POGS Formsv0 10 Blank

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE
version 0.10 Overview Hospital Information Name Code Location Data Period
Instructions 1. The paper Maternal Mortality Form and the paper Gestational Trophoblastic Disease Form STILL HAVE TO
OGICAL SOCIETY
isease Form STILL HAVE TO BE SUBMITTED.

version 0.10 Maternal Fetal Form 0
PATIENT DATA CASE NO LASTNAME FIRSTNAME Birthday Age Service HISTORY ADMIT DATE Gravidity
417364 Mangoba
Marivic
5/15/1991
21 charity
6/8/2012
ICAL SOCIETY
OB Score Parity Term
ADMISSION AOG Preterm Abortion Alive Weeks Days Last Year of Pregnancy
17
2009
MEDICAL/SURGICAL HISTORY Category Condition
OBSTETRIC HISTORY Category
Abortion
PRENATAL Condition Antenatal Procedures
DELIVERY Delivery Date
DELIVERY AOG Weeks Days
Missed abortion
Sonographic biometry
VAGINAL DELIVERY - Only for the CURRENT pregnancy. Route Malpresentation Delivery Other Procedures Episiotomy
Completion curettage
CAESAREAN SECTION Perineal Laceration Elective/Emergency Incision Primary/Repeat Hysterectomy
Tubal Ligation Tubal ligation
Anesthesia Anesthesia Route
INFANT FETAL DATA Number of Infants Gender Fetal Characteristics
IV sedation
Apgar Score Weight (grams) Length (cm) Pediatric Age (weeks) 1min 5min 10min Neonatal Condition
DISCHARGE STATUS DISCHARGE DATE Mother Condition
Fetal Neonatal Condition Category
6/22/2012 Alive
Congenital Anomalies Condition Yes/No Major/Minor Lethal/Non-lethal
Pregnancy Delivered Yes/No
No

version 0.10 Gyne Form 0
PATIENT DATA CASE NO LASTNAME FIRSTNAME Birthday Age Service HISTORY ADMIT DATE Gravidity
GICAL SOCIETY
For Malignancy Only Condition Laterality Stage For Genital Prolapse Only Degree
FINAL DIAGNOSIS Parity Category
OPERATIONS Elective/Emergency Approach Organ Procedure Laterality
DISCHARGE Hysterectomy Status

version 0.10 Maternal Mortality Form 0
PATIENT DATA CASE NO LASTNAME FIRSTNAME Birthday Age HISTORY AOG Days
ADMIT DATE Weeks
OGICAL SOCIETY
ANTECEDENT AND UNDERLYING CAUSE Type Antecedent Underlying
COMPLICATIONS AND DEATH Timing of Death Specific Immediate Cause
Onset of Complications
Specific

version 0.10 GTD Form 0
PATIENT DATA CASE NO LASTNAME FIRSTNAME Birthday Age HISTORY ADMIT DATE Gravidity Parity
OGICAL SOCIETY
OB Score ADMISSION AOG Term Preterm Abortion Alive Weeks Days Last Year of Pregnancy
Diagnosis
HYDATIDIFORM MOLE Type Complications
Metastasis Chemoprophylaxis
Drug
High Risk Factor
Mode of Evacuation
Condition on Discharge
Present Status
Cause of Death
GTN/PSTT/ETT Histopathology Antecedent Pregnancy
Baseline hCG levels (mIU/mL)
FIGO Anatomic Stage
Modified WHO Score
Combined FIGO-WHO Score Risk Age Antecedent Pregnancy
Interval Months from Index Pregnancy
Pretreatment hCG (mIU/mL)
Largest Tumor Size (cm)
Metastasis Site of Metastasis
Number of Metastases Identified
Previous Failed Chemotherapy
Total Score
ADDITIONAL TREATMENT Other Surgical Intervention
Chemotherapy
Radiotherapy
CONDITION Present Condition
Cause of Death

version 0.10 Obstetric Diseases and Procedures Report 0
SECTIONS ONE TWO THREE FOUR FIVE SIX SEVEN EIGHT NINE CONTENTS ADMISSIONS DATA DATA ON DELIVERED PATIENTS OBSTETRIC AND MEDICAL COMPLICATIONS IN DELIVERED PATIENTS PROBLEMS DURING LABOR PROBLEMS AMNIOTIC FLUID AND PLACENTA COMPLICATIONS DURING DELIVERY COMPLICATIONS DURING POST-PARTAL PERIOD PROCEDURES ABORTIONS, ECTOPIC PREGNANCIES, TROPHOBLASTIC DISEASES
SECTION ONE: ADMISSIONS DATA TOTAL NUMBER OF OBSTETRIC ADMISSIONS DELIVERED PATIENTS ANTEPARTAL PATIENTS DISCHARGED NOT DELIVERED ABORTIONS ECTOPIC PREGNANCIES TROPHOBLASTIC DISEASES
CHARITY 0 0 0 0 0 N/A
AGE RANGE OF PATIENTS LESS THAN 20 20 TO 34 35 AND ABOVE PARITY Nullipara Para 1-5 MORE THAN 5 MATERNAL OUTCOME Prepare Maternal Mortality Forms for All Maternal Deaths, Submit forms with this summary DISCHARGED ALIVE DISCHARGED ALIVE BUT MORIBUND DIRECT MATERNAL DEATHS INDIRECT MATERNAL DEATHS NONMATERNAL DEATHS TOTAL FETAL OUTCOME - BASED ON OBSTETRIC AGE OF GESTATION
0 0 0 0 0 0
0 0 0 0 0 0
IMMATURE
LIVE-BIRTHS STILL BIRTHS NEONATAL DEATHS
0 0 0
SECTION TWO: OBSTETRIC AND MEDICAL COMPLICATION IN DELIVERED PATIENTS ( using FIGO Committee on Perinatal Health-simplified ICD 10 coding,April 2000) HYPERTENSIVE DISORDERS in PREGNANCY 010.9 Pre-existing (chronic hypertension with BP 140/90) 011.9 Pre-existing (chronic hypertension with superimposed preeclampsia) 012.1 HELLP Syndrome 012.2 Proteinuria (>0.30 gms/24 hr) 013.x Edema with proteinuria Gestational hypertension 014.0 Mild preeclampsia (BP 140/90, protein 0.3 gms/24 hr) 014.1 Severe preeclampsia (BP > 160/110, protein > 0.3gms/24 hr) 014.9 Preeclampsia unspecified 015.9 Eclampsia Maternal Disorders predominantly related to pregnancy 020.9 VAGINAL
0 0 0 0 0 0 0 0 0 0
Hemorhage in Early Pregnancy (< 22 weeks)

ABORTIONS Threatened abortion Incomplete abortion Inevitable abortion Imminent abortion Missed abortion Blighted ovum
Septic abortion
Induced abortion Ectopic Pregnancy Tubal ectopic pregnancy Abdominal ectopic pregnancy Ovarian ectopic pregnancy Ectopic pregnancy, unspecified 021.1 Hyperemesis gravidarum, severe (demanding treatment in hospital) Venous complications Varicose veins of lower extremity Genital varicose veins Deep vein thrombosis Hemorrhoids
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
022.0 022.1 022.3 022.4
Urinary Tract Infection 023.0 Kidney Urinary Tract Infection VAGINAL
Acute pyelonephritis
Chronic pyelonephritis
0 0 0
023.1
Bladder Acute cystitis Chronic cystitis Renal or ureteral calculus Urinary tract infection Asymptomatic bacteriuria Other
VAGINAL
0 0 0 0 0
023.2 098.1
098.2
Genital Tract Infection
VAGINAL
Syphilis Gonorrhea
Herpes simplex Chlamydia Group B Streptococcus Bacterial Vaginosis HIV or AIDS Other sexually transmitted diseases Malaria Herpes gestationalis Diabetes mellitus VAGINAL
Z21.x 098.3 098.6
0 0 0 0 0 0 0 0 0 0
024.0
Diabetes mellitus Insulin dependent

Diabetes mellitus non-Insulin dependent Gestational diabetes mellitus VAGINAL
024.1 024.4
0 0 0
025.x 026.5 026.6
030.0 030.1 030.x 032.1
Malnutrition (BMI less than 19.8) Supine Hydrotensive syndrome Liver Disorders Hepatitis B Hepatitis A Acute Fatty Liver Multiple gestation Twin Triplet
Other Malpresentation
Frank breech
0 0 0 0 0 0 0 0 0 0 0 0
032.1 032.2 032.2

032.3
Complete breech Footling Breech Transverse Lie
Oblique Lie Face

Brow Chin Prolapsed Arm
032.3 032.3 032.5
Multiple gestation with malpresentation for one or more fetus

VAGINAL
0 0 0 0 0 0 0 0 0
033.9
034.2
Disproportion (known or suspected)
Previous Caesarian Section

Cervical Incompetence Abnormalities of pelvic organs (see later) Fetal Abnormality and Damage Rhesus Isoimmunization Hydrops Fetalis Fetal Hypoxia Intrauterine Death (<22 weeks) Intrauterine Death (>22 weeks) Poor Fetal Growth Excessive Fetal Growth VAGINAL
034.3 034.9 035.9 036.0 036.2 036.3 036.4 036.5 036.6
0 0 0 0 0 0 0 0 0 0 0 0
040.x 041.0 041.1 042.0 042.1 042.9 044.0 044.1 045.0 045.9
Polyhydramnios
Oligohydramnios Chorioamnionitis Premature rapture of membranes Onset of Labor w/in 24 hours Onset of Labor after 24 hours Unspecified Placenta Previa without Hemorrhage Placenta Previa with Hemorrhage Abruptio placenta with coagulation defect Abruptio placenta (only) Placenta accreta Placenta percreta Placenta increta Other antepartum hemorrhage False Labor Preterm Labor
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
WITH METS
046.8 047.9 048.x
Post Term >= 42 weeks

TROPHOBLASTIC DISEASES
Complete Mole Partial Mole Invasive Mole Choriocarcinoma
Gestational trophoblastic neoplasia Placental site trophoblastic tumor Epithelioid trophoblastic tumor
SECTION THREE: COMPLICATIONS OF LABOR AND DELIVERY Preterm Delivery (up to 36 weeks) ABNORMALITIES OF FORCES OF LABOR
0 0 0 0 0 0 0
Failure of Cervical Dilatation (<1 cm/hr in active phase) Arrested active phase of labor
(no progress during 2 hrs after initially normal progress) Precipitate labor (nulli=<1 hours from 3 cm to delivery; multi=<0.5 hr)
0 0 0 0 0 0
Hypertonic uterine contraction

Long labor Prolonged first stage (for nulli > 15 from 3 cm to fully dilated, for multi > 11 h) Prolonged second stage (> 2 h from full dilated to delivery) Obstructed Labor Due to malposition or malpresentation Due to fetopelvic disproportion Due to maternal pelvic abnormality Due to shoulder dystocia Failed forceps or vacuum extraction Intrapartum hemorrhage With coagulation defect Meconium in amniotic fluid Fetal Distress Prolapsed Cord Vasa previa Perineal Laceration Unspecified First Degree
064.9 065.4 065.9 066.0 066.5 067.9 067.0 068.1 068.9 069.0 069.4
0 0 0 0 0 0 0 0 0 0 0
070.0 070.1 070.2 070.3
0 0 0 0
( involving fourchette, labia, skin, vagina, vulva)

Second Degree (involving 1st plus pelvic floor, perineal muscle, vaginal muscle) Third Degree (involving 2nd plus anal sphincter, rectovaginal septum) Fourth Degree
(involving 3rd plus anal mucosa , rectal mucosa) Other Obstetric Trauma Rupture of uterus before onset of labor Rupture of uterus during labor Uterine inversion Laceration of Cervix Pelvic, vaginal, or vulvar hematoma Uterine Dehiscence Postpartum Hemorrhage Due to Uterine Atony Due to Retained Placenta Due to other causes Retained placenta without hemorrhage Anesthetic complications, postpartum hemorrhage Other complications of Labor and Delivery, not elsewhere classified
071.0 071.1 071.2 071.3 071.7
0 0 0 0 0 0 0 0 0 0 0 0 0 0
072.0 072.1 073.0 074.9 075.9
SECTION FOUR: DELIVERY AND OTHER PROCEDURES 080.0 080.1 080.9 081.0 081.1 081.2 081.3 081.4 081.5 Spontaneous vertex delivery Spontaneous breech delivery Spontaneous delivery, unspecified Low forceps delivery Mid cavity forceps delivery Mid cavity forceps delivery with rotation Other and unspecified forceps delivery Elective outlet forceps delivery Vacuum extractor delivery Combination forceps/vacuum extractor VBAC Caesarean Section Elective Low Segment Classical Emergency Low Segment Classical Cesarean Hysterectomy Unspecified Breech extraction Breech Assisting Multiple delivery, all spontaneous Multiple delivery, all by forceps and vacuum extractor Multiple delivery, all by Caesarean section
0 0 0 0 0 0 0 0 0 0 0
082.0
082.1
082.2 082.9 083.0 083.1 084.0 084.1 084.2
0 0 0 0 0 0 0 0 0 0 0 0 0
084.8 084.9
Other multiple delivery Multiple delivery, unspecified Other Procedures Completion Curettage Suction Curettage Induction by prostaglandins Total hysterectomy Subtotal hysterectomy Removal of extra-peritoneal embryo Others Salpingectomy Salpingo-Oophorectomy Manual extraction of placenta
0 0
0 0 0 0 0 0 0 0 0 0
SECTION FIVE: COMPLICATIONS PREDOMINANTLY RELATED TO PUERPERIUM 085.X 086.0 087.1 087.2 088.1 090.0 090.1 090.2 091.0 091.1 Puerperal Sepsis Wound Infection Deep Phlebothrombosis Hemorrhoids Obstetric Air Embolism Disruption of Caesarean Section Wound Disruption of Perineal Obstetric Wound Hematoma Breast Infection Nipple Infection Breast abscess
0 0 0 0 0 0 0 0 0 0 0
SECTION SIX: OTHER MATERNAL DISEASES CLASSIFIABLE ELSEWHERE BUT COMPLICATING PREGNANCY 099.0 099.1 Anemia Disease of blood and immune mechanism Leukemia Megaloblastic Anemia Anti-Phospolipid Antibody Syndrome
Other
Dengue 099.2 Endocrine, nutritional and metabolic diseases Hyperthyroidism Hypothyroidism Nodular Nontoxic Goiter Diffuse Nontoxic Goiter Other Diabetes (see above)
0 0 0 0 0 0 0
0 0 0 0 0 0
099.3
Mental Disorders and Diseases of the Nervous System Seizure Disorders Meningioma Schizophrenia Brief Reactive Psychosis Drug Abuse and Dependency Other Diseases of the Respiratory System Bronchial Asthma in Remission Bronchial asthma in acute asthmatic attack Pneumonia Pulmonary Tuberculosis Other Diseases of the Circulatory System Rheumatic heart disease (RHD), mitral stenosis Rheumatic heart disease (RHD), mitral regurgitation Rheumatic heart disease (RHD), mitral stenosis with regurgitation Rheumatic heart disease (RHD), atrial stenosis Rheumatic heart disease (RHD), atrial regurgitation Rheumatic heart disease (RHD), others Congenital Heart Disease, atrial septal defect Congenital heart disease, ventricular septal defect Congenital heart disease, patent ductus arteriosus Congenital heart disease, others Mitral valve prolapse Coronary Artery Disease Others Diseases of the Digestive System Acid Peptic Disease Other Surgical Condition Acute Appendicitis Acute Cholecystitis Stab wound Gun Shot Wound Others Gynecological Conditions Uterine Myoma Ovarian new growth (ONG), benign Ovarian new growth (ONG), malignant Other
0 0 0 0 0 0
099.5
0 0 0 0 0
099.4
0 0 0 0 0 0 0 0 0 0 0 0 0
099.6
0 0
0 0 0 0 0
0 0 0 0
Cervical Cancer SECTION SEVEN: OTHER PROCEDURES ANTENATAL PROCEDURES (NUMBER OF PATIENTS, NOT NUMBER OF PROCEDURES) Electronic Fetal Monitoring Non-stress testing Contraction stress testing Biophysical Profile Scoring Sonographic biometry Chronic villi sampling Amniocentesis Intrapartal and post-partal procedures Artificial Rupture of the Membranes Internal Version Failed/Trial forceps Repair of cervical laceration Reposition of inverted uterus Evacuation of vulvar hematoma in Pregnancy
0 0 0 0 0 0 0 0 0 0 0 0 0 0
LOGICAL SOCIETY
PRIVATE 0 0 0 0 0 N/A
TOTAL 0 0 0 0 0 0
PRETERM
TERM
POST-TERM
0 0 0
0 0 0
0 0 0
ABDOMINAL
TOTAL
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
ABDOMINAL
TOTAL
0 0 0
0 0 0
ABDOMINAL
TOTAL
0 0 0 0 0
0 0 0 0 0 0
ABDOMINAL
TOTAL
0 0 0 0 0 0 0 0 0 0
ABDOMINAL TOTAL
0 0 0 0 0 0 0 0 0 0
0 0 0
ABDOMINAL TOTAL
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
ABDOMINAL TOTAL
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
ABDOMINAL TOTAL
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO METS TOTAL
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

version 0.10 Perinatal Report 0
PERINATAL STATISTICS BASED ON MANNER OF DELIVERY Normal CS Forceps Breech Others
LIVEBIRTHS -
STILLBIRTHS -
NEONATAL DEATH -
DELIVERIES -
STILLBIRTH RATE -
PERINATAL STATISTICS BASED ON BIRTH WEIGHT 500-999 1000-1499 1500-1999 2000-2499 2500-2999 3000-3499 3500-4000 >4000
LIVEBIRTHS -
STILLBIRTHS -
NEONATAL DEATH -
DELIVERIES -
STILLBIRTH RATE -
PERINATAL STATISTICS BASED ON AGE OF GESTATION 20-21 22-27 28-31 32-36 37-42 >42
LIVEBIRTHS -
STILLBIRTHS -
NEONATAL DEATH -
DELIVERIES -
STILLBIRTH RATE -
PERINATAL STATISTICS BASED ON FETAL CHARACTERISTICS Uncomplicated SGA LGA Lethal
LIVEBIRTHS -
STILLBIRTHS -
NEONATAL DEATH -
DELIVERIES -
STILLBIRTH RATE -
GICAL SOCIETY
NEONATAL MORTALITY -
PERINATAL MORTALITY -
SURVIVAL RATE -
SURVIVAL RATE -
SURVIVAL RATE -
SURVIVAL RATE -

version 0.10 Gynecologic Diseases and Procedures Report 0
SECTIONS CONTENTS ONE ADMISSIONS AND DISCHARGE DATA TWO SIGNS AND SYMPTOMS THREE INFLAMMATORY CONDITIONS FOUR CONGENITAL ANOMALIES FIVE BENIGN CONDITIONS SIX BENIGN NEOPLASMS SEVEN MALIGNANT NEOPLASMS EIGHT OPERATIONS SECTION ONE : ADMISSIONS AND DICHARGE DATA OPERATED PATIENTS PATIENTS ADMITTED NOT OPERATED OTHER PATIENTS CHARITY PRIVATE TOTAL
DISCHARGED ALIVE DISCHARGED ALIVE BUT MORBID MORTALITIES TOTAL NUMBER OF GYNECOLOGIC ADMISSIONS
AGE RANGE OF PATIENTS LESS THAN 20 20 to 34 35 to 50 51 and above PARITY 0 1-5 MORE THAN 5 SECTION TWO: SIGNS AND SYMPTOMS
PATIENT CHARACTERISTICS AND COMPLAINTS UPON HOSPITAL ADMISSION (DO NOT INCLUDE OUT-PATIENT)
MENSTRUAL DISORDERS 626 Primary Amenorrhea 626.1 Secondary Amenorrhea Menorrhagia 626.2 Polymenorrhea Metrorrhagia 626.6 Meno-metrorrhagia
Intermenstrual Bleeding
MENOPAUSE 627.1 Post-Menopausal Bleeding 627 Atrophic/ Senile Vaginitis 628 INFERTILITY Primary Secondary 628.0 Ovarian 628.1 Pituitary-Hypothalamic 628.2 Tubal 628.3 Uterine/ Cervix Male Factor 628.9 Unspecified PELVIC SYMPTOMS 625.4 Premenstrual Tension Syndrome SECTION THREE : INFLAMMATORY CONDITIONS
FOR ADMMITTED PATIENTS ONLY, EXCLUDES THOSE ASSOCIATED WITH PREGNANCY DISEASES OF BARTHOLIN'S GLAND N76 N75.0 N75.1 N75.8 N75.9 Cyst of Bartholin's Gland Abscess of Bartholin's Gland Other Diseases of Bartholin's Gland Bartholinitis Diseases of Bartholin's Gland, Unspecified
PELVIC INFLAMMATORY DISEASE N73 Pelvic Inflamatory Diseases, Prob. Bacterial Salpingo-Oophoritis Endometritis Parametritis Pelvic Cellulitis Pelvic Abscess N74 Other Pelvic Inflammatory Disorders N74.0 Cervical Tuberculosis (A18.1) N74.1 Tuberculosis Pelvic Inflammatory Disease (A18.1) Tuberculosis Endometritis N74.2 Syphilitic Pelvic Inflammatory Disease (A51.4, A52.7) N74.3 Gonococcal Pelvic Inflammatory Disease (A54.2) N74.4 Chlamydial Pelvic Inflammatory Disease (A56.1) N76 N76.5 N76.6 N77.1 OTHER INFLAMMATION OF VAGINA AND VULVA Ulceration of Vagina Ulceration of Vulva, Bacterial Ulceration of Vulva, Herpes
N77.2
Ulceration of Vulva, Tuberculosis Vulva Condyloma Acuminata Vulvovaginitis, Non-bacterial Vulvovaginitis, Herpes Vulvovaginitis, Candidiasis Vulvovaginitis, Foreign Body
SECTION FOUR: CONGENITAL ANOMALIES OF GENITAL ORGANS ICD NO. Absence/ Agenesis of the Ovary Streak Ovary Cyst of the Oophoron/ Fimbriae Parovarian Cyst Gartner's Duct Cyst Doubling of Uterus Bicornuate Uterus Uterus Unicornis Imperforate Hymen Congenital Cyst of Canal of Nuck Embryonal Cyst of the Vagina Congenital Cyst of the Vulva
ANOMALIES OF VAGINA, CERVIX AND EXTERNAL FEMALE GENITALIA Agenesis Uterine Corpus Cervix Clitoris Vagina Vulva Aplasia
SECTION FIVE : BENIGN CONDITIONS OF THE FEMALE GENITAL TRACT ENDOMETRIOSIS Uterus Adenomyosis Ovary Fallopian tube Pelvic peritoneum Rectovaginal septum Unspecified Others STAGE 1 STAGE 2 STAGE 3 UNSPECIFIED STAGE
GENITAL PROLAPSE FIRST Cystocoele alone Rectocoele alone Cysto-rectocoele Urethrocoele Enterocoele Unspecified TOTAL Prolapse of vaginal vault after hysterectomy Old laceration of muscle of pelvic floor Others (specify) Vulvar Hematoma Relaxed vaginal vault FISTULA Female Genital Tract Fistula specify types vaginal polyp SECOND COMPLETE
clitoral mass
SECTION SIX: BENIGN NEOPLASM OF THE GENITAL TRACT UTERINE M8890/0 Leiomyoma N84.0 Endometrial Polyp N85.0 Endometrial Hyperplasia, Unspecified Cystic Hyperplasia Complex Hyperplasia N85.1 Adenomatous/ Atypical Hyperplasia N85.4 Malposition of Uterus N85.5 Uterine Inversion, Non-Obstetric N85.6 Intrauterine synechiae N85.7 Hematometra CERVIX N84.1 N86 N87 N87.0 N87.1 N87.2 N88.2 N88.3 Chronic Cervicitis Polyp of Cervix Uteri Erosion and Ectropion of Cervix Uteri Dysplasia of Cervix Uteri, Not Specified Mild cervical dysplasia or CIN I Moderate cervical dysplasia or CIN II Severe Cervical Dysplasia, Not Elsewhere Classified (Cin lll, Not Cis) Stricture and Stenosis of Cervix Uteri Incompetence of Cervix Uteri
N88.4
Hypertrophic elongation of cervix uteri
SECTION SEVEN : MALIGNANT NEOPLASM OF GENITOURINARY ORGANS OVARY Serous Adenocarcinoma Mucinous Adenocarcinoma Endometrioid Adenocarcinoma Other epithelial Germ Cell Type Other Type Metastatic UNILATERAL BILATERAL BORDERLINE
CERVIX Squamous Cell, Large Cell, NK Squamous Cell, Large Cell, Keratinizing Squamous Cell, Small Cell Other squamous cell type Adenocarcinoma Other Type
STAGE I
STAGE II
STAGE III
FALLOPIAN TUBE Adenocarcinoma, Specify Other Type, Specify ENDOMETRIOD TUBAL CYST CORPUS Endometrial carcinoma Other Endometrial neoplasm Leiomyosarcoma Other MALIGNANCIES OF THE REST OF FEMALE GENITAL TRACT Vagina Greater Vestibular (Bartholin's Gland) Vulva Labia Majora Labia Minora Clitoris Other Site Unspecified FALLOPIAN TUBE Paratubal serous cyst
OVARY EPITHELIAL M8440/0 Cystadenoma Not Specified M8441/0 Serous Cystadenoma M8450/0 Papillary Cystadenoma M8460/0 Papillary Serous Cystadenoma M8470/0 Mucinous Cystadenoma M8471/0 Papillary Mucinous Cystadenoma M8480/0 Pseudomyxoma peritonei Endometrial Cyst GERM CELL TUMORS M9080/0 Mature cystic teratoma M9084/0 Dermoid Cyst M9090/0 Struma Ovarii OTHER BENIGN CONDITIONS M8600/0 Fibro-Thecoma M9000/0 Brenner Tumor N83.0 Follicular Cyst of Ovary N83.1 Corpus Luteum Cyst N83.5 Torsion of Ovary/ Ovarian Pedicle UNILATERAL BILATERAL TOTAL
OTHER PELVIC ORGANS VAGINA N89.0 N89.1 N89.2 N89.3 N89.4 N89.5 N89.7 N89.8 VULVA N90.0 N90.1 N90.2 N90.3 N90.4 N90.5 N90.6 N90.7 N90.8 Mild vaginal dysplasia or VAIN I Moderate vaginal dysplasia or VAIN II Severe vaginal dysplasia or VAIN III Dysplasia of Vagina, Unspecified Leukoplakia of Vagina Stricture and Atresia of Vagina Hematocolpos Others Mild vulvar dysplasia or VIN I Moderate vulvar dysplasia or VIN II Severe vulvar dysplasia or VIN III Vulvar Dysplasia, Unspecified Leukoplakia of Vulva Atrophy of Vulva Hypertrophy of vulva Vulvar Cyst Other Specified Noninflammatory Disorders of Vulva and Perineum
SECTION EIGHT: OPERATIONS ON FEMALE GENITAL ORGANS
OPERATIONS ON THE UTERUS Myomectomy Subtotal Hysterectomy Total Abdominal Hysterectomy Vaginal Hysterectomy Uterine Suspension Fractional Curettage Simple Curettage Radical Abdominal Hysterectomy Radical Vaginal Hysterectomy Pelvic Exenteration Diagnostic Curettage TAHBSO Endometrial biopsy
WITH UNILATERAL BILATERAL HYSTERECTOMY
OPERATIONS ON OVARY Oophorectomy Salpingo-Oophorectomy Ovarian cystectomy/oophoro-cystectomy Partial Oophorectomy Wedge Resection Repair of the Ovary Adhesiolysis of Ovary OPERATIONS ON THE CERVIX Cervical biopsy Endocervical Curettage Conization of the Cervix Excision of Cervical Polyp Amputation of Cervix Cervicectomy Encirclement Suture or Cerclage Other Repair of Cervix Late Repair of Obstetric Laceration Repair of Non-Obstetric Laceration LEEP OPERATIONS ON FALLOPIAN TUBE Salpingectomy Salpingostomy Fimbriectomy Cornual Resection Repair of Fallopian Tube Insufflation
UNILATERAL BILATERAL TOTAL
Tubal Ligation, Interval Reanastomosis of ligated tubes Endoscopic Destruction or Occlusion By Culdoscopy By Laparoscopy Unspecified OPERATIONS ON VAGINA Culdocentesis Incision of the Vagina Colpotomy Culdotomy Hymenotomy Hymenectomy Obliteration and Total Excision of the Vagina Colpectomy Colpocleisis Repair of Cystocoele Repair of Rectocoele Repair of Enterocoele OPERATIONS ON VULVA AND PERINEUM Incision of Vulva and Perineum Drainage of Vulvar Abscess Removal of Foreign Body from Vulva Marsupialization of Bartholin's Gland Excision of Bartholin's Gland Radical Vulvectomy Simple Vulvectomy Perineorrhaphy Other Operations on Female Genital Organs OTHER OPERATIONS AND PROCEDURES Partial Omentectomy Peritoneal Biopsy Peritoneal Fluid Sampling Hartman's Procedure Exploratory Laparotomy Alone Bilaterial pelvic lymph node dissection Bilateral Groin Node Dissection Chemotherapy Other operations LAPAROSCOPIC PROCEDURES Video Laparoscopic Diagnostic
Operative Hysterograms or hysterosalpingography Hysteroscopy Colposcopy Others
ICAL SOCIETY
WITHOUT
STAGE IV

version 0.10 Maternal Mortality Report 0
MATERNAL MORTALITY RATE AVERAGE AGE (years) AVERAGE AOG (weeks) CAUSE OF DEATH I. DIRECT MATERNAL DEATHS %
0% 0 0 VALUE -
A. HEMORRHAGE 1. Spontaneous abortion 2. Induced abortion 3. Retained secundiness 4. Ectopic pregnancy 5. Abruptio placenta 6. Placenta previa 7. Placenta accreta 8. Uterine rupture 9. Cervico-vaginal lacerations 10. Uterine inversion 11. Uterine atony 12. Postop from surgical procedure 13. Trophoblastic disease 14. Abdominal pregnancy 15. Coagulopathy 16. Other hemorrhage B. HYPERTENSION 1. Preeclampsia 2. Eclampsia 3. Preexisting hypertension 4. Combination 5. HELLP syndrome C. INFECTION 1. Induced abortion 2. Pelvic abscess 3. Puerperal infection 4. Chorioamnionitis 5. Adnexal infection 6. Pelvic thrombophlebitis 7. Septic embolism D. VASCULAR ACCIDENTS
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
1. Amniotic fluid embolism 2. Puerperal nonseptic embolism 3. Air embolism E. ANESTHESIA 1. Neurogenic cardiac arrest 2. Post-aspiration asphyxia 3. Respiratory insufficiency F. OTHERS 1. Peri/postpartum cardiomyopathy 2. Transfusion hemolysis 3. Electrolyte imbalance 4. Pregnancy anemia 5. Others (specify)
II. INDIRECT MATERNAL DEATHS
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
A. CARDIAC 1. Rheumatic heart disease 2. Hypertensive heart disease 3. Congenital heart disease 4. Atherosclerotic heart disease 5. Undiagnosed 6. Other cardiac B. VASCULAR 1. Preexisting hypertension 2. Vascular thrombosis/embolism 3. Thrombophlebitis C. REPRODUCTIVE TRACT 1. Uterine anomalies 2. Uterine myoma 3. Ovarian cysts 4. Reproductive tract malignancy 5. Other reproductive tract D. URINARY TRACT 1. Glomerulonephritis 2. Urinary tract infection 3. Hydronephrosis 4. Renal malignancy 5. Other urinary tract E. HEPATIC 1. Infectious hepatitis 2. Liver cirrhosis
3. Hepatic abscess 4. Hepatic malignancy 5. Other hepatic F. PULMONARY 1. Tuberculosis 2. Pneumonia 3. Bronchial asthma 4. Lung cancer 5. Malignancy, with lung metastasis 6. Other pulmonary G. METABOLIC 1. Diabetes mellitus 2. Thyroid storm 3. Adrenal dysfunction 4. Other metabolic H. HEMATOLOGIC 1. Leukemia 2. Aplastic anemia 3. Other hematologic I. GASTROINTESTINAL 1. Acute gastroenteritis 2. Appendicitis 3. Gastrointestinal tract malignancy 4. Other gastrointestinal J. OTHER CAUSES
III. NONMATERNAL DEATHS
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
A. ACCIDENTS 1. Stab wound 2. Gunshot wound 3. Vehicular accident 4. Accidental poisoning B. SUICIDE/MURDER 1. Suicide 2. Murder
MORTALITY BASED ON I. TIMING OF DEATH A. TRIMESTER
1. First trimester 2. Second trimester
0% 0%
3. Third trimester
B. SPECIFIC
0%
1. Antepartal 2. Intrapartal 3. Postpartal 4. Puerperal

II. IMMEDIATE CAUSE OF DEATH A. Shock B. Congestive heart failure C. Respiratory failure D. Hepatic failure E. DIC F. Intracranial bleeding G. Multiorgan failure H. Others (specify) III. ONSET OF COMPLICATIONS A. TRIMESTER
0% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0%
1. First trimester 2. Second trimester 3. Third trimester

B. SPECIFIC
0% 0% 0%
1. Antepartal 2. Intrapartal 3. Postpartal 4. Puerperal
0% 0% 0% 0%
NO. OF LIVE BIRTHS NO. OF MATERNAL DEATHS MATERNAL MORTALITY RATE
0%
LOGICAL SOCIETY

version 0.10 Gestational Trophoblastic Disease Report 0
SECTIONSCONTENTS ONE CASE BY DIAGNOSIS TWO HYDATIDIFORM MOLE THREE GESTATIONAL TROPHOBLASTIC TUMOR FOUR PLACENTAL SITE TROPHOBLASTIC TUMOR FIVE CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF GTT
SECTION ONE: CASE BY DIAGNOSIS
FREQUENCY -
Hydatidiform Mole Complete Partial No data Gestational Trophoblastic Neoplasia Invasive mole Choriocarcinoma Unspecified No data Placental Site Trophoblastic Tumor Epithelioid Trophoblastic Tumor TOTAL
SECTION TWO: HYDATIDIFORM MOLE AGE GROUP 15-19 20-29
30-39
40-49 >= 50 No data TOTAL GRAVIDITY 01 25 6 10 11 16 No data
TOTAL AOG AT DIAGNOSIS (in weeks) <= 12 weeks 12-26 weeks > 26 weeks No data TOTAL COMPLICATIONS Anemia Hyperemesis gravidarum Pre-eclampsia Hyperthyroidism Theca lutein cyst Pulmonary embolism Infectious No data TOTAL HIGH RISK FACTOR Age > 35 years Uterus > AOG Recurrent mole Uterus >= 5 months AOG size Precurettage hCG >= 100,000 mIU/mL Theca lutein cyst >= 6cm Others (specify) No data TOTAL MODE OF EVACUATION Suction curettage Hysterectomy D and C Others (specify) No data TOTAL USE OF CHEMOPROPHYLAXIS No Yes No data TOTAL PROPHYLACTIC AGENT Methotrexate (oral + parenteral)
Actinomycin D No data TOTAL CONDITION ON DISCHARGE No evidence of disease Partial response Progressive disease Death No data TOTAL PRESENT STATUS OPD followup with no evidence of disease Unknown/Lost to followup Readmitted/Referred with evidence of malignant degeneration No data TOTAL CAUSES OF DEATH
SECTION THREE: GESTATIONAL TROPHOBLASTIC NEOPLASIA AGE GROUP 15-19 20-29
30-39
40-49 >= 50 No data TOTAL GRAVIDITY 01 25 6 10 11 16 No data TOTAL ANTECEDENT PREGNANCY Term Abortion Ectopic pregnancy Molar (complete + partial) No data
TOTAL BASELINE bHCG TITER (mIU/ML) < 100 100 1,000 1,001 10,000
10,001 100,000
100,001 1,000,000 > 1,000,000 No data TOTAL WHO PROGNOSTIC SCORE Low risk High risk No data TOTAL FIGO ANATOMIC STAGE Stage I Stage II Stage III
Stage IV
No data
TOTAL
SURGICAL PROCEDURE Curettage TAH Others (thoracotomy + craniotomy + others) No data TOTAL CHEMOTHERAPY
Single agent (oral methotrexate + parenteral methotrexate + actinomycin D) MAC EMACO (true + modified) Others No data TOTAL
RADIOTHERAPY
Yes No No data TOTAL
CONDITION ON DISCHARGE No evidence of disease Partial response Progressive disease Death No data TOTAL CAUSES OF DEATH
SECTION FOUR: PLACENTAL SITE TROPHOBLASTIC TUMOR AGE GROUP 15-19 20-29
30-39
40-49 >= 50 No data TOTAL GRAVIDITY 01 25 6 10 11 16 No data TOTAL ANTECEDENT PREGNANCY Term Abortion Ectopic pregnancy Molar (complete + partial) No data TOTAL BASELINE bHCG TITER (mIU/ML) < 100 100 1,000 1,001 10,000
10,001 100,000
100,001 1,000,000 > 1,000,000 No data TOTAL
WHO PROGNOSTIC SCORE Low risk High risk No data TOTAL FIGO ANATOMIC STAGE Stage I Stage II Stage III
Stage IV
No data
TOTAL
SURGICAL PROCEDURE Curettage TAH Others (thoracotomy + craniotomy + others) No data TOTAL CHEMOTHERAPY
Single agent (oral methotrexate + parenteral methotrexate + actinomycin D) MAC EMACO (true + modified) Others No data TOTAL
RADIOTHERAPY
Yes No No data TOTAL

CONDITION ON DISCHARGE No evidence of disease Partial response Progressive disease Death No data TOTAL
SECTION FIVE: CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF GTN
FIGO ANATOMIC STAGE/CONDITION ON DISCHARGE
CONDITION ON DISCHARGE
No evidence of disease
FIGO ANATOMIC STAGE

Stage I Stage II Stage III
Stage IV No data TOTAL

FIGO ANATOMIC STAGE/SURGICAL PROCEDURE
0 0 0 0 0 0 SURGICAL PROCEDURE
Curettage
FIGO ANATOMIC STAGE


FIGO ANATOMIC STAGE/WHO PROGNOSTIC SCORE
0 0 0 0 0 0 WHO PROGNOSTIC SCORE

Low risk
FIGO ANATOMIC STAGE


WHO PROGNOSTIC SCORE/SURGICAL PROCEDURE
Curettage
WHO PROGNOSTIC SCORE Low risk High risk No data TOTAL

WHO PROGNOSTIC SCORE/CONDITION ON DISCHARGE
0 0 0 0 CONDITION ON DISCHARGE

WHO PROGNOSTIC SCORE/CHEMOTHERAPY
0 0 0 0 CHEMOTHERAPY
Single
0 0 0 0
DIAGNOSIS/CONDITION ON DISCHARGE
CONDITION ON DISCHARGE
DIAGNOSIS Invasive mole Choriocarcinoma Unspecified No data TOTAL
0 0 0 0 0
SECTION SIX: CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF PSTT FIGO ANATOMIC STAGE/CONDITION ON DISCHARGE CONDITION ON DISCHARGE
FIGO ANATOMIC STAGE


FIGO ANATOMIC STAGE/SURGICAL PROCEDURE
Curettage
FIGO ANATOMIC STAGE


FIGO ANATOMIC STAGE/WHO PROGNOSTIC SCORE
0 0 0 0 0 0 WHO PROGNOSTIC SCORE

Low risk
FIGO ANATOMIC STAGE


WHO PROGNOSTIC SCORE/SURGICAL PROCEDURE
Curettage

WHO PROGNOSTIC SCORE/CONDITION ON DISCHARGE

WHO PROGNOSTIC SCORE/CHEMOTHERAPY
0 0 0 0 CHEMOTHERAPY
Single

DIAGNOSIS/CONDITION ON DISCHARGE
DIAGNOSIS Invasive mole Choriocarcinoma Unspecified No data TOTAL
0 0 0 0 0
LOGICAL SOCIETY
PERCENT
NDITION ON DISCHARGE
Partial response Progressive Dead No data TOTAL
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0
0
GICAL PROCEDURE
TAH Others No data TOTAL
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
O PROGNOSTIC SCORE
High risk No data TOTAL
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
GICAL PROCEDURE
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
MOTHERAPY
Triple EMACO Others No data TOTAL
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0
0
GICAL PROCEDURE
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
O PROGNOSTIC SCORE
High risk No data TOTAL
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
GICAL PROCEDURE
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Partial response
Progressive
Dead
No data
TOTAL
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
MOTHERAPY
Triple EMACO Others No data TOTAL
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0

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PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

isease Form STILL HAVE TO BE SUBMITTED.

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

OB Score Parity Term

MEDICAL/SURGICAL HISTORY Category Condition

OBSTETRIC HISTORY Category

PRENATAL Condition Antenatal Procedures

DELIVERY Delivery Date

DELIVERY AOG Weeks Days

CAESAREAN SECTION Perineal Laceration Elective/Emergency Incision Primary/Repeat Hysterectomy

Tubal Ligation Tubal ligation

Anesthesia Anesthesia Route

INFANT FETAL DATA Number of Infants Gender Fetal Characteristics

DISCHARGE STATUS DISCHARGE DATE Mother Condition

Fetal Neonatal Condition Category

Congenital Anomalies Condition Yes/No Major/Minor Lethal/Non-lethal

Pregnancy Delivered Yes/No

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

FINAL DIAGNOSIS Parity Category

OPERATIONS Elective/Emergency Approach Organ Procedure Laterality

DISCHARGE Hysterectomy Status

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

ADMIT DATE Weeks

ANTECEDENT AND UNDERLYING CAUSE Type Antecedent Underlying

COMPLICATIONS AND DEATH Timing of Death Specific Immediate Cause

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

HYDATIDIFORM MOLE Type Complications

High Risk Factor

GTN/PSTT/ETT Histopathology Antecedent Pregnancy

Baseline hCG levels (mIU/mL)

FIGO Anatomic Stage

Modified WHO Score

Combined FIGO-WHO Score Risk Age Antecedent Pregnancy

Interval Months from Index Pregnancy

Pretreatment hCG (mIU/mL)

Largest Tumor Size (cm)

Metastasis Site of Metastasis

Number of Metastases Identified

Previous Failed Chemotherapy

ADDITIONAL TREATMENT Other Surgical Intervention

CONDITION Present Condition

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIE

LIVE-BIRTHS STILL BIRTHS NEONATAL DEATHS

Hemorhage in Early Pregnancy (< 22 weeks)

022.0 022.1 022.3 022.4

Urinary Tract Infection 023.0 Kidney Urinary Tract Infection VAGINAL

Genital Tract Infection

Z21.x 098.3 098.6

Diabetes mellitus Insulin dependent

025.x 026.5 026.6

030.0 030.1 030.x 032.1

032.1 032.2 032.2

Complete breech Footling Breech Transverse Lie

Oblique Lie Face

032.3 032.3 032.5

Multiple gestation with malpresentation for one or more fetus

Disproportion (known or suspected)

Previous Caesarian Section

034.3 034.9 035.9 036.0 036.2 036.3 036.4 036.5 036.6

046.8 047.9 048.x

Post Term >= 42 weeks

Complete Mole Partial Mole Invasive Mole Choriocarcinoma

Hypertonic uterine contraction

070.0 070.1 070.2 070.3