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. Autre-pathologies-chronique, Antécédents obstétricaux : 43) Gestité |__|__| Parité |__|__| (après l " accouchement) 44) FCS : ? 1 Oui ? 0 Non ?si oui, préciser : nb de FCS précoces (?14SA): |__|__| / nb FCS tardives (>14 SA) : |__|__| nb de FCS de terme non renseigné |__|__| 45) IMG : ? 1 Oui ? 0 Non ?si oui, préciser : motif : __________________________ ? NR 46) Mort foetale in utero : ? 1 Oui ? 0 Non ?si oui, préciser : terme : |__|__| SA ? Préciser éventuelle cause identifiée : ____________________ 47) MAP : ? 1 Oui, ) RCIU (biométries foetales < 10ème percentile) : ? 1 Oui ? 0 Non ? Si oui : RCIU sévère (biométries foetales < 3ème percentile) : ? 1 Oui ? 0 Non 50) HTA gravidique isolée : ? 1 Oui ? 0 Non 51) Pré-éclampsie ou éclampsie : ? 1 Oui ? 0 Non 52) Hématome Rétro-Placentaire : ? 1 Oui ? 0 Non 53

. Anémie, Hémorragie de la délivrance : ? 1 Oui ? 0 Non 55) Malformation d " un nouveau né: ? 1 Oui ? 0 Non Grossesse actuelle 56) Âge de la mère à l " accouchement |__|__| ans 57) DDR : ____/____/20____ ou date de début de grossesse : ____/____/20____ 58) Terme de l " accouchement : |__|__| SA +|__|jours 59) Grossesse multiple : ? 1 Oui ? 0 Non Suivi de la grossesse : 60) Nombre de consultations totales : |__|__| 61) Nombre d " échographies :|__|__| 62

. Autre, Préciser : ______________________________ Traitement en cours de grossesse : 70) Supplémentation en Fer : ? 1 Oui Fer I.V. ? 2 Oui Fer P.O. ? 0 Non 71) Supplémentation en Calcium