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					                                                   InCyte Pathology
                                    13103 E Mansfield Ave         Spokane Valley, WA 99216
                                         P.O. Box 3405       Spokane, WA 99220-3405
                                             (509) 892-2700        1(888) 814-6277

                                  REQUEST FOR PLACENTAL EXAMINATION
                                        (Complete and attach to Histology Examination Request)

Mother’s Name:          ___________________________________                                           Date:                  /              /

Mother’s Physician: ________________________________ Infant’s Physician: ______________________________
OB History: G: ___ P: ___ A: _______ (spont/elect) Gestational age: _____ Infant’s weight: ___________
Apgar score: _____ Length of umbilical cord at delivery: _____ Rh: ___ (Rhogam yes/no)
Antibody screen_____ Maternal Serologies: Rubella: ____ RPR: ____ Hepatitis screen_____ GBS ____
Specific issues of concern: ______________________________________________________________________________

               MATERNAL                                        FETAL                                           PLACENTAL

Systemic disorders with clinical concerns    Admission or transfer to other than a          Physical abnormality (eg, infarctions.
  for mother or infant (eg., hypertensive    level 1 nursery                                 masses, abnormal coloration,
  disorders, anemias, etc.)                  Stillbirth or perinatal death                   meconium staining, etc.)
Premature delivery <34 weeks gestation       Compromised clinical condition                 Placental size <350 g or > 650 g
Peripartum fever and/ or infection           defined as any of the following: cord          Umbilical cord lesions (eg. thrombosis,
Unexplained third-trimester bleeding or      blood pH <7.0; Apgar score<6 at 5               torsion, true knot, single artery,
  excessive bleeding >500 cc                 minutes; ventilatory assistance >10            absence of Wharton’s jelly)
Clinical concern for infection during this   minutes; or severe anemia (hematocrit          Total umbilical cord length <32cm at
  Pregnancy (eg., TORCH, parvo)              < 35%)                                          term
Severe oligohydramnios                       Hydrops fetalis
Unexplained or recurrent pregnancy           Birthweight <10th percentile                                    OTHER
  Complication (eg., IUGR, prematurity,      Seizures                                       Abnormalities of placental shape
  recurrent abortions)                       Infection or sepsis                            Long cord (>100 cm)
Invasive procedures with suspected           Major congenital anomalies,                    Marginal or velamentous cord insertion
  Placental injury                           dysmorphic phenotype, or abnormal
Abruption                                    karyotype
                                             Discordant twin growth (>20% weight
                  OTHER                        difference)
Prolonged (>24 hours) rupture of             Multiple gestation
Premature delivery from >34 to 37                             OTHER
weeks                                        Birthweight >95 percentile
 Gestation                                   Asymmetric growth
History of substance abuse                   Vanishing twin beyond the first trimester
Cigarette smoking
Severe maternal trauma

PLUS: Any case with unusual or abnormal clinical circumstances or with an abnormal appearance of the placenta or
                                                                                                     * Based upon the College of American Pathologists
                                                                                                  “Practice guidelines for examination of the placenta.”
                                                                                                                    J:\WPDOCS\FORMS\PLACENTAL REQUEST FORM.DOC

       R.J. Achterberg, DDS T.J. Allerding, MD A.M. Backer, MD T.J. Bassler, MD S.J. Darling, MD M.W. deTar, MD T.M. Fandel, MD
      B.M. Hjermstad, MD D.C Hoak, MD K.M. Ireland, MD G.R. Lindholm, MD F. Martinez, Jr., MD C.J. Montague, MD D. Mornin, MD
                      D.R. Nightingale, MD   G.A. Peterdy, MD W.G. Riches, MD A.M. Wardzala, MD M. Zhang, MD, PhD

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