New Prenatal Consult

Thank you for your referral of Jane Doe, a 28-year-old Gravida 2, Para 1 at 20 weeks gestation. Her EDC is March 15, 2024, by first trimester ultrasound, done at 12 gestational weeks. She was referred because of elevated maternal BMI and gestational diabetes. This Pregnancy: - Elevated maternal BMI, gestational diabetes Past Obstetrical History: - Previous pregnancy complicated by preeclampsia Medical History: - Hypertension - Prenatal vitamins - No known drug allergies - Appendectomy in 2015 - History of HPV, last pap normal in 2022 Social History: - Non-smoker, occasional alcohol use - Software engineer - Supported by partner and family - Lives in urban community Physical Examination: - Blood pressure: 130/85 mmHg, Heart rate: 78 bpm, Weight: 180 lbs, Height: 5'6", BMI: 29 - Symphysis fundal height: 20 cm - Cephalic fetal presentation - Fetal heart rate: 150 bpm Prenatal Investigations: - Blood type: O+, Rh factor: positive, Hepatitis B: negative, Hepatitis C: negative, HIV: negative, Syphilis: negative, Rubella: immune, Varicella: immune, GBS: pending, complete blood count: normal - Maternal serum screen: low risk - Urine tests: normal - EDS score on Edinburgh PPDS: 5 Ultrasounds: - Ultrasound on October 1, 2023, at 20 weeks gestation, findings: cephalic presentation, anterior placenta, normal anatomy, estimated fetal weight in 50th percentile, normal amniotic fluid, BPP score: 8/8 Vaccination: - We discussed the vaccines recommended in pregnancy, including Tdap, influenza, and Covid. Patient is interested and will receive them at the next visit. Impression: - High-risk pregnancy due to gestational diabetes and elevated maternal BMI Plan: - I will assume this patient's care with shared care from the referring physician. - We discussed the Obstetrical call system and reviewed that we work in a teaching hospital and learners including medical students and residents work with our team and will most likely be involved in her care. - Follow-up appointment in 4 weeks - Recommended lifestyle modifications: balanced diet and regular exercise - Continue prenatal vitamins - Referral to a nutritionist for gestational diabetes management Thank you again for involving me in her care.