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PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET

version 0.12
Overview
Hospital Information
Name
Code
Location
Data Period

Instructions
1. The paper Maternal Mortality Form and the paper Gestational Trophoblastic Disease Form STILL HAVE T

LOGICAL SOCIETY

tic Disease Form STILL HAVE TO BE SUBMITTED.

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Maternal Fetal Form
PATIENT DATA
CASE NO

LASTNAME

FIRSTNAME

Birthday

Age

Service

LOGICAL SOCIETY

HISTORY
ADMIT DATE

OB Score
Gravidity

Parity

Term

Preterm

Abortion

Alive

ADMISSION AOG
Weeks

MEDICAL/SURGICAL HISTORY
Days

Last Year of Pregnancy

Category

OBSTETRIC HISTORY
Condition

Category

Condition

PRENATAL

DELIVERY

Antenatal Procedures

Delivery Date

DELIVERY AOG
Weeks

Days

Route

Malpresentation

VAGINAL DELIVERY - Only for the CURRENT pregnancy.


Delivery

Other Procedures

Episiotomy

CAESAREAN SECTION
Perineal Laceration

Elective/Emergency

Incision

Primary/Repeat

Hysterectomy

Tubal Ligation

Anesthesia

INFANT FETAL DATA

Tubal ligation

Anesthesia Route

Number of Infants

Gender

Fetal Characteristics

Weight (grams)

Length (cm)

Pediatric Age (weeks)

Apgar Score
1min

5min

DISCHARGE STATUS
10min

Neonatal Condition

DISCHARGE DATE

Fetal Neonatal Condition


Mother Condition

Category

Congenital Anomalies
Condition

Yes/No

Major/Minor

Lethal/Non-lethal

Pregnancy
Delivered
Yes/No

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Gyne Form

PATIENT DATA
CASE NO

662544
663187
663342
663235
662905
663793
664433
664228
657949
663778
665169
665306
665146
665243
665050
666445
666462
666552
666862
667623
668327
654908
668458
667729
669503
669826
669834
669867
669765
669918
670746
670773
671844
672999
672938
673398
673778
675035

LASTNAME

LUNGTAD
AYA-AY
RELOS
RODRIGO
PELAEZ
ARBUYES
TABEROS
YATAN
REBORTERA
DOTILLOS
DEPOSITARIO
DEL RIO
GENSES
SCHMIDT
CIPRES
REYES
LUNA
BABIA
MAGO
DUMOL
BAYLON
CANLAS
BORDO
MISA

FIRSTNAME

Birthday

HERMITA
1/12/1959
MARISSA DENG
1/4/1967
MA. TERESITA
9/11/1965
CLODUALDA
9/7/1942
JOCELYN
6/16/1976
ELEANOR
7/10/1969
FELINA
3/15/1977
GINA GLORIA
3/11/1959
TERESITA
9/29/1951
CORAZON
10/5/1956
TRINA
12/5/1974
ANA MARGARIT
6/9/1987
LINDA
12/26/1951
CECILIA
4/21/1953
MARCEL
5/29/1969
CHRISTINE
12/1/1965
EVELLA
8/14/1976
LORA
12/22/1951
ALWENDA
5/29/1975
ANABELLE
3/12/1972
MA. LOURDES
7/27/1982
STEPHANIE
8/22/1971
MARY JOY
8/2/1994
LETICIA
12/5/1957
MILMA
GUERRERO
7/4/1969
YGONA
GINA
1/11/1987
HASSIMAN
ROLARINA
10/2/1968
ALIMAGNO
JOSIE
2/14/1968
WAMAR
EVELYN
12/7/1964
FERNANDEZ KATHRINA
6/23/1986
OYSON
KATHERINE
3/15/1943
BARCELON
CRISPINA
6/14/1949
JAROMOHOM EMERENCIANA
1/23/1975
SENERPIDA MA. APRIL
11/14/1986
TENAZAS
STEPHANIE
7/15/1990
REGIS
OLIVA
6/3/1916
LAO
ALTHEA
4/26/1967
SARONA
AILEEN
8/6/1981

Age

Service

56
48
49
72
38
45
37
55
63
58
40
27
63
61
45
49
38
63
39
42
32
43
20
57
45
28
46
46
50
28
71
65
39
28
24
98
47
33

Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private

675822
675740
675750
676275
676205
676691
676655
677687
678759
678909
678736
678836
678964
679571
680747
679918
680386
680688
681478
681707
681802
682690
682713
682713
683275
684287
684296
685200
685992
686139
684499
686458
687096
687149
687741
687907
687896
687920
688201

YU
PHYLLIS
DAKAY
PREZEL
LOBRIGAS
EXEQUIELA
PARINASAN ROCELYN
BARCELON
CRISPINA
ARAAS
BARBARA
GO
KATHERINE
PEPITO
JESSICA
ABELARDE
JENNIFER
CARNACER
FLORENTINA
BODINEZ
EMILE
BABATUAN
FE
QUINONES
GERMAINE
PELICANO
MARIE ANTONE
TAN
IMELDA
DUHAYLUNGS SHEILA
YPANTO
QUENNIE
RAGANAS
RHODORA
ANCAJAS
MA. ELENA
CABAHUG
HERSCHEL NATA
SEPE
JUSTINE GRAC
SALVIO
MARINEL
CODINA
MARIA ELIZABE
CIPRES
KRISTINE
CORALES
LIZA
CARTEN
CLEOPATRA
YU
PIERE
UBANAN
BERNADETTE
ROSALES
HELEN
VELOSO
VANESSA
TANJILI
RADZELIE
BAGON-ON
MARY CAROLIN
OLIVA
MYRA
DIHANSAN
HALLEY ANNE
SUICO
SOR
BARAYUGA
JORJA
VERALLO
OWLETTE
DEGUZMAN GRACIOSA
DACUYAN
FELINA

6/27/1985
8/5/1984
4/10/1937
10/26/1988
6/14/1949
1/27/1965
11/25/1969
4/28/1966
1/23/1976
10/16/1962
3/16/1940
5/22/1973
10/30/1955
1/14/1963
4/4/1973
7/30/1990
9/9/1976
3/7/1985
9/20/1968
10/15/1980
7/5/1998
1/2/1984
2/16/1971
12/17/1991
11/2/1975
8/19/1941
8/31/1958
8/20/1980
2/26/1955
6/17/1985
10/16/1981
2/9/1991
12/16/1977
2/14/1999
9/4/1981
5/24/2000
12/19/1977
12/3/1968
1/16/1959

29
30
77
26
65
49
45
48
38
52
74
41
59
52
41
24
38
29
46
34
16
31
43
23
39
73
56
34
59
29
33
23
37
15
33
14
37
46
56

Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Charity
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private
Private

LOGICAL SOCIETY

HISTORY
ADMIT DATE

3/1/2014
3/2/2014
3/2/2014
3/2/2014
3/2/2014
3/3/2014
3/3/2014
3/3/2014
3/3/2014
3/3/2014
3/4/2014
3/4/2014
3/4/2014
3/4/2014
3/4/2014
3/5/2014
3/5/2014
3/5/2014
3/6/2014
3/7/2014
3/7/2014
3/7/2014
3/7/2014
3/7/2014
3/8/2014
3/9/2014
3/9/2014
3/9/2014
3/9/2014
3/9/2014
3/10/2014
3/10/2014
3/11/2014
3/12/2014
3/12/2014
3/13/2014
3/13/2014
3/15/2014

FINAL DIAGNOSIS
Gravidity

Parity

3
0
3
7
1
2
3
2
3
2
0
2
2
2
0
1
0
5
0
3
2
3
0
2
1
0
2
5
8
0
5
2
0
1
0
8
4
0

Category

3
0
3
7
1
2
3
2
3
2
0
2
2
2
0
1
0
5
0
3
2
3
0
2
1
0
2
4
8
0
5
2
0
1
0
8
3
0

Condition

Malignant Neoplasm of the Cor Endometrial carcinoma, corpus


Pelvic Symptoms
Endometriosis
Adenomyosis, endometriosis
Malignant Neoplasm of the CervAdenocarcinoma, cervix
Endometriosis
Adenomyosis, endome
Malignant Neoplasm of the OvaMetastatic neoplasm, ovary
Benign Neoplasm of the Uterus Endometrial polyp
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Malignant Neoplasm of the OvaMucinous adenocarci
Malignant Neoplasm of the CervOther squamous cell type, cervix
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Genital Prolapse
Cysto-rectocoele
Benign Neoplasm of the Uterus
Endometriosis
Adenomyosis, endometriosis
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Endometrial polyp
Genital Prolapse
Unspecified
Endometriosis
Ovary, endometriosis
Other Benign Conditions of the Corpus luteum cyst,
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Menstrual Disorders
Meno-metrorrhagia
Pelvic Inflammatory Disease
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Malignant Neoplasm of the OvaSerous adenocarcino
Endometriosis
Adenomyosis, endometriosis
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Leiomyoma
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Benign Neoplasm of the Uterus Endometrial polyp
Benign Neoplasm of the Uterus
Endometriosis
Ovary, endometriosis
Pelvic Symptoms
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified

3/16/2014
3/16/2014
3/16/2014
3/17/2014
3/17/2014
3/17/2014
3/17/2014
3/18/2014
19-Mar
3/19/2014
3/19/2014
3/19/2014
3/20/2014
3/20/2014
3/21/2014
3/21/2014
3/21/2014
3/21/2014
3/22/2014
3/23/2014
3/24/2014
3/24/2014
3/24/2014
3/24/2014
3/25/2014
3/26/2014
3/26/2014
3/27/2014
3/28/2014
3/28/2014
3/28/2014
3/29/2014
3/30/2014
3/30/2014
3/31/2014
3/31/2014
3/31/2014
3/31/2014
3/31/2014

0
0
4
5
2
3
4
2
2
3
6
0
0
2
0
0
2
0
3
0
0
0
2
0
0
8
5
2
6
1
0
0
0
0
0
0
1
3
5

0
0
4
5
2
2
2
2
2
3
3
0
0
2
0
0
2
0
3
0
0
0
2
0
0
7
5
1
5
1
0
0
0
0
0
0
1
3
4

Malignant Neoplasm of the OvaGerm cell type, ovary


Benign Neoplasm of the Uterus Leiomyoma
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Pelvic Inflammatory Disease
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Leiomyoma
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Pelvic Inflammatory Disease Pelvic Abscess
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Epithelial Neoplasm of the OvarSerous cystadenoma,
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Benign Neoplasm of the Uterus
Pelvic Inflammatory Disease Other pelvic inflammatory diseases
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Epithelial Neoplasm of the OvarMucinous cystadenom
Benign Neoplasm of the Uterus Leiomyoma
Pelvic Inflammatory Disease
Diseases of Bartholin's Gland Cyst of Bartholin's gl
Other Benign Conditions of the Follicular cyst of ovar
Pelvic Inflammatory Disease
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Pelvic Inflammatory Disease
Malignant Neoplasm of the Cor Endometrial carcinoma, corpus
Genital Prolapse
Relaxed vaginal vault
Benign Neoplasm of the Uterus Leiomyoma
Pelvic Inflammatory Disease Pelvic inflammatory diseases, prob. Bact
Endometriosis
Adenomyosis, endometriosis
Endometriosis
Pelvic peritoneum, endometriosis
Germ Cell Tumors
Pelvic Symptoms
Benign Neoplasm of the Uterus Endometrial hyperplasia, unspecified
Other Benign Conditions of the Paratubal serous cyst, fallopian tube
Epithelial Neoplasm of the OvarSerous cystadenoma,
Epithelial Neoplasm of the OvarMucinous cystadenom
Endometriosis
Pelvic peritoneum, endometriosis
Benign Neoplasm of the Uterus Endometrial polyp
Malignant Neoplasm of the CervOther neoplasm type, cervix

Laterality

For Malignancy For Genital


Only
Prolapse Only

OPERATIONS

Stage

Elective/Emergency

Approach

Elective

Laparotomy Uterus

Elective
Elective
Elective
Elective
Elective

Vaginal
Laparotomy
Vaginal
Laparotomy
Laparotomy

Elective
Elective
Elective
Elective
Elective
Elective
Elective

Vaginal
Vagina
Vaginal
Uterus
Laparotomy Ovary
Laparotomy Uterus
Vaginal
Uterus
Vaginal
Uterus
Laparoscopic Ovary

Degree

Organ

al carcinoma, corpus

sis, endometriosis
inoma, cervix
Both
neoplasm, ovary

III
IV

al carcinoma, corpus
Both
amous cell type, cervix I
al carcinoma, corpus
I
al hyperplasia, unspecified
Complete

sis, endometriosis

First

Uterus
Uterus
Uterus
Uterus
Uterus

Right
Right
al carcinoma, corpus

Elective

Vaginal

Uterus

al carcinoma, corpus

II

Elective
Elective
Elective
Elective

Laparotomy
Laparotomy
Vaginal
Laparotomy

Uterus
Uterus
Uterus
Ovary

Elective

Laparotomy Uterus

Elective
Elective
Elective

Laparotomy Uterus
Vaginal
Uterus
Vaginal
Uterus

Elective

Laparotomy Ovary

Elective
Elective

Laparotomy Uterus
Vaginal
Uterus

al hyperplasia, unspecified
Right
sis, endometriosis

al carcinoma, corpus
al hyperplasia, unspecified

dometriosis

al hyperplasia, unspecified

type, ovary

Elective
Elective
Elective

Laparotomy Ovary
Laparotomy Uterus
Laparotomy Uterus

Elective
Elective
Elective
Elective
Elective
Elective
Elective
Elective
Elective
Elective

Laparotomy Uterus
Laparotomy Uterus
Laparotomy Uterus
Laparotomy Uterus
HysteroscopicUterus
Laparotomy Uterus
Laparotomy Uterus
Laparotomy Ovary
Vaginal
Uterus
HysteroscopicUterus

Elective
Elective
Elective

Vaginal
Uterus
Laparotomy Ovary
HysteroscopicUterus

Left
Both

Elective

Vaginal

Vulva and

al hyperplasia, unspecified

Elective

Vaginal

Uterus

Elective
Elective

Vaginal
Vaginal

Vagina
Uterus

Elective

HysteroscopicLaparosco

Elective
Elective
Elective
Elective
Elective
Elective

HysteroscopicUterus
Laparoscopic Fallopian
Laparotomy Ovary
Laparotomy Ovary
Laparoscopic Laparosco
Vaginal
Uterus

al carcinoma, corpus

III

al carcinoma, corpus

al hyperplasia, unspecified

al carcinoma, corpus
Left
al hyperplasia, unspecified

ic inflammatory diseases
al hyperplasia, unspecified
Left

al carcinoma, corpus
aginal vault

I
Complete

mmatory diseases, prob. Bacterial


sis, endometriosis
toneum, endometriosis

al hyperplasia, unspecified
serous cyst, fallopian tube
Left
Left
toneum, endometriosis

plasm type, cervix

IV

DISCHARGE
Procedure

Laterality

Hysterectomy

Status

Alive
Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Alive
Alive
Alive
Endometrial polypectomy
Without hysterect Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Radical abdominal hysterec With hysterectomy Alive
TAHBSO (total Both
With hysterectomy Alive
Alive
Repair of cystocoele
With hysterectomy Alive
Simple curettage
Without hysterect Alive
Salpingo-ooph Right
With hysterectomy Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Endometrial polypectomy
Without hysterect Alive
Vaginal hysterectomy
With hysterectomy Alive
Ovarian cyste Right
Without hysterect Alive
Alive
Fractional curettage
Without hysterect Alive
Alive
Alive
Radical abdominal hysterec With hysterectomy Alive
Total abdominal hysterectomWith hysterectomy Alive
Fractional curettage
Alive
Salpingo-ooph Both
With hysterectomy Alive
Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Alive
TAHBSO (total Both
With hysterectomy Alive
Fractional curettage
Without hysterect Alive
Endometrial polypectomy
Without hysterect Alive
Alive
Adhesiolysis ofLeft
Without hysterect Alive
Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Fractional curettage
Without hysterect Alive

Ovarian cyste Left


Without hysterect Alive
Myomectomy
Without hysterect Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Total abdominal hysterectomWith hysterectomy Alive
Total abdominal hysterectomWith hysterectomy Alive
Endometrial biopsy
Without hysterect Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
TAHBSO (total abdominal hyWith hysterectomy Alive
Salpingo-ooph Left
Without hysterect Alive
Fractional curettage
Without hysterect Alive
Endometrial biopsy
Without hysterect Alive
Alive
Fractional curettage
Without hysterect Alive
Salpingo-ooph Left
Without hysterect Alive
Myomectomy
Without hysterect Alive
Alive
MarsupializatioLeft
Without hysterect Alive
Alive
Alive
Simple curettage
Without hysterect Alive
Alive
Alive
Other operations
Without hysterect Alive
Vaginal hysterectomy
With hysterectomy Alive
Alive
Alive
Video laparoscopy (operativeWithout hysterect Alive
Alive
Alive
Endometrial biopsy
Without hysterect Alive
Fimbriectomy Right
Without hysterect Alive
Salpingo-ooph Left
Without hysterect Alive
Salpingo-ooph Left
With hysterectomy Alive
Video laparoscopy (operativeWithout hysterect Alive
Endometrial polypectomy
Without hysterect Alive
Alive

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Maternal Mortality Form

PATIENT DATA
CASE NO

HISTORY
LASTNAME

FIRSTNAME

Birthday

Age

ADMIT DATE

GICAL SOCIETY

AOG
Weeks

Days

ANTECEDENT AND UNDERLYING CAUSE


Type
Antecedent
Underlying

COMPLICATIONS AND DEATH


Timing of Death
Specific

Immediate Cause

Onset of Complications

Specific

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
GTD Form

PATIENT DATA
CASE NO

LASTNAME

FIRSTNAME

Birthday

Age

HISTORY
ADMIT DATE

GICAL SOCIETY

Gravidity

Parity

OB Score
Term

Preterm

Abortion

Alive

ADMISSION AOG
Weeks
Days

Last Year of Pregnancy

Diagnosis

HYDATIDIFORM MOLE
Type
Complications

Metastasis

Chemoprophylaxis

Drug

High Risk Factor

Mode of Evacuation

Condition on Discharge

Present Status

Cause of Death

GTN/PSTT/ETT
Histopathology

Antecedent Pregnancy

Baseline hCG levels (mIU/mL)

FIGO Anatomic Stage

Modified WHO Score

Risk

Combined FIGO-WHO Score


Age

Combined FIGO-WHO Score


Antecedent Pregnancy

Interval Months from Index Pregnancy

Pretreatment hCG (mIU/mL)

Largest Tumor Size (cm)

Metastasis

Site of Metastasis

Number of Metastases Identified

Previous Failed Chemotherapy

Total Score

ADDITIONAL TREATMENT
Other Surgical Intervention

Chemotherapy

Radiotherapy

CONDITION
Present Condition

Cause of Death

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Obstetric Diseases and Procedures Report

SECTIONS
ONE
TWO
THREE
FOUR
FIVE
SIX
SEVEN
EIGHT
NINE

CONTENTS
ADMISSIONS DATA
DATA ON DELIVERED PATIENTS
OBSTETRIC AND MEDICAL COMPLICATIONS IN DELIVERED PATIENTS
PROBLEMS DURING LABOR
PROBLEMS AMNIOTIC FLUID AND PLACENTA
COMPLICATIONS DURING DELIVERY
COMPLICATIONS DURING POST-PARTAL PERIOD
PROCEDURES
ABORTIONS, ECTOPIC PREGNANCIES, TROPHOBLASTIC DISEASES

SECTION ONE: ADMISSIONS DATA


TOTAL NUMBER OF OBSTETRIC ADMISSIONS
DELIVERED PATIENTS
ANTEPARTAL PATIENTS DISCHARGED NOT DELIVERED
ABORTIONS
ECTOPIC PREGNANCIES
TROPHOBLASTIC DISEASES

AGE RANGE OF PATIENTS


LESS THAN 20
20 TO 34
35 AND ABOVE
PARITY
Nullipara
Para 1-5
MORE THAN 5
MATERNAL OUTCOME
Prepare Maternal Mortality Forms for All Maternal Deaths, Submit forms with this summary
DISCHARGED ALIVE
DISCHARGED ALIVE BUT MORIBUND
DIRECT MATERNAL DEATHS
INDIRECT MATERNAL DEATHS
NONMATERNAL DEATHS
TOTAL
FETAL OUTCOME - BASED ON OBSTETRIC AGE OF GESTATION

LIVE-BIRTHS
STILL BIRTHS
NEONATAL DEATHS

SECTION TWO: OBSTETRIC AND MEDICAL COMPLICATION IN DELIVERED PATIENTS


( using FIGO Committee on Perinatal Health-simplified ICD 10 coding,April 2000)
HYPERTENSIVE DISORDERS in PREGNANCY
010.9
Pre-existing (chronic hypertension with BP 140/90)
011.9
Pre-existing (chronic hypertension with superimposed preeclampsia)
012.1
HELLP Syndrome
012.2
Proteinuria (>0.30 gms/24 hr)
013.x
Edema with proteinuria
Gestational hypertension
014.0
Mild preeclampsia (BP 140/90, protein 0.3 gms/24 hr)
014.1
Severe preeclampsia (BP > 160/110, protein > 0.3gms/24 hr)
014.9
Preeclampsia unspecified
015.9

Eclampsia
Maternal Disorders predominantly related to pregnancy

020.9

Hemorhage in Early Pregnancy (< 22 weeks)


ABORTIONS
Threatened abortion
Incomplete abortion
Inevitable abortion
Imminent abortion
Missed abortion
Blighted ovum

Septic abortion
Induced abortion
Ectopic Pregnancy
Tubal ectopic pregnancy
Abdominal ectopic pregnancy
Ovarian ectopic pregnancy
Ectopic pregnancy, unspecified
021.1

022.0
022.1
022.3

Hyperemesis gravidarum, severe


(demanding treatment in hospital)
Venous complications
Varicose veins of lower extremity
Genital varicose veins
Deep vein thrombosis

022.4

Hemorrhoids

023.0

Urinary Tract Infection


Kidney
Urinary Tract Infection

Acute pyelonephritis
Chronic pyelonephritis

023.1

Bladder
Acute cystitis
Chronic cystitis
Renal or ureteral calculus
Urinary tract infection
Asymptomatic bacteriuria
Other

023.2
098.1

Genital Tract Infection

098.2

Syphilis
Gonorrhea

Z21.x
098.3
098.6

Herpes simplex
Chlamydia
Group B Streptococcus
Bacterial Vaginosis
HIV or AIDS
Other sexually transmitted diseases
Malaria
Herpes gestationalis
Diabetes mellitus

024.0

Diabetes mellitus Insulin dependent

024.1
024.4

Diabetes mellitus non-Insulin dependent

025.x
026.5
026.6

Malnutrition (BMI less than 19.8)


Supine Hydrotensive syndrome
Liver Disorders
Hepatitis B
Hepatitis A
Acute Fatty Liver
Multiple gestation
Twin
Triplet

030.0
030.1

Gestational diabetes mellitus

030.x

Other
Malpresentation

032.1
032.1

Frank breech
Complete breech
Footling Breech
Transverse Lie

032.2
032.2
032.3

Oblique Lie
Face

032.3
032.3

Brow
Chin
Prolapsed Arm

032.5

Multiple gestation with malpresentation for one or more fetus

033.9

Disproportion (known or suspected)

034.2

Previous Caesarian Section

034.3
034.9
035.9
036.0
036.2
036.3
036.4

Cervical Incompetence
Abnormalities of pelvic organs (see later)
Fetal Abnormality and Damage
Rhesus Isoimmunization
Hydrops Fetalis
Fetal Hypoxia
Intrauterine Death (<22 weeks)
Intrauterine Death (>22 weeks)
Poor Fetal Growth

036.5
036.6

040.x
041.0
041.1
042.0
042.1
042.9
044.0
044.1
045.0
045.9

046.8
047.9

Excessive Fetal Growth

Polyhydramnios
Oligohydramnios
Chorioamnionitis
Premature rapture of membranes
Onset of Labor w/in 24 hours
Onset of Labor after 24 hours
Unspecified
Placenta Previa without Hemorrhage
Placenta Previa with Hemorrhage
Abruptio placenta with coagulation defect
Abruptio placenta (only)
Placenta accreta
Placenta percreta
Placenta increta
Other antepartum hemorrhage
False Labor

Preterm Labor
048.x

Post Term >= 42 weeks


TROPHOBLASTIC DISEASES
Complete Mole
Partial Mole
Invasive Mole
Choriocarcinoma

Gestational trophoblastic neoplasia


Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
SECTION THREE: COMPLICATIONS OF LABOR AND DELIVERY
Preterm Delivery (up to 36 weeks)
ABNORMALITIES OF FORCES OF LABOR

Failure of Cervical Dilatation (<1 cm/hr in active phase)


Arrested active phase of labor
(no progress during 2 hrs after initially normal progress)
Precipitate labor
(nulli=<1 hours from 3 cm to delivery; multi=<0.5 hr)

Hypertonic uterine contraction


Long labor
Prolonged first stage
(for nulli > 15 from 3 cm to fully dilated, for multi > 11 h)
Prolonged second stage
(> 2 h from full dilated to delivery)

064.9
065.4
065.9
066.0
066.5
067.9
067.0
068.1
068.9
069.0

Obstructed Labor
Due to malposition or malpresentation
Due to fetopelvic disproportion
Due to maternal pelvic abnormality
Due to shoulder dystocia
Failed forceps or vacuum extraction
Intrapartum hemorrhage
With coagulation defect
Meconium in amniotic fluid
Fetal Distress
Prolapsed Cord

069.4

Vasa previa

070.0

Perineal Laceration
Unspecified
First Degree

( involving fourchette, labia, skin, vagina, vulva)

070.1
070.2
070.3

Second Degree
(involving 1st plus pelvic floor, perineal muscle, vaginal muscle)
Third Degree
(involving 2nd plus anal sphincter, rectovaginal septum)
Fourth Degree
(involving 3rd plus anal mucosa , rectal mucosa)

071.0
071.1
071.2
071.3
071.7

Other Obstetric Trauma


Rupture of uterus before onset of labor
Rupture of uterus during labor
Uterine inversion
Laceration of Cervix
Pelvic, vaginal, or vulvar hematoma
Uterine Dehiscence

072.0
072.1

Postpartum Hemorrhage
Due to Uterine Atony
Due to Retained Placenta
Due to other causes

073.0
074.9

Retained placenta without hemorrhage


Anesthetic complications, postpartum hemorrhage

075.9

Other complications of Labor and Delivery, not elsewhere classified

SECTION FOUR: DELIVERY AND OTHER PROCEDURES


080.0
Spontaneous vertex delivery
080.1
Spontaneous breech delivery
080.9
Spontaneous delivery, unspecified
081.0
Low forceps delivery
081.1
Mid cavity forceps delivery
081.2
Mid cavity forceps delivery with rotation
081.3
Other and unspecified forceps delivery
Elective outlet forceps delivery
081.4
Vacuum extractor delivery
081.5
Combination forceps/vacuum extractor
VBAC

082.0

082.1

082.2

Caesarean Section
Elective
Low Segment
Classical
Emergency
Low Segment
Classical
Cesarean Hysterectomy

082.9
083.0
083.1
084.0
084.1
084.2
084.8

Unspecified
Breech extraction
Breech Assisting
Multiple delivery, all spontaneous
Multiple delivery, all by forceps and vacuum extractor
Multiple delivery, all by Caesarean section
Other multiple delivery

084.9

Multiple delivery, unspecified


Other Procedures
Completion Curettage
Suction Curettage
Induction by prostaglandins
Total hysterectomy
Subtotal hysterectomy
Removal of extra-peritoneal embryo
Others
Salpingectomy
Salpingo-Oophorectomy
Manual extraction of placenta

SECTION FIVE:
085.X
086.0
087.1
087.2
088.1
090.0
090.1
090.2
091.0

COMPLICATIONS PREDOMINANTLY RELATED TO PUERPERIUM


Puerperal Sepsis
Wound Infection
Deep Phlebothrombosis
Hemorrhoids
Obstetric Air Embolism
Disruption of Caesarean Section Wound
Disruption of Perineal Obstetric Wound
Hematoma
Breast Infection
Nipple Infection

091.1

Breast abscess

SECTION SIX: OTHER MATERNAL DISEASES CLASSIFIABLE ELSEWHERE


BUT COMPLICATING PREGNANCY
099.0
099.1

Anemia
Disease of blood and immune mechanism
Leukemia
Megaloblastic Anemia
Anti-Phospolipid Antibody Syndrome

Other
Dengue
099.2

Endocrine, nutritional and metabolic diseases

Hyperthyroidism
Hypothyroidism
Nodular Nontoxic Goiter
Diffuse Nontoxic Goiter
Other
Diabetes (see above)
099.3

Mental Disorders and Diseases of the Nervous System


Seizure Disorders
Meningioma
Schizophrenia
Brief Reactive Psychosis
Drug Abuse and Dependency
Other

099.5

Diseases of the Respiratory System


Bronchial Asthma in Remission
Bronchial asthma in acute asthmatic attack
Pneumonia
Pulmonary Tuberculosis
Other

099.4

Diseases of the Circulatory System


Rheumatic heart disease (RHD), mitral stenosis
Rheumatic heart disease (RHD), mitral regurgitation
Rheumatic heart disease (RHD), mitral stenosis with regurgitation
Rheumatic heart disease (RHD), atrial stenosis
Rheumatic heart disease (RHD), atrial regurgitation
Rheumatic heart disease (RHD), others
Congenital Heart Disease, atrial septal defect
Congenital heart disease, ventricular septal defect
Congenital heart disease, patent ductus arteriosus
Congenital heart disease, others
Mitral valve prolapse
Coronary Artery Disease
Others

099.6

Diseases of the Digestive System


Acid Peptic Disease
Other
Surgical Condition
Acute Appendicitis
Acute Cholecystitis
Stab wound

Gun Shot Wound


Others
Gynecological Conditions
Uterine Myoma
Ovarian new growth (ONG), benign
Ovarian new growth (ONG), malignant
Other
Cervical Cancer
SECTION SEVEN: OTHER PROCEDURES
ANTENATAL PROCEDURES
(NUMBER OF PATIENTS, NOT NUMBER OF PROCEDURES)
Electronic Fetal Monitoring
Non-stress testing
Contraction stress testing
Biophysical Profile Scoring
Sonographic biometry
Chronic villi sampling
Amniocentesis
Intrapartal and post-partal procedures
Artificial Rupture of the Membranes
Internal Version
Failed/Trial forceps
Repair of cervical laceration
Reposition of inverted uterus
Evacuation of vulvar hematoma in Pregnancy

GICAL SOCIETY

CHARITY

PRIVATE
0
0
0
0
0
N/A

0
0
0
0
0
0

0
0
0
0
0
0

TOTAL
0
0
0
0
0
N/A

0
0
0
0
0
0

IMMATURE

PRETERM
0
0
0

VAGINAL

TERM
0
0
0

ABDOMINAL

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

POST-TERM
0
0
0

TOTAL

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

0
0
0

VAGINAL

ABDOMINAL

0
0
0

VAGINAL

TOTAL

0
0
0

ABDOMINAL

0
0
0
0
0

VAGINAL

TOTAL

0
0
0
0
0

ABDOMINAL

0
0
0
0
0
0
0
0
0
0
VAGINAL

TOTAL

ABDOMINAL

0
0
0
0
0
0
0
0
0
0
TOTAL

0
0
0
ABDOMINAL

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

0
0
0
VAGINAL

0
0
0

0
0
0
TOTAL

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
VAGINAL

0
0
0
0
0
0
0
0
0
0
0
0
ABDOMINAL

0
0
0
0
0
0
0
0
0
0
0
0
VAGINAL

0
0
0
0
0
0
0
0
0
0
0
0
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
ABDOMINAL

0
0
0
0
0
0
0
0
0
0
0
0
TOTAL

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
WITH METS

0
0
NO METS

0
0
0
0
0
0
0

0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0
TOTAL

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0

0
0
0
0
0
0

0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0

0
0

0
0
0

0
0

0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Perinatal Report

PERINATAL STATISTICS BASED ON MANNER OF DELIVERY


Normal
CS
Forceps
Breech
Others

LIVEBIRTHS
-

STILLBIRTHS
-

NEONATAL DEATH
-

DELIVERIES
###
###
###
###
###

NEONATAL DEATH
-

DELIVERIES
###
###
###
###
###
###
###
###

NEONATAL DEATH
-

DELIVERIES
###
###
###
###
###
###

PERINATAL STATISTICS BASED ON BIRTH WEIGHT


500-999
1000-1499
1500-1999
2000-2499
2500-2999
3000-3499
3500-4000
>4000

LIVEBIRTHS
-

STILLBIRTHS
-

PERINATAL STATISTICS BASED ON AGE OF GESTATION


20-21
22-27
28-31
32-36
37-42
>42

LIVEBIRTHS
-

STILLBIRTHS
-

PERINATAL STATISTICS BASED ON FETAL CHARACTERISTICS


Uncomplicated
SGA
LGA
Lethal

LIVEBIRTHS
-

STILLBIRTHS
-

NEONATAL DEATH
-

DELIVERIES
###
###
###
###

GICAL SOCIETY

STILLBIRTH RATE
###
###
###
###

NEONATAL MORTALITY
-

PERINATAL MORTALITY
-

STILLBIRTH RATE
###
###
###
###
###
###
###

NEONATAL MORTALITY
-

PERINATAL MORTALITY
-

STILLBIRTH RATE
###
###
###
###
###

NEONATAL MORTALITY
-

PERINATAL MORTALITY
-

STILLBIRTH RATE
###
###
###

NEONATAL MORTALITY
-

PERINATAL MORTALITY
-

SURVIVAL RATE
-

SURVIVAL RATE
-

SURVIVAL RATE
-

SURVIVAL RATE
-

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Gynecologic Diseases and Procedures Report

SECTIONS
ONE
TWO
THREE
FOUR
FIVE
SIX
SEVEN

CONTENTS
ADMISSIONS AND DISCHARGE DATA
SIGNS AND SYMPTOMS
INFLAMMATORY CONDITIONS
CONGENITAL ANOMALIES
BENIGN CONDITIONS
BENIGN NEOPLASMS
MALIGNANT NEOPLASMS

EIGHT

OPERATIONS

SECTION ONE: ADMISSIONS AND DICHARGE DATA


OPERATED PATIENTS
PATIENTS ADMITTED NOT OPERATED
OTHER PATIENTS

DISCHARGED ALIVE
DISCHARGED ALIVE BUT MORBID
MORTALITIES
TOTAL NUMBER OF GYNECOLOGIC ADMISSIONS

AGE RANGE OF PATIENTS


LESS THAN 20
20 to 34
35 to 50
51 and above
PARITY
0
1-5
MORE THAN 5

CHARITY

PRIVATE

###

SECTION TWO: SIGNS AND SYMPTOMS


PATIENT CHARACTERISTICS AND COMPLAINTS UPON HOSPITAL ADMISSION (DO NOT INCLUDE OUT-PATIENT)

MENSTRUAL DISORDERS
626
Primary Amenorrhea
626.1
Secondary Amenorrhea
Menorrhagia
626.2
Polymenorrhea
Metrorrhagia

626.6

Meno-metrorrhagia

Intermenstrual Bleeding
MENOPAUSE
627.1
Post-Menopausal Bleeding
627
Atrophic/ Senile Vaginitis
628
INFERTILITY
Primary
Secondary
628.0
Ovarian
628.1
Pituitary-Hypothalamic
628.2
Tubal
628.3
Uterine/ Cervix
Male Factor
628.9

Unspecified

PELVIC SYMPTOMS
625.4

Premenstrual Tension Syndrome

SECTION THREE: INFLAMMATORY CONDITIONS


FOR ADMMITTED PATIENTS ONLY, EXCLUDES THOSE ASSOCIATED WITH PREGNANCY
DISEASES OF BARTHOLIN'S GLAND
N76
N75.0
Cyst of Bartholin's Gland
N75.1
Abscess of Bartholin's Gland
N75.8
Other Diseases of Bartholin's Gland
Bartholinitis
N75.9

Diseases of Bartholin's Gland, Unspecified

PELVIC INFLAMMATORY DISEASE


N73
Pelvic Inflamatory Diseases, Prob. Bacterial
Salpingo-Oophoritis
Endometritis
Parametritis
Pelvic Cellulitis
Pelvic Abscess
N74
Other Pelvic Inflammatory Disorders
N74.0
Cervical Tuberculosis (A18.1)
N74.1
Tuberculosis Pelvic Inflammatory Disease (A18.1)
Tuberculosis Endometritis
N74.2
Syphilitic Pelvic Inflammatory Disease (A51.4, A52.7)
N74.3
Gonococcal Pelvic Inflammatory Disease (A54.2)

N74.4

Chlamydial Pelvic Inflammatory Disease (A56.1)

N76
N76.5

OTHER INFLAMMATION OF VAGINA AND VULVA


Ulceration of Vagina

N76.6
N77.1

N77.2

Ulceration of Vulva, Bacterial


Ulceration of Vulva, Herpes
Ulceration of Vulva, Tuberculosis
Vulva Condyloma Acuminata
Vulvovaginitis, Non-bacterial
Vulvovaginitis, Herpes
Vulvovaginitis, Candidiasis
Vulvovaginitis, Foreign Body

SECTION FOUR: CONGENITAL ANOMALIES OF GENITAL ORGANS


ICD NO.
Absence/ Agenesis of the Ovary
Streak Ovary
Cyst of the Oophoron/ Fimbriae
Parovarian Cyst
Gartner's Duct Cyst
Doubling of Uterus
Bicornuate Uterus
Uterus Unicornis
Imperforate Hymen
Congenital Cyst of Canal of Nuck
Embryonal Cyst of the Vagina

Congenital Cyst of the Vulva


ANOMALIES OF VAGINA, CERVIX AND EXTERNAL FEMALE GENITALIA
Agenesis
Uterine Corpus
Cervix
Clitoris
Vagina
Vulva

SECTION FIVE: BENIGN CONDITIONS OF THE FEMALE GENITAL TRACT


ENDOMETRIOSIS
Uterus
Adenomyosis
Ovary
Fallopian tube
Pelvic peritoneum
Rectovaginal septum
Unspecified
Others
STAGE 1

Aplasia

STAGE 2
STAGE 3
UNSPECIFIED STAGE
GENITAL PROLAPSE
FIRST

SECOND

Cystocoele alone
Rectocoele alone
Cysto-rectocoele
Urethrocoele
Enterocoele
Unspecified

Prolapse of vaginal vault after hysterectomy


Old laceration of muscle of pelvic floor
Others (specify)
Vulvar Hematoma

TOTAL

Relaxed vaginal vault

FISTULA
Female Genital Tract Fistula
specify types vaginal polyp

clitoral mass
SECTION SIX: BENIGN NEOPLASM OF THE GENITAL TRACT
UTERINE
M8890/0
Leiomyoma
N84.0
Endometrial Polyp
N85.0
Endometrial Hyperplasia, Unspecified
Cystic Hyperplasia
Complex Hyperplasia
N85.1
Adenomatous/ Atypical Hyperplasia
N85.4
Malposition of Uterus
N85.5
Uterine Inversion, Non-Obstetric
N85.6
Intrauterine synechiae
N85.7

Hematometra

Chronic Cervicitis
Polyp of Cervix Uteri
Erosion and Ectropion of Cervix Uteri
Dysplasia of Cervix Uteri, Not Specified
Mild cervical dysplasia or CIN I
Moderate cervical dysplasia or CIN II

CERVIX
N84.1
N86
N87
N87.0
N87.1

N87.2
N88.2
N88.3

Severe Cervical Dysplasia, Not Elsewhere Classified (Cin lll,


Not Cis)
Stricture and Stenosis of Cervix Uteri
Incompetence of Cervix Uteri

N88.4

Hypertrophic elongation of cervix uteri

SECTION SEVEN: MALIGNANT NEOPLASM OF GENITOURINARY ORGANS


OVARY
Serous Adenocarcinoma
Mucinous Adenocarcinoma
Endometrioid Adenocarcinoma
Other epithelial
Germ Cell Type
Other Type

UNILATERAL BILATERAL

Metastatic

CERVIX

STAGE I
Squamous Cell, Large Cell, NK
Squamous Cell, Large Cell, Keratinizing
Squamous Cell, Small Cell
Other squamous cell type
Adenocarcinoma
Other Type

FALLOPIAN TUBE
Adenocarcinoma, Specify
Other Type, Specify
ENDOMETRIOD

STAGE II

TUBAL CYST

Endometrial carcinoma
Other Endometrial neoplasm
Leiomyosarcoma

CORPUS

Other
MALIGNANCIES OF THE REST OF FEMALE GENITAL TRACT
Vagina
Greater Vestibular (Bartholin's Gland)
Vulva
Labia Majora
Labia Minora
Clitoris
Other

Site Unspecified

FALLOPIAN TUBE
Paratubal serous cyst

OVARY
EPITHELIAL
M8440/0
Cystadenoma Not Specified
M8441/0
Serous Cystadenoma
M8450/0
Papillary Cystadenoma
M8460/0
Papillary Serous Cystadenoma
M8470/0
Mucinous Cystadenoma
M8471/0
Papillary Mucinous Cystadenoma
M8480/0
Pseudomyxoma peritonei
Endometrial Cyst
GERM CELL TUMORS
M9080/0
Mature cystic teratoma
M9084/0
Dermoid Cyst
M9090/0
Struma Ovarii
OTHER BENIGN CONDITIONS
M8600/0
Fibro-Thecoma
M9000/0
Brenner Tumor
N83.0
Follicular Cyst of Ovary
N83.1
Corpus Luteum Cyst
N83.5

Torsion of Ovary/ Ovarian Pedicle

OTHER PELVIC ORGANS


VAGINA
N89.0
Mild vaginal dysplasia or VAIN I
N89.1
Moderate vaginal dysplasia or VAIN II
N89.2
Severe vaginal dysplasia or VAIN III
N89.3
Dysplasia of Vagina, Unspecified
N89.4
Leukoplakia of Vagina
N89.5
Stricture and Atresia of Vagina
N89.7
Hematocolpos
N89.8
VULVA
N90.0
N90.1
N90.2
N90.3
N90.4
N90.5

UNILATERAL BILATERAL

Others

Mild vulvar dysplasia or VIN I


Moderate vulvar dysplasia or VIN II
Severe vulvar dysplasia or VIN III
Vulvar Dysplasia, Unspecified
Leukoplakia of Vulva
Atrophy of Vulva

N90.6
N90.7
N90.8

Hypertrophy of vulva
Vulvar Cyst
Other Specified Noninflammatory Disorders of

Vulva and Perineum


SECTION EIGHT: OPERATIONS ON FEMALE GENITAL ORGANS
OPERATIONS ON THE UTERUS
Myomectomy
Subtotal Hysterectomy
Total Abdominal Hysterectomy
Vaginal Hysterectomy
Uterine Suspension
Fractional Curettage
Simple Curettage
Radical Abdominal Hysterectomy
Radical Vaginal Hysterectomy
Pelvic Exenteration
Diagnostic Curettage
TAHBSO
Endometrial biopsy

OPERATIONS ON OVARY
Oophorectomy
Salpingo-Oophorectomy
Ovarian cystectomy/oophoro-cystectomy
Partial Oophorectomy
Wedge Resection
Repair of the Ovary
Adhesiolysis of Ovary
OPERATIONS ON THE CERVIX
Cervical biopsy
Endocervical Curettage
Conization of the Cervix
Excision of Cervical Polyp
Amputation of Cervix
Cervicectomy
Encirclement Suture or Cerclage
Other Repair of Cervix
Late Repair of Obstetric Laceration
Repair of Non-Obstetric Laceration
LEEP

UNILATERAL BILATERAL

OPERATIONS ON FALLOPIAN TUBE


Salpingectomy
Salpingostomy
Fimbriectomy
Cornual Resection
Repair of Fallopian Tube
Insufflation
Tubal Ligation, Interval
Reanastomosis of ligated tubes
Endoscopic Destruction or Occlusion
By Culdoscopy
By Laparoscopy
Unspecified
OPERATIONS ON VAGINA
Culdocentesis
Incision of the Vagina
Colpotomy
Culdotomy
Hymenotomy
Hymenectomy
Obliteration and Total Excision of the Vagina
Colpectomy
Colpocleisis
Repair of Cystocoele
Repair of Rectocoele
Repair of Enterocoele
OPERATIONS ON VULVA AND PERINEUM
Incision of Vulva and Perineum
Drainage of Vulvar Abscess
Removal of Foreign Body from Vulva
Marsupialization of Bartholin's Gland
Excision of Bartholin's Gland
Radical Vulvectomy
Simple Vulvectomy
Perineorrhaphy
Other Operations on Female Genital Organs
OTHER OPERATIONS AND PROCEDURES
Partial Omentectomy
Peritoneal Biopsy
Peritoneal Fluid Sampling
Hartman's Procedure
Exploratory Laparotomy Alone

UNILATERAL BILATERAL

Other operations

LAPAROSCOPIC PROCEDURES
Video Laparoscopic
Diagnostic
Operative
Hysterograms or hysterosalpingography
Hysteroscopy
Colposcopy

Bilaterial pelvic lymph node dissection


Bilateral Groin Node Dissection
Chemotherapy

Others

CAL SOCIETY

TOTAL

COMPLETE

WITHOUT

###
###
###
###
###
###
###

BORDERLINE

STAGE III

STAGE IV

###
###
###
###
###
###

TOTAL

WITH
HYSTERECTOMY

TOTAL

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Maternal Mortality Report

0%
0
0

MATERNAL MORTALITY RATE


AVERAGE AGE (years)
AVERAGE AOG (weeks)
CAUSE OF DEATH
I. DIRECT MATERNAL DEATHS

VALUE
-

A. HEMORRHAGE
1. Spontaneous abortion
2. Induced abortion
3. Retained secundiness
4. Ectopic pregnancy
5. Abruptio placenta
6. Placenta previa
7. Placenta accreta
8. Uterine rupture
9. Cervico-vaginal lacerations
10. Uterine inversion
11. Uterine atony
12. Postop from surgical procedure
13. Trophoblastic disease
14. Abdominal pregnancy
15. Coagulopathy
16. Other hemorrhage

0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%

B. HYPERTENSION
1. Preeclampsia
2. Eclampsia
3. Preexisting hypertension
4. Combination
5. HELLP syndrome

0%
0%
0%
0%
0%
0%

C. INFECTION
1. Induced abortion
2. Pelvic abscess
3. Puerperal infection
4. Chorioamnionitis
5. Adnexal infection
6. Pelvic thrombophlebitis
7. Septic embolism

0%
0%
0%
0%
0%
0%
0%
0%

D. VASCULAR ACCIDENTS
1. Amniotic fluid embolism
2. Puerperal nonseptic embolism
3. Air embolism

0%
0%
0%
0%

E.
1.
2.
3.

0%
0%
0%
0%

0%
0%
0%
0%
0%
0%

A. CARDIAC
1. Rheumatic heart disease
2. Hypertensive heart disease
3. Congenital heart disease
4. Atherosclerotic heart disease
5. Undiagnosed
6. Other cardiac

0%
0%
0%
0%
0%
0%
0%
0%

B. VASCULAR
1. Preexisting hypertension
2. Vascular thrombosis/embolism
3. Thrombophlebitis

0%
0%
0%
0%

C. REPRODUCTIVE TRACT
1. Uterine anomalies
2. Uterine myoma
3. Ovarian cysts
4. Reproductive tract malignancy
5. Other reproductive tract

0%
0%
0%
0%
0%
0%

D. URINARY TRACT
1. Glomerulonephritis
2. Urinary tract infection
3. Hydronephrosis
4. Renal malignancy
5. Other urinary tract

0%
0%
0%
0%
0%
0%

ANESTHESIA
Neurogenic cardiac arrest
Post-aspiration asphyxia
Respiratory insufficiency

F. OTHERS
1. Peri/postpartum cardiomyopathy
2. Transfusion hemolysis
3. Electrolyte imbalance
4. Pregnancy anemia
5. Others (specify)
II. INDIRECT MATERNAL DEATHS

E.
1.
2.
3.
4.
5.

HEPATIC
Infectious hepatitis
Liver cirrhosis
Hepatic abscess
Hepatic malignancy
Other hepatic

0%
0%
0%
0%
0%
0%

F. PULMONARY
1. Tuberculosis
2. Pneumonia
3. Bronchial asthma
4. Lung cancer
5. Malignancy, with lung metastasis
6. Other pulmonary

0%
0%
0%
0%
0%
0%
0%

G. METABOLIC
1. Diabetes mellitus
2. Thyroid storm
3. Adrenal dysfunction
4. Other metabolic

0%
0%
0%
0%
0%

H. HEMATOLOGIC
1. Leukemia
2. Aplastic anemia
3. Other hematologic

0%
0%
0%
0%

I. GASTROINTESTINAL
1. Acute gastroenteritis
2. Appendicitis
3. Gastrointestinal tract malignancy
4. Other gastrointestinal

0%
0%
0%
0%
0%

J. OTHER CAUSES

0%

A. ACCIDENTS
1. Stab wound
2. Gunshot wound
3. Vehicular accident
4. Accidental poisoning

0%
0%
0%
0%
0%
0%

B. SUICIDE/MURDER
1. Suicide
2. Murder

0%
0%
0%

III. NONMATERNAL DEATHS

MORTALITY BASED ON
I. TIMING OF DEATH
A. TRIMESTER

1. First trimester
2. Second trimester
3. Third trimester

0%
0%
0%

0%
0%
0%
0%

0%
0%
0%
0%
0%
0%
0%
0%

0%
0%
0%

0%
0%
0%
0%

B. SPECIFIC

1.
2.
3.
4.

Antepartal
Intrapartal
Postpartal
Puerperal

II. IMMEDIATE CAUSE OF DEATH


A. Shock
B. Congestive heart failure
C. Respiratory failure
D. Hepatic failure
E. DIC
F. Intracranial bleeding
G. Multiorgan failure
H. Others (specify)
III. ONSET OF COMPLICATIONS
A. TRIMESTER

1. First trimester
2. Second trimester
3. Third trimester
B. SPECIFIC

1.
2.
3.
4.

Antepartal
Intrapartal
Postpartal
Puerperal

NO. OF LIVE BIRTHS


NO. OF MATERNAL DEATHS
MATERNAL MORTALITY RATE

0%

CAL SOCIETY

PHILIPPINE OBSTETRICAL AND GYNECOLOGICAL SOCIET


version 0.12
Gestational Trophoblastic Disease Report

SECTIONS
ONE
TWO
THREE
FOUR
FIVE

CONTENTS
CASE BY DIAGNOSIS
HYDATIDIFORM MOLE
GESTATIONAL TROPHOBLASTIC TUMOR
PLACENTAL SITE TROPHOBLASTIC TUMOR
CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF GTT

SECTION ONE: CASE BY DIAGNOSIS

Hydatidiform Mole
Complete
Partial
No data
Gestational Trophoblastic Neoplasia
Invasive mole
Choriocarcinoma
Unspecified
No data
Placental Site Trophoblastic Tumor
Epithelioid Trophoblastic Tumor
TOTAL

SECTION TWO: HYDATIDIFORM MOLE


AGE GROUP
15-19
20-29

30-39
40-49
>= 50
No data
TOTAL
GRAVIDITY
01
25
6 10

11 16
No data
TOTAL
AOG AT DIAGNOSIS (in weeks)
<= 12 weeks
12-26 weeks
> 26 weeks
No data
TOTAL
COMPLICATIONS
Anemia
Hyperemesis gravidarum
Pre-eclampsia
Hyperthyroidism
Theca lutein cyst
Pulmonary embolism
Infectious
No data
TOTAL
HIGH RISK FACTOR
Age > 35 years
Uterus > AOG
Recurrent mole
Uterus >= 5 months AOG size
Precurettage hCG >= 100,000 mIU/mL
Theca lutein cyst >= 6cm
Others (specify)
No data
TOTAL
MODE OF EVACUATION
Suction curettage
Hysterectomy
D and C
Others (specify)
No data
TOTAL
USE OF CHEMOPROPHYLAXIS
No
Yes
No data

TOTAL
PROPHYLACTIC AGENT
Methotrexate (oral + parenteral)
Actinomycin D
No data
TOTAL
CONDITION ON DISCHARGE
No evidence of disease
Partial response
Progressive disease
Death
No data
TOTAL
PRESENT STATUS
OPD followup with no evidence of disease
Unknown/Lost to followup
Readmitted/Referred with evidence of malignant degeneration
No data
TOTAL
CAUSES OF DEATH

SECTION THREE: GESTATIONAL TROPHOBLASTIC NEOPLASIA


AGE GROUP
15-19
20-29

30-39
40-49
>= 50
No data
TOTAL
GRAVIDITY
01
25
6 10
11 16
No data
TOTAL

ANTECEDENT PREGNANCY
Term
Abortion
Ectopic pregnancy
Molar (complete + partial)
No data
TOTAL
BASELINE bHCG TITER (mIU/ML)
< 100
100 1,000
1,001 10,000

10,001 100,000
100,001 1,000,000
> 1,000,000
No data
TOTAL
WHO PROGNOSTIC SCORE
Low risk
High risk
No data
TOTAL
FIGO ANATOMIC STAGE
Stage I
Stage II
Stage III

Stage IV
No data

TOTAL
SURGICAL PROCEDURE
Curettage
TAH
Others (thoracotomy + craniotomy + others)
No data
TOTAL
CHEMOTHERAPY

Single agent (oral methotrexate + parenteral methotrexate + actinomycin D


MAC
EMACO (true + modified)
Others
No data

TOTAL
RADIOTHERAPY

Yes
No
No data
TOTAL
CONDITION ON DISCHARGE
No evidence of disease
Partial response
Progressive disease
Death
No data
TOTAL
CAUSES OF DEATH

SECTION FOUR: PLACENTAL SITE TROPHOBLASTIC TUMOR


AGE GROUP
15-19
20-29

30-39
40-49
>= 50
No data
TOTAL
GRAVIDITY
01
25
6 10
11 16
No data
TOTAL
ANTECEDENT PREGNANCY
Term
Abortion
Ectopic pregnancy
Molar (complete + partial)
No data
TOTAL

BASELINE bHCG TITER (mIU/ML)


< 100
100 1,000
1,001 10,000

10,001 100,000
100,001 1,000,000
> 1,000,000
No data
TOTAL
WHO PROGNOSTIC SCORE
Low risk
High risk
No data
TOTAL
FIGO ANATOMIC STAGE
Stage I
Stage II
Stage III

Stage IV
No data

TOTAL
SURGICAL PROCEDURE
Curettage
TAH
Others (thoracotomy + craniotomy + others)
No data
TOTAL
CHEMOTHERAPY

Single agent (oral methotrexate + parenteral methotrexate + actinomycin D


MAC
EMACO (true + modified)
Others
No data
TOTAL
RADIOTHERAPY

Yes
No
No data
TOTAL

CONDITION ON DISCHARGE
No evidence of disease
Partial response
Progressive disease
Death
No data
TOTAL

SECTION FIVE: CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF GTN


FIGO ANATOMIC STAGE/CONDITION ON DISCHARGE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
FIGO ANATOMIC STAGE/SURGICAL PROCEDURE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
FIGO ANATOMIC STAGE/WHO PROGNOSTIC SCORE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
WHO PROGNOSTIC SCORE/SURGICAL PROCEDURE

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL

WHO PROGNOSTIC SCORE/CONDITION ON DISCHARGE

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL
WHO PROGNOSTIC SCORE/CHEMOTHERAPY

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL
DIAGNOSIS/CONDITION ON DISCHARGE

DIAGNOSIS
Invasive mole
Choriocarcinoma
Unspecified
No data
TOTAL

SECTION SIX: CROSS TABULATION OF VARIOUS CLINICAL CHARACTERISTICS OF PSTT


FIGO ANATOMIC STAGE/CONDITION ON DISCHARGE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
FIGO ANATOMIC STAGE/SURGICAL PROCEDURE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
FIGO ANATOMIC STAGE/WHO PROGNOSTIC SCORE

FIGO ANATOMIC STAGE


Stage I
Stage II
Stage III

Stage IV
No data
TOTAL
WHO PROGNOSTIC SCORE/SURGICAL PROCEDURE

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL
WHO PROGNOSTIC SCORE/CONDITION ON DISCHARGE

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL
WHO PROGNOSTIC SCORE/CHEMOTHERAPY

WHO PROGNOSTIC SCORE


Low risk
High risk
No data
TOTAL
DIAGNOSIS/CONDITION ON DISCHARGE

DIAGNOSIS
Invasive mole
Choriocarcinoma
Unspecified
No data
TOTAL

GICAL SOCIETY

FREQUENCY

PERCENT
-

CONDITION ON DISCHARGE
No evidence of disease

Partial response

0
0
0
0
0
0

Progressive

0
0
0
0
0
0

Dead

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

SURGICAL PROCEDURE
Curettage

TAH

0
0
0
0
0
0

Others

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

0
0
0
0
0
0

WHO PROGNOSTIC SCORE


Low risk

High risk

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

0
0
0
0
0
0

SURGICAL PROCEDURE
Curettage

TAH

0
0
0
0

Others

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

0
0
0
0
0
0

CONDITION ON DISCHARGE
No evidence of disease

Partial response

0
0
0
0

Progressive

0
0
0
0

Dead

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

CHEMOTHERAPY
Single

Triple

0
0
0
0

EMACO

0
0
0
0

Others

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

CONDITION ON DISCHARGE
No evidence of disease

Partial response

0
0
0
0
0

Progressive

0
0
0
0
0

Dead

0
0
0
0
0

No data

0
0
0
0
0

TOTAL

0
0
0
0
0

0
0
0
0
0

CONDITION ON DISCHARGE
No evidence of disease

Partial response

0
0
0
0
0
0

Progressive

0
0
0
0
0
0

Dead

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

SURGICAL PROCEDURE
Curettage

TAH

0
0
0
0
0
0
WHO PROGNOSTIC SCORE

Others

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

0
0
0
0
0
0

0
0
0
0
0
0

Low risk

High risk

0
0
0
0
0
0

No data

0
0
0
0
0
0

TOTAL

0
0
0
0
0
0

0
0
0
0
0
0

SURGICAL PROCEDURE
Curettage

TAH

0
0
0
0

Others

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

CONDITION ON DISCHARGE
No evidence of disease

Partial response

0
0
0
0

Progressive

0
0
0
0

Dead

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

CHEMOTHERAPY
Single

Triple

0
0
0
0

EMACO

0
0
0
0

Others

0
0
0
0

No data

0
0
0
0

TOTAL

0
0
0
0

0
0
0
0

CONDITION ON DISCHARGE
No evidence of disease

0
0
0
0
0

Partial response

Progressive

0
0
0
0
0

Dead

0
0
0
0
0

No data

0
0
0
0
0

TOTAL

0
0
0
0
0

0
0
0
0
0