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Kusum Doshi

Family Physician, Vileparle (E), Mumbai 400 057.

The family physician is involved in treating women right from early pregnancy up to the seventh month of pregnancy when she is referred to an obstetrician for registering as an ante natal case. This is the style of family practice in big cities. However, in mofussil parts of India the family physician looks after the women all through her pregnancy and even conducts the delivery of the baby either at the patientís residence or in the doctorís nursing home. But here there are a lot of limitations.

The first time that a patient goes to a doctor is when she misses her period and with mixed emotions. Either she is very happy and keen on having a baby; or she goes to the doctor with fear and trepidation of an unwanted pregnancy. This amenorrhoea may be due to irregular periods, early pregnancy or as a result of medications taken to delay periods. A urine pregnancy test is done at this time for confirmation of pregnancy. The family physician need not refer the patient to a pathology laboratory. Now a days pregnancy test kits are readily available and the results are quite reliable. Pregnancy can be detected as early as 4 days after missing the period.

If the pregnancy test is positive; specially after taking some medications to postpone periods; there is a lurking fear in the patients mind that the baby may have some abnormality as a result of the medicines that she has taken. She is under a lot of mental stress. At this point of time it is very difficult for the family physician to emphatically assure that the baby will be normal. The chances of the baby being normal is high if progesterone or progesterone derivatives were used for postponement of her periods. However if an estrogen or an estrogen progesterone combination drug is used the chances of developing fetal abnormalities is raised; chiefly mesoderm related abnormalities e.g. hydramnios, vesicular moles etc. It must be emphasized that progesterone and progesterone derivatives are less harmful as compared with estrogen and estrogen progesterone combinations. Repeated USG at 2-3 months intervals may be able to pick up anatomical abnormalities. It will not be able to pick up mental defects or hearing defects. These abnormalities can be detected around 4 months of pregnancy. USG must not be used for sex determination. The choice of resorting to MTP is left to the patient.

Once the patient decides to continue with her pregnancy; she must be called periodically for ante natal check ups. Use of a printed form is recommended as one is less likely to miss an important finding. Ideally an antenatal form must contain the following details.

Name Age  
Para LMP Due date
Past major illness/operations
Past obstetric history
Systemic examination
Gyn. Exam.
Path. Investigations
Medications (both currently taking and taken for a long time)
AN examination

On the first visit of the patient certain baseline findings are recorded. The age of the patient is important. A young patient or an elderly primi para must be closely monitored all through her pregnancy. If it is not a first pregnancy h/o previous pregnancy is important. A difficult labour, a rise in blood pressure during pregnancy may alert the physician that a similar episode may recur in the present pregnancy. It is advisable not to use an ACE inhibitors as an antihypertensive drug during pregnancy. It acts on the renin angiotensin system and may cause foetal damage. If the previous delivery was by caesarian section one has to look for the indication for caesarian section. You may have to do a repeat caesarian section if the indication was CPD, a narrow pelvic outlet. A repeat caesarian may not be required if the indication was cord prolapse, Breech with extended legs or a transverse lie. A H/O gestational diabetes must alert the doctor to be more vigilant.

The family physician must also take a history of past major illnesses. This is very important as certain conditions tend to flare up during pregnancy. Thus a well compensated case of mitral stenosis may go into failure. Here it is advisable to consult a cardiologist. Pulmonary TB may flare up if she has not taken a full course of AKT. Similarly for thyroid diseases. A known diabetic may have some degree of renal involvement. All these patients fall in the high risk category requiring close monitoring. Their case papers must have a high risk identity tag e.g. coloured paper or a marker on the paper.

A baseline BP, weight and urine report is recorded. If there is a rise of 30 mms in systolic pressure one should think in terms of toxaemia of pregnancy. So also if there is presence of albumin in urine. In the early months of pregnancy pyelitis is a frequent finding. He must take care not to give any drugs that are contraindicated in pregnancy. If vomiting is significant some anti emetics may be prescribed. If it is severe IV fluids may have to be given to maintain the electrolyte equilibrium. Invariably in a short time she settles down.

It is very important to keep a record of weight. A monthly increase in weight of about 1-2 kg is expected and normal. In the initial months of pregnancy there may not be a weight increase because of morning sickness. Pregnancy is a biological normal phenomenon and the patient must not be made to feel that she is ill. Morning sickness is mainly due to increase in progesterone levels. If she has hyperemesis it may be due to abnormal progesterone or other abnormalities of progesterone e.g. vesicular mole, hydramnios etc. The weight increase is relatively more towards the end of pregnancy. An inadequate weight increase may reflect IUGR requiring further investigations. On the other hand a marked increase in weight may also require further investigations. The patient may have twins, hydramnios, diabetes etc. The doctor must try to fine the underlying pathology and treat accordingly.

The patientís blood group must be noted on her first visit. An Rh -ve blood may require special attention. On completion of 2 months amenorrhoea a routine gynaecological examination is done; basically to rule out any local pathology e.g. vaginitis, cervical erosion, ovarian cyst. The size of the uterus must correspond to the period if amenorrhoea. At the same time a thorough systemic examination should be done for the presence of any other disease. Quite often even the patient is not aware of its existence e.g. Mitral stenosis as she is well compensated. Later on in pregnancy she may develop signs of failure. It is better to take a cardiologists opinion for medication and also whether she should opt for an elective caesarean section or to allow her to have a normal delivery.

If during the course of pregnancy she develops any viral fever e.g. measles, mumps, chicken pox etc. there is a risk of having some abnormality of the foetus. Similarly drugs contraindicated in pregnancy must not be given.

The following pathological investigations are routinely done : FBC, blood group, blood sugar (fasting and post prandial), Australia antigen, VDRL, HIV, serum creatinine and urine examination. Even if the blood count is normal she may have subclinical anaemia. Hence it is advisable to give supplemental calcium, folic acid and iron. Iron injections are justified only if the anaemia is very severe and towards the end of pregnancy.

Around the fourth month of pregnancy a USG is done to note if there are any foetal abnormalities and if the size of the foetus corresponds with the period of amenorrhoea. USG must never be used for sex determination. Around this time the patient is aware of foetal movements. Routine periodic ante natal examinations are done in the fifth, sixth and seventh month of pregnancy. The monthly ante natal examination must include a thorough systemic examination.

Prophylactic immunization of tetanus is given by injecting tetanus toxoid in the third and fourth month of pregnancy. This is done so that adequate immunity is developed at the time of delivery.

As regards diet the patient is advised to have normal diet with special emphasis on extra milk and nutritious food. As a precautionary measure the patient is advised salt restriction i.e. no pickles, papad etc,. Even if initially the blood pressure is normal she may have a raised blood pressure later on. This stress may give rise to placental insufficiency (umbilical artery occlusion because of raised blood pressure). Similarly sugar intake is restricted i.e. no extra sweets to be taken. If she develops gestational diabetes later on there may be foetal abnormalities. It must be noted that if she develops gestational diabetes there is an 80% chance of developing congenital foetal abnormalities and missed abortions etc.

Finally around the seventh month of pregnancy the patient is referred to an obstetrician. It is strongly recommended and appreciated if a detailed ante natal record is sent with the patient. This will build bridges and not barriers of communication with the obstetrician.

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