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OB 1st PNCU v2
OB 1st PNCU v2
OB 1st PNCU v2
• Note if there is any cough, colds, exposure to radiation, if there are any other prenatal
check-ups from other hospital & reason for transfer
• Also take note of any viral exanthems/teratogen exposure, medications given
V. Menstrual History
• MIDAS
• Menarche: Age at 1st menstruation
• Interval: 28-30 days (N: 28 + 7 days)
• Duration: 5-7 days (N: 4 – 7 days)
• Amount: 3-4 ppd, moderately soaked (MBL <80mL, Iron loss 13mg/cycle)
• Symptoms: (+) Dysmenorrhea Day 1 relieved by
• LMP: February 27, 2016
• PMP: January 28, 2016
X. Diagnosis
• G2P1 (1001), Pregnancy Uterine 13-14w AOG by LMP
XI. Labs/Ancillaries
• Transvaginal Ultrasound
o <12w AOG
o Requested to establish
§ Fetal aging & viability
§ Intrauterine pregnancy
• Fetal biometry if > 13w for fetal aging & viability
• Biophysical Profile if > 28w to assess fetal well-being
o AFI
o Fetal tone
o Fetal movement
o Fetal breathing
o FHR
• CBC
o Note for leukocytosis & pregnancy but mostly to assess physiologic anemia of
pregnancy
o 1st trimester: <11g/dl
o 2nd trimester: <10.5g/dl
o 3rd trimester: <11g/dl
o Quantify anemia if mild, moderate or severe
§ Mild: 9.5-10.5g/dl
§ Moderate: 8-9.4g/dl
§ Severe: 6.9-7.9g/dl
• Blood typing
o Just in case blood transfusion be needed during labor/delivery
o It is important to note maternal blood type to assess the possibility/risk for
developing hemolytic disease of the new born
• Urinalysis
o To assess for UTI as this may cause abortion/premature labor if left untreated
o Pus must be < 5/hpf, albumin (proteinuria is needed in the diagnosis of Pre-
eclampsia)
• HbSag
o Near term
o Hepatitis Virus is capable of crossing the placental barrier
o A reactive test may indicate the need for neonatal HB IgG
• VDRL/RPR: Near term
o For appropriate treatment to avoid vertical transmission of these diseases
• Pap Smear – baseline, but usually requested if a gravida presents with signs and
symptoms of cervical cancer (foul-smelling vaginal discharge, weight loss, post-coital
bleeding). This primarily detects premalignant lesions of the cervix as a screening tool
for cervical CA.
• HIV Screening – suggest to the patient as the Philippines has the highest rate of new HIV
cases recorded per day as compared to any other Asian country