Subjective
Date of visit
Gestational age (weeks)
Reason for visit (prenatal screening for chromosomal abnormalities)
Past medical history:
Personal or family history of chromosomal abnormalities
Previous pregnancies (number, outcomes)
Prenatal history:
Current prenatal care and medications
Maternal age (advanced maternal age is a risk factor for certain chromosomal abnormalities)
Objective
Vital signs (temperature, blood pressure, heart rate, oxygen saturation)
Prenatal Screening Tests (performed based on gestational age):
First Trimester Screening (11-14 weeks):
Nuchal translucency (NT) ultrasound measurement (increased thickness can indicate a higher risk)
Maternal serum free β-hCG and PAPP-A levels (blood test) – abnormal levels can suggest increased risk
Second Trimester Screening (15-20 weeks):
Quad Screen (blood test) – measures AFP, hCG, uE3, and inhibin-A – abnormal levels can indicate increased risk
Integrated Screening (combines first and second trimester markers) – provides a more comprehensive risk assessment
Genetic Counseling (may be offered based on screening results or family history):
Discussion about chromosomal abnormalities and available prenatal diagnostic tests (amniocentesis, chorionic villus sampling – CVS)
Review of risks and benefits of prenatal diagnostic tests
Assessment
Prenatal screening for chromosomal abnormalities performed (specify which tests)
Screening results (low risk, intermediate risk, high risk) – it is important to note that screening tests are not diagnostic
Consideration for genetic counseling (based on risk assessment and patient preference)
Plan
Discuss the meaning of screening results and limitations of screening tests.
Offer genetic counseling if not already discussed.
Discuss next steps based on risk assessment and patient preference:
Continue with routine prenatal care for low-risk patients.
Consider further evaluation (amniocentesis, CVS) for high-risk patients.
Reassurance and support for patients with intermediate risk.
Education
Explain prenatal screening for chromosomal abnormalities and its purpose.
Discuss the meaning of the screening results and limitations of the tests.
Provide information about prenatal diagnostic tests (amniocentesis, CVS) if applicable.
Offer resources for further information and support.
Follow-up
Schedule for follow-up appointments based on risk assessment and patient preference.
Discuss next steps after genetic counseling (if applicable).
Address any ongoing concerns or questions.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for prenatal screening and diagnosis of chromosomal abnormalities