra is ejaculated into a
healthy Yonimarga. It then reaches the Garbhashaya and unites with Shuddha
Artava resulting in conception.

 According to Acharya Sushruta:

1) Ritu (Ritukala)
2) Kshetra (Garbhashaya)
3) Ambu (Poshana / Rasa)
4) Beeja (Shukra & Artava)
When these four factors come together, conception is bound to occur just like
a seed germinates when it is planted in the appropriate season, inside the
proper ground and required water is supplied.

 According to Acharya Vagbhata:

1) Garbhashaya (Uterus)
2) Marga (Vaginal passage & fallopian tube)
3) Rakta (Ovum)
4) Shukra (Sperm)
5) Anila (Vata Dosha)
6) Hridi / Mana (Mental state)
All these factors in a pure & healthy (Shuddha) state are necessary for
conception.
 Garbhadhanavidhi
Garbhadhanavidhi is the sexual act for the conception of Garbha.
Garbhadana Samskara was described for the first time in Grihya Sutras. Later Dharma
Sutras and Smritis added certain rules and regulation like time and days for conception
while considering astrological constellations.
Ritukala is the most important factor for a successful conception. It is the appropriate
time for conception. Beeja deposited during Ritukala will surely bear fruits.
After Rajodarshana (menstruation), Ritukala persists for 12 days. It can even last for a
whole month if Yoni, Garbhashaya and Artava are healthy. Ritukala may even occur if
Rajodarshana is absent.
Conception of Garbha is only successful in the presence of unimpaired Shukra, Artava,
Garbhashaya and by following Garbhadhana Purvakarma.

 Garbhadhana Purvakarma:
The woman should chant mantras and perform Namaskara (obeisance) to Ishvara,
Agni, Brahmana and Pitru.
After that the couple should undergo Snehana, Svedana, Vamana and Virechana
Karma. After performance of Samsarjankarma, Asthapana and Anuvasana Basti is
administered. The man is given milk which is processed with Madhura Dravya. The
woman is given Tila, Masha, etc.
Celibacy should be followed for one month.

 Garbhadhana vidhi:
The couple should be passionate and avoid over eating. They should go to a
comfortable bed which is sprinkled with pleasant fragrance. The man should step
with his right foot first onto the right side of the bed, the female should step with
her left foot onto the left side of the bed. The couple should engage in sexual
intercourse. Coitus should be done with a woman who is in supine position.
Afterwards, they should be sprinkled with cold water.

 Ayogya:
Coitus is contraindicated in the following conditions:
Excessive food intake, fasting, thirst, fear, dejection, grief, anger, the woman has
desire for another man, excessive desire for intercourse.
One should avoid coitus with a woman who is too young or too old, who is in her
menstrual period, who is suffering from chronic diseases or is afflicted with any
other disease. In the same way, the man must be free of diseases.

Coitus should also be avoided with a woman who is in a flexed or lateral position.
- In flexed position, Vayu gets vitiated and afflicts the Yoni.
- In right lateral position, Kapha gets displaced and obstructs Garbhashaya.
- In left lateral position, Pitta gets displaced and burns Shukra & Shonita.
 Garbhalingotpatti
(Sex determination of Garbha)

 Factors responsible for sex determination:

1) Shukra / Artava Bahulyat (Predominance of Shukra or Shonita)
2) Ishvara-Iccha (God’s will)
3) Dakshina / Vama Nadi Beeja (Gametes from right or left gonad)
4) Graha Sthiti (Planetary position)
5) Manasika Sthiti (Psychological state)
6) Kala Hetu (Time / Day of coitus)

1) Shukra / Artava Bahulyat (Predominance of Shukra or Artava)

Predominance is determined by quantity & quality of Shukra & Artava.

- Predominance of Shukra -> Purusha (Male progeny)

- Predominance of Artava -> Stree (Female progeny)
- Equal -> Napumsaka (Hemaphrodite)

2) Ishvara-Iccha (God’s will)

According to Acharya Bhavamishra and Acharya Sharngadhara, in addition to
predominance of Shukra or Artava, God’s will plays an important role in regard
to the sex determination of the child.

3) Dakshina / Vama Nadi Beeja (Gametes from right or left gonad)

According to Yoga Ratnakara, in addition to predominance of Shukra or Artava,
if the gamete originated from Dakshina Nadi (right side), a male child is born. If
the gamete is originated from Vama Nadi (left side), a female child is born.
Dakshina and Vama Nadi should be considered as right and left ovaries.

4) Graha Sthiti (Planetary position)

The planetary position has influence on whether the child will become a male
or a female.

5) Manasika Sthiti (Psychological state)

The psychological state of a person influences the quality and quantity of
Shukra or Artava. Therefore, it plays an additional role in sex determination.

6) Kala Hetu (Time / Day of coitus)

- Coitus on even days after menstruation -> Purusha (male progeny)
- Coitus on odd days after menstruation -> Stree (female progeny)
Acharya Sushruta advises that one should cohabit on 4 , 6 , 8 , 10th or 12th
th th th

day after onset of menstruation for those who desire a male progeny, and
coitus should be done on 5th, 7th, 9th or 11th day for a female progeny since
Artava is less on even days, and more on odd days.
 Garbhavakranti
Garbhavakranti is the process in which origin of Garbha (fertilization) and its
development takes place.
After the Garbha is formed, it is followed by the formation of organs.
Hence, Garbhavakranti can be considered as Fertilization + Organogenesis.

According to Acharya Sushruta, the heat which is generated during coitus, along with
Vayu is responsible for the unity of Shukra with Artava in Garbhashaya to form Garbha.
The Atma / Jeeva, reaches the Garbhashaya along with Panchamahabhuta, Sattva, Raja,
Tama, Daiva, Asura, etc.

According to Acharya Charaka, when a man with Shuddha Shukra copulates with a
woman having Shuddha Artava, Yoni and Garbhashaya during Ritukala, then the union of
Shukra and Shonita takes place along with Mana & Atma to form Garbha.
This Garbha grows due to the Garbhavriddhikara Bhava.

The following topics are included under Garbhavakranti:

- Garbhavriddhikara Bhava

- Garbhakara Shadbhava

- Garbha Avyavotpatti

- Garbha Varnotpatti

- Panchabhautikatva of Garbha

- Masanumasika Garbha Vriddhi

- Garbha poshana
 Garbhavriddhikara Bhava
Factors responsible for formation, growth and development of the foetus: - 6

1) Matradi Garbhakara Bhava

2) Matruja Vihara (Regimen of the mother)
3) Upasneha (Nourishment through transudation)
4) Upasveda (Nourishment through osmosis)
5) Kala Parinama (Time)
6) Svabhava (Nature)

Matradi Garbhakara Bhava / Garbhakara Shadbhava

Matrija, Pitrija, Atmaja, Satmyaja, Rasaja and Sattvaja are the 6 factors responsible for the
formation and development of organs as well as various functions, feelings and mental state.
Acharya Sushruta describes the Matradi Garbhakara Bhava as follows:
1) Matrija: All the soft parts are derived from the mother i.e. Rakta, Masma, Meda, Majja,
Hridaya, Nabhi, Yakrit, Pleeha, Antra, Guda, etc.
2) Pitrija: All the hard/stable parts are derived from the father i.e. Kesha, Shmashru, Loma,
Asthi, Nakha, Danta, Sira, Kandara, Snayu, Dhamani, Shukra, etc.

3) Atmaja: Jnana & Vijnana, Ayu, Sukha, Dukha, etc. are derived from Atma.
4) Satmyaja: Veerya, Arogya, Bala, Varna, Medha, etc. are derived from Satmya.
5) Rasaja: Shareera-Upachaya (growth of the body), Bala, Varna, Svastha & Roga
6) Sattvaja: Sattvika, Rajasika & Tamsika Guna

Acharya Vagbhata describes the Garbhakara Bhava in a similar manner as Acharya Sushruta.
However, he mentioned Rajasa & Tamasa Bhava separately as the 7th & 8th factor.
6) Sattvaja Bhava: Cleanliness, Theism, Gratitude, Responsibility, Bravery, Intellect, Memory,
Desire for good deeds, Devotion, absence of attachment, following Dharma
7) Rajasa Bhava: Bad behaviour, Bravery, Jealousy, Talkative, Egoism, Pride, Attachment,
Desire, Selfishness, Anger, Joy
8) Tamasa Bhava: Ignorance, Despair, Carelessness, Sleep, Laziness, Hunger, Thirst, Grief,
Jealousy, Hatred, and opposite Guna of Sattva
  Garbha Avyavotpatti
(Organogenesis)

 According to Acharya Sushruta & Acharya Vagbhata:

All the Anga-pratyanga (major & minor body parts) are derived from the different
Dhatus, including their Sara and Kitta under the influence of Tridosha.

ANGA-PRATYANGA ACHARYA SUSHRUTA ACHARYA VAGBHATA

YAKTRIT-PLEEHA Rakta Rakta Sara; Ushna + Samana
Vayu
PHUPHUSA Rakta Phena Rakta Phena
UNDUKA (CAECUM) Rakta Kitta ---
ANTRA, BASTI, GUDA Rakta Sara & Kapha get Rakta Sara & Mamsa Sara
transformed by Pitta & Vayu
JIHVA Mamsa Sara, Rakta, Kapha Mamsa Sara, Rakta, Kapha
PESHI Vayu & Ushma of Pitta enters ---
Mamsa and divides it into Peshi.
SIRA Mridupaka of Sneha of Meda ---
SNAYU Kharapaka of Sneha of Meda ---
ASHAYA Repeated action of Vayu ---
VRIKKA Rakta Sara, Meda Meda, Rakta Kitta
VRISHANA Rakta Sara, Kapha, Meda, Mamsa Mamsa Sara, rakta, Kapha,
Meda
HRIDAYA Rakta Sara, Kapha Rakta Sara, Kapha

 Garbha Varnotpatti
(Factors responsible for the complexion of Garbha)
- Agni, Jala & Akasha Mahabhuta -> Gaura varna
- Agni, Prithvi & Vayu Mahabhuta -> Krishna varna
- All Mahabhuta equally -> Shyama varna
 Panchabhautikatva of Garbha
 Specific functions of Panchamahabhutas:
. . . वायुतवार्जति . . . िे ज एिां पचति . . . आपः क्लेदयर्च्ि . . . पृतथवी सांहर्च्ि . . . आकाशां
तववर्द्ा यति . . . (सु - शा - ५)
- Vayu divides, Teja metabolizes, Apa moistens, Prithvi solidifies and Akasha
increases the size.
- Vayu is responsible for division of Dosha, Dhatu, Mala and all major & minor body
parts.
- Teja provides human features, colour, complexion due to its metabolic function.
- Apa brings moistness to the Garbha and therefore counteracts the dryness caused
by Vayu and Teja.
- Prithvi solidifies/stabilizes the shape of the embryo.
- Akasha increases the size by inflation of Srotas which have been created by
division of Vayu along with Agni.

 Bhautika components of Garbha:

Each and every body part is Panchabhautika, but the Bhutas reflect their relative
predominance in their specific areas.

1) Akashiya Angavaya
- Vata Dosha
- Satva guna, Buddhi, Laghu, Sukshma
- Shabda, Karna, Srotas, Mukha, Kantha, Kostha

2) Vayaviya Angavaya
- Vata Dosha
- Raja guna, Bhaya, Kama, Khara, Ruksha, Utsaha, Chala / Chesta, Gati
- Sparsha, Tvak, Nishvasa, Chankramanadi

3) Agneya Angavaya
- Pitta Dosha
- Sattva & Raja guna, Krodha, Ushna, Prakasha, Pachana
- Rupa, Akshi, Varna

4) Jaliya Angavaya
- Pitta & Kapha Dosha
- Sattva & Tama Guna, Sheeta, Drava, Manda, Picchila
- Rasa, Jihva, Udaka, Kleda, Sveda, Rasa, Rakta, Mamsa, Shukra, Vasa, Mutra

5) Parthiva Angavaya
- Kapha Dosha
- Tama guna, Guru, Sthira, Kathina
- Gandha, Nasa, Nakha, Kesha, Shmashru, Loma, Asthi, Danta, Kandara, Peshi,
Mamsa, Purisha
 Masanumasika Garbha Vriddhi / Garbha Vriddhi Krama
Month wise development of the foetus: (सु - शा - ३)
1) "प्रथर्े र्ातस कललां जायिे..."
2) "तद्विीये शीिोष्णर्तिलै रतर्प्रपचर्ािािाां र्हार्ू िािाां सांर्ािो र्िः सांजायिे यतद तपण्डः पुर्ाि्
स्त्री चे ि् पेशी िपुम्सकां चे दबुादतर्ति..."
3) "िृ िीये हस्तपादतशरसो पञ्च तपण्दका तिवािािेऽङ्गप्रत्यङ्गतवर्ागश्च सूक्ष्मो र्वति..."
4) "चिु थे सवाा ङ्गप्रत्यङ्गतवर्ागः प्रयक्तो गर्ा हृदयप्रव्यर्च्क्तर्ावाच्चे ििाधािु रतर्व्यक्तो
र्वति...तद्वहृदयाां ..."
5) "पञ्चर्े र्िः प्रतिबुर्द्िरां र्वति..."
6) "षष्ठे बुर्च्र्द्ः..."
7) "सप्तर्े सवाा ङ्गप्रत्यङ्गतवर्ागः प्रव्यक्तिरः..."
8) "अष्टर्ेऽर्च्स्थरोर्वत्योजः..."

1) During the first month, Kalala (gelly / mucoid mass) is formed.

2) During the second month, it becomes a hard mass because Panchamahabhuta

get transformed by Sheeta (Kapha), Ushna (Pitta) and Anila (Vata).
If this mass assumes a round shape (Pinda), it will become a male foetus.
If it assumes an elongated shape like the muscles (Peshi), it will become a
female foetus.
If it assumes an irregular shape (Arbuda), it will become a eunuch.

3) In the third month, five projections develop which are the beginning of the arms,
legs and the head. Also the differentiation of major and minor body organs
manifests on a minute level.

4) During the fourth month, all the major and minor parts become clearly
demarcated. Also the heart of the foetus clearly develops and desires of the
foetus are expressed through the mother. This stage is known as Dauhrida. If the
mother does not get her desires fulfilled, she will give birth to a child with
abnormalities.

5) During the fifth month, Mana becomes clearly manifested.

6) During the sixth month, Buddhi becomes clearly manifested.

7) During the seventh month, all the major and minor parts of the body develop fast
and are clearly distinguishable.

8) During the eighth month, Oja is unstable. If birth takes place then, the survival
chance of the foetus is less.

9) Birth should take place in 9th or 10th month.

 Development during the Gestational Period
The whole gestational period can be divided into:
A) Germinal period
B) Embryonic period
C) Foetal period

A) Germinal period
It starts from fertilization and includes cleavage of zygote, formation of morula,
blastocyst, implantation, formation of trophoblast, chorionic villi and formation of
germinal layers.
It extends from 1st – 3rd week.

The fusion of male and female gamete in the ampulla of the fallopian tube giving rise
to a new organism (diploid cell zygote) is known as fertilization.

After ejaculation, the sperms travel a distance of on inch per hour. If ovum is present,
fertilization occurs within 12 hours of intercourse.
Fertilizable life span of the oocyte ranges from 12-24 hours whereas that of sperm is
48-72 hours.

The ovum is picked up by the frimbriae of the fallopian tube as soon as it is ejected by
the mature graafian follicle. As soon as one sperm enters the vitelline membrane, a
zonal reaction causing vitelline block takes place which prevents the entry of other
sperms and immobilizes them in the perivitelline space.

Cleavage: Once the zygote is formed, it undergoes mitoic cell division. The cellular
differentiation without any significant growth is called cleavage.

Morula: Around 30 hours after fertilization, the zygote forms a mulberry-shaped 16

cell structure known as morula. It further undergoes rapid cell division and enters the
uterine cavity by the 3rd-4th day post-fertilization.

The inner cell mass is compact at one pole which give rise to embryo, hence it is
called embryoblast. The outer cells form the trophoblast which adheres to decidua
and is embedded by the 6th day post-fertilization. This is known as implantation.
The fingerlike off-shoots from trophoblast are called chorionic villi after the
development of which the conceptus is called Embryo.

Around 16 days post-fertilization, the inner cell mass proliferate rapidly,

differentiating into three germ layers; this is called gastrulation.

Three germinal layers:

i) Endoderm
ii) Mesoderm
iii) Ectoderm
Epithelia derived from:

Endoderm Mesoderm Ectoderm

GIT – except mouth & Heart, blood vessels, Skin, hair follicles, sweat
anal canal lymphatics glands, seabaceous glands,
mammary glands, female
external genitalia

Auditory tube, mid ear Testis & duct system CNS & PNS

Respiratory tract Mesothelial lining of Cornea, conjunctiva, tympanic

pericardium, peritoneum, membrane
pleural cavities & joint
cavities

Part of urinary bladder, Tubules of kidney, ureter, Parts of the mouth, lower anal
urethra & vagina trigone of urinary bladder, canal, male urethra
uterine tubes, uterus, part of
vagina

B) Embryonic period
It is characterized by changes of shape/external appearance of the embryo. The three
germ layers undergo differentiation to form tissues and organs of the body.
It extends from 4th – 8th week.

1) First month / 4 weeks

▪ Formation of nervous system.
▪ Spinal cord formation & fusion at midpoint.
▪ Head folds forward and becomes prominent.
▪ Arms and legs become bud like structures.
▪ Length = 0.75 - 1 cm
▪ Weight = 1 gm

2) Second month / 8 weeks

▪ Head is disproportionately large due to brain development.
▪ Heart is divided into 4 chambers.
▪ External genitalia are present, but sex is not distinguishable.
▪ Lungs begin to form.
▪ Segments of limbs & rudiments of fingers appear.
▪ Length = 2.5-3 cm
▪ Weight = 4 gm
C) Foetal period
There is rapid growth of the foetus, complete formation and development of
placenta. The foetal period extends from 3rd month until termination of pregnancy.

3) Third month / 8-12 weeks

▪ Kidneys are able to function.
▪ Buds of the milk teeth are formed.
▪ Beginning of bone ossification.
▪ Nail beds formation of finger and toes.
▪ Sex is distinguishable by outward appearance.
▪ Length = 7-8 cm
▪ Weight = 30-45 gm

4) Fourth month / 13-16 weeks

▪ Buds of permanent teeth.
▪ Lanugo appears on the skin.
▪ Liver and pancreas start functioning.
▪ Placenta is well formed.
▪ Meconium is formed.
▪ Length = 10-17 cm
▪ Weight = 55-120 gm

5) Fifth month / 17-20 weeks

▪ Definite sleeping patterns & activities.
▪ Increased muscular development.
▪ Foetal movements are felt by the mother - quickening.
▪ Eyebrows, eyelashes, scalp hair & vernix caseosa appear
▪ Length = 20-25 cm
▪ Weight = 300 gm

6) Sixth month / 21-24 weeks

▪ Skin appears wrinkled.
▪ Nails, eyebrows and eye lashes are well developed.
▪ Vernix caseosa is abundant.
▪ Lanugo darkens and covers the whole body.
▪ Length = 28-30 cm
▪ Weight = 550-680 gm
7) Seventh month / 25-28 weeks
▪ Maturation of lung alveoli.
▪ Scrotal sacs and lower abdominal cavities are well formed.
▪ Fat deposition, skin loses its wrinkled appearance.
▪ Eyelids open and close.
▪ Length= 35-38 cm
▪ Weight = 1100 gm

8) Eighth month / 29-32 weeks

▪ Birth position may be assumed.
▪ Foetus is viable.
▪ Nails extend to end of the fingers.
▪ Eyelids are open.
▪ Subcutaneous fat deposition.
▪ Storage of iron, calcium, phosphorus, etc.
▪ Lanugo begins to disappear.
▪ Length = 38-43 cm
▪ Weight = 1600-2500 gm

9) Ninth month / 33-36 weeks

▪ Face and body have loose wrinkled appearance.
▪ Amniotic fluid decreases.
▪ Lanugo disappears.
▪ Respiratory, digestive and sensory organs are well developed.
▪ Foetus turns to vertex position.
▪ Length = 42-48 cm
▪ Weight = 2000-2800 gm

10) Tenth month / 37-40 weeks

▪ Vernix caseosa is fully formed.
▪ Skin is smooth, pinkish.
▪ Nails project beyond the fingertips.
▪ Thick scalp hair
▪ Urine is present in the bladder.
▪ Meconium is present in the colon.
▪ Length = 48-52 cm
▪ Weight = 3.5 kg
 Garbhashayasthe Garbhasthiti / Garbhashayantrika Garbhasthiti /
Garbhashayanta Garbhasthiti
(Intra-uterine position of the foetus / Attitude)

 According to Acharya Charaka

- Urdhva Shira (Vertex is directed upwards)
- Pristha Vimukha (Face is directed towards the maternal back)
- Sankuchika Angavyavaha (Flexion of all body parts)

 According to Acharya Sushruta

- All body parts are flexed.
- Foetus looks towards the maternal face.

 Foetal Lie, Presentation, Attitude, Position

 Lie
Lie refers to the relation between the long axis of the mother and the long axis of
the foetus.

Types: - 3
1) Longitudinal / Vertical (long axis of the foetus corresponds to the long axis of
the mother)
2) Transverse (long axis of the foetus is perpendicular to the long axis
of the mother)
3) Oblique (long axis of the foetus crosses the maternal long axis
obliquely at an angle other than the right angle)

 Presentation
Presentation is the part of the foetus which occupies the lower segment of the
uterus / birth canal / maternal pelvis.

Types: - 4
1) Cephalic
2) Breech
3) Shoulder
4) Compound
1) Cephalic
- Occurrence = 96.5%
- Foetal head occupies the lower segment of the uterus.
- Depending on the degree of flexion or extension, cephalic presentation is
classificed as:
a) Vertex (normal)
It is the quadrangular area bounded anteriorly by the bregma (anterior
fontanelle) & coronal sutures, posteriorly by the lambda (posterior fontanelle)
& the lambdoid sutures and laterally by the lines passing through the parietal
eminences.

b) Brow (abnormal)
It is an area bounded on one side by the bregma & the coronal sutures and on
the other side by the root of the nose & supra-orbital ridges of both sides.

c) Face (abnormal)
It is an area bounded on one side by the root of the nose & the supra-orbital
ridges and on the other side by the chin.

2) Breech
- Occurrence = 3%
- The buttocks of the foetus occupies the lower segment of the uterus.
- Types: - 4
a) Complete = Arms & legs are fully flexed
b) Incomplete = Arms flexed, 1 leg flexed & 1 leg extended
c) Frank = Legs are extended near the head
d) Footling = Flexed & crossed legs, feet are born first instead of pelvis

3) Shoulder
- Occurrence = 0.5%
- Transverse lie
- Shoulder of the foetus occupies the lower segment of the uterus.
The shoulder does not actually occupy the lower segment of the uterus, but it
is the closest structure. It requires caesarean section (CS).

4) Compound
- Occurrence = Very rare
- Two or more parts of the foetus occupy the lower segment of the uterus.

Relation between Lie, Presentation & Foetal Parts:

Lie Presentation Foetal Part

Longitudinal Cephalic Head -> Normal
Breech Buttocks
Transverse Shoulder Shoulder
 PP = Presentation Part
It is the part on a presentation which lies over the internal OS.
It is the first part which is felt by per-vaginal examination.

Engagement means that the maximum transverse diameter of the presenting part
passes through the pelvic brim.
Cephalic presentation -> Bi-parietal diameter
Breech presentation -> Bi-trochanteric diameter

 Attitude
Attitude refers to the relation of the foetal parts to each other.
Attitude is the relation of the foetal head to the spine.
The universal attitude is flexion.

Types: - 3
1) Flexed attitude = all foetal parts are flexed, chin toward the chest
2) Deflexed attitude = foetal back is straight, head is deflexed & upright on
the spine
3) Extended attitude = fully extended head

Denominator is the fixed bony portion on the presenting part which denotes the
quadrants of the maternal pelvis (anterior, posterior, right, left).
O = Occiput
S = Sacrum
M = Mentum
F = Frontal
Ac = Acromion

Relation between Presentation, Attitude & Denominator:

Presentation Attitude Denominator

Vertex Flexed Occiput
Brow Deflexed Frontal
Face Extended Mentum
Breech --- Sacrum
Shoulder --- Acromion
 Position
Position is the relation of the denominator to the different quadrants of the
maternal pelvis.

Quadrants: - 4
1) Left Anterior (LA)
2) Right Anterior (RA)
3) Right Posterior (RP)
4) Left Posterior (LP)

Relation between Presentation, Denominator & Position:

Presentation Denominator
Cephalic Occiput
Bridge Sacrum
Shoulder Acromion

Cephalic Presentation: Normal positions

(V = Vertex)
- V1 = LOA (Left Occiput Anterior)
- V2 = ROA (Right Occiput Anterior)
- V3 = ROP (Right Occiput Posterior)
- V4 = LOP (Left Occiput Posterior)
= Matu-Vamata-Pristha-Vimukha
= Matu-Dakshina-Pristha-Vimukha
= Matu-Dakshina-Udara-Vimukha
= Matu-Vamata-Udara-Vimukha

Bridge Presentation: Abnormal positions

(S = Sacrum)
- S1 = LSA (Left Sacrum Anterior)
- S2 = RSA (Right Sacrum Anterior)
- S3 = RSP (Right Sacrum Posterior)
- S4 = LSP (Left Sacrum Posterior)

Shoulder Presentation: Abnormal positions; no practical value because foetal lie is

transverse which requires CS.

(A = Acromion)
- A1 = LAA (Left Acromion Anterior)
- A2 = RAA (Right Acromion Anterior)
- A3 = RAP (Right Acromion Posterior)
- A4 = LAP (Left Acromion Posterior)
 Garbha Poshana
Once Garbha is formed, the nourishment takes place through Ahara Rasa and Adhmana
of Maruta / Vayu.
The food taken by the mother, influences the physical and psychological constitution of
the child. The food consumed by the mother is utilized for the following three purposes:
i) Nourishment of her own body
ii) Formation of Stanya
iii) Nourishment of Garbha by Kedarakulya Nyaya

 Phases of Garbha Poshana:

1) Upasneha (Absorption / Post-fertilization)
2) Upasveda (Histotrophic transfer / Post-implantation)
3) Nabhinadi (Haematotrophic transfer)

When all the Shadbhavas are normal with appropriate diet and regimen of the mother, the
Garbha is nourished by Rasa which is derived by Upasneha and Upasveda.
After the body parts are conspicuous, the nourishment occurs mainly through Nabhinadi
(umbilical cord). The foetal umbilicus is attached to the Apara (placenta) by the Nabhinadi,
and the Apara is connected to the Hridaya.
The Ahara Rasa flows from mother’s Hridaya to Apara, from the Apara to Nabhinadi and
then to the Nabhi where it reaches the Pakvashaya and Ahara Rasa is metabolized by
Kayagni of Garbha to provide nourishment.
Since the Rasa which is received is already the essence of Ahara, there is absence of Mala
and all nourishment is utilized for the growth and development of the Dhatus.
 Foetal Nourishment
 Phases:
1) Absorption / Post-fertilization: After fertilization and before implantation, the
zygote is nourished by cellular cytoplasm, yolk of ovum and secretions in
fallopian and uterine cavity.

2) Histotrophic transfer / Post-implantation: After implantation and before

formation of fully functional placenta, nutrion is derived from decidua and
maternal pools of blood formed as a result of trophoblastic invasion.

3) Haematotrophic: After foetal circulation is established at around 3 weeks,

there is passive transfer of substances in the intervillus space.

 Transport Mechanism & Substances transported across the placenta:

Mechanism Function & Transported Substances

Sumple Diffusion Molecules pass from a region of higher concentration to
lower concentration.
Oxygen, Carbondioxide, Water, Electrolytes

Facilitated Diffusion Transportation is quick. Natural sugars, Glucose, Vitamins

Active Transport / Antimetabolites, Inorganic ions, Endogenous substances

Transfer (e.g. amino acids)

Direct Transfer Lipids, fatty acids, calcium, phosphorus, iron, Vitamin B & C

Pinocytosis Villi enguls tiny droplets of plasma and transports them to

the foetus (e.g. proteins)

Leakage Leaks from endothelial lining of villi enter into foetal

circulation (e.g. maternal cells, immunogens, albumin)
 Foetal circulation:
Foetal circulation is fully established by the third week post-fertilization.
Blood flows to and fro from placenta via the umbilical cord. Foetal deoxygenated
blood flows to the placenta through 2 umbilical arteries, maternal oxygenated
blood flows from the placenta through the umbilical vein.

The umbilical vein carries the oxygenated blood to the liver and gives off a branch
proceeding as ductus venosus which joins inferior venacava carrying deoxygenated
blood from lower limbs and trunk to the right atrium. In the right atrium, the major
part of the oxygenated blood is directed to the left atrium via foramen ovale. From
there it passes to the left ventricle via mitral valve mixed with small quantity of
blood from pulmonary veins, and then towards aorta to be carried to the carotid
arteries and coronary circulation.
A small portion of the blood from inferior venacava + deoxygenated blood from
superior venacava (returning from the head and upper extremities) + blood from
coronary sinux pass through tricuspid valve to the right ventricle andthen to the
pulmonary trunk which partially diverts it to the lungs but mainly to the descending
aorta by ductus arteriosus.
Thus the mixed blood is distributed to viscera and lower extremities and returns to
the placenta via umbilical arteries.
 Apara / Placenta
 Introduction: Placenta is a disc-shaped organ and form a link between the mother
and foetus.

 Weight: 500 gm
 Diameter: 15-20 cm
 Surfaces: - 2
1) Foetal (umbilical cord at the centre)
2) Maternal (18-20 lobes)

 Anchoring Villi:
- 4 in each lobe
- Circulation of foetal blood

 Membrane: It covers the foetus.

Surfaces: - 2
1) Orion (outer)
2) Amnion (inner)

 Functions of Placenta:
1) Respiratory function: O2 & CO2 exchange takes place by simple diffusion. Foetal
hemoglobin can take up oxygen even when maternal oxygen saturation is low.

2) Nutritive function: Nutrition is supplied through the placenta by Simple

diffusion, Facilitated diffusion, Active transfer, Direct transfer and Pinocytosis.

3) Excretory function: Metabolic wastes like urea, uric acid and creatinine are
transported to the maternal blood by simple diffusion.

4) Endocrine function: Insulin, adrenal steroids, thyroxine, human placental

lactogen (hPL), human chorionic gonadotropin (hCG) are supplied through the
placenta.

5) Barrier function: Placenta acts as a lipoidal resistant factor slowing down

transfer of water soluble substances and favouring lipid soluble substances.

6) Placental synthesis: Placenta produces enzymes like:

- Diamine oxidase -> Inactivates pressor amines
- Oxytocinase -> Inactivates oxytocin
- Phospholipase A2 -> Influences synthesis of arachidonic acid
- HSAP -> Heart stable alkaline phosphatase

7) Thermoregulation: Foetal heat loss is depentend on umbilical blood flow

through the placenta along with amniotic fluid, which helps in regulation of
foetal temperature.
 Apara Nirmana:
After conception, the opening of Artavavaha Srotas get obstructed, hence
Rajodarshana will be absent. The obstructed Artava accumulates in the
Garbhashaya and forms Apara & Jarayu.

 Formation & Development of Placenta:

1) Pre-Implantation
The development of the placenta begins during implantation of the blastocyst.
The 32-64 cell blastocyst contains two distinct differentiated embryonic cell
types: the outer trophoblast cells and the inner cell mass. The trophoblast cells
form the placenta. The inner cell mass forms the foetus and foetal
membranes.

2) Implantation
On the 6th day, the blastocyst “hatches”, allowing implantation to take place.
The trophoblast cells interact with the endometrial decidual epithelia to
enable the invasion into the maternal uterine cells.

The embryo then secretes proteases to allow deep invasion into the uterine
stroma. Implantation is interstitial. Normal implantation occurs on the anterior
or posterior wall of the body of the uterus. The most common ectopic
implantation site is in the ampulla of the fallopian tube.

On the 8th day of development, the trophoblast cells differentiate into the
outer multinucleated syncytiotrophoblast.

The syncytiotrophoblast is responsible for producing hormones such as Human

Chorionic Gonadotropin (hCG) by the second week, which is used in pregnancy
testing.

3) Post-Implantation
On day 9, lacunae or spaces form within the syncytiotrophoblast. The
syncytiotrophoblast also erodes maternal tissues allowing maternal blood
from uterine spiral arteries to enter the lacunar network. Thus
early uteroplacental circulation is established by the end of week 2.

Meanwhile, the cytotrophoblast begins to form primary chorionic villi (finger-

like projections) which penetrate and expand into the surrounding
syncytiotrophoblast. In the 3rd week, extra-embryonic mesoderm grows into
these villi, forming a core of loose connective tissue, at which point these
structures are called secondary chorionic villi.
 By the end of the third week, embryonic vessels begin to form in the
embryonic mesoderm of the secondary chorionic villi, making them tertiary
chorionic villi.

The cytotrophoblast cells from the tertiary villi grow towards the decidua
basalis of the maternal uterus and spread across it to form a cytotrophoblastic
shell. The villi that are connected to the decidua basalis through the
cytotrophoblastic shell are known as anchoring villi.

4) Establishment of Circulation
Maternal spiral arteries undergo remodelling to produce low resistance, high
blood flow conditions in order to meet the demands of the foetus.
Cytotrophoblast cells invade the maternal spiral arteries and replace maternal
endothelium. They undergo an epithelial to endothelial differentiation, which
increases the diameter and reduces the resistance of the vessels.

Pre-eclampsia is a trophoblastic disorder related to failed or incomplete

differentiation of cytotrophoblastic cells during the epithelial to endothelial
transformation.

5) Placental Barrier
In the first trimester (0-13 weeks), the surface of the chorionic villi is formed
by the syncytiotrophoblast. These cells rest on a layer of cytotrophoblastic
cells that in turn cover a core of vascular mesoderm. Therefore, the placental
barrier is relatively thick.

The surface area for exchange dramatically increases by full-term (27-40

weeks). The placental barrier is much thinner and the cytotrophoblast layer
beneath the syncytiotrophoblast is lost.

The placental barrier is not a true barrier as it allows many substances to pass
between the maternal and foetal circulations. Unfortunately, this means
various drugs (e.g. heroin, cocaine) and viruses (e.g. CMV, rubella, measles)
can enter the foetal circulation. As the maternal blood in the intervillous
spaces is separated from the foetal blood by chorionic derivatives, the human
placenta is known as the haemochorial type.

By the fourth month, the placenta has two components: the maternal
portion i.e. the decidua basalis and the foetal portion i.e. the chorion
frondosum. On the foetal surface, the placenta is covered by the chorionic
plate; on the maternal side it is bordered by the decidua basalis.
 During the fourth and fifth months, the decidua form decidual septa which
project into the intervillous space but do not join the chorionic plate. These
septa have a core of maternal tissue but are covered by a layer of syncytial
cells. At all times there is a syncytial layer that separates maternal blood in
intervillous lakes from foetal tissue of the villi. The septa divide the placenta
into compartments called cotyledons. Cotyledons receive their blood supply
through 80-100 spiral arteries that pierce the decidual plate.

6) Full-Term Placenta
At full term the placenta is discoid in shape with a diameter of 15-25 cm,
approximately 3 cm thick and weighs about 500-600g. At birth, it is torn from
the uterine wall and around 30 minutes after the birth of the child it is expelled
from the uterine cavity.

 Abnormalities of Placenta:
Placenta Accreta
- Natural plane of cleavage for placental separation is obliterated due to adhesion
of uterine wall and placenta.
- Retained placenta requiring manual removal or severe PPH warranting
hysterectomy.

Placenta Increta = Placenta penetrates the uterine wall.

Placenta Percreta = Placenta penetrates upto serous layer of uterine wall.

Oedema of Placenta
It is a large pale placenta with water oozing out associated with hydrop fetalis due
to Rh-isoimmunization.

Placental cyst
Cysts are of varying size and form on the foetal surface of the placenta. They
contain yellowish-brown fluid and are usually harmless.

Placenta Diffusa or Membranacea

- Thin and spread out placenta due to chorion frondosum covering large are of
chorion.
- It causes serious haemorrhage resembling central placenta previa. Placenta may
not separate readily warranting manual removal or hysterectomy in extreme cases
of bleeding.
 Garbha Nabhinadi / Umbilical Cord
The umbilical cord is the connecting link between the placenta and the foetus.
It extends from the centre of foetal surface of the placenta to foetal umbilicus.

 Length: 30-100 cm (50 cm in average)

 Diameter: 1.5-2 cm
 Structures: - 3
1) 1 Vein (Oxygenated)
2) 2 Arteries (Deoxygenated)
3) Wharton’s jelly (Mucoid connective tissues which covers the blood vessels to
prevent their compression)

 Nirmana / Formation:
- Garbha obstructs both the Rasa- and Raktavaha Srotas; Nabhinadi forms from
Rasavaha Srotas.
- The umbilical cord develops from amniotic ectoderm containing vitello-intestinal
duct and yolk sac. It is formed by 5th week post-fertilization.

 Abnormalities of Umbilical Cord

Kanthavesta / Cord around the Neck / Cord Coiling:
- 1/2 loops of cord around the baby’s neck is a common finding at vertex - delivery
and usually does no harm.
- Hypercoiling is common in preterm with cocaine abusers, associated with adverse
perinatal outcome.
- Rarely 6/7 loops are drawn tightly around the neck and as the foetus decends, the
cord tightens, the blood supply is interrupted and foetal distress may occur.

Single Umbilical Artery:

A single umbilical artery (SUA) is a malformation of the umbilical cord where only
one artery instead of two is present. It may be associated with other birth defects.
The pathogenesis of an SUA is thought to be secondary to vessel atrophy of a
previously normal cord in the mid trimester.

Four Vessel Cord:

This is a rare condition in which the umbilical has 2 arteries and 2 veins.

Abnormal length of the Cord:

- Long / Lenghty cord = Up to 300 cm.
Complications: entanglement, knotting, hypercoiling, thrombosis, prolapse, etc.
- Short cord = Less than 30 cm.
Complications: Abruptio placentae, foetal distress, delayed descent, premature
separation of placenta, uterine inversion
- In extreme cases, umbilical cord may be absent. It is known as achordia. In that
case, the foetus is directly attached to the placenta at umbilicus.
Knots in the Cord:
i) True knot: = It occurs when there is a long cord with large amount of liquor amnii,
small infant or overactive foetus. The incidence is high in mono-amniotic twins.
ii) False knot = It occurs when blood vessels are longer than the umbilical cord.
They are folded on themselves and produce nodulations on the surface of the cord.

Haematoma:
Rupture of umbilical cord may lead to haemorrhage and haematoma. It compresses
the vessels of the cord leading to foetal anoxia and foetal death.

Prolapse of Umbilical Cord:

It is the condition in which the umbilical cord lies beside/below the presenting part
and is compressed between the presenting part and maternal pelvis, thereby
reducing or cutting off blood supply which may lead to foetal death if uncorrected.

Classification:
i) Umbilical cord presentation – the membranes are intact.
ii) Umbilical cord prolapse – the membranes are ruptured; the cord may occupy 3
positions: a) It may lie beside the presenting part at the inlet.
b) It may descend into the vagina.
c) It may pass through the vaginal introitus and out of the vagina.

Etiology:
i) Foetal (Abnormal presentation – transverse lie, breech, cephalic; Premature
labour; Multiple pregnancy; Polyhydramnios)

ii) Maternal (CPD – Cephalopelvic disproportion; High presenting part in presence

of ruptured membranes)

iii) Cord/Placentalb (Long cord; Low lying placenta)

iv) Iatrogenic (ARM – Artificial rupture of membranes when the head is not
engaged; Version and extraction; Flexion of extended head)

Diagnosis:
i) Seeing cord at the vulva
ii) Cord is felt on vaginal examination
 Garbhodaka / Amniotic Fluid
The fluid surrounding the embryo/foetus within the amniotic sac is called liquor amnii or
amniotic fluid. It is not a static fluid as it is replaced every 3 hours.

 Origin:
- Mother’s contribution: Transudate from maternal plasma
- Foetal contribution: Secretion from amniotic epithelium; Transudate across
umbilical cord and foeto-placental circulation; Foetal urine at 12 weeks;
Tracheobronchial secretion and saliva; Diffusion through foetal skin up to 20 th
week.

 Volume:
- 10 weeks = 30 ml
- 12 weeks = 50 ml
- 20 weeks = 400 ml
- 36-38 weeks = 800-1000 ml
During the last weeks of pregnancy, the volume decreases again.
- 43 weeks = 100-600 ml

 Composition:
Water = 98-99%
Total lipids = 0.5%
Protein = 0.3%
Glucose = 0.2%
Creatinine = 0.2%
Urea = 0.3%
Uric acid = 0.4%
Hormones = Cortisone, Hydroxycorticosteroids, Pregnanediol, Progesterone,
Ketosteroids, Pregnantriol, Estriol, hCG, hPL, Prostaglandins, Bilirubin

 Appearance:
- Pale starw & slightly turbid = Normal, turbidity is due to vernix caseosa
- Greenish = Due to meconium, indicates foetal distress
- Golden yellow = Due to bilirubin, indicates foetal cell hemolysis
Rh-icompatibility
- Greenish yellow = Postmaturity
- Dark maroon = Due to altered blood in accidental hemorrhage
- Prune juice = Retained dead foetus
- Fresh blood stained = Vasa preva / Low lying placenta
 Functions:
1) Thermoregulation – maintains an even temperature and prevens dehydration.
2) Shock absorber – prevents pressure hazards to the foetus.
3) Bactericidal action – protects the foetus from infections.
4) Prevents adhesion between amnion and foetal parts.
5) Provides a medium for free movement.
6) Helps musculoskeletal development of the foetus.
7) Promotes surfactant synthesis.
8) Promotes growth and development of lungs and GIT.
9) Provides adequate expansion thus ensures proper placental and foetal
circulation.
10) During labour it forms a bag of membranes (forewaters) ensuring best natural
dilator of cervix.

 Amniotic Fluid Index (AFI):

Amniotic fluid index is a quantitative estimate of amniotic fluid and an indicator of
foetal well-being.
AFI is the score (expressed in cm) given to the amount of amniotic fluid seen on
ultrasonography of a pregnant uterus. To determine the AFI, doctors may use a
four-quadrant technique, when the deepest, unobstructed, vertical length of each
pocket of fluid is measured in each quadrant and then added up to the others, or
the so-called "Single Deepest Pocket" technique.
- An AFI between 8-18 is considered normal.
- An AFI < 5-6 is considered as oligohydramnios.
- An AFI > 24-25 is considered as polyhydramnios.

 Oligohydramnios
Oligohydramnios is diminished quantity of amniotic fluid.
An AFI < 5-6 or volume less than 200 ml at term is considered as oligohydramnios.

Causes: Foetal bilateral renal agenesis, Placental insufficiency, IUGR, Chromosomal

anomalies, PROM, Polycystic kidneys, Post-term pregnancy, etc.

Types & Clinical features:

i) Early pregnancy oligohydramnios:
- Amputation of foetal limbs, Constriction and obstruction of umbilical cord.
- Pressure deformities (club feet)
- Skin is dry, leathery and wrinkled.

ii) Late pregnancy oligohydramnios:

- It is a sign of foetal distress.
- Meconium aspiration
- Compression of umbilical cord and obstruction to the flow of blood leading to
foetal hypoxia.
 Polyhydramnios / Hydramnios:
Polyhydramnios is the excessive accumulation of amniotic fluid.
An AFI > 24-25 or volume exceeding 2000 ml is considered as polyhydramnios.
Polyhydramnios occurs in about 1-2% of pregnancies.

Causes: Maternal diabetes, Multiple pregnancy, Hydrops fetalis in Rh-

isoimmunization, Anencephaly, Spina bifida, Oesophageal atresia, Chorioangioma,
Triomy 18, etc.

Types:
i) Acute hydramnios: The liquor rapidly accumulates and produces severe
symptoms. It occurs n the second trimester before foetal viability. It may result in
preterm labour before 28 weeks.

ii) Chronic hydramnios: It occurs between 32-40 weeks. The fluid accumulates
gradually.

Symptoms:
Mild polyhydramnios may cause few or no signs and symptoms. Severe
polyhydramnios may cause:
- Shortness of breath
- Swelling in the lower extremities and abdominal wall
- Uterine discomfort or contractions
- Foetal malposition

Complications:
Preterm labour, Abnormal foetal presentation, Cord presentation, Cord prolapse,
Uterine inertia, Atonic PPH, Amniotic fluid embolism

Diagnosis:
- Uterus is larger than expected. Foetal parts are difficult to palpate. Foetal heart
sound is not heard clearly.
- Ultrasound – Large echo free space between uterine wall and foetus.
- Blood sugar, grouping, Rh factor

Management:
- Mild Polyhydramnios -> Low sodium diet, bed rest, mild sedation
- Severe Polyhydramnios -> Mild management + Induction of labour in case of
mature foetus. In case of immature but normal foetus, amniocentesis (removal of
fluid).
 Jarayu / Foetal Membranes
Foetal membranes consist of 2 layers, the outer chorion and inner amnion.

 Chorion:
- It is the outer layer of the foetal membrane. It is thicker than amnion.
- It consists of outer trophoblast and inner primary mesenchyme which attaches to
the amnion part.
- It is the foetal tissue which takes part in the formation of the placenta.

 Amnion:
- It is the inner layer of the foetal membrane.
- It conists of outer mesoderma connective tissue and inner ectoderm.
- It is a double layered translucent membrane lining the amniotic fluid.
- The inner surface is smooth and shiny; the outer surface is covered by the
chorion.
- It is avascular and has no nerve supply or lymphatic drainage.
- Functions: Protection of the embryo/foetus
Maintenance of amniotic fluid homeostasis
Metabolic functions
Production of bioactive compounds like growth factors and cytokines.

 Decidua:
During pregnancy, the endometrium is called decidua. At the end of pregnancy, the
decidua sheds off with the placenta and membranes.
i) Decidua basalis / Decidual plate: Firmly united with the chorion, it forms the
maternal component of the placenta on which the ovum rests.

ii) Decidua capsularis: It is the covering of ovum and seperates the embryo
from the uterine lumen.

iii) Decidua vera/parietalis: It lines the uterine cavity outside the site of
implantation. The space between decidua capsularis and decidua vera is called
decidual space.
 Chorio-amnionitis:
It is the inflammation of chorion and amnion due to bacterial infection.

Causes & Occurrence:

- It usually occurs from 2nd trimester onwards.
- It is often associated with prolonged labour.
- Improper hygenic measures or repeated vaginal examination during labour or at
term increases the risk of chorio-amnionitis.
- Ascending infection is the most common cause.

Clinical features: Pyrexia, Tachycardia, Tender uterus, Foul smelling liquor,

Leucocytosis, Reduction in foetal movements

Complications: Premature birth, Premature labour, PROM, Abruptio placentae,

Uterine atony

Diagnosis: Amniotic fluid examination, blood & urine test, Histological examination

Management: Antibiotics (intravenous administration), Immediate delivery of

viable foetus

 Premature Rupture Of Membrames (PROM):

There are two main classifications of PROM:

i) Premature rupture of membranes (PROM) – the rupture of foetal membranes at

least 1 hour prior to the onset of labour, at ≥37 weeks gestation.
It occurs in 10-15% of term pregnancies, and is associated with minimal risk to the
mother and foetus due to the advanced gestation.

ii) Preterm premature rupture of membranes (P-PROM) – the rupture of foetal

membranes occurring at <37 weeks gestation.
It complicates ~2% of pregnancies and has higher rates of maternal and foetal
complications. It is associated with 40% of preterm deliveries.

Etiology & Pathophysiology:

The foetal membranes consist of the chorion and the amnion. They are
strengthened by collagen, and under normal circumstances, become weaker at
term in preparation for labour.
The physiological processes underlying this weakening include apoptosis and
collagen breakdown by enzymes.
In cases of premature rupture of membranes and P-PROM, a combination of
factors can lead to the early weakening and rupture of foetal membranes.
- Early activation of normal physiological processes – higher than normal levels of
apoptotic markers and MMPs in the amniotic fluid.
- Infection – inflammatory markers e.g. cytokines contribute to the weakening of
foetal membranes. Approximately 1/3 of women with P-PROM have positive
amniotic fluid cultures.
- Genetic predisposition

Risk Factors:
- Smoking (especially < 28 weeks gestation).
- Previous PROM/preterm delivery
- Vaginal bleeding during pregnancy
- Lower genital tract infection
- Polyhydramnios.
- Invasive procedures e.g. amniocentesis
- Multiple pregnancy

Clinical Features:
- Typical history is of ‘broken waters’ – with women experiencing a painless
popping sensation, followed by a gush of watery fluid leaking from the vagina.
- The symptoms can often be less specific, such as gradual leakage of watery fluid
from the vagina and damp underwear/pad, or a change in the colour or consistency
of vaginal discharge.
- On speculum examination, fluid draining from the cervix and pooling in the
posterior vaginal fornix may be seen. To ensure an adequate examination, the
woman should be laid on an examination couch for at least 30 minutes. This will
allow pooling of any leaking amniotic fluid in the top of the vagina.

Differential Diagnosis:
In the assessment of suspected premature rupture of membranes, it is important to
consider other diagnoses such as urinary incontinence (which is common in the
later stages of pregnancy).

Complications:
The outcome of PROM generally correlates with the gestational age of the foetus.
The majority of women at term will enter spontaneous labour within 24 hours after
membrane rupture, but there is a greater latency period the younger the
gestational age.

- Chorioamnionitis
- Oligohydramnios
- Neonatal death
- Placental abruption
- Umbilical cord prolapse
 Ulba / Vernix Caseosa
 Ulba:
That which covers or envelops the Garbha like a skin is called Ulba.
The Garbha is covered with Ulba and surrounded by Jarayu which both provide
protection.
After delivery, Sarpi along with Saindhava Lavana should be used for the purpose of
removing the Ulba from Garbha.

 Vernix Caseosa:
Vernix caseosa starts to form during 16-20 weeks of intra-uterine life.
By the end of intra-uterine life, the skin is covered by a whitish substance known as
vernix caseosa. It is composed of secretory products from sebaceous glands,
degenerated epidermial cells and hairs.
Vernix caseosa protext the skin against macerating action of the amniotic fluid.
It also prevents overhydration of the skin.

 Garbha Vikriti Vijnana / Teratology

 Garbha Vikrit Vijnana:
The intra-uterine living organism is termed as Garbha. Any condition which is
abnormal is considered as Vikriti. The abnormalities which occur during intra-
uterine period are termed as Garbha Vikriti. The science about Garbha Vikriti is
known as Garbha Vikriti Vijnana.

Samanya Nidana:
1) Beeja Dosha = Defects of Shukra & Shonita
2) Atmakarma Dosha = Defects due to the deeds of previous or present life
3) Ashaya Dosha = Defects in female reproductive organs
4) Kala Dosha = Defects due to time factor (age of conception, ritukala)
5) Ahara-Viharajanya Dosha = Defects due to improper diet & regimen of mother
6) Manasika Dosha = Defects due to psychological factors & emotions
7) Graha Dosha = Defects due to planetary position during conception or
defects due to infectious agent / demons, ghosts, etc.
8) Anyakaranani Dosha = Defects due to any other causative factor

 Teratology:
Teratology is derived from the greek word “Teratos” meaning “monster” or
“malformed”, and “logos” meaning “study”.
Teratology is the study of malformations occurring in the foetus.
The branch of science that deals with production, development, anatomy and
classification of malformed foetus is called Teratology.

General Causative Factors:

1) Chromosomal aberrations 3) Multifactoral disorders
2) Hereditary genetic defects 4) Defects due to environmental factors
 Garbha Shira / Foetal Head / Foetal Skull

 Bones: - 7
1) Right frontal bone
2) Left frontal bone
3) Right parietal bone
4) Left parietal bone
5) Right temporal bone
6) Left temporal bone
7) Occipital bone

Bones of foetal head are कपाल अर्च्स्थ (flat bones).

 Sutures: - 6
1) Frontal suture
2) Coronal suture
3) Sagittal suture
4) Lambdoid suture
5) Right squamous suture
6) Left squamous suture
(joint between the frontal bones)
(joint between the frontal bones & parietal bones)
(joint between the parietal bones)
(joint between the parietal bones & occipital bone)
(joint between rt. parietal bone & rt. temporal bone)
(joint between lf. parietal bone & lf. temporal bone)

Sutures of foetal head are िु न्नसे विी सर्च्ि.

 Fontanelles: - 2
1) Bregma (Anterior fontanelle – fuses at the age of 24 months)
(Meeting point of frontal & parietal bones / frontal & coronal sutures)

2) Lambda (Posterior fontanelle – fuses at the age of 18 months)

(Meeting point of occipital & parietal bones / lambdoid & coronal
sutures)

 Eminences: - 2
1) Right parietal eminence
2) Left parietal eminence

Together they are known as Bi-parietal eminences.

  Divisions: - 6
1) Vertex (Superior)
2) Occiput (Posterior)
3) Sub-occiput (Posterior-inferior)
4) Sinciput (Anterior-superior – it is also called Frontal or Brow)
5) Face (Anterior)
6) Mental (Anterior-inferior)

Vertex:
- It is the upper most portion of the body.
- In Ayurveda, it is called तशर.
- It is the normal PP (presenting part) of the foetus.
- Shape: Kyte-shaped
- Boundaries / Corner points:
▪ Anterior = Bregma
▪ Posterior = Lambda
▪ Lateral = Rt. & Lt. parietal eminences

 Diameters:
a) Transverse Diameter:
- Bi-Parietal Diameter (BPD) = 9.5 cm
- It is the distance between rt. & lt. & parietal eminences
- It is the widest transverse diameter of foetal head, and therefore the only important
transverse diameter for delivery.

b) Anterior-Posterior (AP) Diameter:

- AP Diameter as well as PP depends on foetal attitude.

ATTITUDE ANTERIOR-POSTERIOR LENGTH PRESENTING CONDITION

DIAMETER PART (PP)
01) COMPLETE FLEXION Sub-occipito-Bregmatic Diameter 9.5 cm Vertex Normal
02) PARTIAL FLEXION Occipito-Frontal Diameter 11.5 cm Anterior portion Abnormal
(MILITARY) of Vertex
03) PARTIAL DEFLEXION Occipito-Mental Diameter 12.5 cm Sinciput Abnormal
04) COMPLETE DEFLEXION Sub-mento-Bregmatic Diameter 9.5 cm Face Abnormal

→ The vertex presentation of foetus is the most common and only normal condition.
Complete flexion is the most favourable attitude because the transverse diameter
e.i. Bi-Parietal Diameter and the anterior-posterior diameter e.i. Sub-occipito-
Bregmatic Diameter are both 9.5 cm long. Due to circular shape of the presenting
part and support of foetal head by the spine, cervix is easier dilated.
 CHAPTER V: Garbhini vijnana

 Sadhyograhita Garbha Lakshana

(Immediate signs of conception)

 According to Acharya Charaka:

तिष्ठीतवका गौरवर्ङ्गसादस्तन्द्राप्रहषौ हृदये व्यथा च ।
िृ र्च्प्तश्च बीजग्रहिां च योन्याां गर्ा स् सद्योिुगिस् तलङ्गर्् ॥ (च - शा - २)
- Nisthivika (Excessive salivation)
- Gaurava (Heaviness)
- Angasada (Malaise)
- Tandra (Drowsiness)
- Praharsha (Horripilation)
- Hridaya Vyatha (Palpitation)
- Tripti (Contentment)
- Beejagrahana (Retention of Shukra & Shonita)

 According to Acharya Sushruta:

ित्र सद्योगृहीिगर्ाा या तलङ्गाति श्रर्ो ग्लातिः तपपासा
सर्च्िसदिां शुक्रशोतिियोरवबिः स्फुरिां च योिेः । (सु - शा - ३)
- Shrama (Fatigue)
- Glani (Lassitude / Exhaustion)
- Pipasa (Thirst)
- Sakthisadana (Lassitude of thighs)
- Shukra-Shonita Avabandha (Retention of Shukra & Shonita)
- Yone Sphurana (Quivering of vagina)
 Vyakta Garbha Lakshana
(Early signs of pregnancy)

 According to Acharya Charaka:

- Artava-Adarshana (Amenorrhoea)
- Asya Samsravana (Excessive salivation)
- An-Anna-Abhilasha (Dislike for food)
- Chardi (Vomiting)
- Arochaka (Anorexia)
- Amla kamata (Craving for sour substances)
- Gurugatratva (Heaviness in the body)
- Chakusha glani (Languor in eyes)
- Stanya (Milk secretion)
- Pada Shvayathu (Pedal oedema)
- Ostha & Stanamandala (Hyperpigmentation of lips & areola)
Karshnyam Atyartha

 According to Acharya Sushruta:

- Stana Krishna Mukhata (Hyperpigmentation of areola)
- Romaraji udgama (Development of linea nigra)
- Akshi Pakhmani (Blinking of eyelids)
- Chardi (Vomiting without any specific cause)
- Gandhadudvija (Aversion to fragrances)
- Praseka (Excessive salivation)
- Sadana (Tiredness / Heaviness / Malaise)
 Garbhini Lakshanena Garbhasya Linga Suchanam
(Clinical features of mother denoting the foetal sex)

 According to Acharya Charaka:

If the pregnant woman does her activities predominantly with the left limbs, if she
desires company of males, if in her dreams she drinks, takes food or does any activity
resembling to female behaviour, if conception takes place in the left side of the
womb, if gravid uteris is elongated in shape rather than round, if the left breast is
endowed with lactation first, then such a pregnant woman delivers a female child.
If the above mentioned features are of opposite nature, she delivers a male child.
If there is a combination of the factors, she delivers a hermaphrodite.

 According to Acharya Sushruta:

A pregnant woman will deliver a male child if the following features are seen:
- Milk formation & secretion appears in right breast first
- Heaviness in the right lateral portion of the abdomen
- Lifting the right leg first while walking
- Desire to see, touch, eat and live among articles with masculine nature
- Dreams about substances possessing masculine nature
- Bright face
- Linea nigra is seen in upwards direction and on the right side

A pregnant woman will deliver a female child if the opposite features are seen.
A pregnant woman will deliver a hermaphrodite if the abdomen is depressed on
both sides and projects forward and mixed character of male & female are seen.

 Pumsavana Vidhi
Pumsavana Vidhi / Karma are the procedures for achieving a progeny of desired sex.

 Factors responsible for sex determination:

1) Shukra / Artava Bahulyat (Predominance of Shukra or Shonita)
2) Ishvara-Iccha (God’s will)
3) Dakshina / Vama Nadi Beeja (Gametes from right or left gonad)
4) Graha Sthiti (Planetary position)
5) Manasika Sthiti (Psychological state)
6) Kala Hetu (Time / Day of coitus)

-> Refer to CHAPTER IV: Garbha Vijnana; Garbhalingotpatti

 Kala:
- Acharya Charaka mentions that Pumsavana karma should be done before the
foetal sex is evident while keeping in mind Desha, Kala, etc.; only then the result
would be as expected, otherwise it may be the opposite.
Acharya Chakrapani comments that the body parts are evident by 2 months of
pregnancy; hence the best time for Pumsavana karma is before that.

- Acharya Sushruta mentioned that Pumsavana karma is done after conception,

before completion of 3rd month.
Acharya Dalhana gives an elaborate explanation: Pumsavana karma is not only for
achieving a progeny of desired sex, but has different effects depending on the time
it it applied.
i) Garbhagrahanaya – To achieve conception, Pumsavana vidhi is done before
or immediately after sexual intercourse.
ii) Garbhasthapana-artha – To impart stability and strength to Garbha,
Pumsavana vidhi is done once the pregnancy is confirmed.
iii) Pumsavana-artha – To achieve progeny of desired sex, Pumsavana vidhi is
done until 3 months before the organs are evident.

 Pumsavana Vidhi:
Most of the drugs used in Pumsavana karma are Madhura Rasa, Shita Veerya,
Snigdha, Jivaniya, Balya and Prajasthapaka. The action of the drug will depend upon
the time of its use.

- Kalka of Jivaka, Rishabhaka, Apamarga, Sahachara, etc. cooked with milk should
be taken individually or collectively.

- A red hot miniature of man made of gold, silver or iron dipped in one Anjali of
curd, milk or water is taken during pushya nakshatra to achieve a male progeny.

- Inhalation of steam of Shali pisti during pushya nakshatra. The juice from the
same dough is instilled in her right nostril to achieve a male progeny; left nostril for
female progeny.

- Nasal drops with Lakshmana, Vatashunga, Sahadeva and Vishvadeva triturated

with Go-Dugdha, the woman should not spit it out again. Instillation of nasal drops
into right nostril for male progeny; left nostril for female progeny.

- Svarasa of Shveta-Brihati collected during pushya nakshatra is instilled in the right

nosril for a boy, in the left nostril for a girl.

- Lakshmana mula triutared with Go-Dugdha is taken orally or insitilled through the
nose.

- One Palasha patra is taken with Go-Dugdha.

 Garbhini Paricharya
 According to Acharya Charaka:
A woman who desires a healthy and good looking progeny should not indulge in
unwholesome diet and regimen. She must adopt good conduct, healthy diet and
regimen.

 According to Acharya Sushruta:

From the first day of pregnancy, the woman must always be cheerful, pious, wear
ornaments, clean and white clothes, perform religious rites, auspicious deeds and
worship God.

 According to Acharya Kashyapa:

Whatever is wholesome for the pregnant woman is also good for the foetus. The
woman should consume the diet after considering Desha, Kala, Ritu, Agni, etc.
She must use auspicious, sacred, pious, pure and new clothes & ornaments.
Her residence should be sufficiently illuminated with sunlight, devoid of
mosquitoes, it should be fumigated, worship & Pooja should be performed, vedic
mantras recited by Brahmanas, songs and instruments should be played.
The woman leaving her bed in the morning should perfrom Dinacharya, offer
prayers and worship the rising sun.
 -> Garbhinya Masanumasika Pathya Prayoga
(Monthwise wholesome diet and regimen for a pregnant woman)

Masa Acharya Charaka Acharya Sushruta

1) Prathama Non-medicated milk should be taken as Madhura, Sheeta, Drava Ahara
frequently as desirable according to Bala
& Agni. Wholesome diet should be taken
in the morning and evening.

2) Dvitiya Milk medicated with Madhura Dravya Madhura, Sheeta, Drava Ahara

3) Tritiya Milk with honey & ghee Madhura, Sheeta, Drava Ahara with Shastika
Shali & Dugdha

4) Chaturtha Butter extracted from milk Cooked Shastika Shali with curd, pleasant food
with milk, butter and Jangala mamsa
5) Panchama Ghee prepared from butter which has Cooked Shastika Shali with milk, Jangala
been extracted from milk Mamsa, food mixed with milk & ghee

6) Shastha Ghee medicated with Madhura Dravya Ghee, Yavagu along with Gokshura

7) Saptama Ghee medicated with Madhura Dravya Ghee medicated with Vidarigandhadi Dravya

8) Astama Ksheera-Yavagu: Yavagu prepared with 8th month is considered as Basti-Kala.

milk and ghee For clearing the retained feaces and for
Vatanulomana, Asthapana Bast should be given
Kvatha of Badara, Bala, Atibala, Shatpuspa,
Patala, Ksheera, Dadhi, Mastu, Taila, Lavana,
Madanaphala, Madhu & Ghrita.
Then Anuvasana Basti should be given with
Siddha Taila prepared with Ksheera & Kvatha of
Madhura Dravya.
After this, she should consume Snigdha Yavagu,
Mamsa Rasa.

9) Nava Anuvasana Basti with oil prepared with A woman who has been treated as described
Madhura Dravya and Pichu Dharana with becomes Snigdha. She gains strength and
the same is administered to lubricate delivers the child normally without
Garbhasthana and Marga. complications.
  Benefits:
By following the monthly regimen, the Garbha attains normal growth and
development without any complications. The woman also remains healthy and
delivers a child possessing good health, energy, strength, voice, compactness and is
much more superior than other family members.
Due to the monthly regimen, the woman’s Kukshi, Kati, Parshva and Pristha
become soft, Vatanulomana is restored, and Apana Vayu functions properly which
eases the delivery.
The skin and nails of the mother also become soft, increase in strength,
complexion, etc.
She delivers at the proper time (term) a progeny who is healthy, excellent and will
have a long life.

 Garbha Upaghatakara Bhava

(Factors which injure/destroy/kill the foetus – Contraindications during pregnancy)

 According to Acharya Charaka:

- Ahara: Tikshna, guru, ushna, Madya, Madakara, Mamsa
- Vihara: Ati-Hina-Mithya Indriya-artha samyoga, Vyayama, Maithuna, violent
activites beyond her capacity, red garments, riding / travelling on uneven paths

 According to Acharya Sushruta:

- Ahara: stale, putrified, wet food
- Vihara: Maithuna, Vyayama, Kshaya, Divasvapna, Ratrijagarana, Shoka, Bhaya,
Krodha, Akale sneha yoga, Raktamokshana, Vega sandharana, riding vehicles,
squatting or sitting in abnormal position, touching dirty clothes, smelling and awful
looking substances, hearing exciting or awful stories, visiting lonely places, haunted
trees, cremation ground, tree shade, acts which may cause anger and disgrace, king
in high volume/pitch, etc.
  Dauhrida
The pregnant woman who possesses two hearts (one of her own and of her foetus) is
called Dvihridaya or Dauhridini.
The term Dauhrida denotes various desires or cravings a woman develops during
pregnancy. Garbha expresses its wishes through Garbhini, hence it is seen that at times
the pregnant woman has desires contrary to her usual likes or dislikes.
Such desires should always be fulfilled.

Acharya Charaka Acharya Sushruta

Dauhrida Kala 3rd month 4th month

Along with Indriyas becoming conspicuous, Atma/Chetana resides in Hridayas. Therefore,

Mana is associated with pain, happiness and
sorrow. During the same period, as a result the
foetus expresses the desires of previous life
Dauhrida through the mother.
Utpatti Karana The foetal heart which is formed from Matrija
bhava is attached to mother’s heart by
Rasavaha Srotas through which the desires are
expressed. Through the desires, the foetus tries
to get rid of sorrows and gain happiness.
along with conspicuousness of Hridaya,
Chetana becomes apparent during the 4th
month. So, the foetus desires the objects of
Indriya (Shabda, Sparsha, Rupa, Rasa, Gandha)
through the mother.
Just as the future of the present life depends
upon deeds of the past, likewise the longings of
Dauhrida Kala are influenced by the previous
life, fate and God.

Non-fulfilment of the desires causes

Suppression or non-fulfilment of the desires
Effects of leads to aggravation of Vayu which causes
fulfilment or various diseases, abnormalities or even death.
non-fulfilment
of Dauhrida Whatever a Dauhridini desires should be given
to her, except if the things she desires are
extremely harmful.
teratological deformities/abnormalities such
as hump back, crooked arm/leg,
developmental delay, impaired growth,
deformed/absent eyes, etc.
Suppression of desires related to specific
Indriya produces abnormality of corresponding
Indriya in the foetus.
Whatever she desires should be fulfilled, by
doing so, she gives birth to a progeny
possessing superior qualities and longevity.
 Diagnosis of Pregnancy
The signs and symptoms of pregnancy vary with different periods and may be classified
under three periods or trimesters, namely the first, second and the third trimester.

I) First Trimester: Week 1-12

 Subjective symptoms
1) Amenorrhoea: It is the first symptom of pregnancy in normally menstruating
woman. It is not wholly reliable as it may also result from chronic debilitating
diseases, emotional stress and other factors. It is considered as a sign of
pregnancy until proven otherwise.
2) Morning sickness: It usually follows a missed period and rarely lasts beyong 12
weeks.
3) Frequency of micturition: Polyuria & Polydipsia due to anteverted bulky
uterus resting over the bladder; bladder mucosal congestion; osmoregulatory
changes. Beyond 12 weeks the symptoms disappear, but recur again in the
third trimester due to pressure of the presenting part.
4) Breast discomfort: Feeling of fullness and pricking sensation.
5) Fatigue: Very common in early pregnancy.

 Objective signs
1) Breast changes: Enlargement & engorgement, areola is more pigmented.
Montgomery’s tubercles are prominent, thick yellowish secretion (colostrum)
expressed earliest at 12 weeks.
2) Jacquemier’s / Chadwick’s sign: Dusky hue of vestibule and anterior vaginal
wall at about 8th week of pregnancy due to vascular congestion.
3) Goodell’s sign: Cervix becomes soft as early as 6th week. It feels like lips (non-
pregnant, it is like the tip of the nose), bluish discolouration.
4) Palmer’s sign: Regular rhythmic uterine contractions can be elicited during
bimanual examination as early as 4th-8th week.
5) Osiander’s sign: Increased pulsation felt through lateral fornices at 8th week.
6) Hegar’s sign: Can be demonstrated between 6th-10th week. Upper part of the
body of the uterus is enlarged by the growing foetus, lower part of the body is
empty and extremely soft. On bimanual examination, the two fingers in
anterior fornix seem to almost meet the fingers of the other hand pressing
suprapubically with fundus above and cervix below the level of contact.
7) Uterus size:
Hen’s egg -> 6th week;
Cricket ball -> 8th week;
Foetal head -> 12th week.
Piskacek’s sign -> unilateral enlargement, where one half is more firm than the
other.
II) Second Trimester: Week 13-28
 Subjective symptoms
1) Amenorrhoea continues; nausea, vomiting and frequency of micturition
usually subside.
2) Quickening: Perception of active foetal movements. It is felt in 18th-20th week
in primigravida and 16th-18th week in multigravida.

 Objective signs
1) Chloasma: Pigmentation of skin. It usually presents as dark, brownish patches
of skin, mostly on the forehead, nose, upper lip, and cheeks.
2) Breast changes: Secondary areola is demarcated in primigravida.
Montgomery’s tubercles are prominent and extend upto secondary areola.
3) Linea nigra: Often referred to as a pregnancy line, is a linear
hyperpigmentation that commonly appears on the abdomen. Extending from
symphysis pubis to ensiform cartilage as early as 20th week.
4) Striae: Pink and white striae are visible in lower abdomen, flanks and breast
called striae gravidarum and striae albican respectively.
5) Braxton hick’s contractions: Irregular, infrequent, spasmodic painless
contractions without any effect on dilatation on cervix.
6) Active foetal movements: Positive evidence of pregnancy and a live foetus as
early as 16th-18th week.
7) FHS: Foetal heart sound – most conclusive clinical sign of pregnancy, detected
between 18th-20th week.
8) Bluish discolouration: Observed and more evident at vagina, vulva, cervix.

III) Third Trimester: Week 29-40

 Subjective symptoms
1) Amenorrhoea persist. Enlargement of the adbdomen progresses.
2) Lightening: A sense of relief of pressure sympoms felt at 38th week especially
in primigravida due to engagement of the presenting part.

 Objective signs
1) Cutaneous changes are more prominent with increased pigmentation and
striae. Uterus shape changes from cylindrical to spherical.
2) Braxton hick’s contractions are more evident.
3) Foetal movements are easily felt.
4) Foetal parts are palpable -> identification of lie, presentation and position.
5) FHS is distinctly heard - difficult in obesity, polyhydraminos and OCP positions.
 Antenatal / Prenatal Care
Antenatal care is defined as a comprehensive coordinated approach to medical care and
psychological support for the pregnant woman that begins before conception and
extends throughout the antenatal period.

 Objectives:
- Identification of medical, reproductive, genetic, social and nutritional risk factors
prior to pregnancy.
- To assure that every wanted pregnancy culminates in the delivery of a healthy
baby without impairing the health of the mother.
- To maintain the mother and baby in the best possible state of health.
- To recognize abnormalities and complications at an early stage.
- Patient education – mother and child care
- Adequate psychological councelling

 History Records:
Various medical histories of the woman who wants to conceive or who is pregnant
must be inquired and considered throughout the antenatal care.

1) General History: Name, age, parity, socioeconomic status, diseases like DM,
HTN, hereditary diseases, rheumatic fever, allergies, contraceptive history.

2) Obstetric History:
a) Past Obstetric History: Birth weight, APGAR score, puerperal problems,
Rh negative/positive, Rh immunization, CS, forceps delivery or ventouse
application, miscarriages, APH, pre-eclampsia, eclampsia, stillbirth, etc.
b) Present Obstetric History: Morning sickness, calculation of EDD
(expected due date -> Formula by adding 9 months and 7 days to first day
of last normal menstrual period)

3) Medical/Surgery History: Allergies, drug hypersensitivity, epilepsy, cardiac

diseases, thyroid disorders, bowel surgery, etc.

4) Personal & Family History: Tobacco or alcohol use, drug abuse, occupation,
food habits, occupation of husband, family history of TB, genetic disorders,
thalassaemia, twins, etc.

 Frequency of antenatal visits:

In the absence of complications:
- Every 4 weeks until 28th week of gestation.
- Every 2 weeks until 36th week of gestation.
- Once per week until term.
-> Examination of Pregnant Lady
O/E: “From Head to Toe”

 Head & Neck examination:

1) Face:
▪ Pallor of skin & conjunctiva (Paleness, indication for Anemia)
▪ Oedema / Puffiness (Indication for PIH – Pregnancy-Induced Hypertension,
Hypothyroidism)
▪ Chloasma on forehead, cheeks, lips (Dark pigmentation – common
physiological symptom of pregnancy due to increase of MSH = melanocyte-
stimulating hormone.)
*Note: Lepana with Kalka prepared from Vacha, Lodhra, Haridra, Yastimadhu,
Shuddha Tankana & Gulabarka.

2) Oral Cavity:
▪ Smooth tongue
▪ Pallor of tongue, palate, mucosa (indication for Anemia)
▪ Megaloblastic tongue (purple coloured patches on tongue – indication for
megaloblastic anemia; Folic acid & Vitamin B12 deficiency)
▪ Stomatitis on tongue or in buccal cavity (Ulcerations – indication for Folic acid
deficiency)
▪ Angular stomatitis (indication for Iron deficiency)

3) Neck:
▪ Goiter (enlargement of thyroid gland – indication for Hypothyroidism)
*Note: Hypothyroidism may cause abortion or decrease of IQ.
Investigation: Sr TSH

 Chest examination:
1) RS examination:
To rule out TB, asthma, bronchitis, pulmonary fibrosis, COPD, etc.

2) Breast examination:
▪ Normal / flat / inverted / bifid / cracks / fissures
▪ Condition of nipples, abnormal discharge
  Abdominal examination:

Leopold’s Maneuver: (Grips / Obstetrical Grips)

The woman should lie on her back with her shoulders raised slightly on a pillow and her
knees drawn up a little. Her abdomen should be uncovered, and most women appreciate
it if the individual performing the maneuver warms their hands prior to palpation.

i) First maneuver: Fundal grip

While facing the woman, palpate the woman's upper abdomen with both hands. An
obstetrician can often determine the size, consistency, shape, and mobility of the form
that is felt. The fetal head is hard, round, and moves independently of the trunk while
the buttocks feel softer, are symmetric, and the shoulders and limbs have small bony
processes; unlike the head, they move with the trunk.

ii) Second maneuver: Umbilical grip

After the upper abdomen has been palpated and the form that is found is identified, the
individual performing the maneuver attempts to determine the location of the fetal
back. Still facing the woman, the health care provider palpates the abdomen with gentle
but also deep pressure using the palm of the hands. First the right hand remains steady
on one side of the abdomen while the left hand explores the right side of the woman's
uterus. This is then repeated using the opposite side and hands. The fetal back will feel
firm and smooth while fetal extremities (arms, legs, etc.) should feel like small
irregularities and protrusions. The fetal back, once determined, should connect with the
form found in the upper abdomen and also a mass in the maternal inlet, lower abdomen.

iii) Third maneuver Pawlik’s grip

In the third maneuver the health care provider attempts to determine what fetal part is
lying above the inlet, or lower abdomen.[2] The individual performing the maneuver first
grasps the lower portion of the abdomen just above the pubic symphysis with the thumb
and fingers of the right hand. This maneuver should yield the opposite information and
validate the findings of the first maneuver. If the woman enters labor, this is the part
which will most likely come first in a vaginal birth. If it is the head and is not actively
engaged in the birthing process, it may be gently pushed back and forth.
The Pawlik's grip, although still used by some obstetricians, is not recommended as it is
more uncomfortable for the woman. Instead, a two-handed approach is favored by
placing the fingers of both hands laterally on either side of the presenting part

iv) Fourth maneuver: Pelvic grip

The last maneuver requires that the health care provider face the woman's feet, as he or
she will attempt to locate the fetus' brow. The fingers of both hands are moved gently
down the sides of the uterus toward the pubis. The side where there is resistance to the
descent of the fingers toward the pubis is greatest is where the brow is located. If the
head of the fetus is well-flexed, it should be on the opposite side from the fetal back. If
the fetal head is extended though, the occiput is instead felt and is located on the same
side as the back.
 Limb examination:
1) Upper limbs:
Tightening of ring due to swelling (indication for fluid retention in the body –
Pregnancy-Induced Hypertension)

2) Lower limbs:
▪ Oedema
*Note: - Bi-lateral oedema commonly occurs due to systematic disorders.
- Uni-lateral oedema commonly occurs due to injury, thrombosis,
filariasis)
- Morning oedema – Pathological; does not resolve after taking rest.
Bi-lateral, pitting
May be due to PIH or Hypoproteinemia.

- Evening oedema – physiological in pregnancy; resolves after taking

rest & legs should be kept at a higher position.
Uni-lateral / bi-lateral, pitting
May be due to strong activities during the day & obstructed backflow
of femoral vein due to weight of foetal head.

▪ Vericous veins (indication for Hypoproteinemia, improper drainage)

 Measurement examination:
1) Height:
▪ ≥ 150 cm indicates towards normal pelvis.
▪ ≤ 150 cm indicates towards small / abnormal pelvis.

2) Weight:
▪ Weight gain of a woman with normal BMI during 9 months of pregnancy =
10-11 kg
- 1st trimester = 1 kg increase / Static / 1-2 kg decrease due to emesis,
food aversion
nd
- 2 trimester = 5 kg increase; 1.5-2 kg / month; roughly 500 gm / week
- 3rd trimester = 5 kg increase; 1.5-2 kg / month; roughly 500 gm / week

▪ Insufficient weight gain indicates malnutrition.

- Protein intake should be increased.
- In 3rd trimester Ksheerabasti with Shatavari can be done for Brimhana-artha.

▪ Excessive increase of weight (> 2 kg / month) indicates fluid retention in the

body.
- Risk of HTN
- Punarnavastaka Kvatha
- Restriction of salt in diet
- Diuretics are contraindicated during pregnancy.

3) Blood Pressure:
▪ Hypotension is a normal physiological symptom of pregnancy. It may occur
any time after 20 weeks of pregnancy.
High level of progesterone -> Muscle relaxation -> Relaxation of muscles of arterial
walls -> Hypotensive state (110/70 – 100/60)
*Note: Hypotension may lead to dizziness; administration of lemon water
with salt & sugar helps to relief dizziness.

▪ Hypotension before 20 weeks of pregnancy indicates pathological origin.

▪ Hypertension: PIH – Pregnancy Induced Hypertension (140/90)
*Note: - Investigation = Urine albumin test
- PIH may be due to albumin which indicates pre-eclampsia (PE).
- Pre-eclampsia / Toxemia is a disorder of pregnancy characterized by the
onset of high blood pressure and often a significant amount of protein in the
urine. Toxemia may cause maternal death. Anemia may cause foetal death.

4) Pulse:
Tachycardia (90 / min) is a normal physiological symptom of pregnancy.
High progesterone level -> High Basal Metabolic Rate (BMR) -> Increased
temperature -> Tachycardia
 Laboratory Investigations: (Routine investigations)
- CBC (Hb, PCV) HBsAg, VDRL, HIV, Sugar F/PP
- BT, CT, Blood and Rh grouping, Rubella antibody titre, TSH, FT3, FT4
- Urine analysis

 Miscellaneous Test: (For specific purpose or patients)

- Urine culture, Mantoux test, Extimation of G6PD deficiency, Vitamin B12 deficiency
- Sickle cell test, thalassemia test
- CVS (Chorionic villus sampling), AFP (Alpha-foetoprotein), Genetic evaluation, etc.

 CVS & AFP:

1) CVS – Chorionic Villus Sampling
- Chorionic villus sampling is a prenatal test in which a sample of chorionic villi
is removed from the placenta for testing. The sample can be taken through the
cervix (transcervical) or the abdominal wall (transabdominal).
- During pregnancy, the placenta provides oxygen and nutrients to the growing
baby and removes waste products from the baby's blood. The chorionic villi
are wispy projections of placental tissue that share the baby's genetic makeup.
The test can be done as early as 10 weeks of pregnancy.
- Chorionic villus sampling can reveal whether a baby has a chromosomal
condition, such as Down syndrome, as well as other genetic conditions, such as
cystic fibrosis. Although chorionic villus sampling can provide valuable
information about the baby's health, it can bear certain risks such as:
Miscarriage. The risk of miscarriage after chorionic villus sampling is
estimated to be 0.22 percent.
Rh sensitization. Chorionic villus sampling might cause some of the
baby's blood cells to enter the mother’s bloodstream.
Infection. Very rarely, chorionic villus sampling might trigger a uterine
infection.

2) AFP – Alpha-Foetoprotein
Alpha-foetoprotein is a protein produced in the liver of a developing foetus.
During a baby's development, some AFP passes through the placenta and into
the mother's blood. An AFP test measures the level of AFP in pregnant women
during the second trimester of pregnancy. Too much or too little AFP in a
mother's blood may be sign of a birth defect or other condition.
These include:
- A neural tube defect, a serious condition that causes abnormal development
of a developing baby's brain and/or spine.
- Down syndrome, a genetic disorder that causes intellectual disabilities and
developmental delays.
- Twins or multiple births, because more than one baby is producing AFP.
  The Quad Screen:
The quad screen, also known as the quadruple marker test, the second trimester
screen or simply the quad test, is a prenatal test that measures levels of four
substances in a pregnant women's blood:
1) Alpha-fetoprotein (AFP), a protein made by the developing baby
2) Human chorionic gonadotropin (HCG), a hormone made by the placenta
3) Estriol, a hormone made by the placenta and the baby's liver
4) Inhibin A, another hormone made by the placent
Ideally, the quad screen is done between weeks 15 and 18 of pregnancy - during
the second trimester. However, the procedure can be done up to week 22.
The quad screen is used to evaluate whether a pregnancy has an increased chance
of being affected with certain conditions, such as Down syndrome or neural tube
defects.

-> Routine Advice in Pregnancy:

1) Diet:
- Variety of cereals, grains like bajra, ragi, jowar, etc.
- Pulses like green gram, horse gram, soya bean, black eyed bean
- Fruits and vegetables
- Skimmed milk is better than full cream milk
- Instead of three large square meals, smaller and frequent meals
- Maintain 2 hours between dinner and bed time
- Restrict coffee, tea, spices like garlic, ginger, etc.
- Avoid sweets, deep fried food, soft drinks, alcohol, ice cream, pickles,
processed foods and fat
- Avoid red meat and skin of fried chicken and fish

2) Care of the breasts: Nipple areola should be cleaned twice daily by rubbing
little oil and drawing out the nipple gently. In case of colostrum secretion, it
should be expressed. Tight brassier should be avoided.

3) Immunization: In India, tetanus toxoid 2 doses 4-6 weeks apart, starting from
20 weeks, is mandatory; one booster shot preferable 4 weeks before the
expected delivery.

4) Rest & Exercise: 2 hours rest in the afternoon, 8 hours sleep at night. No
vigorous exercise, simple walking is advised.
 CHAPTER V: Garbha Vyapad

 Garbhasrava / Garbhapata
The expelled foetus up to 4th month is termed as Garbhasrava as it is more in liquid form.
After 5th or 6th month, expelled foetus is termed as Garbhapata as it attains stability.
When a Garbha whose body parts are not conspicuous is expelled, it is termed as
Durdhara.
When a Garbha with complete body parts is expelled, it ist termed as Kalaratri.

 Nidana:
- Acharya Charaka has mentioned that the seven factors i.e. Shukra, Asrika, Atma,
Garbhashaya, Ritukala, Ahara & Vihara are responsible for the growth,
development and delivery of a mature foetus at term; similarly, any abnormality in
those factos may lead to improper growth and expulsion before term due to
aggravated Vayu and other Doshas.

- From 4th month onwards until 8th month, anger, grief, dissatisfaction, negative
criticism, jealousy, fear, terror, excessive indulgence in coitus, exercise, suppression
of natural urges, sitting, standing or sleeping in uneven postures, hunger or thirst,
eating rotten or stale food, etc. leads to abortion.

- Following factors may cause Garbhasrava or Mudhagarbha: Excessive indulgence

in coitus, travelling by chariot, horse riding, walking, stumbling, falling from height,
compression, running, injury, lying down or sitting on uneven places, fasting,
suppression of urges, consuming dry, hot, pungent, bitter food, grief, alkali,
diarrhoea, emesis, purgation, swinging, indigestion, abortifacients, etc.

- Putraghni, Vamini or Asrija Yonivyapad may also cause Garbhasrava / Garbhapata.

- Garbha Upaghatkara Bhava can cause destruction and expulsion of the foetus.

 Lakshana:
- Pain is felt in Garbhashaya, Kati, Vankshana, Basti pradesha along with vaginal
bleeding.

- Pain is due to vitiated Vayu and Rakta srava is due to the expulsion of Amagarbha
or due to reopening of Artavavaha Srotas.
  Chikitsa:
According to Acharya Charaka, the following measures are adopted to stabilize the
foetus to prevent abortion. These treatments should be done immediately if
vaginal bleeding occurs.

- If there is vaginal bleeding during 2 nd and 3rd gestational month due to

unwholesome diet and regimen, it is unlikely that the pregnancy will continue as
the Garbha lacks maturity.
Furthermore, Stambhana karma to prevent Garbhasrava is considered as mutually
contradicting as the Garbha is still in Ama-avastha during the 3rd month, since
Stambhana is done with Mridu, Madhura & Sheeta Dravya which increases Ama.

- If there is vaginal bleeding during 4th month or onwards, following procedures

should be adopted to prevent abortion:
i) Position: The woman should lie down on a soft bed with cooling bed spread,
so that the level of head is lower than the foot end. (Trendelenburg position)

ii) Bahya Chikitsa:

▪ Yoni Pichu Dharana with cotton dipped in Yastimadhu Churna and Ghrita.
▪ Lepana with Shatadhauta Ghrita or Sahasradhauta Ghrita below the Nabhi.
▪ Parisheka with Ati-Sheeta Ksheera, Yastimadhu Kashaya and Nyagrodhadi
Kashaya below the Nabhi.
▪ Snana with Sheeta-Udaka.
▪ Yoni Pichu Dharana with Ksheeravriksha Svarasa and Kashaya Rasa Dravya.
▪ Yoni Pichu Dharana with Ksheera / Ghrita boiled with Nyagrodha shunga.

iii) Abhyantara Chikitsa:

▪ Nyagrodha shunga processed with Ksheera / Ghrita (one aksha – 12 ml).
▪ Ksheera / Ghrita
▪ Lehya prepared with Padmakshara, Utpala, Kumuda, Madhu & Sharkara.
▪ Ksheera boiled with Priyangu, Utpala, Shaluka, Udumbara phala, Nyagrodha
shunga.
▪ Mridu, Sheeta, Saugandha Rakta Shali with Madhu, Sharkara and Ksheera
boiled with Bala, Atibala, Shali moola, Shastika, Ikshu and Kakoli.
▪ Nidana parivarjana – avoiding anger, sorrow, exertion, coitus, exercise,
Garbha upaghatakara bhava.

 Garbha Shosha / Garbha Kshaya

Acharya Sushruta mentions that the absence of quickening and decrease of abdominal
height are the two features of Garbha Kshaya.

Treatment: During Basti Kala (8th month of gestation), Ksheera Basti is given; along with
intake of Medya-anna (Snigdha-ahara Dravya or cereals mixed with Ghrita).
  Upavishtaka & Nagodara / Upashushka Garbha
Upavishtaka & Nagodara are conditions in which Doshas get aggravated due to improper
intake of Ahara by the mother which ultimately leads growth & developmental delay or
drying of Garbha resulting in prolonged intra-uterine stay.

 Nidana & Samprapti & Samanya Lakshana:

When a pregnant woman indulges in diet and regimens contraindicated for
pregnancy; such as Ushna, Katu, Tikshna Dravya; after Sajnatasara (i.e. 4th month of
gestation), it leads to vaginal bleeding or abnormal vaginal discharge. Vayu is
vitiated which in turn aggravates Pitta and Kapha Dosha. The aggravated Doshas
cause obstructions of Rasavaha Nadi and the Garbha does not receive proper
nourishment. Therefore, his growth & development will be delayed and the intra-
uterine stay is prolonged. This condition is known as Upavishtaka.
Generally, if the Nidana includes Vataprakopaka Ahara & Vihara along with
avoidance of Sneha Dravya, Ruksha Guna of Vata gets aggravated, which causes
drying of Garbha and reduction abdominal size. This condition is known as
Upashushka or Nagodara.

 Bheda & Lakshana & Chikitsa:

Vata-Adhikya Pitta-Adhikya Kapha-Adhikya

- Pureesha is loose, fragmented, - Pureesha is coppery-green. - Madhura-Asya
frothy & expelled with sound. - Feeling like mouth & throat - Utklesha
- Mutrasanga is filled with smoke. - Shleshma-Vamana
- Vedana in Kati, Prishta & Hridaya - Amla Chardi, Murcha - Bhaktadvesha
- Jrimbha, Nidranasha, Pratishyaya, - Daha in Kukshi & Hridaya - Shveta Hasta-Pada-Netra
Shuska-Kasa, Sada, Glani - Red or yellowish - Kasa, Shvasa
- Itching in ear, Pricking pain at discolouration of eyes, nails,
temples, Cutting pain in abdomen, urine
Blackouts - Blackening of skin
- Indigestion, Emaciation, Dry, - Weakness
cracked, rough & discoloured skin - Continuous pain

- Basti with Saindhava Lavana &
Ksheera
- Sheeta-Udaka Snana
- Mridu Shali for eating
- Anuvasana Basti Ghrita & Vidaryadi
Gana Dravya
- Living in a place sheltered from wind
- Yavagu cooked with Aja-
Ghrita/Ksheera & Jivaniya
Dravya
- Ghrita cooked with
Ksheera, Payasya Kalka,
Kakoli, Ksheerakakoli,
Sunishannaka -> twice daily
(morning & evening) along
with Mamsa Rasa
- Anupa/Audaka Masma is given
for 7 consecutive days by making it
appetizing with spices. After that
Sura should be taken.
- Churna of Tila, Mudga, Masha,
Lavana and Bilva patra mixed with
Ghrita should be taken along with
boiled and cooled Aja-Ksheera.

If Garbha fails to develop or grow inspite of all the treatments, then it should be
terminated/aborted with Tikshna, Virechaniya and Apara Patana Dravya.
 Leena Garbha
Due to the obstruction of Yoni marga and abnormalities of Srotas caused by Vata Dosha,
the Garbha shrinks and adheres. It becomes inactive and does not quiver. It is forced to
stay inside the uterus for a long time resulting in intra-uterine death.

Chikitsa:
- The pregnant woman is given Mridu, Madhura, Shita, Snigdha Ahara, Rakta Shali
cooked with Yusha prepared with Masha, Mulaka and large quantity of Ghrita.
- Lukewarm oil massage on lower abdomen, groins, thighs, waist, flanks and back should
be done frequently.
- Mridu Svedana, Vamana & Virechan with plenty of Sneha Dravya

 Antah-Mrita Garbha
Antah-Mrita Garbha is the death of the foetus inside Garbhashaya.
It is IUFD – Intra-Uterine Foetal Demise.

 Nidana:
When there is excessive accumulation of Doshas, excessive use of Ushna or Katu
Dravya, Vega Sandharana (Vata, Vit, Mutra), sitting, sleeping, standing in improper
posture, increase in intra-uterine pressure, injury or trauma, anger, grief, jealousy,
fear, frightening, over exertion; then the Garbha will die inside the Kukshi.

 Lakshana:
- Stillness, stiffness, tightness, coldness, severe pain, absence of foetal movements
and contractions, no vaginal discharge, laxity of eyes, blackouts, giddiness,
dyspnoea, discomfort, natural reflexes like bowel and bladder are disturbed,
blackish or whitish discolouration, foul breath

 Chikitsa:
- Aparasanga Chikitsa (Treatment of retained placenta)
- Atharvaveda Mantra (Chanting the hymns of Atharva Veda)
- Shalyahartra Harana (Extraction by an experienced surgeon)

- Amagarbha: After expulsion of Amagarbha (immature foetus), for cleaning of

uterus, soothing the pain and elevating the woman’s mood, varieties of Madya are
given according to her own strength. The for Brimhana and Santapana, Yavagu is
given. This regimen is followed till the Kleda of Dosha & Dhatu is clear. Later
Dipaniya, Jivaniya, Brimhaniya, Madhura & Vatahara Dravya are processed with
Sneha and should be given as Abhyantara Pana, Basti or along with Ahara.
- Pakvagarbha: In case of Pakvagarbha (matured foetus), Sneha is prescribed from
the day of extraction of Mrita Garbha.
 Rakta Gulma
When the aggravated Vata is localized in the abdomen, it causes swelling associated with
Shula resulting in the formation of Gulma.
Rakta Gulma is a type of Gulma which only occurs in women.

 Nidana:
- Ritau Anahara (Fasting during Ritukala)
- Bhaya, Ruksha, Vega Vinigraha
- Stambhana Lekhana (Improper administration of Stambhana and Vamana karma)
- Yoni Dosha (disorders of genital organs)

 Lakshana:
- Pindita Spandate (Palpitation of round mass)
- Sama Garbha Linga (symptoms like pregnancy)

- Artava-Adarshana (Amenorrhoea)
- Asya Samsravana (Excessive salivation)
- An-Anna-Abhilasha (Dislike for food)
- Chardi (Vomiting)
- Arochaka (Anorexia)
- Amla kamata (Craving for sour substances)
- Gurugatratva (Heaviness in the body)
- Chakusha glani (Languor in eyes)
- Stanya (Milk secretion)
- Pada Shvayathu (Pedal oedema)
- Ostha & Stanamandala (Hyperpigmentation of lips & areola)
Karshnyam Atyartha

 Chikitsa:
Raktaja Gulma occurs only in women and should be treated only after the
completion of ten months.

1) Snehana, Svedana followed by Sneha Virechana

2) Kshara prayoga: Prepare a semisolid preparation by heating one part of Palasha

Kshara with one part each of Ghrita and Taila. Administer it in sufficient dose to
soften the Rakta Gulma.

3) Yoni shodhana:
- Palala (sesame paste) mixed with Kshara
- Palala mixed with Sudha Ksheera

4) Dashamula Siddha Basti Prayoga: Basti prepared with Ksheera, Mutra, Kshara
and Dashamula Kvatha should be administered. If even after all these treatments,
Rakta Gulma does not subside and flows out of Yoni, then Shalya Karma is required.
 Bahugarbhatha / Bahupatyata
(Multiple Pregnancy)

1) According to Acharya Charaka: The Shukra-Artava (fertilized ovum) entering the

Garbhashaya is divided by the excessively aggravated Vayu and the number of Garbha
corresponds to the number of division which is under the influence of deeds of previous
life.

2) According to Acharya Sushruta: The Antah Vayu divided the Beeja into two, then two
Jeeva enter the Kukshi and twins are born depending upon Dharma or Adharma, hence it
is called Dharmetarapurah-sarau.

3) According to Acharya Vagbhata: Based on the number of division by Vayu

corresponding number of foetuses are formed.

-> Acharya Charaka mentions that due to the predominance of Rakta, a female child is
conceived; and due to the predominance of Shukra, a male child is conceived.
In case of Yamala (twin pregnancy) the sex of the children depen on the manner in which
Vayu divides the Beeja.

i) One part has predominance of Shukra and the other of Artava. So, one male and
one female child is conceived.

ii) If both parts have predominance of Shukra, both will be male.

iii) If both parts have predominance of Artava, both will be female.

-> Vayu underuence of one’s own deed, divided the Beeja unequally resulting in unequal
growth & development of the twins. The child from the bigger portion will be healthier &
stronger and the one from the smaller portion will be weaker.
 Abortion / Miscarriage
Miscarriage is a naturally occurring event, unlike medical or surgical abortions. A
miscarriage may also be called "spontaneous abortion."

Miscarriage is the spontaneous or unplanned expulsion of a foetus from the womb

before it is able to survive independently.

An abortion is a procedure to end a pregnancy. It uses medicine or surgery to remove the

embryo or foetus and placenta from the uterus.

 Types of Spontaneous Abortion:

1) Threatened abortion
2) Inevitable abortion
3) Incomplete abortion
4) Complete abortion
5) Missed abortion
6) Recurrent / Habitual abortion

 Causes of Spontaneous Abortion:

1) Idiopathic -> Undetermined cause

2) Foetal factors -> Chromosomal anomalies, Blighted ovum, Hydatidiform mole,

Degeneration of villi, Multiple pregnancy, Congenital defects

3) Maternal factors
a) General/Systemic factors
i) Infections: Hyperpyrexia, Malaria, Hepatitis, Syphilis, Septicaemia,
Herpes simplex virus, Toxoplasmosis, etc.
ii) Diseases/Disorders: Hyptertension, Chronic nephritis, Diabets mellitus,
Thyroid disorders, PCOD (Polycystic ovary disease)
iv) Severe hypoxia
v) Surgery & Trauma
vi) Progesterone deficiency
vii) Drugs -> Antimalarials, anticonvulsions, anaesthetic agents, etc.

b) Local factors
i) Uterine anomalies: Bicornuate, Septate uterus, Retroversion at the end
of 1st trimester, Submucous fibromyoma, Cervical incompetence
ii) Surgery during pregnancy: Myomectomy, Appendicectomy, Ovarian
cyst removal
iii) Local trauma
 Abortion Clinical finding Uterus size Internal os USG
1) Threatened Slight bleeding As per GA Closed Live foetus, sub-
chorionic
haemorrhage
2) Inevitable Bleeding, pain, As per GA or Open with Dead foetus
shock less products felt
3) Incomplete Bleeding Smaller Open Retained products
4) Complete Bleeding stopped Smaller Closed Empty cavity
5) Missed Absent of Smaller Closed Dead foetus
minimal

Type Clinical features Investigations Management

1) Threatened Choriodecidual haemorrhage - Hb, PCV - Avoid lifting heavy weight.

Abortion has commenced but has not
progressed to the stage of
irreversibility.
Symptoms:
Amenorrhoea (more than 6
weeks), Scanty & fresh vaginal
bleeding, Mild uterine cramps
or backache
Signs:
Soft uterus & cervix, internal os
is closed, blood present at
external os
- Avoid strenuous activities and
- Blood grouping sexual intercourse.
- Complete rest
- USG – uterus bulky, - Ambulation only after bleeding
gestational sac corresponds ceases
to duration of - Rx hCG 5000 IU
amenorrhoea, blood clot IM weekly
round GS. Micronized progesterone 200-400
mcg till 14 weeks
- Urine pregnancy test: - Follow up USG to rule out if
Positive abortion is progressing to
inevitable/missed abortion.

2) Inevitable The process of abortion has
Abortion progressed to the stage or
extent of inevitability or
irreversibility.
Symptoms:
Amenorrhoea, Profuse vaginal
bleeding, Pain present with
fresh blood and clots, Uterine
contractions present
- Hb, PCV
- Blood grouping
- Rh factor
- USG – Bulky uterus, GS at
lower pole of uterus,
Internal os open, Blood
clots in cervical canal
- Resuscitation with IV fluids,
blood transfusion if required
- Pregnancy < 12 weeks -> suction
evacuation.
- Pregnancy > 12 weeks -> IV
oxytocin
- TT, prophylactic antibiotics

Signs: - Anti D 50 mcg if mother is Rh

Pallor, tachycardia, negative and GA ≥ 12 weeks
hypotension, cold, soft uterus
& cervix, internal os is open, - Histopathological examination
clots in vagina, products of of conceptus/products.
conception are felth through
the os
 Type Clinical features Investigations Management

3) Incomplete Abortion has occurred, but the
Abortion process is incomplete. Os is
open and contents partially
expelled.
Symptoms:
History of amenorrhoea,
Continuous or recurrent vaginal
bleeding – profuse with
passage of products. Lower
abdominal pain due to periodic
uterine contractions and
expulsion of products and
blood clots.
- Hb, PCV - Resucscitation – IV fluids and
blood transfusion if required
- Blood grouping
- Dilatation and suction curettage
- Rh factor
- Premedication with pethidine
- TC, DC and diazepam + Paracervical
block 10 ml lignocaine 1%
- USG

Signs:
Pallor/shock due to profuse
bleeding, Products of
conception felt in cervical
canala / vagina, Internal os is
open, Soft uters, Uterus size
may correspond to GA or may
be small.

4) Complete Products of conception are USG for confirmation - Sedatives

Abortion expelled completely and
uteriny cavity is empty. - Haematinics

Symptoms: - Tetanus toxoid

History of amenorrhoea and
lower abdominal pain. History - Anti-D immunoglobin
of vaginal bleeding with
passage of products, decrease - Curettage only if bleeding
in pain and bleeding. Vaginal continues or USG reveals
discharge subsides within a remaining products in the uterine
week. cavity.

Signs:
In case of heavy bleeding,
patient may suffer circulatory
collapse, Soft cervix, Interal os
is closed, Small uterus, lsightly
bulky, Minimal vaginal
bleeding, GS in vagina
 Type Clinical features
5) Missed Intra-uterine dead foetus
Abortion retained passively in uterine
cavity.
Symptoms:
History of amenorrhoea
followd by vaginal
bleeding/brownish
discharge/spotting. No pain.
Signs:
Uterus size is smaller than GA,
Bulky uterus, Soft cervix,
Internal os is closed.
Spotting/bleeding from cervical
canal is generally brownish.
Investigations
- Pregnancy test: Negative
- USG is diagnostic
- Serum fibrin degradation
products
- BT, CT, Platelet count, etc.
Management
- Uterus is evacuated < 12 weeks,
D and C under antibiotic cover
- PGE1 intravaginally results in
spontaneous expulsion
- >12 weeks -> Cervical ripening
with PG gel and 2 hourly injection
of Prostadin (15 methyl PGF2
alpha).
- Ensure complete evacuation
- Inj. TT, Anti-D gamaglobulin,
Haematinics

6) Recurrent / Spontaneous abortion Preconception stage: - Avoid sexual intercourse,

Habitual consecutively on 3 or more - Hb, CBC, Blood grouping,
Abortion occasions. Rh factor, Karyotyping
- Urine routine,
It may be Primary or Secondary microscopy, culture
(if it occurs after the birth of a - GTT
viable pregnancy) - Liver, renal, thyroid
function test
- TORCH titre estimation
- Antiphosphlipid
antibodies
- HSG
- Cervial swab to rule out
listeria, bacterial vaginosis,
chlamydia
- Rule out cervical
incompetency
Adequate rest
- Treatment of the partiucal cause
- Cervical cerclage in case of
cervical incompetence
- Low dose of ASA for
antiphospholipid syndrome
- Correction of congenital
anomaly (e.g. removal of septum)
- Hormone therapy for LPD (luteal
phase defect)

During pregnancy:
- Routine antenatal tests
- TORCH
- Antiphospholipid
antibodies
- GTT
- USG
- Hormone assays
 Septic Abortion:
Sepsis is a serious condition resulting from the presence of harmful microorganisms
in the blood or other tissues and the body’s response to their presence, potentially
leading to the malfunctioning of various organs, shock, and death.
Septic abortion is associated with sepsis of products of conception. The organisms
are endogenous arising from the patients’ bowel, vaginal flora and endocervix.
Septic aborton is a very serious complication associated with high mortality.

Cause: Spontaneous, missed, incomplete, criminal abortions have a higher risk of

contracting an infection and leading to septic abortion.

Organisms: Polymicrobial
i) Aerobic: E. coli, pseudomonas, β-haemolytic streptococci, staphylococcus
ii) Anaerobic: Bacteroides, neisseria gonorrhea, clostridium

Grades: I) Involves endometrium & myometrium

II) Involves adnexae & pelvic structures
III) Generalized peritonitis

Symptoms: Amenorrhoea, high fever, chills, rigors, vomiting, diarrhoea, diffuse

abdominal pain, foul smelling vaginal discharge may be purulent with vaginal
bleeding and history of passage of products of conception.
Signs: Pallor, sweating, pyrexia, tachycardia, hypotension, delirium, abdominal
tenderness, rigidity, guarding and distension, soft cervix, soft/firm uterus, internal
os may be open

Investigations: CBC, Urine analysis, high vanigal swab, urea, creatinine,

electrolytes, USG, Radiograph of abdomen in case of peritonitis, Chest X-ray in case
of dyspnoea

 Criminal Abortion:
Abortion, legally defined, is the premature expulsion of the foetus before the term
of gestation is complete. The law does not differentiate abortion, miscarriage and
premature delivery. Criminal abortion is the unlawful expulsion of the foetus by
artificial means. It is a felony when any person advises, assists in or performs an
abortion.

 Medical Abortion:
Medical abortion is a procedure that uses medication or surgical intervention to
end a pregnancy. A medical abortion does not necessarily require surgery or
anesthesia and can be started either in a medical office or at home with follow-up
visits. It is safer and most effective during the first trimester of pregnancy.
 Rh-Incompatability & Isoimmunization
 Definition
- Rh factor is a protein on red blood cells.
- Rh incompatibility is when a mother has Rh-negative blood and her baby has Rh-
positive blood.
- Rh isoimmunization is when the blood from the baby makes the mother's body
create antibodies that can harm the baby's blood cells.

 Causes:
- The baby's Rh status is inherited from the mother and father. If the mother is Rh
negative and the father is Rh positive, the baby has at least a 50% chance of being
Rh positive.
- Rh isoimmunization can happen if the baby's Rh positive blood enters the
mother's blood flow. This may happen during in case of:
Miscarriage, Trauma, Ectopic pregnancy, Induced abortion, Amniocentesis or other
pregnancy procedures.
- The mixture of foetal and maternal blood happens most often at the end of
pregnancy. This means it is rarely a problem in a woman's first pregnancy. The
mother's antibodies could affect a future pregnancy with a baby with Rh-positive
blood even if the blood is not mixed.
- The mother can also become sensitized to Rh-positive blood if she has a blood
transfusion that is not a match.

 Risk Factors:
The risk of Rh incompatibility is higher in a Rh-negative pregnant woman who:
- Had a prior pregnancy with a baby that was Rh positive
- Had a prior blood transfusion or amniocentesis.
- Did not get a Rh immunization during a prior pregnancy with a Rh-positive baby.

 Symptoms:
Symptoms will only occur in the baby. They can be mild to severe, such as:
- Haemolytic anemia
- Jaundice
- Swelling of the body, which can lead to heart failure or breathing problems

 Diagnosis:
- Blood test to find out whether the mother is Rh positive or negative.
- Amniocentesis to find out whether the babyis Rh positive or negative.
 Treatment:
- The goal of treatment is to keep the baby healthy and lower the risk of recurrence
in future pregnancies.
- Rh incompatibility will be treated by giving the mother Rh immune globulin to
prevent Rh isoimmunization.
- Not all babies will need to be treated. Those who do may need:
Medicines to improve RBC production; transfusion to replace blood cells that are
being destroyed; early induction of labour.

 Prevention:
Rh incompatibility can be prevented with an injection of Rh immune globulin at 28th
week of gestation. A second injection will be given within 72 hours after delivery.
The injections will block the mother's body from developing antibodies.
 Gestational Trophoblastic Neoplasia (GTN)
Gestational Trophoblastic Disease (GTD)
GTN / GTD is a group of diseases originated from placental villose trophoblastic cells,
including hydatidiform mole, invasive mole, choriocarcinoma and a kind of less common
trophoblastic cell tumor in the placenta.

 Hydatidiform Mole:
Introduction: Hydatidiform mole means that after pregnancy the placental
trophoblastic cells proliferate abnormally, there is stromal oedema, and formation
of vesicula which is like a grape in apparence.

Classification: i) Complete ii) Incomplete / Partial

Risk factors of complete hydatidiform mole:

- Malnourishment
- Age: < 20 years, > 35 years
- History of hydatidiform mole

The morbidity of incomplete mole is much lower than that of the complete type,
and it is not associated with age.

Clinical features of complete hydatidiform mole:

- Vaginal bleeding after amenorrhoea
- Uterus is abnormally enlarged and becomes soft
- Hyperthyroidism
- Theca lutein ovarian cyst
- Gestational vomiting, PIH

Incomplete hydatidiform mole may have similar symptoms as described in the

complete mole, but they are less manifested. Luteinizing cyst does not occur.

Diagnosis: HCG measurement, Ultrasound, Doppler flow

Management:
Emptying uterine cavity, Hysterectomy, Management of luteinizing cyst
 Invasive Mole:
Introduction: Invasive mole means the hydatidiform mole invade the uterine
myometrium or metastasize to extrauterine tissue.

Clinical features:
- Irregular vaginal bleeding
- Uterine subinvolution
- Theca lutein cyst does not disappear after emptying uterus
- Abdominal pain
- Metastatic focus manifestation

 Choriocarcinoma:
Introduction: Choriocarcinoma is a highly malignant tumor. Most choriocarcinoma
occur in the uterus, the tumor has a diameter of 2-10cm.
It can metastasize to the whole body through blood circulation, damage tissues and
organs, cause bleeding and necrosis.
The most common metastatic site are the lungs, vagina, brain and liver.
50% of gestational choriocarcinoma result from hydatidiform mole.

Clinical features:
- Pain
- Vaginal bleeding
- Uterine enlargement
- Presence of abnormal mass

Diagnosis:
Clinical Features, Ultrasonography, Human Chorionic Gonadotrophin, CT, X-ray

Management: Chemotherapy, Surgery

 Ectopic Pregnancy
Ectopic pregnancy is a condition in which the fertilized ovum is implanted and develops
outside the normal endometrial cavity.
 Causes & Risk Factors:
Note: The use of contraception actually reduces the rate of pregnancy. However, if
there is failure of the contraception types below, the pregnancy is more likely to be
ectopic.

Medical History Contraception Iatrogenic

Previous ectopic Intrauterine device or Pelvic surgery – especially tubal

pregnancy intrauterine system surgery (reversal of sterilization)

Pelvic inflammatory Progesterone oral

disease (PID) contraceptive or implant Assisted reproduction
Ednometriosis Tubal ligation or occlusion

 Clinical Features:
The leading symptom of ectopic pregnancy is pain. Patients commonly present with
lower abdominal/pelvic pain, with or without vaginal bleeding. There also can be a
history of amenorrhoea.

Note: Vaginal bleeding in ectopic pregnancy is the result of decidual breakdown in

the uterine cavity due to suboptimal β-HCG levels. Bleeding from a ruptured
ectopic pregnancy is usually intra-abdominal, not vaginal.

Other symptoms include:

- Shoulder tip pain – the irritation of the diaphragm by blood in the peritoneal
cavity leads to referred shoulder tip pain.
- Vaginal discharge – brown in colour. This is the result of the decidua breaking
down.

On examination, the patient may have localised abdominal tenderness, with

vaginal examination revealing cervical excitation and/or adnexal tenderness.

If the ectopic pregnancy has ruptured, the patient may also be haemodynamically
unstable (pallor, increased capillary refill time, tachycardia, hypotension), with
signs of peritonitis (abdominal rebound tenderness and guarding).

 Management:
- Antishock measures are to be taken with simultaneous preparation for urgent
laparotomy.
- Ringer’s solution (crystalloid) is administered.
- Arrangements are made for blood transfusion.
 Intra-Uterine Growth Restriction (IUGR)
Intra-uterine growth restriction refers to a condition in which an unborn baby is smaller
than it should be because it is not growing at a normal rate inside the womb.

 Causes:
- Abnormalities or dysfunctions of the placenta
- Advanced diabetes
- High blood pressure or heart disease
- Infections such as rubella, cytomegalovirus, toxoplasmosis, and syphilis
- Kidney disease or lung disease
- Malnutrition or anemia
- Sickle cell anemia
- Smoking, alcohol, drug abuse
- Chromosomal defects in the baby
- Multiple pregnancy

 Symptoms:
- The main symptom of IUGR is a small for gestational age baby (SGA). Specifically,
the baby's estimated weight is below the 10th percentile or less than that of 90% of
babies of the same gestational age.
- Depending on the cause of IUGR, the baby may be small all over or look
malnourished. The baby may be thin and pale and have loose, dry skin. The
umbilical cord is often thin and dull instead of thick and shiny.

 Complications:
Delayed growth puts the baby at risk of certain health problems during pregnancy,
delivery, and after birth. They include:
- Low birth weight
- Difficulty handling the stresses of vaginal delivery
- Decreased oxygen levels
- Hypoglycemia
- Low resistance to infection
- Low Apgar scores (a test given immediately after birth to evaluate the newborn's
physical condition and determine need for special medical care)
- Meconium aspiration
- Trouble maintaining body temperature
- Abnormally high red blood cell count
- Long-term growth problems
- Stillbirth
  Diagnosis:
- Foetal monitoring, ultrasound to measure the baby's head and abdomen and
compare the measurements to growth charts to estimate the baby's weight.
Ultrasound can also be used to determine the quantity of amniotic fluid. A low
amount could suggest IUGR.
- Doppler flow. Doppler flow is a technique that uses sound waves to measure the
amount and speed of blood flow through the blood vessels.
- Weight checks. Routine examination and record of the mother's weight at every
prenatal checkup. If a mother is not gaining weight, it could indicate a growth
problem in her baby.
- Amniocentesis. In this procedure, a needle is placed through the skin of the
mother's abdomen and into her uterus to withdraw a small amount of amniotic
fluid for testing. Tests may detect infection or some chromosomal abnormalities
that could lead to IUGR.

 Prevention & Management:

Although IUGR can occur even when a mother is perfectly healthy, there are things
mothers can do to reduce the risk of IUGR and increase the odds of a healthy
pregnancy and baby.
- Keep all prenatal appointments to detect potential complications and to treat
them early.
- Be aware of the baby's movements. A baby who does not move often or who
stops moving may have a problem.
- Proper nourishment, plenty of rest and healthy lifestyle choices

 Intra-Uterine Foetal Demise (IUFD)

Intra-uterine foetal demise is the clinical term for stillbirth used to describe the death of
a baby in the uterus.
The term usually applied to losses at or after the 20th week of gestation. Pregnancies
that are lost earlier are considered miscarriages. Parents of a stillborn baby, will receive a
birth and death certificate while those of a miscarried foetus will not.

According to the World Health Organization, there were 2.6 million stillbirths globally in
2015, with more than 7178 deaths a day. Most occurred in developing countries.
98% occurred in low- and middle-income countries. About half of all stillbirths occurred
during the act of birth (intrapartum period), the greatest time of risk.

 Causes: About one in every four stillbirths will be unexplained.

The most common causes include:
- Congenital birth defects
- Genetic abnormalities
- Placental abruption and other placental disorders (such as vasa previa)
- Placental dysfunction leading to fetal growth restriction
- Umbilical cord complications
- Uterine rupture
 Risk Factors:
- Mother's Health: The general health and well-being are key in determining the
ability to carry a child to term. Hypertension, diabetes, lupus, kidney disease,
thyroid disorders, and thrombophilia are some of the conditions associated with
stillbirth. Smoking, alcohol, and obesity can also contribute.
- Race: Ethnicity and race also play a part, both in terms of genetic disposition and
the socioeconomic barriers that prevent mothers from accessing perinatal care.
- Age: Women older than 35 are more likely to have unexplained stillbirths than
younger women.
- Multiple Pregnancy: Carrying more than one baby increases the risk of stillbirth.
- Exposure to Violence: Domestic violence can affect women of all races and
economic standing. However, in poorer communities, high rates of unemployment,
drug use, and incarceration can combine to place a mother and unborn child at
even greater risk.
- History of Problems: A history of pregnancy problems, including foetal growth
restriction and preterm delivery, translates to a higher risk of stillbirth in a
subsequent pregnancy. Meanwhile, women who have had a previous stillbirth are
2-10 times more likely to experience another.

 Clinical Features:
- Cessation of foetal movements & heart sounds
- Loss of symptoms of pregnancy
- Failure of weight gain
- Failure of uterine enlargement
- Diminution of uterus due to absorption of liquor amnii

 Investigations:
- Ultrasound
- Radiology
a) Spalding’s sign (collapse of bones, especially skull)
b) Robert’s sign (gas in large vessels)
c) Ball sign (rolled up foetus due to loss of back muscle tone)

 Management:
1) Inducing labour with medication so it begins within a few days.
2) Waiting for labour to occur naturally within a few days or up to two weeks.
 Multiple Pregnancy / Multifoetal Pregnancy / Multiple Gestation
When more than one foetus simultaneously develops in the uterus, it is called multiple
pregnancy.
Simultaneous development of two foetuses (twins) is the most common; although rare,
development of three foetuses (triplets), four foetuses (quadruplets), five foetuses
(quintuplets) or six foetuses (sextuplets) may also occur.

 Varieties of Twins:
1) Dizygotic (DZ) twins - It is most common (80%) and results from the
fertilization of two ova.

2) Monozygotic (MZ) twins - (20%) results from the fertilization of a single ovum.

 Determination of Zygosity:

Zygosity Placenta Communicating Intervening Sex Genetic Follow-

vessels membranes features, DNA up
fingerprinting
Two (most 4
DZ often Absent (2 amnions, May Differ Not
fused) 2 chorions) differ identical

MZ One Present 2 (amnions) Always Same Usually

identical identical

 Prevalence of dizygotic twins is related to:

- Race: The frequency is highest amongst Negroes, lowest amongst Mongols
- Hereditary: There is a hereditary predisposition likely to be more transmitted
through the female (maternal side).
- Advancing age of the mother: Increased incidence of twinning is observed with
the advancing age of the mother, the maximum being between the age of 30 and
35 years. The incidence of twins is markedly reduced thereafter.
- Influence of parity: The incidence is increased with increasing parity, especially
from fifth gravida onward.
- Latrogenic: Drugs used for induction of ovulation may produce multiple foetuses
to the extent of 20-40%.
 Symptoms:
- Increased nausea and vomiting in early months.
- Cardiorespiratory embarrassment which is evident in the later months - such as
palpitation or shortness of breath.
- Tendency of pedal oedema, varicose veins and haemorrhoids is greater.
- Unusual rate of abdominal enlargement and excessive foetal movements may be
noticed by an experienced parous mother.

 General Examination:
1) Prevalence of anemia is more than in singleton pregnancy.
2) Unusual weight gain, not explained by pre-eclampsia or obesity, is an
important feature.
3) Evidence of pre-eclampsia (25%) is a common association.

 Abdominal Examination:
1) Inspection: The elongated shape of a normal pregnant uterus is changed to a
more “barrel shape” and the abdomen is unduly enlarged.
2) Palpation:
a) The height of the uterus is more than the period of amenorrhea. This
discrepancy may only become evident from mid-pregnancy onward.
b) The girth of the abdomen at the level of umbilicus is more than the
normal average at term (100 cm).
c) Foetal bulk seems disproportionately larger in relation to the size of the
foetal head.
d) Palpation of too many foetal parts.
e) Finding of two foetal heads or three foetal poles makes the clinical
diagnosis almost certain.
3) Auscultation: Simultaneous hearing of two distinct foetal heart sounds (FHS)
located at separate spots.

 Investigation: Sonography

 Complications:
1) Maternal
Anemia, Pre-eclampsia, Hydramnios, Antepartum, Malpresentation, Preterm
labor, Mechanical distress, such as palpitation, dyspnoea, varicosities and
haemorrhoids may be increased, PROM, Umbilical cord prolapse, Increased
operative interference, Postpartum haemorrhage, Subinvolution

2) Foetal
Abortion, Preterm birth, Foetal anomalies, IUFD, Increased chance of perinatal
mortality
 CHAPTER VI: garbhini vyapaD

Kashyapa mentions that all the disorders in Garbhini occur in the same manner as in a
child in Annadi Avastha. Even though, Nidana, Lakshana and Samprapti are the same, the
Chikitsa varies; the same routine treatment as in any other person or non-pregnant
woman is not applicable for Garbhini.

 Samanya Garbhini Vyapad Chikitsa

Garbhini should be treated carefully as it influences development of both, mother and
foetus. The gross and subtle details should be considered and very strong Tikshna Dravya
should not be used.

 According to Acharya Charaka:

- In pregnancy disorders, Mridu, Madhura, Sheeta-Veerya, pleasing and gentle
drugs should be chosen.
- Shodhana Karma like Vamana, Virechana, Nasya, Raktamokshana are
contraindicated. Likewise, Basti should not be used, but in case of emergency, it
can be used in mild form.
- From 8th month, in case of emergency, Vamanadi Karma can be done in mild form.
- Garbhini should avoid Katu Aushadha / Ahara, Maithuna, Vyayama, etc.

 According to Acharya Sushruta:

- Vamana is indicated only in case of emergency during pregnancy. It should be
done by Madhura, Amla Ahara mixed with Anulomana Dravya.
- Shamana Dravya should be Mridu and given along with Ahara.
- Ahara should be Mridu, Madhura and harmless to foetus.

 According to Acharya Vagbhata:

- Garbhini should take and follow sweet, cold, gentle, pleasing -medicines, diet and
regimen.
- Shodhana Karma (Vamanadi, including Raktamokshana) should be avoided
- Basti can be used from 8th month onwards.
- In case of emergency, Mridu Vamana may be done if it is necessary to save the
mother, even though it harm the foetus. Saving the Garbhini should be the first
priority in case of emergency.
- A pregnant woman should be treated like a pot filled with oil, gentle and careful.

 According to Acharya Harita:

The use of following is always beneficial in pregnancy:
Vatsaka, Pippali, Shunthi, Amalaki, Apakva Bilva with Dadhi.
Purgatives are strictly contraindicated in pregnancy.

 According to Rasa Ratna Sammucchaya:

Kvatha of Bala with or without Ghrita / Dugdha cures all diseases of Garbhini.
 Garbhini Hrillasa
- Hrillasa is nausea and is a common condition in Garbhini.
- Along with Mukhapraseka and Chardi, it can be termed as of emesis gravidarum /
morning sickness.
- Chikitsa: Bhunimba Kalka with Madhu

 Garbhini Chardi
- That which fills up the mouth by compression accompanied with pain is called Chardi.
- Doshas expelled through upwards direction is called Chardi.
- When vitiated Doshas are expelled along with food from Amashaya via mouth, filling it
up during the process of expulsion, it is called Chardi.

 Nidana:
- Madhukosha says that the Vayu vitiated by Garbha is pushed upwards causing
Dauhrida Chardi during Garbhavastha.
- Dalhana says that Chardi is due to unfulfilled desires in pregnancy. Chardi which is
due to Garbha, is called Dauhrida Chardi.
- Sushruta has mentioned pregnancy as one of the causes for Chardi.
- Dvistartha

 Bheda:
i) Vatavaigunya (Neurological / Psychological) -> Emesis gravidarum
ii) Dauhrida / Garbhanimitta (Nutritional deficiency) -> Hyperemesis gravidarum
iii) Doshaja Chardi (Maternal hormones / Idiopathic) -> Associated vomiting
a) Vataja
b) Pittaja
c) Kaphaja
d) Sannipataja
e) Krimija -> According to Kashyapa Samhita

 Samanya Chikitsa:
- Dhanvantari Gutika
- Shunti & Bilva Kvatha with Yava Churna cures Chardi and Atisara during
pregnancy.
- Dhanyaka Kalka with Tandulodaka and Sharkara.
- Bilva-majja with Lajja-ambu.
- Bhunimba Kalka & Sharkara in equal quantity.
  Vishesha Chikitsa:
a) Vataja
- Matulunga Svarasa, Laja, Kola-majja, Anjana, Dadimasara, Sharkara & Kshaudra.
- Amla-Dadima Svarasa with Mahisha Dugdha. Lavana should be avoided.

b) Pittaja
- Laja Churna, Sharkara, Kshaudra mixed with Chaturjataka Kalka.
- Laja Peya with Sharkara & Kshaudra.

c) Kaphaja
- Shita Kvatha with Amra patra, Jambu & Kshaudra.
- Mudga Yusha with Dadima, Lavana and Sneha Dravya relieves Shleshmaja Chardi
and increases appetite.

d) Sannipataja
- Combined treatment of the three Doshas is adopted.

e) Krimija
- Treatment should be according to the predominance of Dosha.
- Kvatha of Punarnava Mula & Bhadradaru with Madhu.

 Garbhini Aruchi
ि रोचयति आहारां इति अरोचकः ।
The inability to relish food is termed as Arochaka / Aruchi.

Chikitsa:
- Marjana (cleaning) of Danta & Jihva with Churna of Shringavera, Katuka and Keshara,
followed by Gandusha with Koshnodaka cures all types of Garbhini Aruchi.
- Deepana Dravya in pregnancy:
i) Churna of Pippali, Pippalimula, Musta, Nagara with Dugdha & Sharkara or Dugdha &
Madhu.
ii) Churna of Ajamoda, Nagara, Pippali, Jeeraka with Guda & Madhu.
 Garbhini Atisara
- Atisara is excessive flow of fluid through Guda.
- Atisara is frequent passing of excessive liquid stool.

 Nidana:
- Viruddha Ahara, Adhyashana, Ajeerna, Bhaya, Vega sandharana, Ati-santarpana
- Apakva Kanda, Mula, Phala
- Dusta Toya / Ambu, Kshuda, Shoka, Ruksha & Abhishyanda Ahara grief, etc.

 Bheda:
i) Jvarayukta-Atisara
ii) Ama-Atisara - Shleshmanvita, Pittanvita, Vatanvita, Sannipatettha
iii) Nirama-Atisara - Shleshmaja, Pittaja, Vataja, Raktaja

 Samanya Chikitsa:
- Amatisara -> Pachana Dravya
- Pakvatisara -> Stambhaka Dravya
- All types of Atisara -> Kalyanaka-Avaleha, Hriberadi Kvatha
- Shunti & Bilva Kvatha with Yava Churna cures Chardi and Atisara during
pregnancy.
- Churna of Manjistha, Madhuka, Lodhra mixed with Phanita and Sharkara is
administered to Garbhini in case of Jvarayukta-Atisara, Ama-Atisara and Rakta-
Atisara.

 Garbhini Vibandha
Chikitsa: Shita Triphala Kvatha with Haritaki, Nagara and Guda is effective in Vibandha
and Vidradhi.

-> Udavarta Chikitsa can also be done in Vibandha during pregnancy. The main difference
is that Udavarta is an emergency while Vibandha is not. Hence, the treatment should not
be done vigorously.

 Garbhini Arsha
Chikitsa: Kvatha of Punarnava and Ardraka taken with Dugdha in the night cures
Udavarta, Gulma, Arsha, Shotha, etc. during pregnancy.
 Garbhini Udavarta
- Vayu is the main cause for Udavarta.
- Movement of Vata in opposite direction due to Vatakopa is caused by Vegadharana.

Chikitsa:
A) According to Acharya Sushruta
Procedures which bring Vayu to the proper Marga / Gati should be done.

B) According to Acharya Vagbhata

- If Udavarta occurs in Garbhini, it should be immediately treated with Sneha Ahara and
Basti. If treatment is delayed, it kills both Garbha and Garbhini.
- In Vibandha caused due to Udavarta, Vatahara-Snigdha Ahara is given. Anuvasana Basti
with Madhuka taila can be given from 8th month onwards.
If Udavarta does not subside, Niruha Basti is given with the following Dravya:
Roots of Virana, Shali, Kusha, Kasha, Ikshuvalika, Vetasa, Parivyadha, Bhutika, Ananta,
Kashmari, Parushaka, Madhuka, Mridvika Kalka -> Kvatha is prepared with water and
milk. To this Kvatha, Kalka of Priyala, Bibhitaka-majja, Tila Kalka, Lavana is added.
It should be administered lukewarm as Niruha Basti.
Once Vibandha is relieved, Garbhini can take Snana, Sneha Ahara and Madhuka taila
Basti in the evening.

C) According to Acharya Charaka

During 8th month, if Udavarta does not subside by Anuvasana Basti, Niruha Basti should
be administered. Same ingredients as described by Acharya Vagbhata, except that
Acharya Charaka added Sastika.
- Basti should be administered in flexed posture during pregnancy.
- If Udavarta is neglected, it kills either both Garbhini and Garbha or expels only Garbha.

D) According to Rasa Ratna Sammucchaya

- Kvatha of Punarnava and Ardraka taken with Dugdha in the night cures Udavarta,
Gulma, Arsha, Shotha, etc. during pregnancy.
- Kvatha of Punarnava mula with Gudha & Ghrita cures Udavarta and Shotha during
pregnancy.
 Garbhini Shotha / Oedema in Pregnancy
- That which is raised, immobile and firm is called Shotha.
- Padashopha in Vyakta Garbha Lakshana is considered to be a physiological condition.
- The fluid present in subcutaneous tissue is called oedema.
- In pregnancy, physiological oedema (pedal) is very common around 24 weeks.
- It resolves on its own without any treatment soon after delivery. It is considered
harmless. Patient is advised to restrict salt, raise the foot end while sitting/lying down.
Avoid hanging lower limbs and travelling long hours in sitting position.
- It occurs mainly due to the reduced venous return caused by mechanical obstruction to
the inferior vena cava and common iliac veins by gravid uterus.
- Pedal oedema is rarely associated with pain, night cramps, feeling of heaviness or
discomfort.
- Oedema is considered as pathological if it does not subside in the morning and is
present all day; if there is proteinuria or oedema around the eyes (periorbital oedema).

Chikitsa:
A) Bahya
- Svedana with Ushnodaka is advisable, especially for Shopha developing as Garbha
Upadrava.
- Virechana is strictly contraindicated.
- Lepa of Chandana, Madhuka, Ushira, Nagapuspa, Tila, Ajashringi, Manjistha, Ravimula
and Punarnava.
- Punarnava & Vacha Kalka with Kanji applied on Shotha.

B) Abhyantara
- Kvatha of Punarnava mula mixed with Devadaru & Murva or Bhadradaru, administered
with Madhu.
- Kvatha of Prishniparni, Bala and Vasa.
- Kvatha of Anya and Ardraka mixed with Ghrita, Dugdha, Guda and Pippali Churna.

 Garbhini Parikartika
Parikartika is derived from root “Parikŗt” which denotes, to cut around.
It is a symptom rather than a disease. It is described as a cutting and tearing pain
everywhere, or as cutting type of pain specially localized in Guda.
There is vitiation of Vayu mainly. The involvement of Dushyas will be Tvak, Rakta and
Maṃsa.

Chikitsa:
- Madhura Rasa + Madhu
- Yastimadhu + Sharkara + Taila
- Yastimadhu + Phanita
Cold medicated decoction with any of the above 3 group of drugs individually or
collectively cures Garbhini Parikartika.
 Garbhini Vaivarnya / Chloasma
Chloasma, also called melasma or the “mask of pregnancy,” is a common condition in
pregnant women. In fact, it impacts the majority of pregnancies, affecting up to 50% to
70% of expectant mothers. Chloasma usually presents as dark, brownish patches of skin,
mostly on the forehead, nose, upper lip, and cheeks—hence the "mask" nickname.

These darkened areas, which can range from light tan to dark brown, are usually
symmetrical, showing up evenly on both sides of the face. Less commonly, these patches
can occur on other parts of the body that are exposed to the sun, like the neck or the
forearms.

While chloasma may be bothersome aesthetically, it's not painful and doesn't carry any
risks to the pregnancy. This hyperpigmentation will often fade away after the
postpartum period.

 Kikkisa / Garbhini Vaivarnya & Kandu

- Linear contractions of skin tissue during pregnancy is called Kikkisa.
- The linear striations on Ura, Stana, Udara are called Kikkisa.
- It is caused due to vitiation of Tridosha reaching Ura, Stana and Udara. There they
cause Vidaha, Vaivarnya and Kandu which ultimately leads to Kikkisa.
- Kikkisa is compared with striae gravidarum.

Chikitsa:
A) Bahya: - Kalka of Nimba, Kola, Surasa & Manjistha
- Lepana with Chandana & Ushira
- Udara prakshalana with Nimba & Manjistha Kvatha

B) Abhyantara: Navanita prepared with Madhura Gana Dravya.

 Garbhini Pandu
- The disease condition characterized by Pandutva (paleness) is called Pandu Roga.
- Acharya Kashyapa mentions that Rasavaha Nadis situated around the Nabhi are
compressed by the growing foetus. Rasa does not flow freely, resulting in pallor.
- According to modern, there is an increase in plasma volume (haemodilution) causing
physiological anemia during pregnancy.

 Nidana:
- Ati-Amla & Lavana rasa sevana
- Mrida Bhakshana
- Garbhavriddha (excessive demand due to foetal development)
- Krimikosthata (parasitic infestation in the organs)

 Chikitsa:
- Dhatu poshana, Rasayana, Snehana with Dadimadi Ghrita, Pathya Ghrita
- Anulomana with Haritaki Churna for 7 days; Dugdha after digestion of medicine
- Loha Bhasma for 7 days with Dugdha

 Pathya:
- Vamana, Virechana, Yava, Godhuma, Shali, Mudga, Adhaki, Masura, Yusha, Patola,
Kushmanda, Kadali, Jeevanti, Guduchi, Tandulodaka, Punarnava, Lashuna, Amra,
Abhaya, Bimbi, Gomutra, Amalaki, Takra, Ghrita, Taila, Sauviraka, Tushodaka,
Navanita, Chandana, Haridra, Nagakeshara, Yavakshara, Lohabhasma, Kumkuma

 Apathya:
- Raktamokshana, Dhumapana, Vega Sandharana, Svedana, Maithuna, Shimbi,
Shaka, Hingu, Masha, Tambula, Sarshapa, Sura, Mridabakshana, Divasvapna,
Tikshna Lavana Amla Dravya, Dusta Toya, Viruddha Guru Vidahi Ahara, Agni, Atapa,
Krodha

 Garbhini Kamala
When a Pandu Rogi indulges in Pitta vardhaka Ahara, it leads to Kamala. However, it can
also occur independently.
In Kamala, there is loss of desire for eating food.

Chikitsa:
- Kvatha of Prishniparni, Bala and Vasa.
- Kvatha of Bala, Vasa, Prithakparni, Guduchi cures Kamala, Kasa, Shvasa and Raktapitta.
- Guduchi Svarasa or Kvatha
- Daruharidra Svarasa or Churna
- Nimbapatra Svarasa with Madhu
- Haritaki Churna with Madhu
- Rohitakarista, Drakshadi Kvatha, Patoladi Kvatha, Nimbadi Churna, Haridradi Ghrita
 Makkalla
Makkalla is a condition which is dominated by pain. Due to the vitiation of Vayu, there is
accumulation of blood in Sutika or Garbhini leading to pain in cardiac region, head and
Garbha. It has poor prognosis and can cause Rakta Vidradhi.

 Behda: - 2
1) Garbha-Avstha (During pregnancy)
2) Sutika-Avastha (During puerperium)

 Nidana:
- Accumulation of Rakta in Garbhashaya due to Vataprakopa
- Unpurified or accumulated Rakta after delivery
- Improper use of Aushadha (specifically Panchakola) to purify Rakta after delivery

 Lakshana:
- Formation of Granthi in Udara, around Nabhi, Parshva, Basti
- Shula in and around Nabhi, Basti, Udara, Ura, Pakvashaya
- Atopa, Adhmana, Mutra sanga

 Chikitsa:
- Yavakshara with Ghrita or Ushnodaka
- Trikatu, Trijata, Guda with Dhanyambu
- Pippalyadi Gana Churna with Suramanda
- Varunadi Kvatha with Panchakola Churna
- Shuddha Hingu with Ghrita
 High-Risk Pregnancy
High-risk pregnancy is a pregnancy which is complicated by one or more factors so as to
adversely affect the health of mother, child or both.
The risk factors may be pre-existing or develop during the pregnancy, labour or
puerperium.
60% of all high risk cases end up in caesarean section.

 Initial Screening of Factors:

The ultimate obstetric results of high-risk pregnancies depend upon early screening
and management.

1) Maternal Age: The safest age for pregnancy is considered between 20-35
years. Pregnancy before 17 years and after 35 years is a significant risk factor.
< 17 years -> SGA baby, Preterm labour, Anemia, Pre-eclampsia, etc.
> 35 years -> Gestational hypertension & diabetes, Hyperemesis gravidarum,
Chromosomal anomalies, Placenta previa, etc.

2) Maternal Weight:
Underweight -> Low birth weight
Overweight -> Gestational hypertension & diabetes, pre-eclampsia

3) Reproductive History:
- History of two or more abortions, still birth, neonatal death
- History of preterm labour, pre-eclampsia, anemia, Rh-isoimmunization

4) Family History: Positive family history of diabetes, hypertension, multiple

pregnancy, congenital malformations, etc.

5) Socio-Economic Status: Women from the lower income group have higher
incidence rate of anemia, IUGR, preterm labour, etc.

 During the Course of Prengancy:

After initial screening of factors, the cases are to be reassessed at every antenatal
visit. The risk factors which are likely to develop during the course of pregnancy are
pre-eclampsia, anemia, Rh-isoimmunization, high fever, ante-partum hemorrhage,
pyelonephritis, lack of uterine growth, post-maturity, abnormal presentation,
multiple pregnancy, prolonged pregnancy, medical & surgical disorders, etc.

 During the Course of Labour:

Risk factors during labour include abnormal foetal position & presentation,
placenta previa, abruptiop placentae, Pre-term birth, Foetal distress, Prolonged
labour, Umbilical cord prolapse, Multiple pregnancy, Large foetal size or small
pelvic diameter, anemia, Retention of placenta, PROM, PPH, etc.
  Factors Indicating High-Risk for Neonates:
- Apgar score <7
- Birth weight less than 2.5 kg or more than 4 kg
- Hypoglycemia, Convulsions, Anemia, Jaundice, Respiratory distress, Foetal
infection, Hemorrhagic diathesis, Major congenital abnormalities, etc.

 General Management:
- Identification of high-risk cases
- Proper training of resident, midwives, nurses, referral system
- Improvement of literacy status, economy and health awareness
- Folic acid 4 mg/d starting from pre-pregnant state and continued throughout the
pregnancy.
- Laboratory investigations and imaging
- Avoid intake of medicines in early months of pregnancy
- Assessment of maternal and foetal wellbeing
- Refrain from sexual intercourse
- Caesarean section is commonly necessary in high-risk cases

 Emesis Gravidarum
Emesis Gravidarum / Morning sickness is nausea and vomiting that occurs during
pregnancy. Despite its name, morning sickness can strike at any time of the day or night.
Many pregnant women have morning sickness, especially during the first trimester, but
some women have morning sickness throughout the pregnancy.
Mild nausea and vomiting of pregnancy typically does not cause any complications.
Rarely, morning sickness is so severe that it progresses to a condition called hyperemesis
gravidarum (HG).

 Causes:
The exact cause of emesis gravidarum is not clear, but the hormonal changes of
pregnancy are thought to play a role.

 Risk factors:
- Nausea or vomiting is caused by motion sickness, migraines, certain smells or
tastes, or exposure to oestrogen (e.g. in birth control pills) before pregnancy.
- Morning sickness was present during a previous pregnancy.
- Multiple pregnancy

 Prevention & Management:

- Avoiding triggering factors such as strong odours, excessive fatigue, spicy & oily
foods and foods high in sugar.
- Management options include various home remedies, such as frequent meals,
fresh juice, etc. rich in carbohydrates and proteins; over-the-counter medications
to help relieve nausea.
 Hyperemesis Gravidarum (HG / HEG)
Hyperemesis gravidarum is an uncommon disorder in which extreme persistent nausea
and vomiting occur during pregnancy.

 Causes:
- The condition might be caused by rapidly rising serum levels of hormones such as
HCG (human chorionic gonadotropin) and estrogen.
- Extreme nausea and vomiting during pregnancy might indicate a multiple
pregnancy (the woman is carrying more than one baby) or hydatidiform mole
(abnormal tissue growth that is not a true pregnancy).

 Risk Factors:
- History of HG in previous pregnancy
- History of HG in the family
- Overweight
- First-time pregnancy
- Pregnancy with a girl
- Multiple pregnancy
- Presence of trophoblastic disease

 Symptoms & Complications:

- The symptoms of HG begin within the first six weeks of pregnancy.
- Nausea often does not go away.
- HG can be extremely debilitating and cause fatigue that lasts for weeks or months.
- Women may experience a complete loss of appetite. They may not be able to
work or perform their normal daily activities.
- HG can lead to dehydration and poor weight gain during pregnancy.
- Vomiting occurs more than three to four times per day.
- Losing more than 10 pounds or 5% of body weight.

 Management:
- Natural nausea prevention methods, such as vitamin B6 or ginger.
- Eating smaller, more frequent meals and dry foods, such as crackers. Drinking
plenty of fluids to stay hydrated.
- Severe cases of HG may require hospitalization. Pregnant women who are unable
to swallow fluids or food due to constant nausea or vomiting will need to get
nutrition and liquids intravenously.
- Medication is necessary when vomiting is a threat to the woman or child. The
most commonly used anti-nausea drugs are promethazine and meclizine.
- Taking medication while pregnant can cause potential health problems for the
baby, but in severe cases of HG, maternal dehydration is a more concerning
problem.
 Gestational Anemia
Anemia contributes to 40% of maternal mortality during pregnancy. It is the most
common hematological disorder occurring next to Rhesus isoimmunization.
Nearly 50-80% of pregnant women in India are anemic.

 Classification & Causes:

1) Physiological anemia
2) Pathological anemia
a) Nutritional deficiency anemia
b) Haemorrhagic anemia
c) Haemolytic anemia
d) Aplastic anemia
(Iron, Folic acid, Vit B12, Protein)
(Hook worm, bleeding piles, APH)
(Haemoglobinopathy, Malaria, TB)
(bone marrow dysfunction)

Physiological anemia is due to increased plasma volume compared to RBC & Hb

mass (haemodilution) and the increased demand during pregnancy. This type of
anemia is normocytic and normochromic.

 Risk Factors:
All pregnant women are at risk for becoming anemic since the requirement of iron
and folic acid is higher, but the risk is higher in case of:
- Multiple pregnancy
- 2 pregnancies close together
- A lot of vomiting due to morning sickness
- Early pregnancy (<17 years of age)
- Insufficient intake of foods that are rich in iron
- Presence of anemia before pregnancy

 Symptoms:
The most common symptoms of anemia during pregnancy are:
- Pale skin, lips and nails; Weakness; Malaise; Dizziness; Shortness of breath, Rapid
heart beat; Trouble concentrating
- Early symptoms of anemia are usually non-existent or non-specific. And many of
the symptoms may be experienced during pregnancy even if anemia is not present.
If anemia is severe, tachycardia or hypotension may occur.
 Complications:

Mother Child
Recurrent infections Still birth
Preterm labour Premature birth, IUGR
Pregnancy-induced hypertension (PIH), Neonatal anemia
Ccongestive cardiac failure (CCF)
Obstetric shock, Apruptio placentae Perinatal mortality

 Management:
1) Diet:
- Iron rich food: Green leafy vegetables, cauliflower, papaya, dates, spinach,
jaggery, fenugreek, coriander, cereal, beans, lentils, tofu, etc.
- Folate rich roof: Yeast, legumes, broccoli, asparagus, milk, cheese, etc.
- Foods that are high in vitamin C can help the body to absorb more iron:
citrus fruits and juices, strawberries, kiwis, etc.

2) Prophylactic oral therapy:

- Iron supplement (60 mg/d)
- Folic acid supplement (5 mg/d)
- Vitamin B12 supplement

3) Curative therapy:
- Intramuscular / Intravenous therapy
- Oral iron therapy
- Folic acid / Vitamin B12 therapy
- Blood transfusion
 Gestational Hypertension (GHTN) / Pregnancy-Induced Hypertension (PIH)
Gestational hypertension is high blood pressure in pregnancy. It occurs in about 3 of 50
pregnancies.

If hypertension develops in pregnancy for the first time after 20 weeks and is not
accompanied by proteinuria, the blood pressure returns to normal within 12 weeks post-
partum.

GHTN is diagnoses by the following, observed at least at two occasions:

- Systolic BP ≥ 140 mmHg
- Diastolic BP ≥ 90 mmHg

 Risk factors:
- Presence of HTN before pregnancy -> Pathological chronic HTN
- History of HTN in previous pregnancy
- Kidney diseases
- Diabetes
- Maternal age is younger than 20 or higher than 40 years
- Multiple pregnancy

 Symptoms:
- Continuous headaches
- Oedema
- Sudden weight gain
- Vision changes, such as blurred or double vision
- Nausea or vomiting
- Pain in the upper right side of the belly, or pain around the stomach
- Oligouria

 Complications:
- High morbidity and mortality rate for mother and foetus
- Placental insufficiency
- Abruptio placentae
- Renal changes
- Maternal convulsions
- Pre-eclampsia & eclampsia
 Gestational Diabetes Mellitus (GDM)
WHO and National Diabetes DATA Group (NDDA) have classified diabetes as follows:
1) Pre-existing diabetes a) Type I
b) Type II
2) Gestational diabetes: It is defined as glucose intolerance with onset during pregnancy.

During pregnancy, the body becomes less sensitive to the effects of insulin, which can
lead to a condition known as gestational diabetes. It leads to hyperglycemia and creates
a number of health risks.

 Complications:
Maternal effects
During pregnancy:
- Spontaneous abortion due to congenital
malformation.
- UTI, vaginal candidiasis
- Hydramnios, large placenta
- Pre-eclampsia, Chorio-amnionitis
Foetal effects
Congenital malformation:
- Anencephaly, Spina bifida, Meningomyelocele,
Vertebral dyslplasia, Sacral agenesis, etc.
IUFD: Unexplained stillbirths most likely due to
chronic intrauterine hypoxia, foetal
hypoglycaemia, secondary hyperinsulinaemia

During labour: Foetal macrosomia:

- Prolonged labour - Wt. >3500-4000 gm; increased adiposity with
- Shoulder dystocia increased subcutaneous fat, muscle mass, skin
- Operative deliveries, Caesarean section fold thickness, etc.
- Birth injuries

During puerperium: Newborn complications:

- Postpartum endometritis - Hypoglycaemia, Hypocalcaemia,
- Postpartum haemorrhage Hyperbilirubinaemia, Birth injuries, Dystocia,
- Sepsis Increased perinatal mortality
- Lactation failure

 Diet for GDM:

- 2000-4000 Kcal/day
- 50-60% carbohydrates
- 15-20% proteins
- < 10% saturated fats
- Restrict cholesterol, Avoid sugar, Routine haematinic, Calcium supplements

 Insulin Dose:
- Before breakfast 60-90 mg/dl
- Before meals 60-105 mg/dl
- 2 hours after meals ≤ 120 mg/dl
- 2-6 am > 60 mg/dl
 Toxemia in Pregnancy / Pre-Eclampsia
Hypertension with proteinuria/albuminuria (>0.3 g/L in 24 hrs urince collection or >1 g/L
in random sample) along with generalized oedema after 20 weeks of gestation is known
pre-eclampsia.

 Cause:
The exact cause of pre-eclampsia is unknown. It may be related to abnormal
development of the placenta i.e. inadequate trophoblastic invasion of spiral
arterioles of placental bed.

 Risk factors:
- Pre-eclampsia occurs most frequently in first pregnancies. It affects about 5% of
pregnancies. It occurs in the third trimester of pregnancy.
- Diabetes
- Multiple pregnancy
- History pf pre-eclampsia in previous pregnancy
- Family history of pre-eclampsia

 Symptoms:
- HTN, Albuminuria, Generalized oedema
- Persistent headaches, blurred vision, shortness of breath, nauea & vomiting

 Complications:
- Eclampsia
- Renal failure
- Liver disorders (HELLP – Haemolysis, elevated liver enzymes, low platelet count)
- Brain disoders (Oedema, lesions, hyperaemia, infarcts, thrombosis, haemorrhage)
- Retinopathy

 Treatment:
- Women diagnosed with pre-eclampsia before 37 weeks of pregnancy can often be
treated with medicines and careful monitoring of the condition and the unborn
baby.
- Medicines such as magnesium sulfate can also be given to treat or prevent
eclampsia.
- Calcium supplements have been found to reduce the risk of pre-eclampsia in
women who are at risk of pre-eclampsia, especially if their calcium intake is low.
- The only ‘cure’ for pre-eclampsia is for the baby to be born. Sometimes the baby
will need to be delivered before 37 weeks (premature birth). This is recommended
when the pre-eclampsia is a risk to the mother or baby.
 Eclampsia
Occurrence of convulsions in a patient with pre-eclampsia with no co-incidental
neurological disease is called eclampsia.

 Phases:
Typical eclamptic seizures can be described in 4 phases:
1) Initial prodromal phase: An aura followed by convulsive movements that
begin around the mouth.

2) Tonic phase: The entire body becomes rigid, face is contored and suffused,
arms flexed, fist clenched, respiration ceases. It lasts for 15-20 seconds.

3) Clonic phase: Jerky movements start from facial muscles but involve the entire
body, frothy sputum. The patient is prone to injury and may often be
cyanosed. It lasts for approximately 1 minute.

4) Recovery: Seizure slowly subsides, respiration resumes, patient passes into

unconsciousness of variable duration. The patient may wake up disoriented
and unaware of the events that have taken place.

 Complications:
- Hyperpyrexia
- Pulmonary oedema
- Hemiplegia
- Renal failure
- Coma
- Death
 Jaundice in Pregnancy
Jaundice is caused when the liver does not function properly. Liver disease during
pregnancy includes a spectrum of diseases, which may occur during pregnancy and the
postpartum period that result in abnormal liver function tests, hepatic and biliary system
dysfunction, or sometimes both. It is observed in 3 to 10% of all pregnancies.

Jaundice is a rather a symptom and not a disease per se. The yellow discolouration of
skin, sclera, nails, mucous membrane and urine is the characteristic feature of jaundice
and is caused due to increased bilirubin level in the body.

 Causes:
Pregnancy-Specific Causes:
- Hyperemesis Gravidarum
- Intrahepatic Cholestasis - a condition characterized by severe itching, as the
normal flow of bile is interrupted
- Pre-Eclampsia - a condition where the mother has very high blood pressure and
there is protein in the urine
- HELLP Syndrome - this is a liver disorder which is believed to be a severe form of
pre-eclampsia and may be life-threatening
- Acute fatty Liver

Causes Unrelated to Pregnancy:

- Acute Viral Hepatitis: HAV (Hepatitis A Virus) / HEV (Hepatitis E Virus)
- Chronic hepatitis HBV (Hepatitis B Virus) / HCV (Hepatitis C Virus)
- Drug-induced hepatitis: PCM (paracetamol) overdose
- Wilson’s disease
- Cirrhosis of Liver
- Hepatotoxic drugs

 Symptoms:
- Yellowish discolouration of skin, sclera, nails, mucous membrane and urine
- Pale coloured stools
- Itching, Weakness, Loss of appetite, Headache, Nausea and vomiting, Fever,
Swelling around the liver region, Swelling of the legs, ankle, and feet
 Complications:
- Maternal health risks include fulminant (severe impairment of liver function) or
severe hepatitis, hepatic encephalopathy, liver damage induced kidney problems
like hepatorenal syndrome, liver cirrhosis, abnormal bleedings, and a risk of liver
malignancy in a few cases.
- Delivery related complications include preterm deliveries, stillbirths, abruptio
placentae, postpartum haemorrhages, and risk of transmission of infections in the
newborn during delivery.
- Risks to the newborn include IUGR (intrauterine growth restriction), congenital
hepatitis and neurological complications including kernicterus (brain damage in a
newborn due to jaundice) and cerebral palsy in severe cases.

 Treatment:
Common line of treatment, irrespective of the cause of jaundice, include,
Dietary Measures: Diets low in proteins and avoiding food and drugs harmful for
the liver.
General Supportive Measures: Adequate rest, hydration, continuous monitoring of
vital parameters like BP and urine output, supplemental oxygen and blood
components as and when required with an intensive care facility.

Specific management of jaundice depends upon the underlying conditions:

- Antivirals, vaccinations and interferons in viral hepatitis
- Treatment of specific causes of haemolytic anemia
- Surgical banding for variceal haemorrhages
- Shunt surgeries in cirrhosis of the liver
- Liver transplantation in end-stage liver disease
 HIV & AIDS in Pregnancy
HIV stands for human immunodeficiency virus. It harms the immune system by
destroying CD4 cells. These are a type of white blood cells that fight infection. The loss of
these cells makes it hard for the body to fight off infections and certain HIV-related
cancers.
Without treatment, HIV can gradually destroy the immune system and advance to AIDS.
AIDS stands for acquired immunodeficiency syndrome. It is the final stage of infection
with HIV. Not everyone with HIV develops AIDS.
If the mother has HIV/AIDS, there is a risk of passing the disease to the baby.

Transmission can occur in three ways:

i) During pregnancy
ii) During childbirth, especially if it is vaginal childbirth
iii) During breastfeeding

One can greatly lower that risk by taking HIV/AIDS medicines. These medicines will also
help protect the maternal health. The baby will get HIV/AIDS medicines for 4-6 weeks
after birth – ART (Anti-Retroviral Therapy).

 Symptoms:
Most women are asymptomatic carriers but may develop signs and symptoms
sooner or later which are known as AIDS related complec (ARC):
- Generlized lymph node enlargement, fever, night sweats, weight loss, recurrent
infections
- ARC is followed by the final stage characterized by severe dysfunction of the
immune system -> AIDS

 Effects of HIV on pregnancy:

1) Antepartum
- Ascending infection from vagina
- Abortion
- IUGR
- Preterm labour

2) Intrapartum
- Take proper precautions for personal safety
- Avoid ARM
- Avoid vaginal tear
- Avoid instrumental delivery
- Restrict episiotomy

3) Postpartum
- Wash the newborn after birth
- Mouth suction is avoided
- ART should be started
 Antepartum Hemorrhage (APH)
Antepartum hemorrhage is a serious complication of pregnancy occurring within the
third trimester. In APH there is bleeding from the genital tract after viability (24-28
weeks) but before birth of the child. It is associated with significant maternal and foetal
morbidity and mortality.

 Classification:
1) Placental site bleeding
a) Placenta previa
b) Abruptio placentae

2) Extraplacental bleeding
a) Local causes: Vulvar vein varicosities, Cervical erosions, Cervical polyps,
Cervical carcinoma and trauma
b) Other causes: Excess show, Coagulopathies, Uterine rupture, Idiopathic
bleeding

3) Vasa previa or rupture of marginal sinuses

 Condition Onset Pain Additional Symptoms Risk factors
- Continuous, dark, vaginal
- Previous placental abruption
bleeding
- Hypertension
Usually mild to - Hypertonic contractions
- Sudden - Trauma
Abruptio moderate (rigid uterus)
- Occurs most often in - Smoking
placentae abdominal pain - Uterine tenderness
the third trimester - Cocaine use
- Premature labour
- Preterm premature rupture of
- Fetal distress
the membranes
- Previous placenta previa
- Previous cesarean delivery
- Sudden
Placenta - Multiple gestation
- Prior to rupture of Painless Bright red vaginal bleeding
previa - Advanced maternal age
membranes
- Smoking

- Velamentous cord insertion

- Sudden - Vaginal bleeding (foetal - Placenta previa
Vasa previa - After rupture of Painless blood) - In vitro fertilization
membranes - Foetal distress - Multiple gestation

- Sudden pause in
contractions
Uterine - Sudden Severe abdominal - Foetal distress - Previous cesarean delivery
rupture - During labor pain - Vaginal bleeding - Transmyometrial surgery
- Hemodynamic instability

- Advanced maternal age

- Obesity
- Vaginal bleeding - Smoking
Cramping
Stillbirth --- - Features of labour (e.g., - Multiple gestation
abdominal pain
uterine contractions) - Concurrent medical disorders
- Complicated pregnancy

Rupture of
the
membranes
- Vaginal bleeding
in --- --- ---
- Features of foetal hypoxia
velamentous
cord
insertion
A small amount of blood or
Associated regular blood-tinged mucus that is
Bloody show uterine contractions --- usually passed prior to ---
and cervical changes labour or in early labour.

Mild to moderate
Sudden, typically pelvic pain Bruised and tender cervix
Cervical
caused by sexual depending on without evidence of active ---
trauma
intercourse extent of damage bleeding
 Placenta previa
Placenta previa occurs when a baby's placenta partially or totally covers the mother's
cervix. Placenta previa can cause severe bleeding during pregnancy and delivery.

 Causes: The exact cause of placenta previa is unknown.

 Risk factors:
- Previous pregnancy
- Placenta previa occurred in a previous pregnancy
- Scars on the uterus, such as from previous surgery, including cesarean deliveries,
uterine fibroid removal, dilation and curettage
- Multiple pregnancy
- Age 35 or above
- Smoking, Cocaine

 Symptoms:
- Bright red vaginal bleeding without pain during the second half of pregnancy is
the main sign of placenta previa.
- Some women also have contractions.

 Complications:
- Bleeding. Severe, possibly life-threatening vaginal hemorrhage can occur during
labour, delivery or in the first few hours after delivery.
- Preterm birth. Severe bleeding may prompt an emergency C-section before the
baby is full term.

 Abruptio placentae / Placental abruption:

Placental abruption is where a part or all of the placenta separates from the wall of the
uterus prematurely. It is an important cause of antepartum haemorrhage - vaginal
bleeding from week 24 of gestation until delivery.

 Pathophysiology:
Abruption is thought to occur following a rupture of the maternal vessels within
the basal layer of the endometrium. Blood accumulates and splits the placental
attachment from the basal layer. The detached portion of the placenta is unable to
function, leading to rapid fetal compromise.

 Types:
1) Revealed – bleeding tracks down from the site of placental separation and drains
through the cervix. This results in vaginal bleeding.
2) Concealed – the bleeding remains within the uterus, and typically forms a clot
retroplacentally. This bleeding is not visible, but can be severe enough to cause
systemic shock.
 Risk Factors:
- Placental abruption in previous pregnancy (most predictive factor)
- Pre-eclampsia and other hypertensive disorders
- Abnormal lie of the baby e.g. transverse
- Polyhydramnios (excessive accumulation of amniotic fluid)
- Abdominal trauma
- Smoking or drug use e.g. cocaine
- Bleeding in the first trimester
- Multiple pregnancy

 Symptoms:
- Painful vaginal bleeding (bleeding may not be visible if it is concealed)
- On examination, the uterus may be woody (tense all of the time) and painful on
palpation.

 Differential Diagnosis:
Placental abruption is an important cause of antenatal haemorrhage; but it is not
the most common. Differential diagnoses to consider include:
- Placenta previa
- Marginal placental bleed – small, partial abruption of the placenta which is large
enough to cause revealed bleeding, but not large enough to cause maternal or
foetal compromise.
- Vasa previa – foetal blood vessels run near the internal cervical os. It is
characterised by a triad of
(i) Vaginal bleeding; (ii) Rupture of membranes; (iii) Foetal compromise
- Uterine rupture – a full-thickness disruption of the uterine muscle and overlying
serosa. This usually occurs in labour with a history of previous caesarean section or
previous uterine surgery such as myomectomy.

 Management:
The ongoing management of placental abruption is dependent on the health of the
foetus:
- Emergency delivery – indicated in the presence of maternal and/or fetal
compromise and is usually done by caesarean section unless spontaneous delivery
is imminent or operative vaginal birth is achievable.
Even if an in-utero foetal death has been diagnosed, a caesarean section may still
be indicated if there is maternal compromise.
- Induction of labour – for haemorrhage at term without maternal or foetal
compromise, induction of labour is usually recommended to avoid further bleeding.
- In any case, anti-D is administered within 72 hours of the onset of bleeding if the
woman is rhesus D negative.