Risk assessement for VTE, small baby, diabetes and pre-eclampsia

Please Note:

This form should not be used in clinical practice at present.
This electronic form may look different to the paper version, as it does not contain duplicates. For example, smoking status is asked for in the VTE section but not asked again in the SGA section. However, it is otherwise identical to the paper version.

BMI: What is your height in metres? What is your weight in kilograms?

Age: How old are you?

Section 1 - Screening for hypertensive disease in pregnancy

Do you have a previous history of hypertension in pregnancy or pre-eclampsia?

Yes No

Do you have a history of essential hypertension?

Yes No

Do you have Type 1 or Type 2 diabetes?

Yes No

Do you have chronic renal disease?

Yes No

Do you have SLE?

Yes No

Do you have antiphospholipid syndrome?

Yes No

Section 2 - Screening for hypertensive disease in pregnancy

Are you a primigravid woman?

Yes No

Is your pregnancy interval 10 or more years?

Yes No

Do you have a family history or pre-eclampsia?

Yes No

Do you have a multiple pregnancy?

Yes No

Section 1 - Antenatal VTE risk assessement

Have you ever had a VTE (venous thromobosis embolism), not related to surgery

Yes No

Section 2 - Antenatal VTE risk assessement

Are you currently admitted to hospital?

Yes No

Have you previously had a clot related to major surgery?

Yes No

Do you have a high risk thrombophillia?

Yes No

Do you have medical co-morbidities like cancer, heart failure, active SLE, inflamatory bowel disease, inflamatory polyarthropathy, nephrotic syndrome, type 1 diabetes with nephropathy, sickle cell disease, current IVDU?

Yes No

Have you just had surgery (like appendicitis)?

Yes No

Do you have ovarian hyperstimulation syndrome(OHSS)?

Yes No

Section 3 - Antenatal VTE risk assessement

Are you para 3 or greater?

Yes No

Are you a smoker?

Yes No

Do you have gross varicose veins?

Yes No

Do you have current pre-eclampsia?

Yes No

Are you immobile? e.g. paraplegic or PGP.

Yes No

Do any of your first degree relatives have an unprovoked or oestrogen provoked clot?

Yes No

Do you have a low risk thrombophillia?

Yes No

Was your pregnancy conceived by IVF or Artificial reproductive techniques?

Yes No

Are you dehydrated, have hyperemesis, or had recent long distance travel or infection?

Yes No

Diabetes Screening

Have you had a baby more than 4.5kg in weight?

Yes No

Have you previously had diabetes in pregnancy?

Yes No

Do you have a first degree relative with diabetes?

Yes No

Are you from the following ethnic groups: South Asian, Black Caribbean, Middle Eastern?

Yes No

SGA Screening

Do you take illicit drugs?

Yes No

Have you had a baby less than the 10th centile?

Yes No

Have you had a previous stillbirth?

Yes No

Do you have large fibroids?

Yes No

In early pregnancy was you PAPP-A less than 0.415MoMs? If you did not have a PAPPA-A done, select 'No'

Yes No

At your 20 week scan did your baby have bright bowel (echogenic bowel)?

Yes No

Are you now after 28 weeks and have blood pressure?

Yes No

Are you now after 28 weeks and have unexplained vaginal bleeding?

Yes No