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Use one form for each cord, membranes, and disc (i.e. a singleton should have one form, a twin should have two forms, etc.). Alternatively, use the flexible dictation template (see Placenta).

Patient Name:  ________________________          Surgical #:  _____________________

Specimen:  ______________________    Pathologists:________________________

Patient history if available:

SVD or C-section:        __________________________________ 

Gestational age:        __________________________________

Gravida status:        __________________________________

Maternal age:        __________________________________

Ultrasound data:        __________________________________

Fetal / Infant weight:__________________________________

Fetal / Infant sex:        __________________________________

Maternal symptoms and history:        ___________________________________________

______________________________________________________________________

Singleton:                __________________________________

Twin / multifetal:        __________________________________

      Fused or separate discs:                _____________________________________

      Dividing membrane description:        _____________________________________

      Vascular anastomoses:                _____________________________________

      Gross impression:                        _____________________________________

Umbilical cord (identify as singleton, A, B, C, etc.) ___                                 

Length:        ___ cm                        Diameter:        ___cm

Color:                ________________                Consistency: __________________________

Knots:                ________________        Twists per cm:        ____ / cm

Segmental discoloration:  _________________________________________________

Ulcerations or nodules:  __________________________________________________

Thrombi:        ________________                Insertion site:        ________________

Membranes:

Color:  ________________________________________________________________

Translucency:  __________________________________________________________

Insertion site:          __________________________________________________________

Intact or fragmented:  ____________________________________________________

Rupture site:         __________________________________________________________

Hemorrhage:                        __________________________________

Velamentous vessels:        __________________________________

Amnion nodosum:                __________________________________

Fetal Surface:

Color:                                __________________________________

Translucency:                __________________________________

Mucoid surface:                __________________________________

Vessel radiation:                __________________________________        

Marginal vessels:                __________________________________

Vascular thrombi:                __________________________________

Subchorionic blood or thrombus:        __________________________________

Subchorionic or marginal fibrin:        __________________________________

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Maternal Surface:

Intact:                                        __________________________________

Calcification or discoloration:        __________________________________

Attached or adherent clot:                __________________________________

Soft non-adherent clot:                __________________________________

Villous Tissue:

Consistency:                                __________________________________

Color:                                        __________________________________

Nodules or other focal lesions

       Description:                        __________________________________

       Location:                        __________________________________

       % of villous tissue:                __________________________________

Hemorrhage or congestion:        __________________________________

Weight:

Trimmed _____ g                Post-fixation _____ g        Clots removed _____ g

Dimensions:                        __________________________________

Shape of disc:                        __________________________________

Overall gross impression:        __________________________________

Cassettes for singleton:

#___ – membranes, with rupture site (yes or no?)

#___ – representative cord sections

#___ – representative inner disc with maternal surface

#___ – representative inner disc with fetal surface

#___ – representative inner disc

#___ – #___ -- Submit additional sections for gross lesions as necessary