Head and brain tumors
Face and neck tumors
Throax tumors
Abdomen tumors
Other tumors

Fetal tumors and cysts

PATIENT REGISTRATION 

Center
 
Patient Name Patient ID # Maternal Age Gravida Para  
 
                  (Last name , First name)          
     
  Mode of Conception Specific ART
  ART AI     IVF       IVF-DE-ICSI    IVD-SD  OTHER
  OVULATION INDUCTION GIFT IVF-DE  IVF-ICSI          ZIFT
  NATURAL  
  IUI Specific Fertility Drug
  UNKNOWN CLOMID     HUMAGON METRODIN   PROFASI 
  OTHER FERTINEX  LUPRON    PERGONAL    OTHER
     
  Genetic Testing  
  NOT DONE      AMNIO       CVS     FETAL BLOOD SAMPLING   UNKNOWN     OTHER
     
         
   GA at diagnosis  (wks)           Fetal tumor site  
                     Head and brain  
   Prenatal sonography                  Face and neck  
      Anamoly scan    Yes                  Thorax (inc. heart)  
                               No   (wks)                Abdomen and retroperitoneum  
                     Other  
         
 

 Amount of Amniotic  liquid

           Ultrasound final diagnosis  
     Normal             
     Polyhydramnios      AFI      
     Obligohydramnios      
         
   
  Fetal Anomalies - Category       Specific Fetal Anomaly
  CHROMOSOMAL   
  MENDELIAN  
  CARDIAC  
  CNS  
  GASTROINTESTINAL  
  GENITAL / URINARY  
  STRUCTURAL MARKERS OF INCREASED CHROM. RISK  
   UNKNOWN  
   OTHER   
   
       

 Late Pregnancy 

  Complications    
  ABRUPTION OF PLACENTA   IUGR   MYOMECTOMY   PROM
  FETAL DISTRESS   OLIGOHYDRAMNIOS   PIH   UNKNOWN
  FETAL INFECTION   MATERNAL CHOLESATASIS   PLACENTA PREVIA   OTHER
  GESTATIONAL DIABETES   MATERNAL CHF   (PRE) ECLAMPSIA  
  HYDROPS   MATERNAL DISEASE   PRE-TERM LABOR  
  HYALINE MEMBERANE DISEASE    MATERNAL INFECTION   PROLAPSE OF UMBLICAL CORD  
       

Labor Mode

   Delivery Mode

Reason for C / S

Gestational Age at  PROM
               SPONTANEOUS

          C / S

   BREECH

               INDUCED

        VAGINAL

   CPD  
               NONE         BOTH   FETAL COMPROMISE  
               UNKNOWN         UNKNOWN   FETAL ANOMALY  
      UNKNOWN  
      OTHER  
       
       

 Outcome Summary

      
 GA AT DELIVERY (WKS)
      
GA AT FETAL DEMISE (WKS)
      
WEIGHT
   grams          lbs.  ozs    
SEX
   Male   Female   Unknown     
GENERAL OUTCOME
    MISCARRIAGE <24 WKS    
     IUFD >24 WKS    
     PRE-TERM DEL 24-37 WKS    
     TERM DEL 37+ WKS    
     OTHER    
       
NEONATAL TUMOR
      
       
NEONATAL ANOMALY
    CARDIAC    
     GASTROINTESTINAL    
     GENITAL / URINARY    
     LIMB    
     MUSCLE / SKELETAL    
     NONE    
     UNKNOWN    
     SPECIFY     
       
NEONATAL OUTCOME
    NORMAL    
     NOT HOME W/MOM , NOT IN NICU    
     NICU < 7 DAYS    
     NICU > 7 DAYS    
     NND    
     RDS    
     OTHER    
       
 
   Additonial comments :
 

- Thank you -

 

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