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Introduction

 It is a woman who procreates children and propagates the human species. Ayurveda emphasized on the importance of caring for the mother before, during and after pregnancy. The wisdom regarding the general management of pregnancy is found in both the Charaka Samhita and Sushruta Samhita under the subject of ‘Garbhini Vyakarana’1. There are separate chapter for general management, specific management, diseases in pregnancy and their treatment and many other practical pieces of advice. The guidelines concerning diet, activities, behavior and mental activity (ahar, vihar, achar and vichar, respectively) are also detailed. Vaidya should be cautioned and vigilant during the management of pregnancy. ‘If a cup filled with oil right up to the brim is to be carried without spilling even a single drop, every step has to be taken with care2. Ayurveda advises the same degree of care and attention in the management of pregnant woman. Protection and nourishment of both the growing fetus and the mother is the ultimate goal. Haemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushion. The most common symptom of haemorrhoids is rectal bleeding associated with bowel movement. Pregnancy and vaginal delivery predispose women to develop haemorrhoids. It has been estimated that 25% to 35% of pregnant women are affected by this condition3,4.  In certain populations, up to 85% of pregnancies are affected by haemorrhoids in the third trimester. 5

There are limitations of using drugs in pregnancy. In general drugs should not be used during pregnancy unless necessary because many can harm the foetus. Use of internal ushna tikshna kalpas are contraindicated which can be harmful for life of foetus and mother also along with growth and normal development of the fetus. Surgical and parasurgical procedures also have limitations. As per modern science, the best treatment is prevention. A healthy diet and lifestyle enabling bowel habits, is the most important factor in preventing haemorrhoids. This principle of prevention is already stated in ayurveda as “Swasthasya swasthya rakshanam” “Aturasya Vikara prashamanam Cha6”, the context explains the importance of maintenance and promotion of health in healthy, along with treating a sickness. Ayurveda places an enormous emphasis on the importance of caring for the mother before, during and after pregnancy. ‘Garbhini Paricharya7,8’ described in Prasooti tantra (Ayurvedic obstetrics) prescribed by all ayurved classics is comprehensive references about dietary, medicinal and behavioral regimen especially specified for pregnant women which aims at the healthy progeny and avoiding pregnancy induced complications and conditions like pregnancy induced constipation, haemorrhoids etc. Taking this into consideration the role of Garbhini Paricharya in prevention and management of haemorrhoids in pregnancy as per Ayurvedic and Modern view was studied in this literature.

AIMS AND OBJECTIVES:

1. To study the role of Garbhini Paricharya in prevention and management of Arsha in Garbhini w.s.r to Haemorrhoids.
2. To collect the references for management of Haemorrhoids in pregnancy from different Ayurvedic classic and Modern literature.

METHODOLOGY:

              This study is conceptual; all available references of Arsha in Garbhini, Garbhini paricharya have been collected from Ayurveda treaties whereas references of Haemorrhoids in pregnancy and its management from modern literature. Websites, Research papers and research articles also have been searched for the same. The information collected from literature was correlated with the consequences occur while dealing with the women facing complaints of haemorrhoids during and after pregnancy.

LITERATURE REVIEW:

Haemorrhoids in pregnancy-

             Haemorrhoids are swollen varicose veins located around anus. Pregnancy and vaginal delivery predispose women to develop haemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in haemorrhoidal development. The abnormal dilatation and distortion of the vascular channel, together with disparaging changes in the supporting connective tissue within the anal cushion, is a paramount finding of haemorrhoidal disease.

Causes of Haemorrhoids during pregnancy:

• The growing uterus puts pressure on the pelvic veins and inferior vena cava, which can slow the return of blood from the lower half of the body and increase the pressure on the veins which causes them more dilated and swollen.
• Increased progesterone hormone during pregnancy causes vein wall to relax and swell more easily.
• Progesterone also contributes to constipation by slowing down intestinal tract mobility.
• Constipation and prolonged straining are widely believed to cause haemorrhoids because hard stool and increased intraabdominal pressure could cause obstruction of venous return, which results into engorgement of the haemorrhoidal plexus9.
• Due to reduction in the tone of anal canal cushions, which control bowel movements.

Symptoms:

Haemorrhoids are more likely to occur during the second and third trimester of pregnancy. Haemorrhoids can be internal, external or combination of both. Internal haemorrhoids may bleed a little, but are usually painless. If the vein becomes enlarged or swollen, it can protrude to become an external haemorrhoids with itching, burning, painful swelling at the anus, dyschezia (painful bowel movements) and bleeding.

Treatment:

Haemorrhoids should be treated to prevent more serious complications, including inflammations, thrombosis and prolapse. Because constipation worsens haemorrhoids treatment option center around preventing or managing constipation or reducing pain associated with haemorrhoids. Most form of the conditions can be successfully treated by

• Increasing fiber content in the diet
• Administering stool softeners (laxatives)
• Increasing liquid intake
• Anti-haemorrhoidal analgesics
• Training in toilet habits
• Sitz bath
• Topical medications with analgesics and anti-inflammatory effects provide short-term local relief from discomfort, pain and bleeding.
• Lifestyle changes

Arsha in Garbhini:

It is defined as “Arivat pranan shrinoti hinsati iti arshah” A disease which tortures patient’s vital force (prana) as enemy is called as Arsha.

Aetiology:

According to Aacharya Vaghbhata mandagni is the prime cause of all disease. Secondly the improper dietary and bowel habit interferes with digestive power leading to poor gastric to intestinal digestion and absorption of nutrients leading to constipation with straining habit during defaecation which further plays as risk factor for visibility of pile mass in case of external piles. In causative factors of Arsha, Acharya Vagbhata stated that Miscarriage, abnormal delivery and pressure exerted on Gudvali’s by growing uterus leads to formation of Arsha in Garbhini10.

Lakshana (Symptoms):

Common symptoms of arsha are formation of pile mass of different shapes, constipation, painful defaecation, burning sensation during defaecation, passage of blood mixed with stool, severe pruritus and mucous discharge etc.

Treatment:

As far as possible, medication should be avoided during pregnancy. Only symptomatic treatment with very mild herbs and a suitable diet should be offered. The physician is advised to take into account the severity of the disease, the resistance power of the mother and the stage of the pregnancy, and choose the middle path so that the disease or the treatment do not result in complications for the mother or the fetus. Several substances are absolutely contraindicated in pregnancy. The primary aim of ayurved is “Swasthasya Swasthya Rakshanam” “Aturasya Vikara Prashamanam cha6” the context explains the importance of maintenance and promotion of health in healthy, along with treating a sickness. Significance of prevention lies in intervening at the pre-pathogenic phase of the malady. Dincharya, Ritucharya, Samshodhana, Adhaaraniya Vegas, Rasayanas and Sattvavijaya chikitsa are the points mentioned which can be considered for the concept of primary prevention. Likewise, ‘Garbhini Paricharya’ is a special regimen prescribed by all ayurved classics aims at the healthy progeny and avoiding pregnancy induced complications.

Garbhini paricharya:

‘Garbhini Paricharya’ prescribed by all Ayurved classics is comprehensive references about dietary, medicinal and behavioral regimen especially specified for pregnant women which aims at the healthy progeny and avoiding pregnancy induced complications. It is an important aspect of antenatal care in Prasooti tantra (Ayurvedic obstetrics) as it facilitates easy delivery and healthy postpartum period. Garbhini paricharya is divided into three parts i.e 1. Masanumasika Pathya (Monthly Dietary Regimen), 2. Garbhopaghatakara bhava (Activities and substances which are harmful to foetus), 3. Garbhasthapaka dravyas (Substances beneficial for maintenance of pregnancy).

Masanumasika Pathya: The month wise dietetic regimen is given in details known as masanumasika paricharya11,12,13 (monthly regimen) for woman right from the first month up to the ninth month of pregnancy. The monthly regimen is necessary to make pelvis, waist, sides of the chest, back, healthy and flexible and downward movement of vata (vatanulomana) – this is needed for the normal delivery, Normalization of the urine and stool and their elimination with ease, promotion of strength and complexion, Delivery with ease of a healthy baby, endowed with excellent qualities in proper time.

Garbhopaghatakara bhava: it deals with the aspects which are going to cause upghata or himsa/harm/destruction to the growing garbha. Garbhini should avoid use of tikshna, rooksha, ushna dravyas. Should give up foul smelling articles and should not eat dried up, stale, putrified or wet food, vistambhi, vidahi foods these are harmful for the foetus. She should avoid heavy exercise, coitus, harsh or violent activities, ride over vehicles14, excess satiation, excess emaciation, sleeping in day and awakening in night, sitting in uneven places, suppression of natural urges15 and should avoid fasting, grief, anger, visiting lonely places, cremation ground, prolonged stay near fire or hot sun etc. all these psychological and physical strains like carrying heavy weight or vehicle riding may precipitate abortion due to sudden increase in intra-abdominal pressure.

Garbhasthapaka dravyas: They counter act the effect of the garbhaopaghatakara bhavas and help in the proper maintenance of the garbha. They can also be used in the treatment and prevention of abortion. These are to be used as a routine and are beneficial for the maintenance of proper health, growth and development of the mother and foetus.

Role of Garbhini paricharya in prevention and management of haemorrhoids:

1. Ksheera anna sevana is adviced by aacharyas during first trimester. Ksheer has mild laxative and pitta shamaka gunas which avoid flatulence and constipation helps in preventing haemorrhoids.
2. Aacharya Vagbhata advised to always use butter, ghrita and milk. It acts as a lubricant and will help improve bowel function, promotes digestion strength, eases constipation and makes the fecal matter smooth and unctuous. This helps in easy elimination and prevention of haemorrhoids.
3. During 1st trimester Aacharya Sushruta has advised sweet, cold and liquid diet. Liquid diet is easy for digestion, prevent nausea, vomiting and constipation.
4. Basti in 8th month: After 7 months because of effect of hormones, Kapha Vata prakopa and increasing weight of baby backache and constipation are very common problems. Hence, in 8th month our Acharyas mentioned Madhura aushadhi siddha Asthapan basti16 and anuvasana basti17,18, ksheera yavagu with sarpi orally for purana pureesha shuddhi and vatanulomana containing mainly Kapha and Vata shamak drugs. This basti causes anulomana of vayu and clear the retained faeces. Due to movement of vayu in its right direction, it delivers the baby without difficulty and remains free from complications. Vayu anulomana causing urine, faeces and placenta excretion easy by their respective passages which will be effective in both prevention and management of haemorrhoids.
5. Basti in 9th month: Increased progesterone hormone during pregnancy causes vein wall to relax and swell more easily. Due to reduction in the tone of anal canal cushions haemorrhoids are common during pregnancy. Anuvasana basti given in 9th month not only enhances women’s health and relaxes the pelvic bones for the preparation of labour but also strengthen Garbhini kukshi, sacral region helps in maintaining strength of anal cushion and prevention of haemorrhoids.
6. Guda Vedana: Acharya Kashyapa mentioned that Gudvedana19 (pain in anal region) and bleeding per anum is very common in pregnancy, occurs mainly because of Parikartika (fissure in ano) or piles due to uterus pressure and constipation. Anuvasana basti with Ghritamanda is advised as its vatashamaka properties relieves pain and constipation and pitta shamaka properties stop bleeding.
7. Basti in Udavarta in Garbhini: Udavarta means vata in opposite direction. Acharya Vagbhata mentioned that due to udavarta in pregnancy vibandha (constipation) will occur. Anuvasana basti is indicated for udavarta contents oil with madhuka and sweet group drugs. This basti is given in udavarta and constipation. It regulates function of vata mainly ‘Apana vayu’ and increase pachaka agni by which udavarta is treated. Along with this Vatahara and snigdha annapana should be given20.
8. Diet is an important factor during pregnancy. Ayurveda considers food to be the best source of nourishment as well as medication for the pregnant women. In Garbhopaghatkara bhava aacharya has mentioned not to take abhishyandi, vidahi, sankirna, ajeerna, shushka, paryushita, klinna, asatmya, etc anna dravya. If dietary schedule is not balanced througout pregnancy it can cause many hazards to mother and foetus too which leads to many complications. These types of food articles are also mentioned in the Aharaj Nidan of Arsha vyadhi. They are vyadhijanak nidan i.e they initiate the pathology of Arsha also. Hence, should be strictly avoided during pregnancy.
9. Garbhopaghatkara bhava also includes Ati Vyayama, Ati Vyavayam, Vegadharana, Vishama Kathina asanam, utkatukasana, Ati pravahana, Diwaswapnam, Ratri jagarana, yana sankshobha, krodh, visiting lonely places, etc. excessive indulgence in these activities cause physical and psychological strains may precipitate abortion due to sudden increase in intra-abdominal pressure. All these factors are also described as a Viharaj hetu of Arsha vyadhi. Prolonged squatting, riding vehicles and animals influence pressure on the pelvic veins and inferior vena cava, which can slow the return of blood from the lower half of the body and increase the pressure on the veins which causes them more dilated and swollen resulting in haemorrhoid formation, hence, are contraindicated in pregnancy.
10. There are limitations of using drugs in pregnancy. Drug treatment presents a special concern due to the threat of potential teratogenic effect of the drug. Certain medications can reach the fetus and cause harm. Various Surgical, Parasurgical procedures and more aggressive therapies are contraindicated. Only symptomatic treatment with very mild drug combinations is advised. This is already stated by our Acharyas as the diseases of the pregnant women should be treated with the use of mrudu, Madhura, shishira, sukumara aushadha, ahara and uapchara21. All shamana aushadhi should be soft and should be given with food or drinks. It should consist of an ingredient which are mruduveerya and Madhura, shouldn’t cause any harm to the growing foetus22.

Discussion

Ayurveda is an indigenous system of medicine, emphasizes the Garbhavkranti (process of decent of a variety of components in embryo) to Prasava (process of labour and delivery) and Sutika (post-partum) very well. In Ayurveda, Garbhini Paricharya is intended for systemic supervision and care of a woman during nine months of pregnancy, helps in maintaining proper health of mother and proper development of foetus. Derangement of Jatharagni leads to vitiation of tridosha, mainly Vata dosha. These vitiated Doshas get localized in Guda Vali and Pradhana Dhamani which further vitiated Twak, Mansa and Meda dhatus due to Annavaha shrotodushti leads to development of Arsha. It is described as ‘Ashtaumahagada’ i.e a group of eight cripple and fatal diseases having incurability primarily due to development of complications. Because constipation worsens haemorrhoids, treatment option center around preventing or managing constipation or reducing pain associated with haemorrhoids. Any disease occurring in a pregnant woman should be treated with drugs that are mild in action, compatible and safe to the foetus. Panchakarma (detoxifying procedures) should not be advocated, except Basti (enema) in the eight and nine months of pregnancy. As far as possible, medication should be avoided during pregnancy. Only symptomatic treatment with very mild herbs and a suitable diet should be offered. The physician is advised to take into account the severity of the disease, the resistance power of the mother and the stage of the pregnancy, and choose the middle path so that the disease or the treatments do not result in complications for the mother or the foetus. More aggressive therapies, such as sclerotherapy, cryotherapy or surgery, are reserved for patients who have persistent symptoms after conservative therapy. Some recent studies have shown the effectiveness of botulinum toxin injections as a treatment for chronic anal fissure and haemorrhoids. Because of its mechanism of action, however, botulinum toxin is contraindicated during pregnancy and lactation.  As per modern medicine haemorrhoids should be treated by increasing fibre content in the diet, administering stool softeners, increasing liquid intake, antihemorrhoidal analgesics, and training in toilet habits. It is expected that these conservative measures can alleviate symptoms in most patients. If required, patients should receive topical treatment. But at present, there are no reproductive safety data available for any of the compounds commonly used for haemorrhoids. Ayurveda has always emphasized on prevention rather than cure. Ayurveda pays more attention on avoiding the factor causing disease state. Garbhini Paricharya can be considered as the concept of primary prevention as if actual lifestyle and dietary schedule are not balanced throughout pregnancy; it can cause many hazards to mother and foetus too which leads difficulty in labour (prasava). The management of haemorrhoids given in modern science is already explained in Ayurveda in Garbhini Paricharya as intake of liquid diet during 1st trimester - eases digestion, ksheer anna sevana- act as a mild laxative, intake of butter, ghrita- promotes digestion, prevent constipation, use of anuvasana and asthapana basti during 8th and 9th month- causes anulomana of vayu, causes urine, faeces and placenta excretion easy by their respective passages which will be effective in both prevention and management of haemorrhoids.

Avoidance of Garbhopaghatkar bhava like ati pravahana, Vegadharana, Vishama Kathina asanam, utkatukasana etc- helps in prevention of complications of pregnancy. Avagaha swedana (procedure to sit in medicated warm water) explained by Acharya Charaka in Arsha Chikitsa adhyay- promotes healing and ease discomfort by encouraging blood flow to the rectal area. Relieves the congestion of pile mass and relaxes the anal sphincter muscle due to hot fomentation.

Conclusion

Pregnancy and vaginal delivery predispose women to develop haemorrhoids. It is very uncomfortable and distressing during such a delicate condition. There are limitations of using drugs in pregnancy. The severity of the disease, the resistance power of the mother and the stage of the pregnancy should be considered, and middle path should be chosen so that the disease or the treatments do not result in complications for the mother or the foetus. All the discussion about the dietary, behavioural and medicinal regimen prescribed in Garbhini Paricharya by Ayurved classics aims at the healthy progeny and avoiding pregnancy induced complications.

Dos and Don’ts for pregnant lady show the vigilant aspect of scholars and carefulness about the prevention of any adverse effect of food, drug, its interactions and incompatibility. The clinical trials should be done to document the benefits of Garbhini Paricharya mentioned by Acharyas in Ayurveda.