Information sheets:
PERINATAL DEATH: FETAL (≥25th gestational week)- NEONATAL (within the first week of life)
ANAGRAPHIC DATA of the MOTHER:
Last name…………………………….First name ………………………………
Date of birth (dd/mm/yyyy)…..…/…..…/…..…. Age……………………
Place of birth…………………………Province/state…………………
Race/ethnicity:
□Caucasian □ Ispanic□ Middle Eastern
□Indian (subcontinental)□ Asian□ Black
□mixed ethnicity □ Magrebin □ other □ unknown
□missing data
Occupation…………………………………………
Previous conceptions □ Yes □ No □Missing data
Number of previous births………….
Number of live births……………
Number of stillbirths (≥25th gestational week- National Italian Law no. 31/2006)………………….
Number of miscarriages …………….at gestational week ……..………………………….
Number of voluntary abortions…………….
Date of the last birth: (dd/mm/yyyy)……………
CIGARETTE SMOKE / ACTIVE / PASSIVE/SECONDHANDNO / YES / No. cigarettes/
day / at home / at workplace
NO / YES / NO / YES
before conception / from the age of______/ from the age of_____ / from the age of_____
during pregnancy / until gestational week no.____ / until gestational week no.___ / until gestational week no.___
after delivery / until baby reached age of__ / until baby reached the age of__ / until baby reached the age of___
Does the mother drink alcohol? □ yes □ No Missing data
Does the mother use drugs? □Yes □ No □ Missing data
Did the mother use drugs during pregnancy? □ Yes □ No □Missing data
Is the mother HIV positive? □ Yes □ No □ Missing data
Did the mother use sedative-drugs or other drugs during pregnancy?
□ Yes □ No □Missing data
INFORMATION ABOUT PREGNANCY
Date of last period (dd/mm/yyyy)……………………… ………………..
Anamnestic-estimated date of delivery (due date) (gg/mm/aaaa)…………………………
Ultrasound-estimated date of delivery (dd/mm/yyyy)……………………………
Number of check-ups during pregnancy…………………………………………..………
First pregnancy check-up ( gestational week)…………………………….
MOTHER’S DISEASES:
Hypertension □ Yes : gestational / pre-gestational
□ No □ Missing data
Diabetes □ Yes : gestational / pre-gestational
□ No □ Missing data
Hemoglobin alterations □ Yes, specify……………………………………...
□ No □ Missing data
Coagulation anomalies□Yes □ No □ Missing data
Autoimmune diseases□Yes □ No □ Missing data
MATERNAL INFECTIONS (peri/post-conceptional)
□ HIV □ HBV
□HCV □ Syphilis (LUE)
□ TOXO □ CMV
□ RUBEO□other
OTHER DISEASES OF THE MOTHER
□Thyroid gland □hypophysis
□cardiopathy □kidneys
□pregnancy-related cholestasis □ parodontopathies
□other
SCREENING TESTS FOR CHROMOSOMAL ABNORMALITIES
Screening: □ Yes □ No □ Missing data
NT (Nuchal translucency): □ abnormal □ normal □ Missing data
NT+BI TEST: □ abnormal □ normal □ Missing data
Triple screen test: □ abnormal □ normal □ Missing data
↓
□ Down S. □ DTN □ Missing dataPRENATAL INVASIVE TESTS
Chorionic villus sampling (CVS): □ normal □ not performed □missing data
□ pathologic, specify…………………………………………………………
Amniocentesis: □ normal □ not performed □ missing data
□ pathologic, specify…………………………………………………………
Funicolocentesis: □ normal □ not performed □ missing data
□ pathologic, specify…………………………………………………………
Fetoscopy: □ normal □ not performed □ missing data
□ pathologic, specify…………………………………………………………
Ultrasound: □ normal □ not performed □ missing data
□ pathologic
↓
Fetal abnormalities□ heart □ CNS
□ abdominal wall □ gastrointestinal tract
□ single umbilical artery □ muscle/bones
placenta
□ premature detachment □ previa
□ vasa previa □ infarction
□ accreta-percreta
Uterus abnormalities:
…………………………………………………………………………………………….
ADMITTANCE TO HOSPITAL DURING PREGNANCY: □Yes, diagnosis…………………
□ No □Missing data
SIBILINGS (of the dead fetus or newborn)
ALIVEborn on / died at age / cause*
months / years
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2
3
*please specify if SIDS
ANAGRAPHIC DATA of the FATHER
Last name…………………………….First name ………………………………
Date of birth (dd/mm/yyyy)…..…/…..…/…..…. Age……………………
Place of birth…………………………Province/state…………………
Race/ethnicity:
□Caucasian □ Ispanic□ Middle Eastern
□Indian (subcontinental)□ Asian□ Black
□mixed ethnicity □ Magrebin □ other □ unknown
□missing data
Occupation…………………………………
CIGARETTE SMOKE □ No □ Yes, specify time frame: from……………..until…………………
no. cigarettes/day: □ 1-5 □ 6-10 □ 11-20 □ >20
At what age did he start smoking? ………………………
ALCOHOL □ No□ Yes…………………………………….
DRUGS □ No□ Yes…………………………………….
Present pathologic anamnesis
………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………..
Remote pahologic anamnesis
………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………..
Familiarity for diseases:
………………………………………………………………………………………………………………………………………..
FETUS FORM
Last name ……………………..……………..
Name……………………..……………..
Address: street……………………..……………..No.………...... Area Code……..…………..
City…………………………………..….. Province/state………...……..………..
Sex: □ Male
□ Female
Date of death (dd/mm/yyyy)…………………………….Time…………………………….
Age (gestational week) …………………
Date of last medical check-up (dd/mm/yyyy)……………………..
amniotic fluid: □normal □ pathologic, specify…………………………………………………
□ missing data
Scheleton X-ray: □normal □ pathologic, specify…………………………………………………
□ missing data
Was the post-mortem investigation performed?
□Yes □ No □ Missing data
Were the specimens collected following the Italian Protocol (Law 31)?
□Yes □ No □ Missing data
Date of post-mortem investigation(dd/mm/yyyy)…..……./…..……./………..
Performed by Dr.……………………………..
NEWBORN FORM
Last name ……………………..……………..
Name……………………..……………..
Address: street……………………..……………..No.………...... Area Code……..…………..
City…………………………………..….. Province/state………...……..………..
Sex: □ Male
□ Female
Date of birth (dd/mm/yyyy)…..…/…….…/…….…
Post-conceptional age (gestational age…………… + postnatal age………….)
Date of death (dd/mm/yyyy)…..…/…….…/…….…
Was the post-mortem investigation performed?
□Yes □ No □ Missing data
Were the specimens collected following the Italian Protocol (Law 31)?
□Yes □ No □ Missing data
Date of post-mortem investigation(dd/mm/yyyy)…..……./…..……./………..
Performed by Dr.……………………………..
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