First Prenatal Visit History
1. History of Present Pregnancy:
• LMP: first day of last normal period
• Determine EDC (estimated date of confinement)
2. Past Obstetrical History:
• All Ob/Gyn histories include a summary of G and P
• For more complicated patients, can further categorize into GTPAL:
G: any pregnancy (include losses, ectopic, mole, current)
T: term – infants delivered after 37 completed weeks
P: preterm – infants delivered 20 - 36+6 weeks
A: abortions – pregnancy loss prior to 20 weeks and/or fetus weighing <500 grams
L: live – number of currently living children
• If pregnancy loss prior to 20 weeks, inquire:
---• how did loss happen (did they have a termination? or bleed and cramp? did they feels pressure and have PPROM?) - differentiate between causes such as therapeutic abortion, spontaneous abortion, fetal anomaly, maternal issues (incompetent cervix)
---• was a surgical procedure required such as a D and C (Dilatation and Curettage) or D and E (Dilatation and Evacuation)
---• was medical intervention required such as misoprostol (for missed abortion or blighted ovum)
• If pregnancy loss after 20 weeks, inquire:
---• date of delivery, location, sex, birth weight, gestational age at delivery, mode of delivery (vaginal – assisted or spontaneous; Cesarean – low segment or classical); were there any antepartum, intrapartum or postpartum complications and/or fetal anomalies.
3. Past Medical and Surgical History
4. Family History: genetic diseases, congenital malformations, consanguinity
5. Medications, Allergies
6. Social History: smoking, alcohol, recreational drugs, home environment
7. Review of Systems (tailor to patient)