Pregnancy and Perinatal History



**Date family history taken (MM/DD/YYYY):Pregnancy History**Prior pregnancy (both term and not to term): FORMCHECKBOX Yes FORMCHECKBOX No (Skip A-D) FORMCHECKBOX Unknown (Skip A-D)Number of prior pregnancies: pregnanciesYear of last delivery / miscarriage/ medical termination:Number of miscarriages: miscarriagesNumber of medical terminations: medical terminationsPediatric-specific Perinatal HistoryThese elements are recommended for pediatric stroke studies of neonates ONLY (i.e., not appropriate for stroke studies of children).**Mother’s age at the time she gave birth to the participant/subject: years**Number of live born children the participant/subject’s mother has delivered? children**Total number of times the participant/subject’s mother has been pregnant, regardless of whether these pregnancies were carried to term (A current pregnancy, if any, is included in this count):**Did the mother experience any of the following during the prenatal period, at the time of delivery, or soon after delivery with the participant/subject?Preeclampsia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownb. Other hypertensive disorder FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatalc. Oligohydramnios FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownd. Gestational diabetes FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknowne. Prolonged (i.e., > 24 hours) rupture of membranes during delivery FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownf. Chorioamnionitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIF YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatalg. Other illness(es) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify illness(es):If YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatal FORMCHECKBOX Postnatalh. Decreased fetal movement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatali. Fever during delivery of participant/subject FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownj. Meconium staining of the amniotic fluid FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownk. Intravascular catheter placed in newborn period FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownl. Placenta sent for pathology FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownm. Placental abnormalities FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownn. Fetal heart rate abnormality FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatalo. Fetal abnormalities recognized in utero FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify abnormality(ies):p. Maternal infection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify infection(s):If YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatal FORMCHECKBOX Postnatalq. Lack of prenatal care FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknownr. Maternal drug abuse FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknowns. Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify: FORMCHECKBOX Prenatal FORMCHECKBOX Perinatal FORMCHECKBOX PostnatalPediatric-specific Delivery HistoryThese elements are recommended for pediatric stroke studies of neonates ONLY (i.e., not appropriate for stoke studies of children).**Birth weight: kilograms**Gestational age at birth: weeks**APGAR 1 minute score: FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10**APGAR 5 minute score: FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10**APGAR 10 minute score: FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10***Was the child delivered full–term (>36 weeks)? FORMCHECKBOX No FORMCHECKBOX Yes**Mode of delivery of the neonate: FORMCHECKBOX Spontaneous FORMCHECKBOX Induced, specify reason: FORMCHECKBOX Unknown**Route of delivery of the neonate: FORMCHECKBOX Vaginal FORMCHECKBOX Caesarean**If caesarean, timing of the caesarean: FORMCHECKBOX Emergency FORMCHECKBOX Elective FORMCHECKBOX Unknown**Delivery modality type of the neonate: FORMCHECKBOX Breech FORMCHECKBOX Cephalic FORMCHECKBOX Unknown FORMCHECKBOX Other**Instrument(s) used to assist with the delivery of the participant/subject? FORMCHECKBOX None FORMCHECKBOX Vacuum FORMCHECKBOX Forceps FORMCHECKBOX Vacuum and Forceps FORMCHECKBOX Unknown***Timing of intracranial aneurysm rupture during pregnancy FORMCHECKBOX Before delivery FORMCHECKBOX During delivery FORMCHECKBOX After delivery*Date of Delivery: General InstructionsThis case report form (CRF) contains data elements related to pregnancy and perinatal history. The first question on the CRF may be applicable to both adult and pediatric stroke studies. The later questions are labeled as “pediatric-specific” and probably are only applicable for stroke studies in neonates.Important note: Data elements included on this CRF are considered Core (i.e., strongly recommended for all stroke clinical studies to collect), Supplemental – Highly Recommended (for studies of perinatal stroke) or Exploratory, as indicated by asterisks below:* Element is Core** Element is Supplemental – Highly Recommended*** Element is ExploratorySpecific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.The CRF includes all instructions available for the data elements currently. ................
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