Fetal Examination

NAME OF PROCEDURE

Fetal Examination

CPT CODE

To be assigned by Pathologist

  • 88300 – Level I: Surgical pathology gross examination only
  • 88309 – Level VI: Surgical pathology gross and microscopic

SYNONYMS

Fetal Pathology; Premature Infant Examination:  Stillborn infant examination

TEST INCLUDES

Gross and microscopic examination and diagnosis, chromosome studies (if requested) of intact fetuses (if not immersed in formalin).

SPECIMEN

Entire specimen with placenta (in the same or a separate container)

CONTAINER

Submit specimen fresh in a sterile saline soaked gauze or towel or in a sterile plastic container.  Sterile saline may be used to avoid drying of specimen if chromosome analysis studies are requested.

Label with patient’ name (or mother’s name if live-born fetus), date, time of collection, and type of specimen.

Deliver immediately to the laboratory.  Refrigerate specimen if it cannot be processed immediately.  Specimen may be submitted in formalin only if chromosome studies are not needed.

Permit for <Disposition of Fetus> must also be sent with the specimen.

REQUEST FORM

Complete a <Anatomical Pathology Requisition>.

If parents choose that the hospital laboratory dispose of the fetus:

  1. A <Permit for Disposition of Fetus> is obtained by the appropriate nursing unit.
  2. The original copy is placed on the mother’s chart, and a copy is sent to the laboratory with fetus.

If the hospital request that the laboratory (Southeastern Pathology Associates) dispose of the fetus, please notify gross room personnel @912-261-2669, otherwise the fetus will be returned after examination to the originating hospital laboratory for disposition.

The vital records clerk must sent a copy of the mother’s prenatal medical record with the specimen.

CAUSES FOR REJECTION

Specimen container not properly labeled.

ADDITIONAL INFORMATION

Embryo:  an embryo is recognized as a conceptus up to the 10th and 12th weeks of gestation at which time the conceptus is 4-6cm in length and weighs 14-25g.  An embryo is processed as surgical pathology specimen in all cases.  No disposal form or autopsy permit is required.

Stillborn fetus:  (under 500g) or <20 weeks gestation (foot length <3.3cm:  A stillborn fetus weighing 25-500g or <20 weeks (foot length <3.3cm) is process as a surgical specimen and held for the routine three week time span for routine surgical specimens.  If the family desires the laboratory to dispose of a stillborn fetus the appropriate form, <Permit for Disposition of Fetus>, must be signed by the mother and by the father if available or in the case of a widow or unmarried mother, the mother alone may sign.

NOTE

The fetus will be returned to the originating hospital laboratory for disposition unless prior arrangements have been made with SEPA gross room personnel to dispose of the fetus after examination is complete.

A complete autopsy is not a feasible procedure with these specimens.

Sill born fetus: (over 500g) or >20 weeks:  A stillborn fetus weighing 500g or more or >20 weeks gestation (foot length >3.3cm) is processed as a surgical specimen and held six months prior to disposal.  In unusual circumstances, the physician may request an autopsy.  In such cases an autopsy permit must be signed by routine procedure.  If the family desires, the laboratory to dispose of a stillborn fetus, the appropriate form <Permit for Disposition of Fetus>, must be signed by the mother and by the father if available or in the case of a widow or unmarried mother, the mother alone may sign.

NOTE:

The fetus will be returned to the originating hospital laboratory for disposition unless prior arrangements have been made with SEPA gross room personnel to dispose of the fetus after examination is complete.

The parents have the clear right to bury a fetus and this right should be explained at the time for obtaining the proper authorizations and forms.

Information regarding the type of specimen, admitting diagnosis, and pertinent clinical history (i.e. age, clinical impression past diagnosis, radiographic findings) is essential to interpretation and should be noted on the requisition.  Infectious diseases suspected and special studies should be specified on the request.  Special handling requirements (isolation) should be noted on the requisition.

Any fetus that exhibits any type of life, including spontaneous breathing, heartbeat, or voluntary movement after delivery is designated a live-born infant.  A death certificate is required for all live-born infants.