Post Partum Principles of Diagnosis and Treatment

I am currently working as a co-author on a book that will be published through People’s Medical Publishing House in Beijing.  The book is a gynecology text made up of case studies and discussions on a variety of topics.  I asked the publishers if I could use some of the material I am working on in my blog post here and they were happy to allow that.  I am posting a short bit of a chapter on postpartum dizziness and postpartum tetany here.  It starts with a case study and my commentary follows.

I think this chapter is useful not only for the specific treatment of postpartum dizziness and tetany but also because some basic diagnostic skills for postpartum women are described.  In addition, I think that the use of classic formulas here will be of interest to many of you! I hope this is useful for those of you who are working with women after pregnancy.

Case Study from a Chinese Obstetric and Gynecology clinic:

Postpartum Tetany

Postpartum tetany refers to rigid nape and back, convulsions of the limbs, and even clenched jaws and arched-back rigidity that occurs during the postpartum period. It is also known as “postpartum tetany wind”, “postpartum fright wind” and “postpartum wind”. It is one of the three major postpartum conditions.

Etiologies include the internal factor of blood loss damaging liquid and the external factor of contraction of external evil. The internal factor is more predominant. The pathomechanism involves blood loss leading to malnourishment of sinews and vessels, or evil toxin affecting the channels and collaterals.

Commonly seen patterns include yin blood depletion and contraction of evil toxin.

CASE STUDY

Ms. Wang, age 21.

Chief complaint: Convulsion with clenched jaw for four days.

The patient delivered a healthy boy with relatively profuse bleeding. One month after labor, she contracted wind outdoor at noon. Around nine p.m. she presented upward staring eyes, clenched jaw, rigid neck and nape, tremor of the upper left limb, slight shaking of other body parts, and clouding of consciousness. After pinching was applied to shuĭ gōu (DU 26), the patient regained consciousness, and her clenched jaw and tremors were relieved. The symptoms would reoccur every two to four hours. There were dizziness and heart palpitations before each onset, followed by upward staring eyes, clenched jaws, twitching of the upper left limb and tremor. All symptoms would cease after approximately two minutes.

Three days after the initial onset, patient was conscious with no rigidity of the neck or nape during the onset; however, convulsion recurred more frequently. Phenobarbital and Năo Lè Jìng (Naolejing Syrup) had been applied for three days with no observable effect. Patient was admitted with suspected epilepsy.

History: No history of epilepsy or convulsion

Physique examination: BT temperature. BP 132/110mm Hg

Physicochemical examination: Blood routine: Hb120g/L, WBC 5×10⁹／L, neutral 0.69, lymph 0.41, ESR10mm/h. No other abnormality.

Procedure:

1. Clarify the triggering factors, chief manifestations, and the tongue and pulse images.

2. Clarify the etiologies, nature of condition, and the affected organs.

3. Establish the diagnosis and presenting pattern for the condition.

4. Clarify the treatment methods and selected medicinals.

Pattern Differentiation:

During child labor, there is profuse blood loss that leads to liquid and blood depletion and malnourishment of the sinews and vessels, and liver wind stirring results. Child labor also damages qi. Sweating after delivery causes insecurity of exterior yang and disharmony of ying and wei. Although it has been a month since the child labor, the original qi has not been restored and the interstices are not secured, therefore the woman contracts wind evil outdoor, which then triggers the internal wind and results in tetany.

As stated in Essentials from the Golden Cabinet: Postpartum Disease (Jīn Guì Yào Lüè: Fù Rén Chăn Hòu Bìng), “After labor, there is blood deficiency, profuse sweating, and susceptibility to wind stroke that causes tetany.”

Diagnosis:

Postpartum tetany due to blood loss.

Treatment:

Principles: Nourish blood, engender fluids, emolliate the liver, extinguish wind

Formula:

Guā Lóu Guì Zhī Tāng (Trichosanthes and Cinnamon Twig Decoction) modified with Sì Wù Tāng (Four Substances Decoction)

Ingredients:

Tiān huā fĕn (Radix Trichosanthis) 20g
Guì zhī (Ramulus Cinnamomi) 6g
Bái sháo (Radix Paeoniae Alba) 30g
Zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle) 6g
Dāng guī (Radix Angelicae Sinensis) 15g
Shú dì huáng (Radix Rehmanniae Praeparata) 20g
Mù guā (Fructus Chaenomelis) 30g
Gé gēn (Radix Puerariae Lobatae) 20g
Jiāng cán (Bombyx Batryticatus) 10g
Gōu téng (Ramulus Uncariae cum Uncis) 20g
Chán tuì (Periostracum Cicadae) 15g
Tiān má (Rhizoma Gastrodiae) 10g (wrapped and decocted separately)

Zhĭ Jìng Săn (Tetany-Checking Powder), composed of equal proportions of quán xiē (Scorpio) and wú gōng (Scolopendra) was also applied at 6g, twice a day a half an hour after the above medicinals, taken with warm yellow liquor.

Formula Analysis:

This condition is caused by a combination of internal and external pathological factors. The branch and root should both be treated.

To treat the root, Sì Wù Tāng (Four Substances Decoction) with removed chuān xiōng (Rhizoma Chuanxiong) and added huā fĕn (Radix Trichosanthis) is applied to enrich yin, nourish blood, emolliate and moisten sinews and vessels.

To treat the branch, guì zhī (Ramulus Cinnamomi) and gé gēn (Radix Puerariae Lobatae) are applied to resolve muscle and regulate ying and wei. Gé gēn (Radix Puerariae Lobatae) enters the du vessel which is connected to the brain and specifically acts to treat rigidity of the neck and nape.

Tiān má (Rhizoma Gastrodiae) and gōu téng (Ramulus Uncariae cum Uncis) extinguish wind and check tetany, thus reinforce the channel-freeing wind-expelling action of the formula.

Sharon’s Commentary on Post Partum Dizziness and Post Partum Tetany

After a woman gives birth there is a strong tendency toward blood deficiency.  This is due to several factors including bleeding or hemorrhaging during or just after the birth, sweating and general exhaustion.  Because of the tendency to deficiency, a woman may continue to sweat easily after the birth.  She will also have a tendency toward exhaustion due to nursing and the interrupted sleep of having a newborn. This deficiency of blood and fluids can easily lead to post partum dizziness or tetany. Though there may be other pathological mechanisms at play that explain why a woman develops the internal wind symptoms of dizziness or tetany, by far, the most common cause of these pathologies is deficiency of the fluids: Ying, Blood and Yin.

Post partum dizziness is a mild expression of internal wind while post partum tetany is a more extreme expression of internal wind.  These symptoms can be seen as a continuum of seriousness.  In spite of the difference in severity, most often post partum dizziness and tetany come from the same root pathology: deficiency of Yin aspects with Yang aspects loosing rootedness.

To understand the patho-mechanism of these pathological manifestations, we must first understand the relationship between Yin and Yang.  First we must see that internal wind is a phenomenon of pathological Yang. When Yang is in a healthy physiological position, it is stored in the Yin aspects of the body.  Yin aspects of the body are made up of the Yin, blood and fluids.  Yang is physiological when it is integrated within the Yin aspects and is pathological when it looses its relationship with the Yin aspects.  Wind is Yang relative to these Yin aspects and is an expression of pathological Yang coming out of right relationship.  For this discussion it is helpful to think of the Yin aspects in three forms each of which relates to different areas of the body:

Whether we are referring to Ying/Wei, Blood/Qi or Yin/Yang, in order to be healthy, each of these pairs require the Yin aspect (Ying, Blood or Yin) to be abundant in order to house, root and store the Yang aspects (Wei, Qi or Yang).  This concept can be summarized in the basic Yin/Yang symbol we are all familiar with:

Wei is housed in Ying, Qi is housed in Blood and Yang is housed in Yin.  When the Yin aspects are weak, the Yang aspects of Wei, Qi and Yang become homeless and can float about as wind.

Though there are some key differences between the dizziness and tetany that accompanies pre-eclampsia and eclampsia, this basic patho-mechanism is at play in both scenarios.

If we are working with pregnant women in our practices, it is important to regularly check up on her during the post-partuent period.  It is also important to know what to look for in terms of diagnosing the condition of her Ying, Blood and Yin.  Post partum dizziness is relatively common for post partum women and not a serious illness unless it is left untreated.  However, post partum tetany is a much more serious problem.  The chapter here on post partum tetany points to the profound importance of the basic post partum care Chinese medicine can offer.  As this chapter makes clear, most post partum tetany is due to fluid and blood deficiency caused by blood loss, sweating and exhaustion occurring during or just after the birth.  If a woman is receiving good post partum care from an acupuncturist and Chinese herbalist, there is no reason a patient such as this would develop tetany.  For those Chinese medical practitioners who work with women during pregnancy, there needs to be a clear protocol for evaluating our patients just after birth in order to prevent tetany.  My teacher Dr. Qiu Xiao-mei instructs us to follow the wisdom of the ancients on the subject of the diagnosis of fluids in post partum women:

The Jin Gui Ru Ren Chan Hou Bing Mai Zheng Bing Zhi Diseases, Pulse, Symptoms and “Treatment of Post Partum Women’s Diseases of the Golden Cabinet, points out that a woman who has just given birth has three possible illnesses. The first is convulsions, the second is encroaching depression[1], and the third is difficult bowel movements.  This book illustrates this as follows:  “Having just given birth, Blood is vacuous and profuse sweat goes out. This creates an inclination to seizures and can cause convulsions. The loss of blood, further sweating and an abundance of cold leads to encroaching depression. Loss of Jin and Ye fluids leave the stomach parched and causes the bowels to be difficult“.

In view of the fact that a special characteristic of a post partum woman is physical exhaustion combined with excess stasis, our predecessors had three examinations for the diagnosis and treatment of post partum women. The first is to examine whether or not the lower abdomen is painful. This will tell you if there remains any lochia. The second is to see if the bowels are open or blocked. This will tell you whether the fluid is abundant or lacking. Finally, examine the breast milk to determine if it is flowing well and if the woman has a desire for food and drink. This will show you the strength or weakness of the Stomach Qi. In order to carry out a synthesized analysis, this information is combined and compared with the partuant woman’s body type, pulse, tongue and other symptoms. Only in this way is one able to carry out the correct differential diagnosis and treatment for postpartum diseases”.

Dr. Qiu is pointing out that we must pay attention to how our post partum patient’s milk is coming in as a guage for determining the condition of the stomach Qi.  The stomach Qi is of utmost importance in the production of milk as well as blood.  If the milk is scanty due to deficiency of the stomach qi, the Ying, blood and Yin may also be quite deficient.  Dr. Qiu is also encouraging us to pay attention to the bowel movements of our post partum patients.  Constipation due to dry bowels is often an indication of depleted fluids.  Constipation can also prevent new fluids from being generated.  We should ask our patients to keep a log for us regarding their bowel movements so we can make sure all is flowing as it should.  In addition, Dr. Qiu is encouraging us to palpate the lower abdomen, looking for the presence of pain.  Pain beyond the basic tenderness of a uterus that has just given birth may be an indication of static blood remaining in the womb.  We should remember the relationship between blood stasis and blood deficiency in that the presence of static blood can prevent the generation of new fresh blood.  Blood stasis can contribute to the tendency toward post partum dizziness and tetany.

Finally, Dr. Qiu encourages us to pay attention to other signs and symptoms such as tongue, pulse and body type.  I would add here to pay special attention to the woman’s body temperature, tendency to sweat and her relative thirst.  Does she tend to be particularly cold or warm?  Is her skin moist with easy sweating, indicating a disharmony of Ying and Wei?  Is her skin dry with little sweat, indicating a possible deficiency of fluids?  Is she very thirsty, indicating a deficiency of fluids in the stomach?  Does she have a dry mouth with no desire to drink, indicating possible water accumulation in her stomach with an inability to absorb fluids?

Hopefully with our ability to diagnose and treat women in the early days after they have given birth we can avoid post-partum dizziness and tetany.  In these cases of Ying, Blood and Yin deficiency, we will not need to use herbs to resolve wind because the Wei, Qi and/or Yang will not have become unrooted yet.  We can focus on nourishing formulas.  However, sometimes patients do not come to us until they have a more debilitating condition.  In these cases we must consider the protocols discussed in these chapters.

When a post-partum woman is diagnosed with dizziness or tetany due to depletion of Ying, Blood and/or Yin the treatment principle is not only to enrich and nourish these aspects but also to harmonize the Ying, Blood and/or Yin with the Wei, Qi and/or Yang.  To harmonize means to encourage the Yin and Yang aspect to move into right relationship.  The basic formulas to do this are as follows:

In the chapter on tetany, Dr. ? recommends the use of Gua Lou Gui Zhi Tang which is a formula from the Jin Gui Yao Lue.  This is modified with Si Wu Tang.  Gui Zhi Tang harmonizes Ying and Wei while Si Wu Tang harmonizes Blood and Qi.  This formula is also modified by adding pungent herbs to resolve internal wind and stop spasms.  Because the post-partum period is often characterized by deficiency, it is important to use caution when prescribing pungent dispersing herbs.  In the case above, these pungent herbs were combined with sweet nourishing and enriching herbs, which will moderate the dispersing effect.

When a woman has Yin deficiency with internal wind, we may want to use herbs for resolving internal wind that are pungent as above, however, we must be even more cautious and Yin deficiency is more severe than Blood or Ying deficiency.  In addition, the method for resolving wind when there is Yin deficiency needs to include settling and calming.   For Yin and Blood deficiency post-partum tetany, Dr. ? reccommends the use of San Jia Fu Mai Tang.  This is a Qing dynasty formula that is a modification of the Shang Han Lun formula, Zhi Gan Cao Tang.  Zhi Gan Cao Tang itself is a modification of Gui Zhi Tang.  The shells added are Mu Li, Gui Ban and Bie Jia.  All three of these shells not only help to settle and calm internal wind.  They are also salty and they all enrich the Yin.  When combined with Zhi Gan Cao Tang, they help the formula home to the Kidneys to enrich the Kidney Yin and root the floating Yang.

[1] This term “encroaching depression” refers to depressive binding of Qi and Blood that gets worse and worse. Especially post partum; there is a likelihood of remaining static Blood in the womb. The longer it remains the more chance even greater amounts of Blood will accumulate.