Postmortem findings in term neonates

Stillbirth Investigations: An Iconographic and Concise Diagnostic Workup in Perinatal Pathology

Introduction  Stillbirth is a dramatic event for the parents, health care team, and anyone close to the expectant parents. Multidisciplinary team (MDT) meetings are essential to improve communication in health care. We review the most frequent findings discussed at MDT meetings. Methods  A PubMed search was conducted through December 2021 since the inception (1965) using clinical queries with the key terms "stillbirth" AND "investigation" AND "pathology" AND "human." The search strategy included reviews, meta-analyses, randomized controlled trials, clinical trials, and observational studies. This systematic review is based on, but not limited to, the search results. It is the experience of more than 30 years of pediatrics, obstetrics, and pathology staff. Results  Two hundred and six articles were screened and complemented through the perusal of congressional activities and personal communications. Pathological findings following perinatal death can be divided into macroscopic, histologic, and placental findings. The placenta is crucial in fetal medicine and is key in determining the cause of stillbirth in a substantial number of events. Perinatal lung disease is essential to evaluate the response of newborns to extrauterine life and address newborns' outcomes appropriately. Conclusions  Stillbirth remains one of the less explored areas of medicine, and we can determine the cause in a limited number of cases. Nevertheless, placental pathology is critical in the etiology discovery pathway. Accurate investigations and discussion of photography-supported findings are vital in promoting communication at MDT meetings.

Sudden cardiac death in children with congenital heart disease: a critical review of the literature

Sudden cardiac death is an uncommon but yet catastrophic event, which can occur in neonates and young children. Although extensive research has been carried out assessing the underlying causes, there still remains a degree of uncertainty around this area. Congenital heart disease (CHD) is one known cause of sudden cardiac death in children, the aetiology of which embraces virally induced mechanisms, genetic susceptibility, drug-induced, and maternal factors. Screening tools and investigations including electrocardiograms and echocardiograms alongside a concise history taking and physical examination can be used to identify the potential cardiovascular risk factors of sudden death. This review has comprehensively studied the causes and risk factors for sudden cardiac death in children with CHD and provides a collation and summary of the evidence available so far underpinning the complex link between the two. Moreover, current screening and prevention methods are discussed in detail in order to increase awareness and understanding of how we can improve patient outcomes.

Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction

BACKGROUND

Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients.

METHODS

We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016).

RESULTS

31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031).

CONCLUSIONS

The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year.

LEVEL OF EVIDENCE

This is a prognostic study with Level IV evidence.

Neural Tube Defects: A Retrospective Study of 69 Cases

Objective:

Neural tube defects (NTDs) are congenital disorders that significantly increase the risk of death and disability in the 1^st year of life. The aim of this study was to retrospectively evaluate the patients admitted to our neonatal intensive care unit because of NTD.

Materials and Methods:

We retrospectively examined the demographic features, familial risk factors, physical examination and radiological findings, and accompanying diseases of 69 patients with NTD.

Results:

Of the 69 patients hospitalized in a 5-year period, 38 were female and 31 were male. The median birth weight was 3150 g and the median delivery week was 38 weeks. Forty-nine of the patients (71%) had meningomyelocele, 11 patients (16%) had encephalocele, and nine patients (13%) had meningocele. Forty-five of the patients (65.2%) had Arnold–Chiari type 2 malformation. Twenty-five percent of the mothers had a history of periconceptional use of folic acid. The median time of making a diagnosis of NTD by prenatal ultrasonography was 20 (16–24) weeks. Thirty-nine of the patients (56.5%) had other organ disorders, some with multiple systemic disorders.

Conclusion:

The use of periconceptional folic acid in mothers and a decision for termination in selected cases may be effective in reducing the frequency of NTD.

Temporal arachnoid cysts: are they congenital?

CASE REPORT

The authors report two cases of arachnoid cysts (ACs) neither detected during pregnancy nor shortly after birth when newborns underwent CT scan evaluation after birth head trauma. ACs were diagnosed at 10 months and 6 years, respectively. The first one becomes symptomatic, and the other one was incidentally found during a head trauma investigation.

DISCUSSION

These cases give support for the postnatal pathogenesis for some of the assumed congenital ACs. We collected data from the literature that supports the acquired hypothesis for ACs.

Stillbirth and intrauterine fetal death: role of routine histological organ sampling to determine cause of death

OBJECTIVES

Guidelines for the investigation of intrauterine death and sudden unexpected death in infancy (SUDI) recommend, based on expert opinion, autopsy procedures and tissue sampling strategies for histological analysis. Although stillbirth is much more common than SUDI, there have been no large-scale studies published which evaluate the usefulness of histological evaluation of specific organs in stillbirth for determining cause of death. Our aim was to evaluate the use of macroscopic and microscopic assessment of internal organs to determine cause of intrauterine death.

METHODS

As part of a larger study evaluating several aspects of autopsy findings in intrauterine death, a dedicated database was used to collate antenatal and postmortem examination details for cases of intrauterine death examined between 2005 and 2013 at two tertiary specialist centers in London, UK. Histological findings for all organs were examined in relation to the final cause of death, as determined by objective criteria.

RESULTS

Among 1064 intrauterine deaths, the majority (> 80%) of cases had internal organs that were normal on both macroscopic and microscopic examination. There was no case in which histological cardiac examination provided the cause of death when the macroscopic appearance of the heart was normal. Microscopic examination of lung tissue revealed 13 (1%) cases with histological abnormalities that provided the cause of death when the macroscopic appearance was normal, but there was only one (0.1%) case in which the diagnosis would not have been apparent on placental examination: a case of congenital cytomegalovirus infection. There was no case in which microscopic examination of macroscopically normal liver, kidneys, adrenals, spleen, thymus, intestines, pancreas, brain or thyroid provided the cause of death.

CONCLUSION

In this large series of autopsies in cases of intrauterine death, only around 1% of cases demonstrated histological abnormalities which provided the cause of death when the internal organs appeared normal macroscopically. There was no case in which routine histological examination of most tissues provided diagnostically useful information that was not apparent from other examinations, such as placental pathology. There is little benefit, purely in terms of determining cause of death, in obtaining tissue from most macroscopically normal organs for routine histological examination. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Whole-genome sequencing for identification of Mendelian disorders in critically ill infants: a retrospective analysis of diagnostic and clinical findings

BACKGROUND

Genetic disorders and congenital anomalies are the leading causes of infant mortality. Diagnosis of most genetic diseases in neonatal and paediatric intensive care units (NICU and PICU) is not sufficiently timely to guide acute clinical management. We used rapid whole-genome sequencing (STATseq) in a level 4 NICU and PICU to assess the rate and types of molecular diagnoses, and the prevalence, types, and effect of diagnoses that are likely to change medical management in critically ill infants.

METHODS

We did a retrospective comparison of STATseq and standard genetic testing in a case series from the NICU and PICU of a large children's hospital between Nov 11, 2011, and Oct 1, 2014. The participants were families with an infant younger than 4 months with an acute illness of suspected genetic cause. The intervention was STATseq of trios (both parents and their affected infant). The main measures were the diagnostic rate, time to diagnosis, and rate of change in management after standard genetic testing and STATseq.

FINDINGS

20 (57%) of 35 infants were diagnosed with a genetic disease by use of STATseq and three (9%) of 32 by use of standard genetic testing (p=0·0002). Median time to genome analysis was 5 days (range 3-153) and median time to STATseq report was 23 days (5-912). 13 (65%) of 20 STATseq diagnoses were associated with de-novo mutations. Acute clinical usefulness was noted in 13 (65%) of 20 infants with a STATseq diagnosis, four (20%) had diagnoses with strongly favourable effects on management, and six (30%) were started on palliative care. 120-day mortality was 57% (12 of 21) in infants with a genetic diagnosis.

INTERPRETATION

In selected acutely ill infants, STATseq had a high rate of diagnosis of genetic disorders. Most diagnoses altered the management of infants in the NICU or PICU. The very high infant mortality rate indicates a substantial need for rapid genomic diagnoses to be allied with a novel framework for precision medicine for infants in NICU and PICU who are diagnosed with genetic diseases to improve outcomes.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Human Genome Research Institute, and National Center for Advancing Translational Sciences.

The stillbirth collaborative research network postmortem examination protocol

After reviewing the state of knowledge about the scope and causes of stillbirth (SB) in a special workshop sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the participants determined that there is little guidance regarding the best use of postmortem examination (PM) to address the pathogenesis of stillbirth. In this report, we describe the PM procedure designed and used in the NICHD-supported Stillbirth Cooperative Research Network (SCRN). Perinatal pathologists, clinicians, epidemiologists, and biostatisticians at four tertiary care centers, a data coordinating center, and NICHD developed a standardized approach to perinatal PM, which was applied to a population-based study of stillbirth as part of the SCRN. The SCRN PM protocol was successfully instituted and used at the four medical centers. A total of 663 women with stillbirth were included: 620 delivered a single stillborn infant, 42 delivered twins, and one delivered triplets for a total of 676 stillborn infants. Of these women, 560 (84.5%) consented to PM (572 stillborn infants) that was conducted according to the SCRN protocol. A standardized PM protocol was developed to evaluate stillbirth consistently across centers in the United States. Novel testing and approaches that increase the yield of the PM can be developed using this model.

A comparison of stillborn birth weights and postmortem weights

Birth weights obtained by the nurses in the labor and delivery room were compared with the postmortem weights examination prospectively in 212 stillborns. The effects of gestational age, degree of maceration, birth weight, gender, and time elapsed from delivery to postmortem examinations were also examined. There were 96 female and 116 male stillborns in the study. The gestational ages ranged from 14 to 42 weeks. The degree of maceration ranged from 0 to 5, 0 being no maceration and 5 representing the most extreme condition, which was mummification. There was an average of a 50 g decrease in the weights of all stillborns when their birth weights and postmortem weights were compared. This was equal to an average relative weight loss of 7.1%. When all the variables were examined, only the degree of maceration and gestational age were identified to play significant roles in weight loss (P < 0.0001 for both). A higher degree of maceration meant more weight loss, whereas older gestational age led to less weight loss. There is significant discrepancy between the birth and postmortem examination weights of stillborns. Although gender, birth weight, and time elapsed from delivery to postmortem examination did not have any significant effects, the degree of maceration and gestational age affected the observed weight loss. In stillborns, birth weights are more accurate than weights obtained at postmortem examination.

Haploinsufficiencies of FOXF1 and FOXC2 genes associated with lethal alveolar capillary dysplasia and congenital heart disease

Neonatal deaths account for about 67% of all deaths during the first year of life in the USA. Genetic defects are important factors contributing to neonatal deaths and congenital anomalies. Here we report on the identification of a 1.37 Mb de novo deletion of chromosome 16q24.1-q24.2 by microarray-based comparative genomic hybridization (aCGH) technique in a newborn boy with lethal severe alveolar capillary dysplasia and multiple congenital anomalies who died of irreversible pulmonary hypertension, respiratory failure and cor pulmonale at three days of age. The phenotypic findings and causal genes (FOXF1 and FOXC2) involved in producing this unusual syndrome are detailed. Our findings independently confirm the results in a previous publication describing multiple patients with similar clinical and genetic observations, and highlight the importance of scanning human genomes at high resolution for identifications of micro-imbalances as pathogenic causes in neonates with unexplained congenital anomalies. (c) 2010 Wiley-Liss, Inc.

Prevalence and outcome of congenital heart disease in patients with neural tube defect

A prospective clinical study was designed to establish the risk factors, the prevalence, and the progress of congenital heart defects in children with neural tube defects. Study included 90 children with a mean age of 13.5 +/- 30.4 months. There were 53 (59%) patients with spina bifida occulta and 37 (41%) patients with spina bifida aperta. The overall prevalence of congenital heart disease was 27.8% (40.5% in spina bifida aperta and 18.9% in spina bifida occulta; P = .024). There was no statistically significant difference for maternal age, usage of periconceptional folate, and maternal diabetes between the patient and control groups. The authors conclude that congenital heart defects are more common than reported in neural tube defects, and screening echocardiograms are warranted. This should be kept in mind especially in patients requiring minor or major surgical procedures. Furthermore, routine obstetric examination and therefore the use of periconceptional folic acid during pregnancy is still lacking in our country.

Management of patients with congenitally malformed hearts in Indonesia

At a crude rate in Indonesia of 20 births per 1000 population, the total number of annual live-births is approximately 4.5 million. Considering the estimate of 9 of each 1000 affected live-births, 40,500 infants with congenitally malformed hearts are added every year to the total pool. The number of surgical procedures for such congenital cardiac malformations in the whole country in 2005 was 706. The majority of cases are undetected, contributing to a high rate of infant mortality. In the period of 3 years from 2003 through 2005, 1366 patients underwent open and closed cardiac surgical procedures at the National Cardiovascular Center in Jakarta. The rate of death was 5.56%, with a complexity score as calculated for the Aristotle system of 6.25, which is at the medium level. The proportion of surgical procedures performed in infancy has increased, but the rate of mortality for complex surgery in this particular group is still high. Non-surgical interventions have increased every year, but the cost is higher than for surgery, except for balloon pulmonary valvoplasty. Thus, by any reckoning, paediatric cardiac care in Indonesia is still in its infancy. The barriers are: lack of awareness of congenitally malformed hearts, limited resources and facilities, the high cost of treatment, and limited financial support. Training programmes exclusively dedicated to paediatric cardiology and paediatric cardiac surgery need to be established in centers with good standards of paediatric cardiac care.

Characterization of pulmonary cell growth parameters in a continuous perfusion microfluidic environment

In vitro models of the alveolo-pulmonary barrier consist of microvascular endothelial cells and alveolar epithelial cells cultured on opposing sides of synthetic porous membranes. However, these simple models do not reflect the physiological microenvironment of pulmonary cells, wherein cells are exposed to a complex milieu of mechanical and soluble stimuli. In this report, we studied alveolar epithelial (A549) and microvascular endothelial (HMEC-1) cells within varying microfluidic environments as a first step towards building a microfluidic analog of the gas-exchange interface. We fabricated polydimethylsiloxane (PDMS) microdevices for parallel studies of cell growth under multiple flow rates. Cells adhered and proliferated in the microculture chambers for shear stresses up to approximately 2 x 10(-3) dynes/cm(2), corresponding to media turnover rates of approximately 53 seconds. Proliferation of these cells into confluent monolayers and expression of cell-specific markers (SP-A and CD-31) demonstrated successful pulmonary cell culture in microscale devices, a first for alveolar epithelial cells. These results represent the initial steps towards the development of microfluidic analogs of the alveolo-pulmonary barrier and tissue engineering of the lung.

My approach to performing a perinatal or neonatal autopsy

An opportunity to determine the cause of death, factors that may have a role in it, and the extent and cause of malformations is provided by perinatal autopsy. The family may be assisted in finding closure after the death of their infant by the information obtained. Insight into classifying infants appearing normal into one of three groups, small, appropriate and large for gestational age, has been provided, as each group tends to have specific causes of death. In infants with congenital anomalies, patterns of malformation may lead us to the diagnosis. An accurate diagnosis is required to provide counselling for a subsequent pregnancy.

Etiology, pathogenesis and prevention of neural tube defects

Spina bifida, anencephaly, and encephalocele are commonly grouped together and termed neural tube defects (NTD). Failure of closure of the neural tube during development results in anencephaly or spina bifida aperta but encephaloceles are possibly post-closure defects. NTD are associated with a number of other central nervous system (CNS) and non-neural malformations. Racial, geographic and seasonal variations seem to affect their incidence. Etiology of NTD is unknown. Most of the non-syndromic NTD are of multifactorial origin. Recent in vitro and in vivo studies have highlighted the molecular mechanisms of neurulation in vertebrates but the morphologic development of human neural tube is poorly understood. A multisite closure theory, extrapolated directly from mouse experiments highlighted the clinical relevance of closure mechanisms to human NTD. Animal models, such as circle tail, curly tail, loop tail, shrm and numerous knockouts provide some insight into the mechanisms of NTD. Also available in the literature are a plethora of chemically induced preclosure and a few post-closure models of NTD, which highlight the fact that CNS malformations are of hetergeneitic nature. No Mendelian pattern of inheritance has been reported. Association with single gene defects, enhanced recurrence risk among siblings, and a higher frequency in twins than in singletons indicate the presence of a strong genetic contribution to the etiology of NTD. Non-availability of families with a significant number of NTD cases makes research into genetic causation of NTD difficult. Case reports and epidemiologic studies have implicated a number of chemicals, widely differing therapeutic drugs, environmental contaminants, pollutants, infectious agents, and solvents. Maternal hyperthermia, use of valproate by epileptic women during pregnancy, deficiency and excess of certain nutrients and chronic maternal diseases (e.g. diabetes mellitus) are reported to cause a manifold increase in the incidence of NTD. A host of suspected teratogens are also available in the literature. The UK and Hungarian studies showed that periconceptional supplementation of women with folate (FA) reduces significantly both the first occurrence and recurrence of NTD in the offspring. This led to mandatory periconceptional FA supplementation in a number of countries. Encouraged by the results of clinical studies, numerous laboratory investigations focused on the genes involved in the FA, vitamin B12 and homocysteine metabolism during neural tube development. As of today no clinical or experimental study has provided unequivocal evidence for a definitive role for any of these genes in the causation of NTD suggesting that a multitude of genes, growth factors and receptors interact in controlling neural tube development by yet unknown mechanisms. Future studies must address issues of gene-gene, gene-nutrient and gene-environment interactions in the pathogenesis of NTD.