Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Document any pregnancy-related complaints the patient may have, such as:
Nausea and vomiting
Fatigue
Back pain
Urinary frequency
Inquire about any concerns related to advanced maternal age.
History of Present Illness:
Gravida (number of pregnancies) and Para (number of deliveries)
Current gestational age by dating method (ultrasound or LMP – last menstrual period)
Prenatal care history (number of prenatal visits, adherence to prenatal testing)
Past Medical History:
Chronic medical conditions (e.g., diabetes, hypertension)
Past surgical history (including cesarean sections)
Family history (genetic conditions)
Social History:
Occupation and potential workplace exposures
Tobacco, alcohol, or drug use
Prenatal vitamins and supplements use
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal unless pre-existing medical conditions are present.
General examination: Assess for weight gain, edema, and overall well-being.
Fundal height measurement to estimate gestational age (correlated with ultrasound dating).
Fetal heart rate monitoring (Doppler) to assess fetal well-being.
Prenatal Testing:
First Trimester:
Nuchal translucency scan (NT scan) and combined first-trimester screening for chromosomal abnormalities (Down syndrome, etc.).
Second Trimester:
Quad screen (maternal serum AFP, hCG, uE3, and inhibin-A) for Down syndrome and neural tube defects.
Anomaly scan (detailed ultrasound) to assess fetal anatomy for any structural abnormalities.
Amniocentesis or chorionic villus sampling (CVS) – may be offered based on patient’s age, risk factors, or abnormal screening results. These are invasive prenatal diagnostic tests to directly analyze fetal chromosomes.
Laboratory Findings:
Routine prenatal labs (complete blood count, blood type, Rh factor, rubella immunity, etc.)
Additional tests as indicated (glucose tolerance test for gestational diabetes, Group B strep screening)
Assessment:
Document the gestational age and estimated due date.
Discuss any concerns or risks related to advanced maternal age, such as:
Increased risk of chromosomal abnormalities in the fetus.
Increased risk of pregnancy complications (e.g., gestational diabetes, preeclampsia).
Summarize the results of prenatal testing and any interventions performed.
Plan:
Continued routine prenatal care: Regular visits with a healthcare provider to monitor the pregnancy and fetal development.
Fetal monitoring: Ultrasound scans and fetal heart rate monitoring as needed.
Management of pre-existing medical conditions: Collaboration with specialists if necessary to optimize maternal health during pregnancy.
Genetic counseling: May be offered if there is a family history of genetic conditions or abnormal prenatal screening results.
Delivery plan: Discuss options for vaginal delivery or cesarean section based on individual circumstances.
Education:
Provide information on healthy lifestyle choices during pregnancy (diet, exercise, sleep).
Discuss potential pregnancy discomforts and coping strategies.
Explain the rationale and benefits of prenatal testing options.
Encourage communication of any concerns or questions throughout the pregnancy.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. The specific management of an AMA pregnancy will depend on the individual patient’s health and risk factors. Regular prenatal care with a qualified healthcare provider is crucial for a healthy pregnancy outcome.