Antenatal initial consultation

{Antenatal initial consultation}

EXPLANATORY NOTES
[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not performed, not applicable
[?] unknown, unsure

PRESENTING COMPLAINTS OR ISSUES
This Pregnancy: 
  LNMP (date): 
  Menstrual cycle length: 
  Estimated date of delivery:
  Ultrasound date:
    K = 
    EDD =

G:0, P:0, M:0, T:0

Clinical concerns for this pregnancy:
[+] 
[?]

PAST MEDICAL HISTORY
Past obstetric history: 
  (1)
  DOB: 
  Gestation: 
  Outcome: 
  Delivery method: 
  Sex: 
  Birth weight: 
  Complications:

(2)
  DOB: 
  Gestation: 
  Outcome: 
  Delivery method: 
  Sex: 
  Birth weight: 
  Complications: 
  
  (3)
  DOB: 
  Gestation: 
  Outcome: 
  Delivery method: 
  Sex: 
  Birth weight: 
  Complications:

Gynaecological history:
[-] previously abnormal pap smear
[-] fertility problems
  [-] IVF
[-] STI
[-] gynaecological issues
  Details:

Past general medical history:
[-] asthma/respiratory disease
[-] heart disease
[-] hypertension
[-] kidney disease/uti
[-] diabetes
  [-] type 1
  [-] type 2
  [-] gestational
[-] thyroid disease
[-] orthostatic hypotension
[-] epilepsy
[-] musculoskeletal disorder
[-] thrombophilia
[-] VTE
[-] mental health issues

FAMILY HISTORY
Family And Genetic History:
[-] diabetes
[-] hypertension
[-] cystic fibrosis
[-] fragile X
[-] tay-sachs disease
[-] thalassaemia
[-] sickle cell anaemia
[-] spinal muscular dystrophy
[-] other congenital abnormaity
  Details:

[Medications and medical devices]

Current medication (List): 
[+]

SOCIAL HISTORY
Substance Use History:
[-] tobacco  
[-] alcohol 
[-] other

IMMUNISATIONS
Immunisations up to date:
[-] MMR
[-] varicella (vaccination or clear history of infection)

Social History:

[Examination findings]

Heart rate (bpm):
  Blood pressure (mmHg):
  Height (m):
  Weight (kg):
  BMI (weight/height^2):

Other examination findings: (abnormalities)
[-] periodontal 
[-] breasts/nipples
[-] cardiovascular
[-] respiratory
[-] abdominal
[-] skeletal
[-] thyroid

Urinalysis: 
[-] Protein
[-] Glucose
[-] WBC
[-] Nitrite

ASSESSMENT
Risk summary:
[-] complicated medical history
[-] previous pregnancy requiring specialist obstetric care
[-] pregnancy that is not progressing normally
[-] multiple pregnancy

MANAGEMENT PLAN
Diagnostic investigations requested:
1. Initial screening investigations:
[+] FBE (Thalassaemia screen) 
[+] Blood group and antibody screen 
[+] Ferritin [+] CRP 
[+] Rubella IgG serology (titre) 
[+] HIV serology 
[+] Hepatitis B serology 
[+] Hepatitis C serology 
[+] Syphilis serology 
[+] Urine MCS 
[+] Chlamydia/Gonorrhoea EIA (vaginal swab)

2. As Required Investigations:
[-] Cervical screening test (CST)
  [-] Up to date (within 5 years)
  [-] Offered and declined
[-] HbA1c or OGTT (if high risk of gestational diabetes)
[-] Vitamin D (if high risk of deficiency)
[-] Measles serology^
[-] Varicella serology^
^ If immune status is uncertain.

3. Down Syndrome Screening:
[+] Standard screening
  Blood test (performed 10/40 --> range 9/40 to 13/40+6D)
    free beta human chorionic gonadotrophin
    pregnancy-associated plasma protein A
  Ultrasound measurement of nuchal translucency thickness
    (performed 12/40 --> range 11/40+1D to 13/40+6D)
    
OR (NOTE no Medicare rebate)

[-] Non-invasive prenatal testing (DNA-based blood test) NIPT
  (Performed any time from 10/40)

4. Other genetic carrier screenin:^^
[-] Cystic fibrosis
[-] Fragile X syndrome
[-] Spinal muscular atrophy
^^ Usually performed before pregnancy or in the first trimester. Female partner tested first, then male partner if the female is identified as a carrier of CF or SMA.

5. Gestational diabetes screening:
[-] 24-28 weeks OGTT (earlier if PHx)

6. Ultrasound scans:
[-] 8-9 weeks dating scan.
[-] 11-13 weeks first trimester screen (see below*).
[-] 18-20 weeks morphology and foetal anatomy scan.
  
7. Additional routine syphilis serology:
[-] 26-28/40
[-] 36/40

Treatment/Management: 
[+] Folic acid supplements
  0.5-1.0 mg/day
  5.0 mg/day if significant risk of NTD
[+] Influenza vaccination (at any time during pregnancy)
[+] DTpa vaccination (single dose between mid 2nd trimester and early 3rd trimester of each pregnancy [-] ideally at 20–32 weeks)

[?] RhD negative women --> anti-D injections x 2:
  * 26-28 weeks, and
  * 34-36 weeks

Patient Education:
[-] Smoking cessation advice
[+] Alcohol advice
[+] Diet with sufficient iron, calcium, folate, iodine, calories
[+] Adequate vitamin D (sun exposure or supplement)
[+] Regular, moderate intensity exercise
[+] Oral health

Planning: 
[?] Planning shared care for low-risk pregnancy
[?] Special needs

Referrals: 
[+] Antenatal service/obstetrician:
  [-] Urgent referral within 7 days (high-risk pregnancy)
[-] Dietitian (BMI < 18.5, > 29.5; multiple pregnancy)

FOLLOW-UP
Next appointment:
[+]

Outstanding issues:
[+] 
[-]

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Antenatal initial consultation

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