Dr. Jorge Alberto Renzi
The current trend in medical education is focused on the acquisition of tools to acquire knowledge, skills and attitudes to exercise primary health care.
With this view, should take into account that in front of the consultation of a woman of childbearing age, she may be pregnant, so that despite the fact that her consultation is for another pathology, it is necessary to discard it. With this view, an iatrogenesis in the product of pregnancy will be avoided as a consequence of the prescribed treatment studies (eg radiographs, drugs, etc.).
For this, there are resources that range from the simplest that are within the reach of the primary care physician and in case of doubt, know how to think about this possibility to make a timely referral.
In the first place, the questioning is carried out, which is sometimes easy (it is simply stated or it is very evident) and in other circumstances it may be difficult due to concealment (social, moral reasons, etc.) or simply because the patient is unaware of her condition. A correct history is the simplest way to presume a pregnancy. The starting point is to interrogate the date of the last menstruation and its characteristics so as not to make an error. Remember that an amenorrhea in a woman during her fertile stage is a pregnancy until proven otherwise. Sometimes the patient apparently continues to menstruate but it is a pseudo-menstruation, which is more rare and of another aspect, and that can lead to making an error. In other circumstances it may happen that there is never menstruation, the case of an adolescent or a woman in the final stage of her reproductive life that did not menstruate for a while or occurs sporadically. Here the doctor must act with caution and question the sexual activity of the patient. Once the existence of sexual activity is confirmed, it is essential to ask about their regularity and an important aspect to take into account is the use or not of some contraceptive method. It will be interpreted that she is not pregnant if the patient menstruates regularly and normally in terms of the appearance and quantity of it and if she refers that she has not noticed changes in the characteristics. There is a presumption of pregnancy when a patient who was eumenorrheic until recently, stops menstruating. On the other hand, it must be borne in mind that the etiology of amenorrhea may be the result of diseases:
As previously expressed, the existence of two or three bleeds coinciding with the menstrual date is a relatively common fact in the pregnant woman, but as already mentioned, bleeding (more rare and brief and of a different color) is often of different characteristics. It is important to take into account all these aspects of the anamnesis, because if it is necessary to carry out some studies for another reason or treatment for any pathology, iatrogenesis (damage to the embryo) may be caused. These aspects should be remembered when it is necessary to carry out an x-ray, administer a drug, carry out studies or treatments with substances, radioactive, chemotherapy, etc. They should be carried out in the first half of the menstrual cycle, since an unexpected pregnancy of a few days could be present in the second half.
In the interrogation, the presence of presumptive signs such as: nausea and vomiting, changes in the sense of taste and smell, marked asthenia, lipotimias, polaquiuria, all of low specificity, should be investigated.
They can occur very frequently: hyperesthesia, increased breast swelling, very sensitive nipples.
Although the genital examination is the heritage of the specialist, a suitably trained general practitioner can perform it. During the examination it will verify the modifications in the genitals: change of color of the cervix and the most significant thing will be to verify the increase in the size and the decrease in the consistency of the uterus, these signs of probability of pregnancy. If the patient is asked in the period prior to eight weeks for a chorionic gonadotropin laboratory and an early ultrasound scan of the pregnancy, it may be an appropriate measure to confirm it, an important fact to assess more precisely the weeks of gestation, fetal vitality, number of embryos and if the pregnancy is orthotopic, that is, it is in the uterine cavity. In this way, an early diagnosis can be made, adequate and timely pregnancy to take the necessary preventive measures that the circumstances require, fulfilling one of the fundamental objectives of primary care. In this way errors in the gestational age will be avoided, the diagnosis of the pregnancy is ectopic and it will be possible to anticipate its complications. If it is a multiple pregnancy, extreme preventive measures will be taken as it is a high risk pregnancy, if it is diagnosed ultrasound a hematoma without clinical manifestations (bleeding, pain) is more likely to prevent an abortion.
As the pregnancy progresses, the obstetric examination is facilitated by palpation. The uterus is perceived as a smooth, shifting pyriform mass. The abdomen increases in size gradually and with the course of the pregnancy, the fetal movements can be perceived. Thereafter, fetal heartbeats are detected by auscultation. All these diagnostic tools are facilitated with the progress of the pregnancy, being more evident to detect the fetal parts.
Given the presumption of pregnancy, it must be confirmed with laboratory tests that can be qualitative: a) immunological reaction in urine (Gravindex) or b) immunological reaction in blood (Dap Test) and c) the most accurate and sensitive, but of greater cost and complexity for its realization is the investigation and dosing of the beta subunit fraction of chorionic gonadotropin.
Once the diagnosis is made, the control of the pregnancy must be carried out by a specialist doctor who will take charge of the control and assistance if the conditions of the environment allow it.
It is also important that the primary care physician has the basic knowledge of changes in the maternal organism, so that when a patient comes to the consultation for a suspected pathology other than pregnancy, she knows that many of the physical and laboratory changes must to gestation. The most important ones to consider are mentioned. If the pregnancy is more advanced, a change in abdominal volume is observed. A moderate increase in heart rate is verified and the cardiac minute volume increases, reaching its maximum increase around thirty-four weeks of gestation.
Continuing with the circulatory system, there is an increase in venous pressure. It can be ten times greater than the non-pregnant as a consequence of the increase in blood volume, circulatory loss due to the mechanical compression of the pregnant uterus and hormonal changes. Blood pressure tends to decrease in the first half of pregnancy and stabilizes in the second half. The primary care physician must take into account that any rise in blood pressure, at any stage of gestation, is pathological and therefore that patient should be referred to a more complex center.
A change in blood volume occurs, mainly at the expense of plasma, causing changes in the relative values of the figurative elements (hemodilution). The professional will keep in mind that there is a physiological leukocytosis with a relative decrease in erythrocytes (pseudoanemia of pregnancy), an increase in platelets and an increase in the rate of erythrocyte sedimentation due to modifications, fundamentally, of plasma proteins (an increase in fibrinogen, a high protein molecular weight). It is very important that the doctor takes these aspects into account so that he does not make diagnostic errors, sometimes interpreting these changes as an infectious picture (for example) by performing inadequate treatment.
As a conclusion, the clinical doctor in the face of a pathology associated with pregnancy must take into account this state to carry out studies and / or treatments of said condition with the certainty that they do not imply damage to the product of gestation (teratogenesis). Interconsultation with the specialist will be important in some cases to balance the risks against the benefits that said studies or treatments produce in pregnancy.p
These concepts that have just been enumerated will be extremely useful for the primary care physician to contribute to achieving safe motherhood, benefiting the mother-son pairing.