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ACOG Antepartum Record FORM D:
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INITIAL LABS:
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INITIAL LABS Date:
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BLOOD Type (ABO/Rh):
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Antibody Screen:
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Antibody Comment
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Hgb / Hct:
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Platelets Count:
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TSH:
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Free Thyroxine (T4)
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Rubella:
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VDRL/RPR Result:
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HIV Screen
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HBsAg:
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GC
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Chlamydia
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PAP Test Result:
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OPTIONAL LABS:
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Sickle Screen
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Hgb ELECTROPHORESIS:
• • •
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PPD Result:
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Cystic Fibrosis Screen Done
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Cystic Fibrosis Result:
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Tay-Sachs Screen Done?
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Tay-Sachs Result:
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Fam'l Dysautonomia Screen Done?
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Familial Dysautonomia
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Repeat HEMOGLOBIN Date:
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Repeat HEMOGLOBIN RESULT:
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Other Genetic Screening Test(s):
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Other Genetic Screening Test Dat
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Other Genetic Screen Result:
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Other Testing:
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Other Testing Comment(s):
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8-20 WEEK LABS:
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1st TM Aneuploidy Screen
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1st TM Aneuploidy Screen Date:
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1st TM Screen Result
• • •
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1st TM Screen Comment
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2nd TM Screen Obtained
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2nd TM MSAFP/Tri-Screen Date:
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2nd TM MSAFP/Tri-Screen Result:
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2nd TM Screen Comment
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Amnio/CVS Obtained
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Amnio/CVS Date:
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Amnio/CVS Result:
• • •
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Amnio/CVS Comment
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Early RhIG Needed ?
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RhIG Date:
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RhIG INDICATION:
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24-28 WEEK LABS:
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Hgb / Hct:
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Hgb/Hct Date:
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50g 1h GTT Date:
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50g 1h GTT Result:
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50g 1° GTT
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100g 3° GTT Date:
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FBS:
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1 Hour:
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2 Hour:
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3 Hour:
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28 wks RhIG?
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RhIG Given Date:
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32-36 WEEK LABS:
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3rd TM Hgb/Hct:
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3rd TM Hgb/Hct Date:
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3rd TM HIV (When Indicated) Date
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3rd TM HIV Result:
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3rd TM HIV Comment(s):
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3rd TM VDRL Date:
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3rd TM VDRL Result:
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3rd TM GC Date:
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3rd TM GC Result:
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3rd TM CT Date:
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3rd TM CT Result:
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GBS Screen Date:
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GBS Result
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