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Introduction

Proper restoration of body physiology is the aim of sutika paricharya. proper management of sutika and sutika vyadhis have been described in various ayurvedic texts. A woman has just given birth to a baby along with placentais called "sutika" in ayurveda and "puerperal woman" in modern science. Thus the word puerperal means to give birth to a child and puerperium is the period from the termination of labor to complete involution of uterus usually 42 days or 6 weeks.By six weeks after the delivery, most of changes of pregnancy, labor and delivery has resolved, and body has reverted to the non-pregnant state.   Makkalla is of two types [1]garbhini makkalla  [2]prasuti makkalla or sutika makkalla. Post delivery complication of "sutika makkalla" have been described in sushrut shariradhyaya . After delivery,blood does not flow out but returns due to dhatukshinata,vayuprakopa, dryness of body or due to no availability of drugs required for shodhana done after delivery due to obstructed pathway. This result in the uterus getting stretched due to hematoma causing severe discomfort, pain below umbilical and bladder region, abdomen and cardiac region.[3] Per vaginal bleeding quantity is regulated by apana vayu, since it plays a vital role in dharana and nishkramana of raja. Vitiation of apana vayu therefore leads to sashoola raja pravrutti. [Ash.H.Su 12/7].The common line of treatment for vata dosha in sutika makkalla shoola; according to ayurveda is vata shamana and garbhashaya shodhana to expel out the avaruddha rakta.In ayurvedic classics various treatment are mentioned for sutika makkala.[4]

Material and method :

Disease Review  Sutika-

A woman who has just given birth to a child followed by expulsion of the placenta is called as Sutika. In almost all the samhitas, the acharyas have mentioned the specific management of sutika only after the expulsion of placenta.

 Sutika makkala-

Granthi-The retained rakto attains the form of granthi which is a knot like structure  in the region of adhonabhi, bastiparshwa and bastishiras. 

Shoola - Pain is confined to the nabhi, basti, hridaya, shira, koshtha, udara, etc region. These regions are the sthana of vatadosha. The nature of the pain is of pain), "bhidyate" (splitting) suchibhiriva nistudyate" (pricking and "deeryate"(cutting). 

Associated complaints- Vitiated vata not only retains the dushtarakta but also the vata, mutra and mala, causing adhmana and mutrasanga which also contribute to the pain in these particular sites. Apanvata is responsible for the artavanishkramana and also to expel out the mala, mutra,

artava etc. Vitiated vata if move in a way opposite to its normal downward direction, retains the mala, mutra etc. along with the retention of the dushshitarakta inside the uterus after prasava, causing various symptoms.

 Causes of sutikamakkala :

The vitiated vata dosha and shonita are the main causative factors of makkala.

                 -Vatadosha gets aggravated by its rukshaguna due to two  important factors.

-Ruksha sharira- Dryness due to labor strain causes weakness of the body tissue.

-Exhaustion during labor aggravates the vata dosha and causes dhatu - kshaya. The symptoms of vata vitiation are manifested in the form of shoola in different part of body.

-Avishodhita rakta - If diet regimen and activities advised during sutika kal, are not followed properly expulsion of dushita rakta does not occur leading to retention complicated by pain.

Drug Review -

Panchakola consists of Pimpali, Pimpalimula, Chavaka, Chitraka and Shunthi. The properties of Panchakola are described in Bhavaprakash Nighantu Therefore, Panchakola Churna is Katu, Ushna, Tikshna and Pachana. Characteristic property of Katu rasa is Bhedana of Sanghata therefore it liquefies the blood clots and causes excretion of dushta Rakta collected inside the uterus and vagina which causes good involution of uterus. Tikshnaguna causes Shodhana of Garbhashaya (Uterus) which causes excretion of residual endometrium and remaining parts of membranes which remain adhere to uterine wall and prevent uterus to contract completely[8]. 

 Ingredients:

1)Pippali(piperlongum)fruits-

Antiinflammatory, antibacterial,insecticidal,antihelminthic,hypoglycaemic,antispasmodic,

Immunostimulatory, antiulcerogenic,k aphavatahara[9]

2)Pippalimula (piper longum) root-vataharaa

3)Chavya(piper retrotractum)-work on Abdominal colic pain,indigestion[10 ]

4)Chitraka(plumbago zeylanica)-Antispasmodial action,antibacterial action ,wound healing action,Anti-inflammatory action[11].

5)Shunthi (Zingiber officinalis)-Spasmolytic, useful in treating chronic inflammation because it partially inhibits two important enzymes that play a role in inflammation cyclooxygenase (COX) and 5-lipoxygenase (LOX)[12]Rogaghnata[13].

Makkala shool, gulm, pleehavrudhi,Anaha, udar related diseases.

Dose: 6 gm BD

Anupana :With warm water

Discussion

The vitiated vata dosha and shonita are the main causative factors of makkala. Vatadosha gets aggravated by its rukshaguna due to two important factors. Ruksha sharira- Dryness due to labour strain causes weakness of the body tissue. Exhaustion during labour aggravates the vata dosha and causes dhatu - kshaya. The symptoms of vata vitiation are manifested in the form of shoola in different part of body. Avishodhita rakta - If diet regimen and activities advised during sutika, are not followed properly expulsion of dushita rakta does not occur leading to retention complicated by pain. Panchakola has Pachana, Ruchikara and the best dipana property which helps to increase appetite of Sutika because due to labor she suffers from Agnimandya. Also, due to Pachana guna dushita dhatus get metabolized and mala bhaga is excreted in the form of 'Lochia' Panchakola is described as Anaha and Shoolanashaka which causes decrease in pain in abdomen earlier than normal. It is Kapha and Vata Nashaka.Makkala is a state of Vata dominance. Therefore, it causes Vatanashana and helps Vata to maintain its normal Gati. It causes complete expulsion of all the products of conception without interruption earlier than normal which in turn results in proper involution of uterus.

Conclusion

Makkala is a shoola pradhana vyadhi occuring during sutikavastha. It is listed as one among the 74 diseases occurring in the sutika. The vitiated vata and shonita are the main causative factors of makkala.   Panchakol churna used in sutika makkala is ushnagunatmaka, vatashamaka, shoolahara, balya, garbhashaya shodhaka Thus it not only helpful in shoola reduction but also in garbhashaya shodhana.