Gyno Speciality Hospital, GIFT- Gyno IVF Center, Kerala, India.

Yoga and other complementary medicine practises can be helpful for a number of diseases, including moderate hypertension brought on by stress. This is a case study of a 49-year-old patient receiving yoga therapy.

Following undergoing donor egg IVF, the patient conceived twins and at 7 weeks after the birth, preeclampsia set up on top of moderate hypertension. M Dopa and Labetalol therapy did not successfully control hypertension. On an experimental basis, yoga and meditation were performed, and it was discovered that they worked wonders for her. Her hypertension medications were gradually decreased and stopped after she began a twice-daily pranayama and meditation regimen. At 37 weeks, she gave birth to healthy twins weighing 2.5 and 2.6 kilogramme each.Yoga is extremely accessible, inexpensive, and free of any negative drug side effects. It is past time to acknowledge this and use it as an adjuvant in medical care.

Keywords: Multiple pregnancy difficulties, donor egg IVF, meditation, breathing exercises, and hypertension in pregnancy

Regarding high blood pressure during pregnancy, there are a few things to think about. Pregnancy in older women is more likely to involve essential hypertension [1]. Women with essential hypertension have an increased risk of developing preeclampsia [2]. Preeclampsia occurs more frequently in numerous pregnancies, as has been demonstrated [3]. IVF programmes using donor eggs also increase the risk of preeclampsia [4]. In all pregnancies, the blood pressure actually decreases a few units after the first trimester [5]. Anti-hypertensive medication use is restricted during pregnancy [6]. Early diagnosis of preeclampsia that has been added to essential hypertension is challenging [7].Particularly in older women and in donor egg IVF protocols, severe anxiety and stress are typical in ART pregnancies [8]. Strong social pressure might elevate stress levels and cause mild essential hypertension, especially in Asian women without children [9].

This case study concerns a patient who is 49 years old and who married later in life when she was 44. She wanted to get pregnant using donor eggs via IVF because her periods were erratic. She had no major past medical, surgical, or therapeutic history.

Her clinical parameters and general examination were both normal, with the exception of her blood pressure reading of 130/90 mmHg. Her uterus was typical in size, with minor adenomyosis and a 1.5 cm tiny fibroid, according to a transvaginal ultrasound. She was most likely perimenopausal based on the size and atrophic condition of her bilateral ovaries. Her FSH and LH levels were found to be elevated, with the ranges being 30 mIU/ml and 25 mIU/ml, respectively. Her AMH level of 0.1 ng/dl also supported this finding. The analysis of her husband's sperm was normal.

She received in-depth guidance regarding an IVF procedure using donor eggs. Both spouses had thorough physical examinations, routine blood tests, such as Blood Pressure (BP), Sugar, HIV, HBsAg, HCV, VDRL, Thyroid Function Test, Liver Function Test (LFT), and Renal Function Test (RFT), and due to their ages, they both had ECGs. With the exception of the female partner's slightly increased blood pressure of 130/90, all the parameters were found to be normal. At the time, anxiousness was said to be the cause.

From the second day of her period for five days, the wife received priming drugs in the form of estradiol valerate [Progynova 2 mg] twice daily. After that, the progynova 2 mg dosage was increased to 3 times daily for an additional 7 days, and on day 12, she underwent a transvaginal [TVS] scan to evaluate the endometrial lining, which revealed that it was 9 millimetres thick with an excellent trilaminar pattern.

IVF with donor eggs was carried out the following cycle once her cycles were synchronised with the egg donor. She began receiving luteal assistance on the day the eggs were picked up. Estradiol valerate 2 mg [Progynova] PO twice daily, progesterone gel PV at night [HS], progesterone [susten 300 mg] capsule vaginal morning and afternoon, folic acid 5 mg [Folsafe] am, and multivitamin pill in the form of nutricell were among the luteal support medications. Two grade one embryos were transplanted to the recipient on day 3 while she was lightly sedated.

Upon checking, all of her metrics were normal with the exception of her blood pressure (130/90), which was positive after two weeks of her urine pregnancy test (UPT). She was instructed to maintain the luteal support and to check her blood pressure three times each week. At four weeks and six days, a scan revealed a double intrauterine sac, and the woman was asymptomatic. Her blood pressure had risen to 150/90 mmHg at the time of the second scan, which revealed two sacs both with viable pregnancies (foetal cardiac activity was noted). She was advised to check her blood pressure daily at a nearby clinic and bring her reports the following week when she was due for the third scan.

The foetus and she were both growing normally, and the only issue found on the subsequent scan was that she had a blood pressure of 170/90 mmHg. Her standard blood tests, such as those for haemoglobin, blood sugar, LFT, and RFT, were performed, and all of them at the time were deemed to be normal. She was told to check herself in so her blood pressure could be monitored. When the patient was admitted, she was still asymptomatic, and her estradiol dosage was decreased to once daily while she was started on 75 mg of aspirin once day. We kept taking the progesterone gel and pill. Her blood pressure remained in the 160/90 range for the following 4 days.

After talking with her, it was decided that we would attempt antihypertensive medications.

When the patient was 6 weeks and 5 days old, labetalol 100 mg twice daily was started, and her blood pressure was checked every day. Despite labetalol, the blood pressure stayed at 150/90 for a week. After consulting with the patient, it was decided to begin methyldopa therapy as well. She was given 250 mg of M-dopa three times per day in addition to 100 mg of labetalol, and her blood pressure was checked daily as was done with the patient. Every week, the usual tests for blood and urine albumin were repeated and determined to be normal. She had some light leg edoema. Urine albumin tests were negative every day.

Despite medicine, the blood pressure remained between 140 and 150/90. Because her blood pressure wasn't being regulated, we suspected preeclampsia. She sought counselling from our counsellor to express her pregnancy-related concerns. She remained a patient, and by the ninth week, despite taking Labetalol and M-dopa, her blood pressure had started to rise once more and was over 150/100. Her weekly blood tests, LFT, RFT, and ECG were all normal. However, there were a few incidents where her blood pressure spiked to 170/110; even though her urine albumin was always negative, this was concerning because she was clearly demonstrating signs of preeclampsia.

Despite taking antihypertensive medications, her blood pressure was uncontrollably rising, and we continued to administer these medications because they were thought to be pregnancy-safe. The fact that she was still very early in her pregnancy and that there is always a larger risk of preeclampsia in donor egg IVF programmes, especially when carrying twins, as well as the fact that her advanced age made her particularly vulnerable, were the additional concerns.

The patient and her husband were very interested in attempting yoga-based breathing exercises called Pranayama as well as meditation under the guidance of a trained yoga teacher when we first brought up trying alternative methods to lower high blood pressure.

Under the guidance of a certified yoga master, she completed two 30-minute sessions of breathing exercises and meditation each morning and evening. The patient was permitted to adopt any position she choose, including lying down or sitting on the floor or in a chair. The patient chose to do this procedure at 7 a.m. and 6 p.m., and it was carried out in a serene setting with pleasant ambiance. The patient chose to undergo this procedure on an empty stomach in the morning.

This was done every day, and it was noticed that there was a minor drop in blood pressure, which in just three days went from 150/100 to 140/90. After these sessions, the patient made the decision to stick with the same routine every day and remain an inpatient since she felt so calm, refreshed, and renewed and was pleased with the reduction in her blood pressure. It was reported that after another week, her blood pressure dropped even more, to 130/90, and after another week, after 11 weeks, it was 130/80. Weekly scans revealed that the twin pregnancy was progressing regularly.

Medication for hypertension decreased and was withdrawn: Once she reached 11 weeks and her blood pressure was 130/80, we had a conversation with her to try to lessen her anti-hypertensive medications. Her luteal support had been continuing in the same dosage up until that point. We lowered the antihypertensive medications with her and her husband's cooperation so that M-dopa was fully removed and only Labetalol 100 mg twice daily was being given at 11 weeks. After a scan proved viability at 12 weeks, her blood pressure was 130/80, she continued to practise daily breathing exercises and meditation, and she made the decision to try to totally stop using Labetalol.

Her blood pressure was still within the normal range after another three days, so we talked to her about ceasing the luteal support at that point. She agreed, and we stopped the progesterone gel at 13 weeks, but her progesterone tablets were continued until 28 weeks.

She resumed her breathing and meditation routine after feeling quite at ease and feeling some hope that she might be able to carry the pregnancy further. Her pregnancy was developing healthily without the use of any hypertension medications, and at 20 weeks of gestation, she had a normal abnormality scan. Her Scan and Doppler results at 28 weeks revealed that she had gained weight and all other indicators were normal. After 32 weeks, the CTG was obtained, and after 32 weeks, her blood was monitored once every two weeks. At 32 weeks and 34 weeks, the repeat Scan and Doppler were normal. The ultrasound revealed a 36-week-old breech twin pregnancy with normal growth.

The pregnancy of twins in an elderly woman with high blood pressure (perhaps preeclampsia) of early onset ended well, and yoga may have had a part to play in managing the stress and the BP.

Twins weighing 2.4 kg and 2.5 kg who were both boy newborns and had an apgar of 8 at one minute and 10 at five minutes underwent an elective caesarean surgery at 37 weeks.

complications of high blood pressure: This patient had essential hypertension, and it's very likely that preeclampsia set in when her blood pressure began to rise after seven weeks. Preeclampsia increases the risk of morbidity and mortality for both the mother and the foetus, especially when it occurs in conjunction with repeated pregnancies [10]. For severe, escalating preeclampsia, termination of pregnancy at any time may be the only option [10].

Her blood pressure was not being controlled by conventional medications, so alternative therapy was examined. The scientific management of both moderate essential hypertension and hypertension related to anxiety and stress has shown meditation and other relaxation strategies to be helpful [11].Her managed blood pressure raises a high chance that yoga was successful in her situation [12,13]. A growing foetus can benefit greatly from breathing exercises by having their lung capacity and blood flow of oxygen increased [13]. Despite the patient being an elderly menopausal primp, the twins had healthy weights and good apgar scores at birth. There are, however, not many other factors that could have caused the BP to drop.

1. Pregnancy can lower blood pressure due to a significant decrease in systemic vascular resistance and a decrease in blood viscosity [5]. Thus, that might have been advantageous for this patient.

2. Hospitalization can actually help the patient's psychological condition by isolating them from a bad familial environment [8–9]. It has been demonstrated that tender loving care lowers the risk of pregnancy loss [10].

3. The lowering of those medications may have reduced BP in this situation because hormones like progesterone and oestrogen can alter blood pressure.

4. Dietary guidance might have been helpful. The effects of a certain diet, such as a high salt or fat intake, might actually influence the course of medical disorders, particularly illnesses like hypertension [14].

1. Effective alternative practises, such as yoga, meditation, etc., are not always included into medical practise in the present [15], but we have done so.

2. The influence of social and environmental elements, such as stress, in contributing to medical problems is sometimes overlooked by modern medicine. Pregnancy outcomes can be impacted by the socioeconomic state of a certain area and the stress associated with ART [7-9,16]. Even though she was hospitalised, separating her from the in-laws actually worked.

3. In ART facilities in developing nations, there are sadly not enough counsellors to go around.Prenatal counselling for our patient covered all pertinent information, including the length of the procedure, the approach, the processes required, the drugs, and any potential side effects or pregnancy issues [17]. The patient and the doctor talked about the expense of the procedure, and they agreed to accept any financial hardship that could arise.

Better pregnancy outcomes would ideally come from a single embryo transfer, especially in older women [18]. Her odds of developing difficulties would have been lower if we had just transferred one embryo [19,20].

Additional study in this area may aid in using yoga as a therapeutic adjunct to allopathic treatment.

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Anita Mani. A Case Report on the Successful Use of Meditation and Pranayama to Treat Hypertension and Preeclampsia in a 49-Year-Old Twin Pregnant. Insights of Clinical and Medical Images 2022.