Subject:

Version 4 created July 17^th 2021 by Dr. John Robertson, licensed under a GPL.
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Reason For Referral

Maternal Medical Complications
Severe Hypertension ≤ 34 weeks
Diabetes Maternal Disease
Diabetes Fetal Complications

Significant Maternal Disease
Choose from list Renal Disease ≤ 34 weeks with impaired renal function and/or hypertension Cardiac Disease Gastrointestinal Disease ≤ 34 weeks unresponsive to treatment History of solid organ transplant Significant neurological disorder Psychiatric disorder requiring hospital admission Significant respiratory disorder Connective tissue disorder Endocrine disorder other than diabetes Pre-pregnant BMI ≥ 40

OB Complications in Prior Pregnancy
Cervical incompetence
Uterine Anomaly
PPROM Preterm Birth
Severe IUGR HTN del ≤ 34 wk
Poor outcome Stillbirth

OB Complications in Current Pregnancy
PPROM PremLabour
Multiples IUGR Oligo APH
Arrythmia Placental concerns

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* Click on “EDC by LMP” or “EDC by U/S” to circle your choice.