Gynecological History

17

Genital infection

1 = yes, 2 = no

Past toxicological history

18

Alcohol

1 = yes, 2 = no

19

Tabaco

1 = yes, 2 = no

Present pregnancy

20

Gestational age (day)

21

Number of fetuses

1 = one

2 = two

3 = three

22

Number of prenatal consultations

23

ANC done by:

1 = Gynecologist

2 = General practitioner

3 = Mid-wife

4 = Other

24

If CPN done by other precise

25

HTA during pregnancy (ANC)

1 = yes, 2 = no

26

Gestational diabetes

1 = yes, 2 = no

27

Urinary infection during pregnancy

1 = yes, 2 = no

28

Frequency of sexual intercourse per week

Medical History

29

Chronic hypertension

1 = yes, 2 = no

30

Diabetes

1 = yes, 2 = no

31

HIV serology

1 = Positive

2 = Negative

3 = Not known

32

Urinary malformation

1 = yes, 2 = no

33

Kidney failure

1 = yes, 2 = no

34

Cardiac insufficiency

1 = yes, 2 = no

35

Past urinary tract infection

1 = yes, 2 = no

Section III: Laboratory Test

36

Dipstick done

1 = yes, 2 = no

37

Dipstick

1 = Positive

2 = Negative

38

Leucocytiuria

1 = yes, 2 = no

39

If leucocytiuria

1 = Trace

2 = +

3 = ++

4 = +++

40

Proteinuria

1 = Yes, 2 = No

41

If proteinuria

1 = Traces

2 = +

3 = ++

4 = +++