Principles And Treatments Of Chinese Medicine During Pregnancy – part two

By: Keren Zelicha

In part One of the article “Principles And Treatments Of Chinese Medicine During Pregnancy” I presented the involvement of organs and substances in accordance with physiology in Chinese medicine throughout the three trimester in pregnancy. Pregnancy is a condition in which there is the creation and accumulation of blood, body fluids and nutrients to support and develop the fetus. In order to enable the development and growth of the fetus and pregnancy, spleen-stomach, liver and triple warmer are under load and peak functionality.

In the second part of the article we will dwell on chapter 20 of the book Jin Gui Yao Lue by Zhang Zhong Jing. This chapter elaborates various pregnancy conditions such as: nausea, bleeding or abdominal pain, edema and un-peaceful fetus (intention of abortion danger). We will try to understand by analyzing formulas from this chapter, which organs are involved and what pathologies may appear during pregnancy. Severe conditions that are known to endanger the pregnancy are manifested by abdominal pain during pregnancy or situations defined in the literature as 胎动不安 “stirring and un peaceful fetus” ( Tai dong bu an) . Therefore, I will elaborate and focus on the formulas that address this condition as an example of a major imbalance that may occur and impair the existence of the pregnancy.

Zhang Zhong Jing’s major formulas and herbs during pregnancy:

Zhang zhong jing’s flagship formula for abdominal pain in pregnant women that years later was the basis for writing Xiao yao san is: Dang gui shao yao san

By analyzing the indications and herbs of this formula, we can understand what are the main strategies in Zhang zhong jing’s opinion that we should take when treating pregnant women. In the book Jin Gui Yao Lue (Essential Prescriptions from the Golden Cabinet) [1], in chapter twenty that describes diseases during pregnancy it is written:

妇人怀娠腹中㽲痛当归芍药散主之

20-5 “A pregnant woman, sever abdominal pain use Dang gui shao yao san“

Dang gui 9, Shao yao 48, Chuan xiong 24, Fu ling 12, Ze xie 24, Bai zhu 12

Modern indications: A pregnant woman with acute, persistent abdominal pain. There may also be swelling in the legs and difficulty in urination.

Treatment strategy: nourish the blood and regulate liver blood flow, support spleen qi, drain damp.

Analyzing the formula Dang gui shao yao san:

Looking at the dosage of the herbs in the formula you can see that the dominant plant used is Shao Yao. In Zhang Zhong Jing’s time it was not written whether the use is made with Bai Shao or Chi shao and the choice is ours. I usually use Bai Shao. As mentioned above, this case is a matter of an acute abdominal pain during pregnancy. Therefore, a large amount of Shao yao is used to emphasize the treatment on the contraction and abdominal pain. The herb is cool and generates fluids, it supports liver yin- blood and therefore will also supports spleen qi. The taste of Shao yao is sour it can relax the muscles and ease pain. The source of the abdominal pain is liver blood deficiency which leads to qi and blood stagnation. That’s why Shao yao was chosen as the dominant herb here.

Chinese herbs for pregnancy

Chuan xiong is the second most important herb in the formula, regulating the blood in the liver and channels. The herb enters the liver, the gallbladder and the pericardium, it is acrid and warm. The taste is a bit sweat therefore it contains fluids and act as an envoy to generate blood. Chuan xiong is unique: it works on the inner and outer layers of the body, disperses upwards and reaches the entire body. Its internal effect is through regulating the flow of qi and blood in the liver. This is its main use and can be adjusted by dose: to bring menstruation the herb should be used in a high dosage. But, if we want it to regulate blood flow, the dosage must be lower. Chuan xiong also affects the exterior – as a pungent plant, it relieves pain and releases external wind. Through its influence on the qi of the lungs it moves the blood. The functionality of harmonizing and moving qi and blood through the lungs was less emphasized after the Jin Yuan dynasty but in my opinion this strategy is very suitable during pregnancy in various situations.

Ze xie + Fu ling: This pair handles the dampness created by spleen qi deficiency. This damp can cause fluid build-up and edema.

Clinical Note: Pregnant women may complain of shoulder pain with radiation sensation towards the hands or even the appearance of carpal tunnel syndrome due to fluid accumulation and not necessarily a neurological problem. Damp is one of the common pathologies in pregnancy caused due to the effort of spleen qi activity that deals with transformation and transportation throughout the three trimesters.

Bai Shao + Bai Zhu: This combination emphasizes the balance between yin and yang. Bai shao is cool and sour, Bai zhu is sweet and bitter. Bai shao has a deep yin quality which enter the blood- yin level, allows the liver to store blood. Bai Zhu is warm and dry, it enters the qi level, strengthens yang and builds the center (spleen) to produce blood. This pair has a Yin quality herb and a Yang quality herb. This way we can achieve an influence on the blood and the qi aspects. Strengthening blood can support qi, supporting Yang will nourish Yin. Combination of warming without drying, moistening without stickiness. A perfect balance between Yin and Yang.

Dang gui in this formula is in low-dose compared to other ingredients. Dang gui enters the liver, heart, and spleen meridians. It is sweet and warm, supports the spleen to produce blood and supports the heart to move blood. In this formula, his role together with Bai shao is to support blood and relieve abdominal pain.

Note on using Dang gui during pregnancy:

In pregnancy it is important to focus on dang gui’s function on the blood and its effect on the lungs as well:

The Divine Farmer’s Materia Medica Classic “Shen non Ben Cao Jing” mentions Dang gui as a sweet and warm, nontoxic herb. Treating mainly cough and counter flow qi ascent. During pregnancy there is a great relationship between the quality and condition of the blood to the lungs and skin.

Ye Tian Shi in his book “Explanation of the classic of material medica” 本草经解 explains:

“When the blood is dry, the liver wood will cause heart fire to scorch the metal, causing cough and rebellious qi will appear. Dang gui enters the liver to nourish blood, enters the heart to clear fire, therefore it governs cough with dyspnea. When liver blood is sufficient wind is dwell”.

One of the common conditions we encounter in pregnant women is skin itching. Itching can occur due to stretching of the skin as the fetus grow or can manifest as a red rash or sores. One of the common pathology of itchy skin is blood deficiency leading to dryness and heat that scorch the metal. In these situations, it is advisable to refer the patient for medical consultation to rule out conditions such as preeclampsia or bile salts. At the same time, we can think of a suitable formula combining Angelica-Dang gui as an important plant to treat blood deficiency and dryness causing wind and itching of the skin. It should be noted that, from the point of view of western herbal medicine, dang gui may cause uterine contractions, so its dosage within the formula should be considered and combined with other herbs to balance the synergy.

From the analysis of Dang gui shao yao san that treats abdominal pain in pregnancy, it can be seen that the main condition the formula refers to is spleen qi deficiency and lack of blood generation, difficulty in transportation and transformation and damp accumulation. The liver stores blood and is responsible for releasing qi and blood flow. During pregnancy both liver and spleen must work together and balance each other in order to nourish the fetus. A state of qi or blood deficiency in one of these organs can lead to stagnation and therefore sharp pain.

Remember: from Dang gui shao yao san we understand that during pregnancy deficiency of qi & blood and stagnation of qi or fluids accumulation are very common!

Dang gui san the formula for a pregnant woman:

Another formula from the same chapter that I would like to expand on in order to understand the dynamics of organs and substances during pregnancy is Dang gui san. The source text does not mention a particular type of pathology or any indication for use rather than knowing that the woman is pregnant.

妇人妊娠，宜常服当归散主之。当归散
当归黄芩芍药芎穷各一斤白术半斤
右五味，杵为散，酒饮服方寸匕，日再服。妊娠常服即易产，胎无疾苦。产后百病悉主之。
20-9 “Pregnant woman use Dang gui san”.
Dang gui 30, huang qin 30, Shao yao 30, Chuan xiong 30, Bai zhu 24
The five herbs are grind into powder, drink one Cun with wine.
Frequent use during pregnancy will ensure easy birth and a healthy child. It can also be used for various postpartum diseases”.

Modern indications: un-peaceful fetus (intention of abortion danger)

Treatment Strategy: Nourish liver Blood, clear heat, Drain dampness, calm the fetus.

Preparation: The herbs are grind to powder and taken together with wine. The powder formula refines the moving blood effect of the herbs not harm the fetus.

Analyzing the formula Dang gui san:

The function of this formula is to nourish the fetus in conditions involving blood deficiency with damp heat. Liver deficiency and poor transformation and transportation of the spleen in the mother can cause an internal heat and the condition of an “restless fetus”. A restless fetus during pregnancy in Chinese medicine classics reflects a danger to the fetus that can manifests as vaginal bleeding or threatened miscarriage.

From analyzing the herbs, we can see that the formula nourishes liver blood, drains damp heat and supports spleen qi. This formula is the root for “Four treasures Si wu tang” combination, but the herb- Shu di is omitted because it is sticky and does not fit heat situations.

Bai zhu + Huang qin calm the fetus, they are effective together for draining damp heat and clearing interior heat. Huang qin clear yang heat from the three burners, helping the Shao yang axis link between the ministerial fire and the movement of blood fluids. When the ministerial fire is unbalanced, it can damage yin or blood leading to coagulation and even bleeding. On the other hand, a deficiency of the ministerial fire will have a difficulty in transporting blood and lead to fluid retention or dampness. The combination of Huang qin with Bai zhu will treat fluid pathologies and prevent them from accumulating. Bai Zhu supports spleen function and thus prevents miscarriage. The herb can help fluid transportation and transformation that accumulates due to the deficiency of the ministerial fire. When the middle Jiao is functional Jing- essence can be transformed into blood to nourish the fetus. The combination of Huang qin and Bai zhu was the foundation upon which the well-known physician Zhu dan xi relied on his treatment of pregnant women. He claimed that the main herbs for calming the fetus and preventing miscarriage were Huang qin and Bai zhu, but years later other doctors criticized him and recommended using the pair only when damp heat pathology is seen during pregnancy or after birth.

The formula affects spleen, liver, Chong and Ren channels through the functions of Dang gui, Bai shao, Chuan xiong. When blood is abundant, it fills the Chong and Ren channels, the fetus can be nourished and relaxed. At the same time, from a different perspective, Huang qin can clear heat and cools the blood, it will prevent blood from flooding out of the vessels and therefore it also calms the fetus.

The formula contains three out of four herbs of the “Four Treasures” (Si Wu Tang) in order to nourish and move the blood. In addition, Huang qin + Bai zhu maintaining the qi axis (in terms of its movement and strength).

Dang gui san reflection on pregnancy physiology

By analyzing the formula, it can be understood that the main organs which the formula refers to are the spleen, liver and triple warmer. These organs are the main factors to cause imbalances during pregnancy. When we focus on the activity of the spleen and liver we are in other words talking about the balance between qi and blood or the balance of Chong-Ren. These organs and systems affect women hormones, menstruation and pregnancy.

The word Tiao 调 in Chinese means balance or regulation. This word describes a process of maintaining regularity, health, vitality or abundance of woman’s cycle. It is important to understand that the meaning of the word Tiao “调“, is not implied or intended to be understood as “to take over” or “regulate the cycle using force”. Sabine Wilms in her wonderful book “Channeling the moon” [2] refers to the translation of the word Tiao 调 and interprets it as to attune– as attuning a musical instrument. It refers to the gentle influence on the intention or the balance of the physiological processes in women which form the basis for creating and bringing new life into the world.

Women are affected by hormonal fluctuations throughout their lives. It is a natural, dynamic process that changes a woman’s life and affects her daily behavior and feeling. These waves are linked to the Chong-Ren systems and depend on the qi and blood state. During pregnancy, there is a great need for generating and supplying qi and blood. In addition, the distribution and flow of these substances is essential, therefore, the spleen and liver organs may experience functional imbalances and lead to variety pathologies.

In conclusion:

In the second part of the article “Principles And Treatments Of Chinese Medicine During Pregnancy” I tried to introduce you to the importance of the diagnosis and treatment of liver and spleen organs throughout pregnancy. By analyzing Zhang Zhong Jing’s formulas from the Jin gui yao lue section on pregnancy, we can see that sweet warm herbs such as Dang gui and bitter cool herbs such as (Huang qin, Bai shao) are used. Pregnancy is a very dynamic condition that involves nourishment of qi- blood and body fluids, therefore it is important to maintain their quality and function. But on the other hand, there is a risk that these substances will lead to accumulation of qi or liquids and sometimes we will have to disperse and drain them. This dynamic between nourishment and distribution in pregnancy creates different pathologies and symptoms. Therefore, even when there are no major complaints, it is important to support and address the state of the qi- blood- body fluids and their movement throughout the three trimesters during pregnancy. The spleen, Liver and Triple warmer – Ming men, are the main systems we need to look after in order to achieve a smooth and quiet pregnancy.

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