Ayurvedic management of Immune Thrombocytopenic Purpura (ITP) in Pregnancy

G Divyashree; Vidya Ballal

Ayurvedic management of Immune Thrombocytopenic Purpura (ITP) in Pregnancy

Divyashree G.^1*, Ballal V.²

DOI:

^1* G Divyashree, First Year Post Graduate Scholar, Department of Prasuthi Tantra and Stree Roga, Sri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.

² Vidya Ballal, Associate Professor, Department of Prasuthi Tantra and Stree Roga, Sri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a low platelet count and mucocutaneous bleeding. Its highest frequency is in young women of reproductive age and it also occurs in 0.83 of 10,000 pregnancies. Pregnancy does not increase the incidence of ITP nor does it exacerbate a pre-existing disease. Sometimes platelet autoantibodies facilitate increased platelet destruction by the reticuloendothelial system especially the spleen and also these autoantibodies (IgG) can cross the placenta and place the foetus at risk for thrombocytopenia and may cause bleeding problems such as intracranial haemorrhage. Although some pregnant women with ITP may experience several maternal and foetal complications, in most cases even with a very low platelet count, there is neither maternal nor foetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women or intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D and splenectomy during pregnancy have been reported. In Ayurveda, it can be correlated to Tiryak Rakthapitta, which is caused due to excessive consumption of Ushna, Tiktha and Amla Rasa. It is Tridoshaja Vyadhi and its manifestation will be subcutaneous bleeding. Since Apathya Ahara is also cause of any disease, Ayurveda highlights on diet and lifestyle changes along with Garbhini Paricharya to combat any such diseases seen in pregnancy. Further we can adopt Rasayana therapy and Samshamana Kriya, which are safe during pregnancy. Careful monitoring of the mother throughout pregnancy is critical to avoid risk to both the mother and neonate.

Keywords: ITP, Tiryakgata Rakthapitta, Autoantibodies, Samshamani Kriya

Corresponding Author	How to Cite this Article	To Browse
G Divyashree, First Year Post Graduate Scholar, Department of Prasuthi Tantra and Stree Roga, Sri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India. Email:	G Divyashree, Vidya Ballal, Ayurvedic management of Immune Thrombocytopenic Purpura (ITP) in Pregnancy. J Ayu Int Med Sci. 2023;8(2):79-82. Available From https://jaims.in/jaims/article/view/2212

Introduction

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a low platelet count and mucocutaneous bleeding. Its highest frequency is in young women of reproductive age and occurs in 0.83 of 10,000 pregnancies.^[1]In ITP, platelets are the target, they are marked as foreign by the immune system and eliminated in the spleen and sometimes the liver. It is certainly not unusual for women who have been in clinical remission for several years to have recurrent thrombocytopenia during pregnancy. Although there is no evidence that ITP is aggravated during pregnancy but this disorder can cause increased bleeding intrapartum or post-partum. Also, platelet associated IgG antibodies cross the placenta and may cause thrombocytopenia in the foetus and neonate. Maternal platelet count cannot predict neonatal platelet count. So neonatal platelet count can be predicted through foetal scalp blood sampling during labour or by percutaneous umbilical blood sampling (PUBS). Some pregnant women with ITP may experience several maternal and foetal complications, in most cases even with a very low platelet count; there is either maternal nor foetal morbidity or mortality. In Ayurveda, it can be correlated to Tiryak Rakthapitta^[2], which is caused due to excessive consumption of Ushna, Tiktha and Amlarasa. It is Tridoshaja Vyadhi and its manifestation will be subcutaneous bleeding.

Conceptual Analysis of ITP in Ayurveda

According to Acharya Charaka, the excessive consumption of Ushna, Tikshna, Katu, and Lavana Rasa Ahara the Pitta gets vitiates, this vitiated Pitta associates with Rakta and causes Raktapitta. Further, if vitiated Rakta flows out from all orifices including Romakupa (hair follicles) is called as Tiryakgata Rakthapitta. ITP can be defined as bleeding disorder caused by an abnormal response of the immune system which leads to a decrease in platelet count and leads to excessive bleeding, purpura, and petechia. Based on this definition of ITP, it can be correlate to Triyakgata Rakthapitta in Ayurveda.

Causes: The specific reason for ITP is not known, but the possible cause of ITP is the abnormal functioning of immune system, Infections like HIV, Hepatitis C or chicken pox may lead to severe damage of immune

system, Other immune disorders like Lupus or Rheumatoid arthritis, pregnancy can alter immunity and sometimes lead to ITP and Certain conditions like Leukaemia may produce antibodies against platelets.

Symptoms

Purpura (A bruise - blood under the skin)
Petechia (tiny red dots under the skin that are a result of very small bleeds)
Nose bleeding
Bleeding of gums
Blood strains in stool, urine and as well as vomit.
Radiological observation of internal bleeding inside the head.

Nidana for Raktapitta is excessive consumption of Ushna, Tikshna, Katu, and Lavana Rasa Ahara, due to which the Pitta gets vitiated, this vitiated Pitta associates with Rakta and causes Raktapitta. Further, if vitiated Rakta moves in abnormal direction, then it’s called as Tiryakgata Raktapitta.^[3]

Tiryakgata Raktapitta is the Tridoshaja Vyadhi, in this disease Vata Pitta and Kapha are vitiated resulting in the imbalance of the Agni in the Raktha Dhatu. This imbalance affects the immune system of the body attacking the platelets, destroying them and may be correlated to the Pitta Dosha imbalance with manifestations like subcutaneous bleeding.

Ayurvedic management of ITP in Garbhini

According to Ayurveda, a sedentary lifestyle and abnormal diet is the main cause of every disease. Hence, a focus on diet and lifestyle changes to relieve symptoms of ITP. Can be adopted Garbhini Paricharya along with Pitta Shamaka, Rasayana and Raktha Sodhaka drugs may be beneficial. There are also various herbs like Guduchi, Ashwagandha, Haridra, Punarnava etc. to regulate immune function and increase platelet count in the body.

Rasayana Therapy: Rasayana therapy helps to increase the immunity^[4] in the mother by increasing the Bala and Vyadhishamatva. Drugs like Amalaki, Ksheera, Mamasa Rasa, Ghrita, Navanitha, Madhu, Sharkara along with drugs mentioned in month wise regimen such as Shalaparni, Madhuyashti, Parushaka, Gokshura, Vidarigandhadi Varga, Jeevaniya Gana Dravya and Madhura Gana

Dravyas like Bala, Kharjura, Draksha, Shatavari, Jivanthi, Ashwagandha, etc. having the Madura Rasa, Sheeta Veerya, Madhura Vipaka, and Rasayana properties.^[5,6,7] As Rasayana drugs boosts the immunity and prevent infections in the mother, they are also passively transferred to foetus through placenta, preventing infections and building immunity in foetus, most of these are also mentioned in Garbhini Paricharya of our Acharyas.

Samshamani Kriya: In Charaka Samhita 4th chapter Raktapitta Chikithsa Adhyaya, Charaka Acharya, mentioned Samshamani Kriya^[8], which is also indicated in Garbhini. Samshamani Kriya comprises of administering medicines, herbs and formulations which have disease modifying effect and are safe during pregnancy.

The formulations like Atarushakadi Kwatha, Padhmakadi Kwatha, Bala Kwatha, Ushiradi Churna, Kiratatiktadi Churna, Ushiradi Peya, Priyangvadi Peya, Drakshadi Yoga, Vasa Ghrita, Sathavaryadi Ghrita, and Pancha Panchamula Ghrita are mentioned in Charaka Samhita Rakthapitta Chikithsa Adhyaya.

The other classical medicines advised in Rakthapitta are Pravala Panchamrita, Rakthapittantaka Lauha, Kamadhgha Rasa, Godanti Bhasma, Pravala Pishti, Usheerasava, Lodhrasava, and Pushyanuga Churna.

Single Drugs

Guduchi - It has Rasayana, Sangrahi, Balya, Agnidipana, and Tridoshashamaka And also, pharmacological action of immunomodulation, Anticoagulant, and antineoplastic activity so it reduces the immunologic destruction of platelets and increased megakaryocytes in the bone marrow.^[9]
Durva - Durva (extract) has action as Rasayana (rejuvenation), Sangrahi (astringent), Balya (increases the strength), Agnidipana (increases digestive fire) and Tridoshshamaka.^[10] Durva grass contains crude proteins, carbohydrates and mineral constituents, oxides of magnesium, phosphorous, calcium, sodium and potassium and vitamin c. It has property of haemostasis, refrigerance and healing so externally it is used in wounds, haemorrhages, burning sensation (like urticaria, erysipelas) and dyspigmentation of skin. Internally the plant is used in various diseases like bleeding in dysentery, piles, epistaxis, menorrhagia, diarrhoea and urinary tract infection.

Shatavari - It acts as Raktapitashamaka because it has Madhura, Tikta Rasa, Guru-Snighdha Guna.^[11] It is Rasayana, Balya and Also contains Oligospirostanoside referred to as Immunoside which has action of anti-inflammation.
Amalaki - Amalaki has Amla, Madhura, Kashaya Rasa; Guru, Ruksha, Sheeta Guna; Sheeta Veerya, Madhura Vipaka and it is Rasayana, Tridoshashamaka, especially Pittashamaka.^[12] It is indicated in Paittikavikara, Raktapitta, Raktavikara and as It contains vitamin C, carotene, nicotinic acid, riboflavine, Gallic acid, Tannic acid and glucose.

Pathya-Apathya

Pathya	Apathya
Green leafy vegetables and fruits like Dadima, Amalaki, Karjura etc.	Excessive consumptions of Lavana, Amla, and Katu Rasa Ahara Sevana
Madhura, Tiktha and Kashaya Rasa Ahara Sevana	Excessive consumptions of Ushna, Tikshna, Kshara and Vidahi Anna
Guru, Snigdha, and Sheeta Guna Ahara like Ksheera, Navaneeta and Takra etc.	Vyaayama (excessive physical exercise), Aatapa Sevana (excessive exposure to heat of sun), Shoka and Adhva (excessive walking)
Ksheera Yavagu Sarpishmatim (gruel prepared with milk and mixed with ghee) in 8th month of pregnancy	Viruddha Bhojana, Asatmya Bhojana, and Vidahi Bhojana
Pradeha, Parisheka and Sheetasnana.	Masha, Tila, Kulattha, Nishpava, Dadhi and Sura

Discussion

In Ayurveda ITP can be correlated with Tiryakgata Rakthapitta. It is Tridoshaja Vyadhi, these vitiated doshas imbalances Agni and Raktha Dhatu, leads to subcutaneous bleeding. Hence, the concept of Garbhini Paricharya along with Pitta Shamaka, Rasayana and Raktha Sodhaka drugs are good, single drugs like Guduchi, Ashwagandha, Vasa, Shatavari and Amalaka etc. regulate immune function and increase platelet count in the body. Also, Rasayana theraphy and Samshamani Kriya is also indicated in Garbhini, Samshamani Kriya comprises of administering medicines, herbs and formulations which have properties like Balya, Agnideepaniya, Sangrahi, Jeevaniya, Rasayana and disease modifying effect in the pregnancy.

Conclusion

Some pregnant women with ITP may experience several maternal and foetal complications like thrombocytopenia, and intracranial haemorrhage. Corticosteroids are the first line of therapy

in pregnant women or intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D and splenectomy during pregnancy have been reported.

However long-term use of steroids and surgical procedure mainly splenectomy has immediate and long-term side effect. Therefore, there is a need to understand this disease in contemporary science.

In Ayurveda, Apathya Ahara also a cause of any disease, highlights on diet and lifestyle changes along with Garbhini Paricharya to combat any such diseases seen in pregnancy can be implied. Further we can adopt Rasayana theraphy, Samshamani Kriya, and single drugs like Guduchi, Ashwagandha, Shatavari and Amalaki etc. are having immunomodulating, anti-inflammatory and anticoagulant action, and these drugs are safe to use in pregnancy. Careful monitoring of the mother throughout pregnancy is critical to avoid risk to both the mother and neonate.

Reference

1. Care A, Pavord S, Knight M, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG 2018; 125:604-12.

2. Agnivesha, Charaka samhita of Charaka and Drdhabala with Vaidyamanorama commentary edited by Acharya Vidyadhar Shukla, Ravi Dutt Tripathi, Chaukhamba Sanskrit Pratishthan, Delhi, Reprint 2011, Nidanasthana, 2nd chapter.

3. Agnivesha, Charaka samhita of Charaka and Drdhabala with Vaidyamanorama commentary edited by Acharya Vidyadhar Shukla, Ravi Dutt Tripathi, Chaukhamba Sanskrit Pratishthan, Delhi, Reprint 2011, Nidanasthana, 2nd chapter, shloka no.4-6, p484-485.

4. Gautam M, Saha S, Bani S, Kaul A, Mishra S, Patil D, et al. Immunomodulatory activity of asparagus racemosus on systemic Th1/Th2 immunity: implications for immune adjuvant potential, Journal of ethnopharmacology, 2009;121:241-247

5. Agnivesha, Caraka samhita, edited by Vaidya Yadavji Trikamji Acharya, Shareera sthana, Chapter 8, Verse 32, Chowkambha surabharathi prakashana, varanasi, reprint 2013, p. 346.

6. Sushruta, Sushruta samhita, edited by Vaidya Yadavji Trikamji Acharya, Shareera sthana Chapter 10, Verse 4, Chowkambha sanskrit samsthan, varanasi, reprint 2013, p. 387.

7. Vagbhata, Astanga samgraha, edited by Shivaprasad Sharma, Shareera sthana, chapter 3, verse 2-11, Chowkambha sanskrit series office, varanasi, 2006. p.285

8. Agnivesha, Charaka samhita of Charaka and Drdhabala with Vaidyamanorama commentary edited by Acharya Vidyadhar Shukla, Ravi Dutt Tripathi, Chaukhamba Sanskrit Pratishthan, Delhi, Reprint 2011, Chikisthsasthana, 4th chapter, shloka no.62-72.

9. Chaudhary N, Siddiqui MB, Azmat S, Khatoon S. “Tinospora cordifolia: Ethnobotany, phytopharmacology and phytochemistry aspects”. International Journal of Pharmaceutical Science and Research, 2013; 3(1): 11-14. [Internet], [cited on 24 Nov], 2018

10. Shri. Bhavamisra, Bhavaprakasa Nighantu edited by Late Dr. G. S. Pandey Chaukhambha Bharati Academy Varanasi, Reprint, 2015; 372

11. Chunekar Krishnashastri, Pandey G.S. Bhavaprakash Nighantu. 2nd ed. Haritakyadi Varga 19-20. Varanasi: Choukhambha Bharati Academy. 2010, P.392

12. Chunekar Krishnashastri, Pandey G.S. Bhavaprakash Nighantu. 2nd ed. Haritakyadi Varga 19-20. Varanasi: Choukhambha Bharati Academy. 2010, P.5

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-12-31	2023-01-02	2023-01-09	2023-01-16	2023-01-23
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	17%

Review Article

Immune Thrombocytopenic Purpura

Journal of Ayurveda and Integrated Medical Sciences