Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Prenatal visit for confirmed multiple gestation (twins, triplets, etc.)
(Specify) Symptoms may be similar to a singleton pregnancy but can be more pronounced due to increased fetal demands (e.g., increased nausea, fatigue, earlier Braxton-Hicks contractions).
History of Present Illness:
Gestational age at confirmation of multiple gestation.
Method of confirmation (ultrasound).
Chorionicity (monochorionic or dichorionic) and amnionicity (monoamniotic, diamniotic, or triamniotic) determined by ultrasound (relevant for potential complications).
Fetal number and viability confirmed by ultrasound.
Any bleeding, cramping, or other pregnancy-related symptoms.
Past Medical History:
Underlying medical conditions (e.g., chronic hypertension, diabetes) that may require closer monitoring in a multiple gestation.
History of infertility treatments (associated with increased risk of multiples).
Previous pregnancy history (previous multiple gestations, preterm delivery, etc.).
Family History:
Family history of multiple gestations (may increase risk).
Medications:
List all current medications, including prenatal vitamins.
Social History:
Assess social support system and ability to manage a multiple gestation pregnancy.
Physical Exam:
Vital signs: Monitor for signs of preeclampsia (elevated blood pressure, protein in urine).
Fundal height: May be larger than expected for gestational age due to multiple fetuses.
Abdominal palpation: Leopold maneuvers may be used to assess fetal position and estimate fetal number (limited accuracy in higher-order multiples).
Fetal heart tones: Doppler ultrasound used to assess heart rate of each fetus (important for identifying potential complications).
Laboratory Tests:
Complete blood count (CBC)
Basic metabolic panel (BMP)
AFP (alpha-fetoprotein) and hCG (human chorionic gonadotropin) levels (may be used for monitoring in some cases)
Imaging Studies:
Ultrasound: Essential for:
Confirming chorionicity and amnionicity.
Monitoring fetal growth, development, and position.
Assessing for potential complications like nuchal translucency (increased risk for down syndrome) or congenital anomalies.
Amniocentesis or chorionic villus sampling (CVS) (may be offered for prenatal diagnosis of genetic conditions, especially in high-risk cases).
Assessment:
Multiple gestation (twins, triplets, etc.): Confirmed by ultrasound.
Chorionicity and amnionicity: Determined by ultrasound and influence potential complications.
Gestational age: Estimated by ultrasound based on fetal measurements.
Fetal viability: Confirmed by ultrasound assessment of fetal heart rate.
Differential Diagnoses:
Consider other conditions that can mimic a multiple gestation on initial ultrasound:
Uterine fibroids
Twin reversed arterial perfusion sequence (TRAP sequence) – a serious complication in monochorionic twins
Plan:
Increased frequency of prenatal visits: Closer monitoring for potential complications associated with multiple gestations (preeclampsia, preterm labor, fetal growth restriction).
Nutritional counseling: Increased calorie and nutrient intake to support the growth of multiple fetuses.
Fetal movement monitoring: Earlier awareness of potential complications by monitoring fetal kicks at home.
Delivery planning: Early discussion about potential delivery options (vaginal delivery vs. cesarean section) based on chorionicity, amnionicity, fetal presentation, and potential complications.
Referral: Consider referral to a high-risk pregnancy specialist for complex cases.
Education:
Educate the patient about the increased risks associated with multiple gestation.
Discuss the importance of prenatal care, healthy lifestyle choices, and adherence to medication regimens.
Provide information about potential delivery options and considerations.
Offer resources and support groups for parents expecting multiples.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Multiple gestation pregnancies require close monitoring and management due to the increased risk of complications. Early detection and proactive management are crucial for optimal outcomes for both mother and babies.