Prenatal and Perinatal History
Prenatal HistoryThese elements are most relevant to pediatric studies.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: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):Does the participant/subject’s mother have a history of:Previous pregnancy loss? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPreeclampsia during pregnancy of the participant/subject? (Preeclampsia is defined as a physician diagnosis of either preeclampsia or pregnancy-induced hypertension.) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownAnother hypertensive disorder during pregnancy of the participant/subject? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOligohydramnios (condition in pregnancy characterized by a deficiency of amniotic fluid)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownGestational onset diabetes during pregnancy of the participant/subject? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownFever during delivery of participant/subject? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownProlonged rupture of membranes (i.e., > 24 hours) during delivery of participant/subject? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownSecond stage of labor more than two hours? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownMeconium staining of the amniotic fluid? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownDelivery HistoryBirth weight Gestational age at birth (weeks):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 10APGAR 10 minute score: FORMCHECKBOX 0 FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10Mode of delivery of the neonate: FORMCHECKBOX Spontaneous FORMCHECKBOX Induced FORMCHECKBOX UnknownRoute of delivery of the neonate: FORMCHECKBOX Vaginal FORMCHECKBOX CaesareanIf Caesarean, timing of the procedure?: FORMCHECKBOX Emergency FORMCHECKBOX Elective FORMCHECKBOX UnknownDelivery modality type of the neonate: FORMCHECKBOX Breech FORMCHECKBOX Cephalic FORMCHECKBOX UnknownInstrument(s) used to assist with the delivery of the participant/subject? FORMCHECKBOX None FORMCHECKBOX Vaccum FORMCHECKBOX Forceps FORMCHECKBOX Vaccum and Forceps FORMCHECKBOX UnknownIs there a history of the following:Resuscitation of the participant/subject at delivery? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIntravascular catheter placed in newborn period? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPlacenta sent for pathology? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownPlacental abnormalities? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownCord abnormalities? (Cord abnormalities include tight nuchal cord, umbilical cord knot, and body cord.) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownFetal heart rate abnormality? (Fetal heart rate abnormalities are considered present if a treating physician noted repetitive or prolonged late decelerations, fetal bradycardia, nonreassuring fetal heart tracing, or fetal distress according to electronic fetal heart rate monitoring.) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownDecreased fetal movement? (Decreased fetal movement refers to a maternal report of decreased fetal movement before labor or decreased fetal movement during a nonstress test.) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownChorioamnionitis? (Chorioamnionitis is defined as a maternal temperature of at least 37.8 degrees C [100.4 degrees F] or a physician diagnosis of chorioamnionitis according to clinical symptoms alone.) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownOther pregnancy/delivery risk factors? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownGeneral InstructionsThis case report form (CRF) contains data elements related to pregnancy and perinatal history. The questions on the CRF are applicable to pediatric Friedreich’s Ataxia studies. Important note: None of the data elements included on this CRF is considered Core (i.e., strongly recommended for all Friedreich’s Ataxia clinical studies to collect). Rather, all of the data elements are exploratory and should only be collected if the research team considers them appropriate for their study.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module. ................
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