Iron prophylaxis in Pregnancy - Modern and Ayurvedic View

[Find the meaning and references behind the names: Low, Ida, Pandu, Jyoti]

REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 235 Iron prophylaxis in Pregnancy - Modern and Ayurvedic View Madhuri Bhalgat¹, Jyoti Pawar² 1 HOD & Professor, Dept. of Stree Roga and Prasuti Tantra, S.V.N.H Ayurved Mahavidyalaya, Rahuri, Ahmednagar, Maharashtra, India. 2 Post Graduate Scholar, Dept. of Stree Roga and Prasuti Tantra, S.V.N.H Ayurved Mahavidyalaya, Rahuri, Ahmednagar, Maharashtra, India. I NTRODUCTION In a global perspective, the most frequent nutritional insufficiency is definitely iron deficiency, which is encountered with a high prevalence in women of fertile age as well as in pregnant and postpartum women [1] In many developing countries, iron deficiency anemia (IDA) in pregnancy is more the rule than the exception with a prevalence of approximately 52% [2] In the prosperous western societies, the frequency of IDA is lower due to better nutrition, approximately 25% in pregnant women not taking iron supplements and less than 5% in women taking prophylactic iron supplements of 40- 60 mg ferrous iron Address for correspondence: Dr. Jyoti Pawar Post Graduate Scholar, Dept. of Stree Roga and Prasuti Tantra, S.V.N.H Ayurved Mahavidyalaya, Rahuri, Ahmednagar, Maharashtra, India. E-mail: ayushiksha 0601@gmail.com Submission Date: 09/11/2023 Accepted Date: 18/12/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.1.36 per day [3,4] Regarding the prevention and the treatment of severe anaemia, the World Health Organization has reported that a more rapid erythropoietic response is observed and complete correction of iron deficiency with parenteral iron therapy compared to oral iron administration [5] Consumption of high levels of iron on empty stomach have been shown to cause gastrointestinal distress in women [6] Whereas, intravenous or intramuscular iron supplementation is said to be connected with anaphylactic shock and allergic reactions; it is also observed that venous thrombosis, cardiac arrest and death are predisposed by parenteral iron therapy [7,8] Hence, there is a need for the effective management of Gestational anaemia that affects the pregnant others in the delivering a normal healthy baby. India is brimming with a rich heritage of traditional system of medicine. Among various systems of medicines that are followed, Ayurveda is one such traditional Indian system of medicine that focusses on prevention and curing the diseases. Ayurveda encompasses a scientific tradition of management of diseases based on Aptopadesha and its traces of origin can be found in Rigveda and Atharvaveda . Ayurveda more than a medical science, is a life science that has surplus of knowledge on the maintenance of health, A B S T R A C T Iron is mandatory for normal fetal development, including the brain. Iron deficiency may have deleterious effects for intelligence and behavioral development. It is important to prevent iron deficiency in the fetus by preventing iron deficiency in the pregnant woman. Iron deficiency anemia during pregnancy is a risk factor for preterm delivery and low birth weight. Ayurveda has recorded some of the complications of pregnancy under the name Garbhopdravas . Garbhini Pandu is the commonest Upadrava among them. Garbhini Pandu is described as a symptom and not as a Vyadhi in Ayurveda classics. Key words: Garbhini Pandu, Gestational anaemia, Ayurveda.

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Madhuri Bhalgat et al. Iron prophylaxis in Pregnancy - Modern and Ayurvedic View ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 236 therapeutic drugs, treatment of various diseases and ethnic folklore practices [9] Ayurveda , an ancient science that is 5000 yrs old and practiced even today because of its authenticity has given more importance of women and thereby has a vast elucidation of women health, pregnancy, labour and their disorders with the management. In this study, an attempt has been made to evaluate the concept of Gestational Anemia which is called Garbhini Pandu in Ayurveda in detail. DISCUSSION Individual Iron Prophylaxis The serum ferritin concentration should be analyzed when pregnancy is planned or as early in pregnancy as possible, preferably within 10 weeks gestation. Each μg/L of ferritin indicates approximate mobilizable body iron reserves of 7- 7.5 mg. Multivitamin -multimineral tablets (preferably without iron) containing 0.4 mg folic acid should be recommended from the time pregnancy is planned. 1) Ferritin above 70 –80 μg/L (~20– 25% of pregnant Danish women): body iron reserves are larger than 500 mg and iron supplements are not indicated. If ferritin is above 100 –150 μg/L, consider to check for inflammation, kidney disease, liver disease, hereditary hemochromatosis, cancer. 2) Ferritin in the range of 30 –70 μg/L (~40% of women): iron reserves are 200 –500 mg. Advocated iron supplements are 30 –40 mg ferrous iron daily 3) Ferritin below 30 μg/L (~40% of women): iron reserves are small and depleted in those women having values below 15 μg/L: advocated iron supplements are 60 –80 mg ferrous iron daily Individual iron prophylaxis has since 2002 been advocated by the Danish National Food Institute and since 2005 by the Danish Council of Nutrition. Both institutions conclude that iron supplements should be restricted to women with a clear demand for extra iron. However, the Danish National Board of Health, having the final decisive authority, still needs to approve these recommendations. In Sweden, individual iron prophylaxis has been recommended by the Swedish Society for Obstetrics and Gynaecology since 2008. Aetiology and Pathogenesis ( Nidana and Samprapti ) In developing countries, the causes of anemia are multifold including deficiencies of iron, folate, and vitamins A and B 12 etc. micronutrient deficiencies, anaemia due to malaria and hookworm etc parasitic infections, anemia due to chronic infections like TB and HIV. Etiology may also vary based on the dietary practices, seasonal variations and geographical location too. During the pregnancy, the overall iron requirement is significantly higher in the woman’s life despite the losses incurred during menstruation. In pregnancy, there is greater production of red blood cells; increase in the iron needs to expand the plasma volume to compensate the iron loss at delivery and for the support and growth of fetal-placental unit. In a pregnant woman with average weight of 55 kg, the physiological iron demand roughly corresponds to 1000-1200 mg, about 500 mg associated with expansion in red cell mass, 350 mg associated with fetal and placental growth and around 250 mg associated with blood loss at delivery. In the process of gestation, requirement of iron varies in different trimesters with lower iron necessity in the first trimester (0.8 mg/day) and a much higher need in the third trimester (3.0- 7.5 mg/day). Iron deficiency anaemia if undiagnosed and untreated can affect both the maternal and fetal health to greater extent. Chronic iron deficiency being very dangerous leads to fatigue reduced working capacity and disturbs the quality of life. In addition, palpitations, headaches, dizziness, pallor, breathlessness and irritability are also seen. Evidences show a significant correlation between the premature birth and low birth weight, intrauterine growth restriction, low neonatal iron status, preeclampsia, and post-partum hemorrhage and the severity of anemia. In the current situation, women are playing a multitasking role and therefore unable to follow proper diet and lifestyle practices during pregnancy. These Apathyakara Aaharavihara , leads to vitiation of Rasa Dhatu and causes Uttarottaara Dhatunirmiti Hani or Vikrut Dhatu Utpatti and manifestation of Garbhini Pandu . For pregnant women, Ayurvedic way of life will be very good and plays a significant role in the birth of a healthy progeny. Woman is said as the center of

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Madhuri Bhalgat et al. Iron prophylaxis in Pregnancy - Modern and Ayurvedic View ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 237 Suprajanirmiti due to the dependency of fetus on the mother for nutrition. According to Acharya Haritha , Garbhini Pandu is one among the Ashtagarbhopadravas and the most common disease occurring in pregnancy which means the diseases caused by fetus in pregnant women. Ayurvedic science enlists the causes of such disease as consumption of excessive Amla (sour) Lavana (salty) and Katu (pungent) Rasa (taste) Aahara , indulging in Diwaswapa (day time sleep), Vishamashana (improper dietary habits), Vegavidharana , (suppression of urges) and afflicted with Manasika Bhava (psychological effects). This in turn leads to the vitiation of Rasavaha and Raktavaha Srotas and to Pandutva in Garbhini . Clinical Presentation ( Roopa ) During pregnancy, it is very crucial to screen for anemia as it is one of the commonest problems faced in the developing countries. Guidelines recommend that the anemia screening should be initiated in the first trimester, second at 24 – 28 weeks and third at 36 th week of gestation. While defining the physiologic anemia of pregnancy, in addition to the haemoglobin values given by World Health Organization and Centre of Disease Prevention for anemia in pregnant women, pallor with peripheral smear showing normal morphology of RBC is taken as criteria and any deviation from this is considered as pathologic. Biochemically iron deficiency anemia is characterized by hypochromia where the mean corpuscular hemoglobin is less than 27 pg and microcytosis where mean corp uscular volume is less than 80 fl. Established bio-markers of iron deficient anemia or the erythropoiesis includes the reticulocyte hemoglobin content, percentage hypochromic reticulocytes and percentage circulating microcytes that are measured using modern automated analyzers. Ayurveda does not speak about Garbhini Pandu separately. After reviewing the literature in detail, the theories and the Nidanapanchaka in correlation with Garbhini , Samprapti of Garbhini Pandu involves the dominance of Pitta Dosha and that increases the Dravabhava of Rasa Dhatu . This Rasadushti leads to Uttarottara Dhatunirmiti and finally the manifestation of Dhatushaithilya and Vaivarnya . Pandu is also described as disease related to Rasavaha and Raktavaha Srotasas . In Pandu Roga, Panduta is the main feature which means paleness or the pallor of skin which occurs as a result of qualitative and quantitative deficiency of Rasadhatu and Raktadhatus . It presents with pallor of tongue, lip, skin, sclera and nails. Fetal requirements increase as pregnancy progresses based on its developmental milestones and hence makes the Rasa Dhatu of the Garbhini works additionally to fulfill the demands of Garbha . Garbhini needs to consume healthy food and also the quantity should be increased, but due to unavailability, she lands up in Pandu . Management of Gestational Anemia ( Chikitsa of Garbhini Pandu ), evaluation of the cause and the severity of anemia is required for the successful management of anemia during pregnancy. Some of the factors such as the severity of anemia, additional risks, maternal comorbidity, and time remaining until delivery are essential for the right therapeutic approach. The current management of anemia includes the oral and parenteral routes through which iron is supplemented and parenteral iron therapy is given intravenous from the second trimester. In addition to the supplementation, diet and nutrition plays an important role and this should be properly communicated to all pregnant women for preventing anemia in pregnancy. According to CDC, a 30 mg per day iron supplement should be started at the first prenatal visit. Though recommendations varies based on the regions. British guidelines do not recommend any routine iron supplementation in pregnancy, whereas WHO advises 30-60 mg of elemental iron per day for all pregnant women. WHO also states that, when daily iron intake is not possible due to gastrointestinal side effects, weekly intermittent oral iron supplementation can be implemented. According to the association of Nutrition, the (RDA) of iron for a pregnant woman in third trimester is 30 mg/day. For all the pregnant women who are native to the areas of prevalence of hookworm/Trichuris, WHO recommends routine deworming using single dose Albendazole (400 mg) or mebendazole (500 mg). In Ayurvedic science, Garbhini Pandu or the gestational anemia is treated effectively.

[Find the meaning and references behind the names: Nielsen, Ann, Rosa, Danielson, Nil, Med, Bahadur]

Madhuri Bhalgat et al. Iron prophylaxis in Pregnancy - Modern and Ayurvedic View ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 238 CONCLUSION One prevalent health problem that affects many pregnant women in underdeveloped nations is gestational anaemia, which calls for quick treatment to preserve the lives of both the mother and the unborn child. An ancient Indian science called Ayurveda offers extensive descriptions of pregnancy, labour, and the management issues that arise, placing a greater emphasis on women and their health. Ayurvedic science's description of Garbhini Pandu is associated with gestational anaemia. The ancient experts have successfully treated Garbhini Pandu since ancient times, and they are still treating them today. The current investigation has concentrated on defining the notions of Garbhini , its treatment, and its relationship to gestational anaemia in contemporary medicine. REFERENCES 1 Milman N. Anemia-still a major health problem in many parts of the World! Ann Hematol. 2011;90(4):369-377. 2 World Health Organization. Worldwide prevalence of anaemia 1993-2005. WHO Global Database on Anaemia. Switzerland; 2008. Available from: http://whqlibdoc.who.int/publications/2008/97892415 96657_eng.pdf. 3 Milman N, Agger AO, Nielsen OJ. Iron supplementation during pregnancy. Effect on iron status markers, serum erythropoietin and human placental lactogen. A placebo controlled study in 207 Danish women. Dan Med Bull. 1991;38(6):471-476. 4 Milman N, Bergholt T, Eriksen L, et al. Iron prophylaxis during pregnancy - How much iron is needed? A randomized dose-response study of 20 –80 mg ferrous iron daily in pregnant women. Acta Obstet Gynecol Scand. 2005;84(3):238 – 247. 5 Komolafe JO, Kuti O, Ijadunola KT, Ogunniyi SO. A comparative study between intramuscular iron dextran and oral ferrous sulphate in the treatment of iron deficiency anaemia in pregnancy. J Obstet Gynaecol. 2003;23(6):628 – 631. 6 Pena-Rosas JP, Viteri FE. Effects of routine oral iron supplementation with or without folic acid for women during pregnancy. Cochrane Database Syst Rev. 2006;(3):CD 004736. 7 Reveiz L, Gyte GM, Cuervo LG. Treatments for iron deficiency anaemia in pregnancy. Cochrane Database Syst Rev. 2007;(2):CD 003094. 8 Danielson BG, Salmonson T, Derendorf H, Geisser P. Pharmacokinetics of iron (III)-hydroxide sucrose complex after a single intravenous dose in healthy volunteers. Arzneimittel-Forschung. 1996;46(6):615 – 621. 9 Mukherjee PK, Harwansh RK, Bahadur S, et al. Development of Ayurveda - Tradition to trend. School of Natural Product Studies, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, India; Research & Development Center, Healthcare Division, Emami Limited, Kolkata, India. ******************************* How to cite this article: Madhuri Bhalgat, Jyoti Pawar. Iron prophylaxis in Pregnancy - Modern and Ayurvedic View. J Ayurveda Integr Med Sci 2024;1:235-238. http://dx.doi.org/10.21760/jaims.9.1.36 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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