The epidemiology of perinatal mortality. The power of the autopsy

Feasibility of postmortem examination in the era of COVID-19 pandemic: the experience of a Northeast Italy University Hospital

With the continuous spreading of SARS-CoV-2 and increasing number of deaths worldwide, the need and appropriateness for autopsy in patients with COVID-19 became a matter of discussion. In fact, in the COVID-19 era protection of healthcare workers is a priority besides patient management. No evidence is currently available about the real risk related to the procedure as well as to the subsequent management of the samples. We herein describe the procedure that has been used to perform the first series of postmortem examinations in the COVID center of the Padua University Hospital, Padua, Italy, after the implementation of an ad hoc operating procedure, to minimize the risk of infection for pathologists and technicians. Provided that the procedure is performed in an adequate environment respecting strict biosafety rules, our data indicate that complete postmortem examination appears to be safe and will be highly informative providing useful insights into the complex disease pathogenesis.

Wisconsin Stillbirth Service Program: I. Establishment and assessment of a community-based program for etiologic investigation of intrauterine deaths

Although stillbirth is a common event, few programs have previously been established for the comprehensive etiologic investigation of intrauterine death. Fewer still have been prospective, unbiased in ascertainment, and consistent in protocol utilization. The Wisconsin Stillbirth Service Program was established in 1983 as a unique model for the investigation of the causes of stillbirth. This community-based, University-supported model for health care delivery is here described. Through it more than a thousand infants have been etiologically investigated. We demonstrate that a community-based program of stillbirth assessment can succeed, that compliance with recommended protocols is high and that a specific primary cause of fetal death can be demonstrated in about 40% of referrals. A majority of the established causes of intrauterine death are fetal etiologies. Furthermore, it appears that there are no substantial referral biases. Lack of such biases, together with the prospective, protocol driven nature of the program provides a unique population upon which to base estimates of the frequency of various etiologic diagnoses and classes and categories of cause.

Clinical and post-mortem assessment of the cause of death

Analysis of the clinical and post-mortem assessment of the underlying cause of death in 742 autopsies showed that over- and underdiagnosis cancelled each other out in the majority of the main diagnostic groups, so there was little difference in the total number of cases recorded in the different groups after clinical and post-mortem investigation. However, in the individual case the reliability of the clinical diagnosis varied greatly with the nature of the diagnosis and its degree of certainty. Reliability was for example high with clinically certain arteriosclerotic heart disease and low with cerebrovascular disease. Underdiagnosis of lung cancer is still a problem. Lack of interest in autopsy investigation may be reflection of lack of clinical involvement or therapeutic frustration rather than the use of sophisticated diagnostic procedures, as has been assumed by previous authors. It is suggested that the idea of selection of cases for autopsy should be replaced by selection of autopsies for microscopic investigation on the basis of the macroscopic post-mortem findings. It is suggested also that clinicians might profitably attend autopsies on patients in their sphere of interest that were not admitted under their care.

Body size and neonatal hypoglycemia in intrauterine growth retardation

The relationship between blood glucose and body physique of 233 (42 hypo-and 191 normologycemic) intrauterine growth-retarded neonates was analyzed using different body measurements and indices of body proportions. Classification by combination of weight and length deficit for fetal age revealed that the disproportionately retarded infants (deficit in weight for age > 30%; deficit in length for age less than equal to 15%) were particularly prone to hypoglycemia. The lowest incidence of hypoglycemia was observed in the group with severe proportionate retardation (weight deficit for age > 30%; length deficit for age > 15%). Among the indices of body proportions ponderal index (W/L3), and percentage deviation from the expected weight for length turned out to be a sensitive predictor of the risk of hypoglycemia. The majority of hypoglycemia neonates were underweight for length and a considerable number of normoglycemic infants were overweight for length. These findings point to the significance of soft tissue wasting rather than low birth weight for gestational age itself, in the development and diagnosis of neonatal hypoglycemia. The significance of anthropometry in the classification of different types of intrauterine growth impairment, as well as in predicting specific hazards after birth is discussed.

Do the right children have necropsies? Analysis of selected determinants

An analysis of the frequency of post-mortem examinations was conducted in the paediatric age group. Among the factors found to influence necropsy rates were (i) age at death, the frequency of necropsy decreasing with age; (ii) cause of death, necropsy frequency varying with major diagnostic groups; (iii) investigation conducted before death, necropsy frequency decreasing when the clinical picture was ill-defined; and (iv) place of death, necropsy being less frequent when death occurred outside hospital. These findings imply (a) that necropsy practices may be governed by habit and convenience as well as by desire to complete the clinical picture, and (b) that more equitable balances in such practices should be sought if there is to be improvement in the quality of mortality data.

Necropsy rates in the United Birmingham Hospitals

The necropsy rate in the United Birmingham Hospital has fallen from 74-4% in 1958 to 46-0% in 1972. In the Birmingham region as a whole the rate is 27-3%, approximately equal to the national rate. Most clinicians in the group who replied to a standard questionary considered that the necropsy still has an important part to play in their own practice and in undergraduate training, and they viewed the declining rate as a matter for concern. Some measure of disagreement was found between the ante-mortem and post-mortem diagnoses of patients in the two largest hospitals in the group. This suggests that the necropsy has a role to play in medical audit and that attempts to reverse the declining trend should be encouraged.

Maternal protein depletion and small-for-gestational-age babies

It has been established that there is a high incidence of small-for-gestational-age babies among underprivileged urban Africans. This community suffers from endemic malnutrition. Serum albumin studies on mothers of low birthweight babies showed a direct correlation with size of babies for gestational age. Thus maternal protein depletion, and probably therefore malnutrition, was associated with the high incidence of small-for-age-gestational babies.