In Unani System of Medicine Threatened abortion is called Isqat Ehtemali and Ajhaze manzar are the Arabic vernacular of Threatened abortion. It is defined as vaginal bleeding before 20 weeks gestational age in the setting of a positive urine and/or blood pregnancy test with a closed cervical os, without passage of products of conception and without evidence of a fetal or embryonic demise. In unani system of medicine Plants have been used extensively in unani system of medicine to maintain the health of female reproductive system. These have been used mostly in combination or monotherapy. Much of the scientific interest has been directed towards prevention of abortion. The herbs often used in the prevention of threatened abortion are Ashok chal, Mazu, Mayan etc. This review paper highlighted on unani concept of Threatened abortion, its prevention and management with unani medicine.

Keywords: Isqat Ehtemali, Ajhaze manzar, threatened abortion, prevention, unani drugs, management

Isqat Ehtemali and Ajhaze manzar are the Arabic vernacular of Threatened abortion. It is said to occur when a pregnant woman experience spotting from the vagina prior to 24 weeks of gestation without dilation of the cervix. It is one of the most common problems in Obstetrics, which has been reported in ancient classical literature of unani system of medicine.¹

Classically abortion is the termination of pregnancy before the foetus is sufficiently developed to survive in extra uterine environment. It is the most serious complication of pregnancy and can be associated with grave risks to the health and life of the mother. In ancient literature it is stated that the fetus is protected in the womb by Quwat Masika (Retentive power) of uterus and failure or temporary dysfunction of this power lead to abortion. It is believed that impairment of Quwat Masika is caused by dominance of humors having abnormal temperament.¹

Threatened abortion is the loss of a pregnancy without medical or mechanical means before completion of the 20th week of gestation. The fetus is not sufficiently developed to have been able to survive outside the mother’s womb. Threatened miscarriage is a very common in early pregnancy. Most threatened miscarriages occur in the first 12 weeks of pregnancy and become evident as vaginal bleeding, abdominal and low back pain that persist for days or weeks. So far, therapies have limited effectiveness in preventing early pregnancy loss due to threatened miscarriage. Unani herbal medicines are a part of Traditional Medicines and are made up of products from plants and some animal and mineral substances. They have become very popular and are commonly used as an alternative treatment for threatened abortion.

Classification:

 According to unani system of medicine Isqat hamal can be divided into two stages:^1,5

1. Isqat hamal prior to the entry of the Ruh (soul) into the fetus
2. 2. Isqat hamal after the Ruh enters into the fetus.

The Ruh enters the fetus at 120 days (4 months) from conception.

In conventional medicine abortion is classified into²

1. Spontaneous abortion
2. Induced abortion

Spontaneous abortion: It is again classified into Threatened, Inevitable, Incomplete, Complete, Missed, and Habitual and Septic abortion.

Induced abortion: Legal and Illegal abortion

Isqat ehtemali or Ajhaze manzar (Threatened Abortion) is a clinical entity where the abortion process has started but has not progressed to a stage from which recovery is impossible. The earliest sign is spotting. It is usually slight and bright red in colour and painless. On rare occasion, it may be brisk; there may be mild backache or dull pain in the lower abdomen.^2,5

Clinical feature of Threatened abortion includes period of amenorrhea, scanty, bright red bleeding or blood-stained discharge. No abdominal pain, at times lower abdominal period like discomfort. No history of expulsion of any fleshy lump.^2,5

Per abdomen gravid uterus is felt soft, enlarged corresponding to the period of amenorrhea. On vaginal examination cervical os is close and blood-stained discharge is present. Vaginal examination should be performed with great care and gentleness. Sedative to relieve pain and anxiety of the patient are indicated.^2,6

Diagnosis

Clinical feature with gentle bimanual palpation given the diagnosis. vaginal examination is of paramount importance to avoid wrong diagnosis. ^(5,6) Urinary hCG test becomes positive in clinically doubtful cases.⁶

Prognosis

Approximately 50% of threatened abortion aborts. Chances of fetal malformation do not increase. Thus, mother is assured. Risk of preterm labour, Antepartum hemorrhage, Antennal and intranatal fetal distress is increased.

Principle of treatment

Herbs for threatened abortion include uterine-relaxants with uterine regulators, relaxing herbs, and/or hormone-regulating herbs. Herbs are appropriate to prevent threatened abortion i.e prevent spotting.

Management

The treatment of abortion in Unani System of medicine is generalized, it is of paramount importance to properly examine and look for the causative factors of abortion before the treatment is started.

The first line of treatment lies in correction of temperament of body by administrating appropriate dugs.

Most of the drugs like Ashok chal, Mazu, Zarward, Lodh Patani etc, which are used in prevention of abortion are reported to be Muhafiz Janeen (Feto protective), Qabiz (Astringent), Muqqavi rehm (Uterine tonic), Muhallil (Resolvent), Mubarid (Refrigerant) and Habis dam (Styptic).⁴ Hence by virtue of their properties these drugs enhance the Quwat Masika and inhibit the Quwat Dafia of uterus. Moreover these drugs being resolvent lead to dispersion of deranged humors which in turn helps in correction of deranged temperament and restoration of Mizaj and Quwa (Temperament and Faculties). Similarly styptic action of the drugs helps in prevention of spotting (Figure 1).¹

Sl. no	Unani name	Botanical name	Figure
1.	Ashok chal	Saraca india
2	Satawar	Asparagus racemosus
3.	Mazu	Quercus infectoria
4.	Lodhpatani	Symplocos racemosa
5.	Sandal safed	Santalum album
6.	Neem	Melia azadirachta
7.	Guldhawa	Woodfordia floribunda
8.	Aslasoos	Glycyrrhiza glabra
9.	Babuna	Aticaria chamomile
10.	Afsanteen	Artimesia absanthium

Figure 1 Single drug useful in Threatened Abortion.

The nutritive action of the drugs provides the nutrients and nourishment to the foetus in utero by supplementing the essential nutrients. Astringents improve Quwat Masika of the uterus and thus prevent abortion.^1,5

A study on women's health-care revealed that medicinal plants (28 plant species) were regularly used for the treatment of dysmenorrhoea and amenorrhoea, followed by the relieving of morning sickness in pregnant women and for promoting foetal stabilization.^9,10

Drugs which can used in Isqat ehtemali^3,4

Plants have been used extensively in unani system of medicine to maintain the health of female reproductive system. These have been used mostly in combination or monotherapy. Much of the scientific interest has been directed towards prevention of abortion. The herbs often used in the prevention of threatened abortion are: Ashok chal, Mazu, Mayan etc.

Principles of treatment

It includes bed rest; it is very necessary that the patient be at rest in bed till the bleeding and pain have been completely absent for at least 1 week. Patient stays at home, but moves in the room, she does not do household work for 1 month and no sex throughout pregnancy. The bladder should be kept empty.⁸ Pregnant woman complaint mild vaginal bleeding and mild backache immediately the following line of treatment is to be followed:

Bed rest, restrict activities, avoid heavy work and Avoid intercourse during this period. Use Habisate Dam advia for this purpose.

Patient education: No drug can repair placental tear, but only bed rest is helpful.

No drug now internationally prescribed for Threatened abortion. Progesterone is not beneficial since serum progesterone level in viable early threatened abortion remain same as that of early normal pregnancy.

The following drugs are useful in prevention of Isqat Ehtemali^3,4,7,11

1. Ashok Chal (Saraka Indica): Temperament: Cold-Dry

Ashoka means without sorrow. It keeps the women healthy and beautiful. Ashok chal considered as uterine tonic (imparts healthy tone to uterus). It restores the functions of the uterus. If the bark is used along with mazu and zarward during pregnancy provide strong astringent effect to the uterus and cervix.

The bark has numerous polyphenolic compounds: Procyanidin B2, Leucopelargonidin, Leucopelargonidin 3-O-B-D glycoside, Leucocyanidin, - epicathechin, catechin, flavonoids and sterols.

2. Satawar ( Asparagus racemosus ) Temperament: Cold-Moist⁹

The roots are used in unani system to protect the woman against threatened abortion.⁹ Satawar is a climbing plant which grows in low jungle areas throughout India. This sweet and bitter herb is particular in balancing the humors.

Satawar is perhaps best known as a female rejuvenator. It is useful for infertility, decreased libido, threatened abortion, menopause and leucorrhoea and has the ability to balance pH in the cervical area.

3. Zarward: Temperament

 It has an important role in providing strength to the fibrous tissue of the external and internal os of the cervix by its strong Astringent effect and renders the vaginal vault and cervical canal narrow and helps in restoration and retention of the product of conception. 

4. Mazu (Quercus infectoria): Temperament: Cold-Dry

 It is powerful Astringent and has styptic property. It prevents dilatation of the cervix by its astringent effect. It contains flavonoids i.e. phytoestrogens. It gives hormonal support to the foetus and prevents premature expulsion and also strengthens the capillaries and its Styptic property prevents spotting.

5. Lodh Pathani (Symplocos racemosa Roxb): Temperament: Cold-Dry

Bark is used as specific remedy for uterine complaints, vaginal diseases. It has Astringent and Refrigerant property and provides strength to the uterus in case of weakness of uterus. It resolves stagnant fluids and reduces the frequency and intensity of contraction of uterus.

The bark contains colloturine, Harman (loturine) & loturidine. Stem bark contain proanthocyanidine, 3-monoglucofuranosides of 7-0 methyl & 4-0 methyl-leucopelargonidin. Betulinic olemolic, acetyloeanolic & ellagic acids.

The bark extract have been reported to reduce the frequency and intensity of the uterine contractions in vitro of both pregnant and non-pregnant uterus in animals.

The dose: Stem bark: 3-5 g powder

20-30 g for decoction

6. Sandal safed (Santalum Album): Temperament: Cold-Dry

It has Antispasmodic, Vasodilator, Sedative, Refrigerant (Cooling) and Analgesic properties. Because of its vasodilator action it increases placental perfusion and thus prevents abortion. Its Antispasmodic action on irritable uterus reduces the contractions of uterus. Sandal contains phytooestrogens. The bark contains a triterpeneurs 12-en-3 butyl palmitate.

Dose: 3-6 g powder

7. Gul Dhawa (Woodfordia floribunda or Woodfordia fruticose): Temperament: Cold-Dry

The dried flowers are regarded as astringent because it contains tannins prescribed in uterine disorder and are much used in combination with other astringent medicines; particularly in hemorrhages. The bark is uterine sedative.

Flowers contain polyphenolan-ellagic acid, polystachoside and myricetin 3-galactoside and 12-20% tannins.

Bark contain Ta C-glucoside, bergenin and 20-27 % tannins

Dose: 3-6 g powder.

8. Neem (Melia azadirachta): Temperament: Hot-Dry

It has Sedative, Vasodilator, Estrogenic, Astringent; Hemostat, Antispasmodic, Utero-sedative and Haemostatic properties.

9. Aslasoos ( Glycyrrhiza glabra): Temperament: Hot-Moist

It is Antispasmodic, Estrogenic, Hemostatic, Sedative and Vasodilator.

10. Kharkhsk (Tribulus terristris): Temperament: Hot-Dry

The plant contains saponin. It has Antispasmodic and Vasodilator properties

11. Afsanteen (Artimesia absanthium): Temperament: Hot-Dry

It contains absinthum. It has Antispasmodic and Analgesic action.

12. Pyaz (Alium cepa): Temperament: Hot-Dry

Antispasmodic, Vasodilator, Uterosedative, Uterotonic, Astringent and Estrogenic properties. Bulb contains flvanoids, phenolic acids and sterols.

13. Anjabar (Bistort) (Polygonum bistorata): Temperament: Cold-Dry

It is one of the most strongly astringent of all herbs and it is used to contract tissues. The root is powerfully astringent, demulcent, febrifuge and strong styptic. It is much used, both internally and externally, in the treatment of internal and external bleeding, uterine affection particularly irritable uteurs. The roots contain up to 21% tannin.

14. Babuna (Maticaria chamomile): Temperament: Hot-Dry

Babuna is mildly sedative, antispasmodic and analgesic. Chamomile extract contain chamazulene, responsible for anti-spasmodic action.

Compound formulations

1. To control the bleeding give the powder of Geru and Sange jarahat each 1 masha along with Murbae amla
2. To reduce the pain gives the decoction of Habul Aas, Beekh Anjabar and Tukhme Khurfa siya each 3 masha Arq Goazaban 12 tola along with 2 tola of Sharbat Khashkhas.
3. Dilute Alum in the water and soak the gauze then insert it into the vagina as suppository. It prevents the dilatation of cervical os.
4. Mazu, Mayen, Supari, Kamarkas, Baobadang, Kushta Marjan, Gule Dhawa, Tabasheer, Lodh pathni, Kushta Sadaf take all ingredients in equal quantity make it into powder. 6 masha along with Muraba Amla two times per day is effective in prevention of abortion.
5. To prevent bleeding during pregnancy boil Barg Babuna (Maticaria chamomile linn) 10 tola in 50 ml water. When the decoction remains half add Misry and give it to the patient. It is beneficial for bleeding during pregnancy

Habe muhafize janeen

Make pea size pill of the powder of Chaksu and preserve it and advice to take a pill for two times in the morning and bedtime from the date of conception.

For recurrent abortion take equal proportions of Aslasoos, Lodh pathani and Amla and make fine powder and preserve it. 5 gram powder along with milk or honey for two times per day for one month or at the time of symptoms of Threatened abortion. It prevents the progress of abortion.

Kushta foulad, Godae Kanwargandal each 3 tola, Kushta Summulfar one and half rati, Kushta Jast Safed 3 masha, Misry 3 tola make a fine powder of all ingredients and prepare a pills (Wt.1 rati) one tablet two times along with milk. It prevents recurrent abortion. The medicine should not be taken continuously, two days gap should be given in a week.^3,4

Sandal Safed, Sandal Surkh, Barge Neem, Barge Hina, Aslasoos, Majeet, Kachoor, Geru all ingredients in equal proportion and make powder. 1-2 rati daily along with water is effective in prevention of abortion.^3,4

Compound preparations like Majoon Nashara Aaj, Majoone Hafize Janeen and Dawae Hafiz Hamal are also beneficial to prevent abortion.

Isqate ehtemali (Threatened Abortion) is a common complication of pregnancy. The incidence of about 15%–20% and 20%–25% of the cases end up in spontaneous miscarriage. In unani medical practice, many herbal interventions both oral and parenteral have been used to prevent threatened abortion. But, most of them lack of sufficient evidence to support their efficacy due to the multiple etiology and pathogenesis of threatened abortion. Thus, alternative medicines are greatly needed especially when conventional medicine and other treatments are unable to provide a satisfactory therapeutic effect.

None.

None.

The authors declare that there are no conflicts of interest.

1. Ahmed SI. Al Umur-Al Tabiya. 1st Ed. AD-1401AH. 1980;185–188.
2. Dutta DC. Text book of Obstetrics. New central book agency (P) Ltd. 2001:172–173.
3. Ghani N. Khazanul Advia, Idare Kitaus Shifa. 1190, 1208.
4. Safiuddin: Unani Advia Mufrada, Quomi council urdu zaban, 2004;173:35.
5. Ibn sina, Al Qanoon, Urdu Trans. by Kantoori, Idare Kitabul Shifa, New Delhi, 2007;2:341.
6. Williams Obstetrics. Paras publication, Hyderabad, 9th Ed. 2018;120–126.
7. Trivedi PC. Ethanomedicinal plants of India, 1st Ed. 2007.
8. Mudaliar AL, Krinshna MK. Clinical obstetrics. 8th Ed. 1978;223–234.
9. De Wet H,Ngubane SC. Traditional herbal remedies used by women in a rural community in northern Maputaland (South Africa) for the treatment of gynaecology and obstetric complaints. South Africa J Botany. 2014;94:129–139.
10. Venkat K, Kartik GM. Herbal medicine for threatened miscarriage: an updated systematic review and meta-analysis systematic review. Ethnopharmacology, 2021;14:31–35.
11. Gaitondi BB, Jetmalani MH. Anti oxytocic effect of saponis isolated from Asparagus recemosus (Shatavari) on uterine muscle. Arch Int Pharmacodyn Ther. 1969;179(1):121–129.