Pregnancy module (form 1): complete on admission/enrolment, 11 May 2020

PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 PREGNANCY MODULE (Form 1): complete on admission/enrolment Is Subject Pregnant or recently delivered within 21 days from onset of symptoms? ☐Unknown If “yes” Answer the following Q1. STATUS UPON ADMISSION Pregnant not in labour Pregnant in labour Postpartum [days]* Post-abortion, miscarriage Number of fetuses Best estimate of gestational age in completed weeks ☐ ☐ ☐ [days] Breastfeeding? ☐ YES ☐ NO ☐ ☐Singleton ☐Twin ☐Triplet ☐Other [number] ☐ Unknown [_W_][_ W_] weeks * This form does not need to be completed if symptoms of COVID-19 started more than 21 days after the end of the pregnancy Q2. ABORTION OR MISCARRIAGE prior to admission Date of induced abortion or spontaneous abortion/miscarriage? Were symptoms of COVID-19 disease present at the time? [_D_][_ D_]/[_ M_][_ M _]/[_2_][_0 _][_ Y _][_ Y _] ☐ YES ☐ NO ☐ UNKNOWN Q3. OBSTETRIC HISTORY Number of previous pregnancies beyond 22 weeks gestation [number] Number of previous vaginal deliveries [number] Number of previous caesarean deliveries [number] ☐Yes ☐No Please tick any which apply to previous deliveries: Preterm birth (<37 weeks’ gestation) Congenital anomaly Stillborn Neonatal death (0-6 days) Weight < 2.5kg ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES (day: ) ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 Q4. ALCOHOL, DRUGS– RISK FACTORS Alcohol consumption during this pregnancy ☐ YES ☐ NO ☐ UNKNOWN Illicit and recreational drug use during this pregnancy ☐ YES ☐ NO ☐ UNKNOWN Q5. MEDICATIONS DURING THIS PREGNANCY (Prior to onset of current illness episode) Fever or pain treatment Acetaminophen/paracetamol ☐YES ☐NO ☐UNKNOWN NSAID/s ☐YES ☐NO ☐UNKNOWN Other/s (specify): [__________________________________________] Anticonvulsants ☐YES ☐NO ☐UNKNOWN If yes, specify generic name: [__________________________________] Anti-nausea ☐YES ☐NO ☐UNKNOWN If yes, specify generic name: [__________________________________] Prenatal vitamins and micronutrients ☐YES ☐NO ☐UNKNOWN If yes, specify generic name: [__________________________________] Antivirals ☐YES ☐NO ☐UNKNOWN If yes, specify generic name: [__________________________________] Antibiotics ☐YES ☐NO ☐UNKNOWN If yes, specify generic name: [__________________________________] Q6. ADMISSION SIGNS AND SYMPTOMS Vaginal watery discharge ☐ YES ☐ NO ☐ UNKNOWN Vaginal bleeding ☐ YES ☐ NO ☐ UNKNOWN Headaches ☐ YES ☐ NO ☐ UNKNOWN Vision changes ☐ YES ☐ NO ☐ UNKNOWN Right upper quadrant (abdominal) pain ☐ YES ☐ NO ☐ UNKNOWN Decreased or no fetal movement ☐ YES ☐ NO ☐ UNKNOWN Uterine contractions ☐ YES ☐ NO ☐ UNKNOWN Q7. FETAL HEART RATE (first available data at presentation/admission) Fetal heart rate (FHR): [_ _][_ _][_ _] beats/min Weight > 4.5kg PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 PREGNANCY MODULE (Form 2): follow-up (For Daily Assessment, frequency of completion determined by available resources) Date of follow up [_D_][_D_]/[_M_][_M_]/[_2_][_0_][_Y_][_Y_] Q1. FETAL HEART RATE (Follow up) Fetal heart rate (record most abnormal value between 00:00 to 24:00) (FHR): [_ _][_ _][_ _] beats/min Q2. TREATMENT DURING HOSPITALISATION At ANY time during hospitalisation, did the patient receive/undergo: Tocolysis ☐ YES ☐ NO ☐ UNKNOWN Induction of labour ☐ YES ☐ NO ☐ UNKNOWN Blood transfusion ☐ YES ☐ NO ☐ UNKNOWN PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 PREGNANCY MODULE (Form 3): complete at discharge/death *Form 3 should still be completed if delivery occurred in a prior hospitalization Q1. DELIVERY, PREGNANCY AND MATERNAL OUTCOMES Delivery during admission ☐Yes ☐ No Delivery date: [_D_][_ D_]/[_ M_][_ M _]/[_2_][_0 _][_ Y _][_ Y_] Mode of delivery: ☐ Vaginal delivery ☐ Caesarean section Onset of labour ☐ Spontaneous ☐ Induced ☐ Caesarean section before labour ☐ Unknown Fetal presentation at delivery ☐ cephalic ☐ transverse ☐ breech Amniotic fluid at delivery ☐ Clear ☐ Meconium stained ☐ Unknown Other maternal outcomes/pregnancy complications Gestational diabetes Gestational hypertension Anaemia (Hb < 11 g/dL) Hyperemesis Intrauterine growth restriction Placental previa/accreta/percreta Bacterial infection prior to hospital visit Pre eclampsia/eclampsia Placental abruption Preterm contractions Preterm labour Preterm rupture of membranes Early or mid term miscarriage Haemorrhage If haemorrhage, which type: Embolic disease Anaesthetic complication ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN ☐ Antepartum/intrapartum ☐ Postpartum hemorrhage ☐ Abortion-related ☐ YES ☐ NO ☐ UNKNOWN ☐ YES ☐ NO ☐ UNKNOWN PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 Q2. PREGNANCY STATUS AT DISCHARGE Pregnancy outcome ☐Undelivered ☐Spontaneous abortion ☐ Induced abortion ☐Missed abortion ☐Macerated stillbirth ☐Fresh stillbirth ☐Livebirth ☐ Postabortion/postpartum on admission Maternal death If yes, what was the underlying cause of death? ☐ YES ☐ NO [ ] Abortive outcome [ ] Hypertensive disorders in pregnancy, childbirth and the puerperium [ ] Obstetric haemorrhage [ ] Pregnancy-related infection [ ] Other obstetric complication not included in above causes [ ] Unanticipated complications of management (e.g. anaesthesia-related complications) [ ] Indirect maternal death [ ] Obstetric death of unspecified cause [ ] Deaths from a coincidental cause (e.g. motor vehicle accident) Q3. Sample Collection Any sampling conducted? If so, please describe the test and the results ☐ Amniotic fluid [_test description__] [_date of collection__] [_____result______] ☐ Placenta [_test description__] [_date of collection__] [_____result______] ☐ Cord blood [_test description__] [_date of collection__] [_____result______] ☐ Vaginal swab [_test description__] [_date of collection__] [_____result______] ☐ Faeces/rectal swab [_test description__] [_date of collection__] [_____result______] ☐ Pregnancy tissue in the case of fetal demise / induced abortion [_test description__] [_date of collection__] [_____result______] ☐ Breastmilk [_test description__] [_date of collection__] [_____result______] Q4. NEONATAL OUTCOMES Date of birth [DD/MM/YYYY] Time of birth [e.g. 14:21] [_D_][_ D_]/[_ M_][_ M _]/[_2_][_0 _][_ Y _][_ Y _] [____:____] PARTICIPANT ID I___I I___I I___I I___I I___I -- I___I I___I I___I I___I PREGNANCY MODULE 11 MAY 2020 This module is a part of the COVID-19 CASE RECORD FORM RAPID version (14APR2020). © World Health Organization 2020. Some rights reserved. This publication is available under the license CC BY-SA 3.0 IGO. This publication is adapted from the COVID-19 Case Record Forms (CRF) published by ISARIC on behalf of Oxford University. WHO reference number: WHO/2019-nCoV/Pregnancy_CRF/2020.4 Participant ID of the mother: [___][___][___][___][___]-- [___][___][___][___] – [__Single digit Baby ID_]* *Complete one form per neonate COVID-19 lab test of fetus or neonate ☐ Performed ☐ Not performed ☐ Unknown If yes: [_sample collected__] [_test description__] [_date of collection__ ] [_____result______] Apgar score at 5 minutes Score: [___][___] Gestational age Weeks: [___][___] Days: [_____] Birth weight Grams: [___][___][___][___] Respiratory distress syndrome ☐ YES ☐ NO ☐ UNKNOWN Neonatal outcome ☐ Discharged healthy ☐ Discharged with complications/sequelae Details: [________________________________________] ☐ Clinical referral to specialist ward /other hospital Details: [________________________________________] ☐ Death Date of death: [_D_][_ D_]/[_ M_][_ M _]/[_ Y _][_ Y _] ☐ Unknown If neonate died, primary cause of death ☐ Preterm/low birth weight ☐ Birth asphyxia ☐ Infection ☐ Birth trauma ☐ Congenital/birth defects ☐ Other ☐ Unknown Any congenital anomalies ☐ Neural tube defects ☐ Microcephaly ☐ Congenital malformations of ear ☐ Congenital heart defects ☐ Orofacial clefts ☐ Congenital malformations of digestive system ☐ Congenital malformations of genital organs ☐ Abdominal wall defects ☐ Chromosomal abnormalities ☐ Reduction defects of upper and lower limbs ☐ Talipes equinovarus/clubfoot