Effect of Pre-Conceptional Care in the Management of Repeated Pregnancy Loss With Torch Infection: A Case Report

Introduction – Pregnancy is a complex phenomenon which includes physiological, psychological and social changes. RPL is a distressing condition that affects millions of women worldwide. RPL is defined as the loss of two or more consecutive pregnancies before 20 weeks of gestation. RPL can be correlated with Putraghni Yonivyapada and Garbhastravi Vandhya explained in Ayurvedic classics. Aim-To evaluate the effect of Pre-conceptional Ayurvedic protocol in RPL with TORCH infection. Methodology – A female patient aged 32 years having previous history of two pregnancy loss visited in the OPD of PTSR department, ITRA Jamnagar on September 2022. She took allopathic medications for 1 year. Her investigation revealed positive TORCH Pannel test and follicular study showed oligo-ovulation. Pre-conceptional care plan includes Shodhana Chikitsa followed by Shamana Chikitsa. Result – After 4 months of pre-conceptional care she conceived without any complications. Now she is having healthy pregnancy of 7 Months 22 days. Discussion -


INTRODUCTION
Recurrent miscarriage or Recurrent Pregnancy Loss is defined as the loss of two or more consecutive pregnancies before 20 weeks of gestation. 1, 2 RPL can be caused by genetic, hormonal, anatomical or immunological factors.RPL is a distressing condition that affects millions of women worldwide.RPL is an important reproductive health issue, because it affects 2%-5% of couples. 3, 4 The incidence of RPL varies widely between reports because of the differences in the definitions and criteria used, as well as the populations' characteristics.Primary RPL refers to multiple losses in a woman with no previous viable infants, whereas secondary RPL refers to multiple losses in a woman who has already had a pregnancy beyond 20 weeks of gestation.Tertiary RPL refers to multiple pregnancy losses between normal pregnancies 5 , 6 The incidence of RPL is increasing and its management is quite varied and challenging.
Almost half of the causes remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. 7TORCH is groups of infections which is the main threats of serious congenital infection during pregnancy, which may ultimately cause fetal damage or other anomalies.In most cases, the infection can be severe enough to cause serious damage to a fetus than his/her mother.The gestational age of the fetus influenced the degree of severity. 8Ayurveda can bring promising results by Shodhana Karma or purificatory procedures ending with Uttara Basti.It is estimated that 10-15 % of clinically recognized pregnancies worldwide end in a miscarriage.The occurrence of spontaneous miscarriage in India has been reported to be around 10 %.However, the actual rates of miscarriage might be higher as many women have very early miscarriages without ever realizing that they are pregnant. 9pre-conceptional intervention can be divided into 3 ways i.e., Physical, Psychological and Spiritual.1. Physical interventions include Panchkarma, Aahar -Vihar, Yoga, Pranayam.2. Psychological -In Ayurveda,the achar rasayanwas clearly mentioned.The thoughts which occupy the mind of the couple before & during conception can produce fetus resembling the nature of thoughts.3. Spiritual Interventions-(Daivavyapashryaya Chikitsa) -Acharya Charak and Kashapadescribed "Putreshti yagna vidhi" for the progeny. 10The spiritual energy will have some psychological effect on woman & man.Acharya Charaka has mentioned Garbha Sanjaaya Sampada in Atulyagotriyashariram. 11As per Acharya Sushruta, without the congruence of the four factors it is not possible to achieve conception. 12itu -optimum time of conception i.e., time of ovulation, fertilization and window of implantation.Kshetra -Garbhashaya and its Anushanga Anga.Ambu -nourishing fluid through mother's Ahara Rasa.Beeja -Shukra and Shonita.Pre-conceptional care plays an important role to stabilizing the previous disease conditions, to prevent any reproductive disease and to ensure that women enter pregnancy with optimal state of health which would be safe for both fetus and her.

PRESENTING CONCERNS
A 32 years old married female patient visited to OPD of Streeroga Evum Prasuti Tantra, Department of ITRA, Jamnagar on September 2022.She had a previous history of two pregnancy loss in 2022.After 1 st pregnancy loss she started taking allopathic medications for 1 year.After first pregnancy loss her menses became irregular.So, ovulation induction started with medications during which her ovulation study showed delayed ovulation (24 th day).During this treatment she conceived again but missed abortion was diagnosed and induction was done with MTP pills.Her investigations revealed positive TORCH test (Rubella and CMV).So, for pre-conceptional care and healthy progeny outcome she approached OPD of PTSR department.

Procedure of Matra Basti Poorva Karma:
• The patients will be instructed to come after taking a light diet.• They will be subjected for local Abhyanga and Mrudu Swedana prior to the administration of Matra Basti.Pradhana Karma: • After Poorva Karma patient will be is advised to lie down in left lateral position.
• A small quantity of SahacharadiTaila will be applied on the patient's anal canal and rubber catheter.
• The catheter will be gently inserted into the anal canal and enema syringe containing 60ml Sahachara Taila will be administered with uniform pressure.Pashchat Karma: • Patient will be asked to take rest for at least 30 minutes in supine position.
• Yoni Prakshalana: With Triphala Kwatha (Q.S.) Pradhana Karma-• 5 ml Intrauterine Uttara Basti of Kashmarya Kutaja siddha Ghrutha (for 6 days) will be given as per Uttara Basti procedure in proper aseptic condition in O.T. Pashchat Karma-• Complete bed rest in head low position for at least 2 hours.Hot fomentation on lower abdomen will be done with hot water bag.• Light diet will be advised during the course of treatment.Acharya Charaka classified this under Vatika Yonivyapad whereas Acharya Sushruta considered it as Paithika Yonivyapad.Acharya Sushruta explained that in this condition, the fetuses are repeatedly destroyed due to bleeding besides there are other clinical features of vitiated Pitta like burning sensation and heat. 14Acharya Charaka and Acharya Sushrutha have mentioned Putraghni Yonivyapad while Acharya Vaghbhata has mentioned Jathaghni Yonivyapad.

SHAMANA AUSHADHI
Recurrent Pregnancy Losses especially in unexplained cases, Ayurveda can bring promising results by Shodhana Karma or purificatory procedures ending with Uttara Basti.Shodhana therapy is helpful in improving the quality of Beeja in males and females (sperm and ovum) thus begetting a healthy child.As per the causes of RPL, the primary cause being chromosomal abnormalities which is becoming an important factor now a day.So pre-conceptional care plays more significant role in Beeja Dushti as per Ayurveda.For every couple pregnancy is one of the most beautiful precious events created by nature and it should always be planned not by accident or chance.The concept of Preconception is described in Ayurveda as Garbhdhanavidhi.It explains about the right mode of conception and importance of diet, lifestyle and Shodhana.Pre-conceptional care plays important role to identify the risk factors, stabilizing the previous disease conditions, to prevent any reproductive disease and to ensure that women enter pregnancy with optimal state of health which would be safe for both fetus and her.
In RPL we can expect vitiated Doshas to accumulate in the body.To eliminate those, Shodhana Karma will be required.The main Dosha vitiation in RPL is Vata and Pitta with association of Raktadushti.Virechana is the best Shodhana Karma to normalise these Doshas.Yoniroga, Yoni Shukrashaya Roga are mentioned as Virechana Sadhya diseases as per both Susruta Samhita and Ashtanga Hrudaya. 15, 16 Virechana is the treatment modality for Adhobhaga Doshahara 17 and best Shodhana in eliminating Pitta Dosha. 18Palashadi Yoga Basti mentioned in Charaka Siddhisthana specially indicated in Yonidosha. 19Acharya Charaka while explaining the benefits of Anuvasana Basti, states that Anuvasana Basti will help women in getting a progeny. 20Acharya Vagbhata explained Sahacharadi Taila in Chikitsa Sthana ,Vatavyadhi Chikitsa.The Yoga is indicated for Yoniroga as well. 21Uttara Basti is the main line of treatment in Yonirogas.It acts on endometrium, increases receptivity of endometrium and facilitates ovulation and nidation of fertilized ovum.The Ghrutha is processed with drugs like Kashmari and Kutaja which are Vata Pitta Shamaka, Garbha Sthapaka, Raşayana, Brumhana, Raktasthambhaka and Sangrahi.Also, Acharya Charaka has mentioned that Uttara Basti with this Yoga in Raktayoni, Arajaska and Putraghni Yonivyapad. 22

CONCLUSION
The incidence of RPL is increasing and its management is quite varied and challenging.Most studies demonstrate a spontaneous miscarriage rate of 10-15%; of which 80% spontaneous abortion occur during the second and third month of pregnancy.Almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. 23Management of RPL has to be revised as it requires intervention from the pre-conceptional period itself.Ayurveda gives great importance for the pre-conception care & Garbhini Paricharya, to ensure a healthy and successful progeny i.e., Supraja 24 .

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Last menstrual period -01/09/2022 Menarche: -14 years Married life: -7 years Menstrual history: Duration -5 days, Interval -29-30 days Painless, without clots 3-4 pads/day, fully soaked Contraceptional history: -Nil Coital history: -2-3 times/week No dyspareunia No burning sensation GENERAL EXAMINATIONS Height -142 cm Weight -48 kg, Body mass index -25 kg/m2 Blood pressure -116/72 mm Hg.Appetite -Good Sleep -Sound Urine -Regular Bowel -Non-satisfactory SYSTEMIC EXAMINATIONSCentral Nervous System -Patient was conscious and well oriented Cardiovascular System -S1 & S2 normal, no abnormal sounds was heard Respiratory System -Bilateral clear, no added sounds was there Per Abdomen examination -Soft, no tenderness Per speculum & per vaginal examination - Pramana Height: 142 cm • Email: editor@ijfmr.comIJFMR23057352 Volume 5, Issue 5, September-October 2023 4 Patient is in regular follow-up since September 2022.After these pre-conceptional treatment protocol patient conceived and her LMP is 5 th January 2023.Recurrent pregnancy loss can be correlated with Putraghni Yonivyapad and Garbhasravi Vandhya explained in Ayurvedic classics.Putraghni is a Yoniroga characterised by Repeated Pregnancy Losses due to the excessive use of Rooksha Ahara and Vihara which leads to Vata Prakopa further causing Shonita Dusti and Artava Dusti which in turn results in repeated loss of pregnancy.
• Yoga and meditation after performing regular bowel habits.APATHYA • Use of sour, salty and spicy food.•Processedfood, Coffee /Tea /Cold drinks, Alcohol, Pan, Chocolate fast-food.•Unpasteurized dairy products like milk and cheese.