THE FINAL WORD:THE FINAL WORD:Obstetric and Gynecologic Obstetric and Gynecologic Diagnostic NomenclatureDiagnostic Nomenclature

PHILIPPINE BOARD OF OBSTETRICS AND GYNECOLOGYPHILIPPINE BOARD OF OBSTETRICS AND GYNECOLOGYandand

COUNCIL FOR RESIDENCY EDUCATION ENHANCEMENT COUNCIL FOR RESIDENCY EDUCATION ENHANCEMENT AND DEVELOPMENTAND DEVELOPMENT

DiagnosisDiagnosis

Purpose is to know basic information Purpose is to know basic information about the patient:about the patient:

- Nature of the disease or - Nature of the disease or conditioncondition

- Intervention / Management- Intervention / Management

- Outcome- Outcome

- Complications - Complications

Obstetric Diagnosis

Components of Obstetric Final Components of Obstetric Final Diagnosis:Diagnosis:

I. Obstetrical StatusI. Obstetrical Status

II. Obstetrical/ Medical/ Surgical II. Obstetrical/ Medical/ Surgical Complication/sComplication/s

III. Management/ InterventionIII. Management/ Intervention

IV. Outcome IV. Outcome

Obstetric Diagnosis

I. Obstetrical Status:I. Obstetrical Status:1.1. Gravidity /Parity/ OB Score -Gravidity /Parity/ OB Score -

- Important for GSIS and PHIC - Important for GSIS and PHIC claimsclaims- Adapt the new scoring method - Adapt the new scoring method ex. G1P1(0202)ex. G1P1(0202)

Obstetric Diagnosis

2. Pregnancy location2. Pregnancy location

- Uterine- Uterine

- Ectopic- Ectopic

- specify site- specify site

- if tubal, which part of the tube- if tubal, which part of the tube

- ruptured/unruptured- ruptured/unruptured

- if embryo identified, state if w/ cardiac - if embryo identified, state if w/ cardiac activityactivity

Obstetric Diagnosis

3. Age of Gestation3. Age of Gestation

Admitting diagnosis:Admitting diagnosis:

- based on LNMP/ Ultrasound - based on LNMP/ Ultrasound

Final Diagnosis: Final Diagnosis:

- based on Ballard’s score- based on Ballard’s score

- if Term, may just write Term- if Term, may just write Term

- if Preterm/Postterm – write Pediatric - if Preterm/Postterm – write Pediatric aging aging

Obstetric Diagnosis

4.a Presentation4.a Presentation- Cephalic- Cephalic- Breech- Breech

a.a. CompleteCompleteb.b. IncompleteIncompletec.c. FootlingFootling

- Transverse lie- Transverse lie

4.b Position - optional4.b Position - optional

Obstetric Diagnosis

5. Labor Status:5. Labor Status:- In labor- In labor- Not in labor- Not in labor- In preterm labor/ - In preterm labor/ controlledcontrolled- Delivered- Delivered

Obstetric Diagnosis

Examples:Examples:

- G1P1 (1-0-0-1) Pregnancy Uterine, - G1P1 (1-0-0-1) Pregnancy Uterine, term, cephalic, deliveredterm, cephalic, delivered

- G2P2 (2-0-0-2) Pregnancy uterine, - G2P2 (2-0-0-2) Pregnancy uterine, term, Complete Breech, deliveredterm, Complete Breech, delivered

- G2P1 (1-0-1-1) Tubal Pregnancy, - G2P1 (1-0-1-1) Tubal Pregnancy, AmpullaryAmpullary

11 weeks, ruptured11 weeks, ruptured

Obstetric Diagnosis

II. Obstetrical / Medical/ Surgical II. Obstetrical / Medical/ Surgical Complication/s:Complication/s:

- state the medical/surgical - state the medical/surgical complication/scomplication/s

- state the status of the - state the status of the condition/s condition/s

Obstetric Diagnosis

II. Obstetrical / Medical/ Surgical II. Obstetrical / Medical/ Surgical Complication/s:Complication/s:

Examples:Examples:

- Preeclampsia, Severe- Preeclampsia, Severe

- Acute Asthma, controlled- Acute Asthma, controlled

- Acute Appendicitis, - Acute Appendicitis, rupturedruptured

Obstetric DiagnosisObstetric Diagnosis

III. Management: Manner of deliveryIII. Management: Manner of delivery

- Vaginal Spontaneous Delivery- Vaginal Spontaneous Delivery

- Vaginal Assisted Delivery: indicated/ - Vaginal Assisted Delivery: indicated/

electiveelective

- Inclusion of Episiotomy and repair is - Inclusion of Episiotomy and repair is optionaloptional

- Cesarean Section: should include the - Cesarean Section: should include the

indicationindication

Obstetric DiagnosisObstetric Diagnosis

III. Management:III. Management:

Obstetrical: Obstetrical:

- Repeat Cesarean Section -- Repeat Cesarean Section - MUSTMUST include the indication for include the indication for the Primary CSthe Primary CS

Obstetric DiagnosisObstetric Diagnosis

III. Management:III. Management:

Obstetrical: Obstetrical: MUSTMUST indicate manner of deliveryindicate manner of delivery

Anesthesia: Anesthesia: MUSTMUST indicate the type of indicate the type of anesthesia usedanesthesia used

Medical ManagementMedical Management: : NOTNOT to be included in to be included in the diagnosisthe diagnosis

Surgical Management: Surgical Management: MUSTMUST be included in be included in the Final Diagnosis the Final Diagnosis

Obstetric DiagnosisObstetric Diagnosis

III. Management:III. Management:

- Blood Transfusion - Blood Transfusion MUSTMUST be be indicated together with the diagnosis indicated together with the diagnosis and cause of anemiaand cause of anemia

Example:Example:

Blood Transfusion for Anemia Blood Transfusion for Anemia secondary to Acute Blood Loss secondary to Acute Blood Loss secondary to Placenta Previa, secondary to Placenta Previa, complete complete

Obstetric DiagnosisObstetric Diagnosis

Management - Examples:Management - Examples:

- Normal Spontaneous Delivery under epidural anesthesia- Normal Spontaneous Delivery under epidural anesthesia

- Indicated outlet forceps extraction under pudendal block - Indicated outlet forceps extraction under pudendal block anesthesiaanesthesia

- Low Segment Transverse Cesarean Section under SAB - Low Segment Transverse Cesarean Section under SAB anesthesiaanesthesia

- Appendectomy under spinal anesthesia- Appendectomy under spinal anesthesia

Obstetric DiagnosisObstetric Diagnosis

IV. Fetal OutcomeIV. Fetal Outcome

1. General Outcome1. General Outcome

- Term- Term

- Preterm/ Postterm – must indicate - Preterm/ Postterm – must indicate Pediatric agingPediatric aging

- Livebirth- Livebirth

- Stillbirth – freshstillbirth or macerated- Stillbirth – freshstillbirth or macerated

- Sex- Sex

Obstetric DiagnosisObstetric Diagnosis

1. General Outcome – con’t:1. General Outcome – con’t:

MUSTMUST include: include:a.a. Significant neonatal Significant neonatal

complication/scomplication/sb.b. Significant placental Significant placental

abnormalityabnormality

Obstetric DiagnosisObstetric Diagnosis

2. Detailed outcome:2. Detailed outcome:

a. Birth weighta. Birth weight

- actual weight is optional- actual weight is optional

- indicate if SGA/LGA- indicate if SGA/LGA

Optional:Optional:

b. Birth lengthb. Birth length

c. Placental weight c. Placental weight

d. APGAR Score d. APGAR Score

Obstetric DiagnosisObstetric Diagnosis

IV. Fetal OutcomeIV. Fetal Outcome

Example:Example:

- Preterm birth live baby - Preterm birth live baby girl, Pediatric aging of 33 to 34 girl, Pediatric aging of 33 to 34 weeks, Multiple congenital weeks, Multiple congenital anomalies, SGA, Placenta anomalies, SGA, Placenta succenturiatasuccenturiata

Obstetric DiagnosisObstetric Diagnosis

G1P1 (1-0-0-1) Pregnancy Uterine, G1P1 (1-0-0-1) Pregnancy Uterine, delivered, term, cephalic, live baby delivered, term, cephalic, live baby girlgirl

Multiple congenital anomaliesMultiple congenital anomalies

SGA (BW-1900 gm.)SGA (BW-1900 gm.)

Preeclampsia, SeverePreeclampsia, Severe

By Primary Low Segment Transverse By Primary Low Segment Transverse Cesarean Section under spinal Cesarean Section under spinal anesthesia for non-reassuring fetal anesthesia for non-reassuring fetal status status

Gynecologic DiagnosisGynecologic Diagnosis

I. Obstetric StatusI. Obstetric Status

II. Current Gynecologic/Medical II. Current Gynecologic/Medical condition/scondition/s

III. Surgical management/ III. Surgical management/ InterventionsInterventions

IV. Pertinent Past Surgeries IV. Pertinent Past Surgeries

V. Surgical/Medical Complications V. Surgical/Medical Complications

Gynecologic DiagnosisGynecologic Diagnosis

I. Obstetrical StatusI. Obstetrical Statusa. Gravidity/Paritya. Gravidity/Parityb. Obstetrical Scoreb. Obstetrical Score

Gynecologic DiagnosisGynecologic Diagnosis

II. Current Gynecologic Condition/DiagnosisII. Current Gynecologic Condition/Diagnosis

a.a. Location/ Organ InvolvementLocation/ Organ Involvement

I.I. SolitarySolitary

II.II. BilateralBilateral

III.III. MetastasisMetastasis

b. Activityb. Activity

I.I. BenignBenign

II.II. Malignant, include Stage (FIGO Staging) Malignant, include Stage (FIGO Staging)

c. Histologic Type – if available, if none yet, may c. Histologic Type – if available, if none yet, may write probably Benign/Malignant write probably Benign/Malignant

Gynecologic DiagnosisGynecologic Diagnosis

Example:Example:

- Multiple Myomata Uteri, fundal, - Multiple Myomata Uteri, fundal, intramural with submucous componentintramural with submucous component

- Squamous Cell Ca, Cervix, Stage II B- Squamous Cell Ca, Cervix, Stage II B

- Ovarian New Growth, Bilateral, - Ovarian New Growth, Bilateral, probably Mucinous Cyst Adenocarcinoma, probably Mucinous Cyst Adenocarcinoma, Stage II BStage II B

Gynecologic DiagnosisGynecologic Diagnosis

Concomitant Medical/ Surgical Condition and StatusConcomitant Medical/ Surgical Condition and StatusControlledControlledUncontrolledUncontrolled

Example:Example:

Diabetes Mellitus, controlledDiabetes Mellitus, controlled

Rheumatic Heart Disease, in failureRheumatic Heart Disease, in failure

Gynecologic DiagnosisGynecologic Diagnosis

III. Management/ InterventionIII. Management/ Intervention

a. State complete primary a. State complete primary surgical proceduresurgical procedure

b. Additional surgical procedure b. Additional surgical procedure should also be includedshould also be included

Example:Example: AdhesiolysisAdhesiolysis

CystorrhaphyCystorrhaphy

Gynecologic DiagnosisGynecologic Diagnosis

III. Management/ InterventionIII. Management/ Intervention

c. Frozen Sectionc. Frozen Section

- if done must be stated with - if done must be stated with the frozen section readingthe frozen section reading

- performance of the frozen - performance of the frozen section must be justified by the section must be justified by the Pre-operative diagnosis Pre-operative diagnosis

Gynecologic DiagnosisGynecologic Diagnosis

V. Surgical MorbiditiesV. Surgical Morbidities

- surgical morbidities - surgical morbidities MAY OR MAY OR MAY NOT MAY NOT be part of the diagnosisbe part of the diagnosis

Example:Example:

- Ureteral transection- Ureteral transection

- Urinary Bladder tear- Urinary Bladder tear

Gynecologic DiagnosisGynecologic Diagnosis

IV. Pertinent previous surgeriesIV. Pertinent previous surgeries

- history of previous pertinent surgeries and - history of previous pertinent surgeries and its indication must be part of the diagnosisits indication must be part of the diagnosis

- year of the previous surgery is optional- year of the previous surgery is optional

Example:Example:

S/P Oophorocystectomy, Right, for S/P Oophorocystectomy, Right, for Endometriotic cyst (2008)Endometriotic cyst (2008)

S/P Salpingectomy for Ectopic Pregnancy S/P Salpingectomy for Ectopic Pregnancy (2002) (2002)

Gynecologic DiagnosisGynecologic Diagnosis

G2P2G2P2

Multiple Myomata Uteri, Intramural and Multiple Myomata Uteri, Intramural and Subserous typesSubserous types

Diabetes Mellitus, controlledDiabetes Mellitus, controlled

Total Abdominal Hysterectomy with Bilateral Total Abdominal Hysterectomy with Bilateral Salpingooophorectomy under spinal anesthesiaSalpingooophorectomy under spinal anesthesia

Histopath:Histopath:

Myoma, intramural, subserousMyoma, intramural, subserous

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