EUROAPS Form
Hospital
Case Number
Birth Date of the patient:
Ethnics: Caucasian/Indo-Arian ; American (Latino) ;Semitic/Arab ;
African; Afro American/Caribbean; Asian ; Amerindian; Polynesian
and Pacific Islander
Smoker:
Yes
; No
;
Length (In centimeters)
Weight (In Kilograms)
SLE: Yes ; No  ;
APS classical criteria:
Yes ;  No 
Diabetes (Diabetes Mellitus (I or II) excluding diabetes of pregnancy) Yes ;
No 
Idiopathic Thrombocytopenic Purpura: Yes ; No 
Other auto-immune disease (AID) (Specify)
Previous Thrombosis
No ;  Yes  Date:(dd/mm/yy)…………………
Type of Thrombosis
Venous:;
Arterial:;
Chronic Pathology Other (Specify) (only chronic pathology)
Previous Pregnancies
Fetal Status
Order of
1) Alive; 2) Stillbirth; 3) Perinatal Death; 4)
Pregnancy
Miscarriage; 5)Termination of Pregnancy
Weeks of
pregnancy
Placental pathology
available
(TOP)
1
2
3
4
5
6
7
8
No; Yes.
No; Yes.
No; Yes.
No; Yes.
No; Yes.
No; Yes.
No; Yes.
No; Yes.
Current Pregnancy
Last Menstrual Period
Conception: : Spontaneous ; Artificial Insemination by husband ; Artificial
Insemination by donnor ; IVF ovum homologous insemination by husband ; IVF
ovum homologous insemination by donnor ; IVF ovum donnor 
Date of Delivery/Miscarriage
Weight at start of pregnancy (Metrical)_________
Weight at end of pregnancy(Metrical)____________
Pregnancy: Single ; Twins Dichorionic ; Twins Monochorionic Multiple 
Previous Intrauterine Growth Restriction (IUGR): Onset before 32 weeks with
Doppler alterations ; Onset after 32 weeks with Doppler alterations ; Any kind of
Onset without Doppler alterations  ; Unknown
Hypertensive Disease of Pregnancy (HDP): Chronic Hypertension ; Preeclampsia
Early Onset (Before 32 weeks); Preeclampsia Late Onset (After 32 Weeks);
HELLP; Unknown.
Current pregnancy occurrences
Yes
Yes
Miscarriage (before 10th week)
Arterial Thrombosis Pulmonary
Fetal Loss (10 to 24 week)
Arterial Thrombosis Renal
Stillbirth From (24th weeks to end)
Arterial Thrombosis Mesenterics
Prematurity
Arterial Thrombosis Extremities
IUGR Early Onset (Before 32 weeks)
Arterial Thrombosis Other Localitations
IUGR Late Onset (After 32 weeks)
Venous Thrombosis Portal-Cave Vein
Abruptio Placentae
Venous Thrombosis Brain Sinus
Placental Haematoma
Venous Thrombosis Renal
Preeclampsia Early Onset (Before 32 weeks)
Venous Thrombosis Pulmonary
Preeclampsia Late Onset (After 32 weeks)
Venous Thrombosis Ilio-femoral
HELLP
Venous Thrombosis Femoro-popliteal
Abnormal Uterine Blood Flow
Venous Thrombosis Calves
Cord Blood Flow Restriction
Venous Thrombosis Other Localitations
Abnormal Middle Cerebral Artery Blood Flow
Venous Thrombosis Suprahepatic
Arterial Thrombosis Myocardial
CAPS
Arterial Thrombosis Brain
Other (Specify)
th
th
Other occurrences not listed:
Laboratory Data
Item
Results
Normal Values Item
Urea
anti-ANX-A5 IgG
Creatinine*
anti-ANX-A5 IgM
Uric acid*
anti-Prothrombin IgG
AST*
anti-Prothrombin IgM
ALT*
anti-PE IgG
Haptoglobin
anti-PE IgM
Alcaline Phosphatase
anti-Ro/La/U1RNP
GGT
Anti-dsDNA*
LDH*
Platelets*
PAPPA (Before12 weeks)
MPV
Beta-HCG (Before12 weeks)
Homocisteinèmia
Gamma globulin*
aPTTp/aPTTc Ratio*
Compl C3*
Prothrombin Time(%)*
Compl C4*
Fibrinogen*
Compl C3PA
F II
Compl CH50
F VIII
LA*
Protein C
ANAs*
Protein S
ANA_Pattern
Antithrombin III
ANA_Titter
Activate Protein C Resistance
AMA type 5
Mut_MTHFR C677T
aCL IgG*
Mut_Protromb G202010A
aCL IgM*
Factor V Leiden
Anti-B2GPIgG*
PAI-1 mutation
Anti-B2GPIgM*
anti-F Xa activity
Anti-aPS IgG
RPR/VDRL
Anti-aPS IgM
FTA-ABS
Results
Normal Values
Treatment
Low Dose AAS previous to pregnancy: None ; Standard Dose; Other
Time of commencement___________ Time of termination___________
Low Dose AAS During Pregnancy: None  ; Standard Dose ; Other
Time of commencement___________ Time of termination___________
Heparine:
None; Fractionated; Unfractionated; Unknown
Time of commencement___________ Time of termination___________
LMWH Type:
Enoxaparin; Fraxiparin; Tinzaparin ;
Bemiparin
Other
(Specify)…………………………………………………………………………………
LMWH Dose:
None; Low Prophylactic; Medium Prophylactic;
High Prophylactic; Therapeutic; Unknown
IV Gammaglobulins : No  ; Yes; Unknown
Time of commencement___________ Time of termination___________
IV Gammaglobulins
(Description)…………………………………………………………
……………………………………………………………………………………………
……….
Progesterone :
None; Oral; Vaginal; Combined
Progesterone total dose per day
(Specify)………………………………………………
Progesterone Time of commencement___________ Time of termination___________
(Weeks of pregnancy or exact date when possible)
Prednisone
Dose per day _________ Time of commencement___________ Time of
termination___________ (weeks of pregnancy or exact date when possible)
Hydroxychloroquine
Dose per day__________ Time of commencement___________ Time of
termination___________ (weeks of pregnancy or exact date when possible)
Other Treatment Related to the disease (Specify)
Other Treatment Related to pregnancy (Specify)
Labor and Newborn
Labor : Spontaneous ; Induced; Cesarean Section ; Unknown
Indication for Labor induction: (Specify):
Delivery: Spontaneous; Vaginally Assisted; Cesarean Section
Weight of the Newborn (Metrical)
Apgar First Minute: __________
Apgar Fifth Minute: __________
pH Umbilical Vein: __________
pH Umbilical Artery:
__________
Anesthesia: None ; Neuroaxial; General;Unknown
Newborn Status: Alive; Stillbirth; Perinatal Death; Miscarriage
Intensive Neonatal Care: Yes; No; Unknown
Neonatal Complications (Specify)
Placenta
Measurements (Metrical) Weight : Length :
Width:
Thickness:
Infarcts: None ; <10 per cent; 10-24.9 per cent; 25-50 per cent; >50 per
cent; Unknown
Infarcts Localization: Central; Peripheral; Multiple; Unknown
Fibrin deposits terminal villi: No; 1-19 per cent; 20-49 per cent; 50 per
cent or Higher; Unknown
Fibrin deposit Localization: Central/Basal; Marginal; Transmural;
Subchorionic; Maternal Floor Infarct (Thickness More than 3mm);
Unknown
Calcifications: None; Yes; Unknown
Villitis: None; VUE; Infectious Villitis; Unknown
Villitis Grade: Mild; Moderate; Severe; Unknown
Vasculitis with Villitis: No; Yes; Unknown
Fetal Thrombotic Vasculopathy: None; Avascular villi; Villous Stromal or
Vascular Karyorrexis; Both Villous Stromal and Vascular Karyorrexis;
Unknown
Fetal Thrombosis Vessels: None; Chord; Chorionic Plate Vessels;
Stem Villi; Unknown;
Decidual Vasculopathy : None; Acute Atherosis; Lack of physiologic
transformation ; Chronic Perivascular Inflammation; Decidual Vascular
Thrombosis; Unknown.
Placental Low Flow Changes: None; Very Small villi (distal villous hyploplasia);
Increased Syncytial knots; Prominent Villous stromma; Small fetal Capillaries;
Unknown.
Hematoma: None; Subchorionic; Intervillous; Retroplacental;
Subamniotic; Marginal ; Unknown;
Chorioangiosis : None; Yes, Moderate; Yes, Marked ; Unknown.
Chorioamnionitis: None; Yes; Unknown
Inflammatory Maternal Response Stage: Stage1 ; Stage2 ; Stage3 ;
Unknown
Inflammatory Maternal Response Grade: None ; Grade1; Grade2; Unknown;
Inflammatory Fetal Response Stage: Stage1 ; Stage2 ; Stage 3 ; Unknown;
Inflammatory Fetal Response Grade:
None ; Grade1 ; Grade 2 ;
Unknown;
Chorioamnionitis Fetal Vascular Thrombosis:
None; Chord Vessels; Chorionic Vessels; Others; Unknown
Puerperium
Arterial Thrombosis:
Never Myocardial ; Pulmonary; Brain ;
Renal; Mesenterics ; Extremities; Other; Unknown
Venous Thrombosis: Never ; Cave ; Brain; Renal ; Pulmonary  ; Arms ;
Iliofemoral ; Femoropoplyteal ; Calves; Others ; Unknown
Puerperal Hypertension: No  ; Transient Hypertension ;Preeclampsia  ;
HELLP; Unknown
Catastrophic Antiphospholipid Syndrome: No; Yes ;
Hemorrhage
No ; Methrorragia ;Other ;Unknown ;
Infection
No ; Yes ; Unknown ;
Infection (Description: Type; Main agents)
Idiopathic Thrombocytopenic Purpura
No ; Yes.
Systemic Lupus Erytematous No ; Yes SLE-like Disease No ;
Yes
Other Complications (Specify)
Long Term Follow-up
Full blown SAP:
SLE-Like:
No ; Yes Full blown SLE:
No ; Yes;
ITP:
Other chronic autoimmune diseases: No ; Yes
No ; Yes
No ; Yes