Clinical utility of fetal autopsy and comparison with prenatal ultrasound findings

Minimally invasive autopsy in the evaluation of fetal malformations and stillbirths: A feasibility study

BACKGROUND

Minimally invasive autopsy (MIA) using post-mortem magnetic resonance imaging with ancillary investigations is reported as accurate as conventional autopsy. This study assesses MIA's feasibility and accuracy compared to conventional autopsy.

METHOD

MIA and/or conventional autopsy were performed on malformed fetuses (14-20 weeks gestation) and stillbirths (>20 weeks gestation), with/without malformation. Concordance in diagnostic accuracy (95% confidence interval [CI]) and agreement (Kappa coefficient [k]) were assessed in malformed cases where both MIA and autopsy were conducted.

RESULTS

We enrolled 200 cases, including 100 malformed fetuses (<20 weeks) and 100 stillbirths (with/without malformations). Concordance of 97.3% was observed between MIA and autopsy in 156 malformed cases. The overall diagnostic accuracy of MIA was 96.04%.

CONCLUSION

While conventional autopsy remains the gold standard, MIA is feasible in tertiary care settings. It can be considered a potential alternative for post-mortem assessment, particularly in settings with limited facility of conventional autopsy and parental refusal.

Differences in prenatal diagnosis rate of congenital anomalies associated with singletons and multiple births: An observational study of more than 1.9 million births in Zhejiang Province, eastern China, during 2012-2018

OBJECTIVE

To characterize differences in the prenatal detection of congenital anomalies (CAs) associated with singleton and multiple births.

METHODS

This observational study covered all births registered in the CA surveillance system in Zhejiang Province of China during 2012-2018. Differences in the incidence and characteristics between singletons and multiple births with CAs were tested. Multivariate logistic regression models were performed to explore the associations of prenatal detection rate of CAs with multiple births.

RESULTS

Totals of 49 872 singletons and 3324 multiple births with CAs were analyzed. The mean incidences of CA for single and multiple births were 27.12 and 54.42 per 1000 births, respectively. After adjustment for covariates, CAs associated with multiple births were less likely to be diagnosed prenatally (adjusted odds ratio [OR] 0.38, 95% confidence interval [CI] 0.34-0.43), as were congenital heart defects, congenital hydrocephalus, cleft lip with cleft palate, cleft lip without cleft palate, limb reduction defects, congenital diaphragmatic hernia, trisomy 21 syndrome, congenital malformation of the urinary system, and other chromosomal malformation, compared with singletons with CAs.

CONCLUSION

Multiple birth is associated with a significantly higher risk of CA, but a significantly lower prenatal diagnosis rate. Therefore, the healthcare of women with multiple pregnancy and their fetuses should be strengthened.

Comparison of Prenatal and Postmortem Diagnoses from 251 Fetal Autopsies: High Rate of Placenta Pathologies, Low Rate of Discrepancies

Background: In cases of intrauterine fetal death (IUFD), autopsy and placenta pathology can provide additional information to sonographic findings. We assessed the frequency of prenatally missed relevant diagnoses. Materials and methods: A retrospective evaluation of fetal autopsies from 2006 to 2021 was performed and were classified as: i) agreement, ii) cases where autopsy revealed additional findings, or iii) postmortem findings which changed the diagnosis. Results: A total of 199/251 spontaneous IUFD and 52/251 induced abortions were included. In spontaneous IUFD, placenta pathologies were the leading cause of death (89%). Full agreement was found in most cases (91% and 87% in spontaneous IUFD and induced abortion, respectively), while additional findings (7% and 12%) and major discrepancies (each 2%) were detected less frequently. Conclusion: In some cases where major findings were missed, autopsy could establish a diagnosis.

Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set

BACKGROUND

A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority.

OBJECTIVES

To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth.

SEARCH STRATEGY

Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021.

SELECTION CRITERIA

Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention.

DATA COLLECTION AND ANALYSIS

Interventions, outcomes reported, definitions and outcome measurement tools were extracted.

MAIN RESULTS

Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome.

CONCLUSIONS

Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

A Spectrum of Congenital Anomalies of the Kidney and Urinary Tract (CAKUT)-Diagnostic Utility of Perinatal Autopsy

OBJECTIVE

To describe the spectrum of congenital renal anomalies and emphasize the critical role of comprehensive autopsy examination in identifying CAKUT, especially of lower urinary tract malformations correlating with prenatal imaging methods.

METHODS

Retrospective analyses of CAKUT diagnosed at fetal autopsy were analyzed over a 7-y period and correlated with prenatal imaging findings.

RESULT

Among the 255 fetal autopsies, 45 cases were detected with CAKUT. Isolated (27%), syndromic CAKUT (51%), and CAKUT associated with other system anomalies (22%) were found. Hydronephrosis, followed by cystic renal diseases and agenesis were the common renal malformations. The gastrointestinal tract (GIT) was the commonest system associated with CAKUT. Among the syndromic CAKUT, the urorectal septum malformation (URSM) was the most frequent one, followed by VACTER-L, acrorenal syndrome, and OEIS complex. When correlating prenatal USG and autopsy findings, a significant change in final diagnosis was observed in 60% of cases.

CONCLUSION

Extrarenal malformations and syndromic associations of CAKUT predominated over isolated ones. Detection of lower urinary tract anomalies in CAKUT is difficult through antenatal imaging methods if associated with oligohydramnios. In these circumstances, the perinatal autopsy has a significant role in arriving at the final diagnosis which guides the clinician in predicting the recurrence risk and the need for genetic workup.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy

OBJECTIVES

To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

DESIGN

This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

PARTICIPANTS

Deaths from conception to one adjusted year of age.

SEARCH METHODS

MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

DIAGNOSTIC TESTS

Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

DATA COLLECTION AND ANALYSIS

Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

MAIN OUTCOME MEASURES

Direction of effect was expressed as percentage of patients per study.

FINDINGS

We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results.

CONCLUSIONS

Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.

Comparison of Prenatal Ultrasound and Autopsy Findings of Fetuses Terminated in Second Trimester: A Five-Year Experience of a Tertiary Center

Objective: The aim of this study is to compare the prenatal ultrasonography (US) and the autopsy findings of the fetuses of 12-24th gestational weeks. Methods: This retrospective study comprises 84 fetuses autopsied. The correlation between US and autopsy findings was classified into four categories: (A) Compatible, (B) Minor findings added, (C) Major findings added, and (D) Incompatible. Results: Malformations were the most common medical termination indication. The most frequent findings at autopsy were multiple system findings followed by central nervous system. Prenatal US and autopsy findings were completely compatible in 48 fetuses (57.1%), while additional minor and major autopsy findings were found in 26 (31.0%) and 4 (4.8%), respectively. Autopsy and US findings were incompatible in 6 fetuses (7.1%). Conclusion: Prenatal ultrasound and fetal autopsy are complementary tools to obtain detailed and complete diagnosis of fetal anomalies and fetal autopsy is still a valuable tool to obtain further diagnostic information.

Diagnostic value of fetal autopsy after early termination of pregnancy for fetal anomalies

Background

In early terminations of pregnancy for fetal anomaly (TOPFA) without identified cytogenetic abnormality, a fetal autopsy is recommended for diagnostic purposes, to guide genetic counseling. Medical induction, which allows analysis of a complete fetus, is generally preferred over surgical vacuum aspiration. Our objective was to assess the diagnostic value of fetal autopsies in these early terminations, relative to the first-trimester ultrasound, overall and by termination method.

Materials

For this retrospective study at the Port Royal Maternity Hospital, we identified all TOPFA performed from 11 weeks to 16 weeks diagnosed at the first-trimester ultrasound in cases with a normal karyotype. The principal endpoint was the additional value of the autopsy over /compared to the ultrasound and its impact on genetic counseling, globally and by termination method. The secondary objective was to compare the complication rate by method of termination.

Results

The study included 79 women during period of 2013–2017: 42 with terminations by medical induction and 37 by aspiration. Fetal autopsy found additional abnormalities in 54.4% of cases, more frequently after medical induction (77.5%) than after aspiration (21.4%, p < .01). Genetic counseling was modified in 20.6% of cases, more often after induction (32.5% vs 3.6%, p < .01). The length of stay was significantly longer and a secondary aspiration was required in 16,7% of case in the medical induction group (p < .01).

Conclusion

Medically induced vaginal expulsion appears preferable and can change genetic counseling for subsequent pregnancies.

Evaluation of prenatal central nervous system anomalies: obstetric management, fetal outcomes and chromosome abnormalities

Objective

To study the outcomes of fetuses who were diagnosed with central nervous system (CNS) anomalies during prenatal period and to describe the obstetric management of those pregnancies.

Methods

In this retrospective study, fetuses who were detected to have central nervous system anomalies by prenatal ultrasound from January 2010 to December 2019 were recruited. Data regarding prenatal diagnosis and obstetric outcomes were retrieved from maternal and paediatric records. The prognosis of fetuses who were born alive was classified based on their neurodevelopmental outcome within two years of life.

Results

There were a total of 365 fetuses with CNS anomalies within the 10-year study period, with a mean gestational age of 24.65±7.37 weeks at diagnosis. Ventriculomegaly (23.36%) was the commonest CNS anomalies seen. 198 (54.20%) of these fetuses had associated extra-CNS anomalies, with cardiovascular being the most common system involved. Fetal karyotyping was performed in 111 pregnancies, with chromosomal aberrations detected in 53 (49.07%) cases and culture failure in 3 cases. Majority of the chromosomal abnormalities were Edward syndrome (trisomy 18) and Patau syndrome (trisomy 13). Fetuses with congenital CNS anomalies and abnormal chromosomal karyotyping were more likely to be diagnosed earlier by prenatal ultrasound and tend to have poorer obstetric and neurocognitive prognosis. Prenatally, 86 (23.56%) of the cases were lost to follow up and likely to deliver elsewhere. Among the 279 cases whom their pregnancy outcomes were available, 139 (49.82%) pregnancies resulted in live births, 105 (37.63%) pregnancies were electively terminated, while the remaining 35 (12.54%) pregnancies ended in spontaneous loss. The decision of termination of pregnancy largely depends on mean diagnostic gestational age, presence of chromosomal aberrations and abnormal amniotic fluid volume in those fetuses. Two years after delivery, only 75 (53.96%) children out of 139 live births were still alive, 43 (30.93%) died and 21 (15.11%) cases were lost to follow-up. 32 (23.02%) children with prenatally diagnosed CNS anomalies had normal neurodevelopmental outcome. The presence of multiple CNS anomalies and involvement of extra-CNS anomalies indicated a poorer neurodevelopmental prognosis.

Conclusion

Less than 50% of fetuses with prenatally diagnosed CNS anomalies resulted in live births. Even if they survive till delivery, 36.45% of them passed away within 2 years and 62.79% of children who survived till 2 years old had neurodevelopmental disability.

A 6.3 Mb maternally derived microduplication of 20p13p12.2 in a fetus with Brachydactyly type D and related literature review

Background

With the introduction of genetic tests such as chromosomal microarray analysis (CMA) and exome sequencing (ES) into fetal medical practices, genotype–phenotype correlations in intrauterine-onset disorders have substantially improved. The BMP2 gene, located on the long arm of chromosome 20 plays a role in bone and cartilage development and is associated with Brachydactyly type A2, an autosomal dominant disease characterized by malformations of the middle phalanx of the index finger and abnormalities of the second toe. However, the BMP2 gene has so far never been reported as a candidate gene for Brachydactyly type D (BDD) affecting only the thumbs.

Methods and results

Here, we report one family possessing a maternally inherited 6.3 Mb microduplication of 20p13p12.2 including the BMP2 gene with discordant phenotypes between the mother and the fetus. The mother was affected with BDD alongside mild facial dysmorphism and learning difficulties, while the female fetus showed BDD, severe symmetric intrauterine growth restriction combined with oligohydramnios. The CMA and Trio ES tests were implemented. Trio ES ruled out other possible monogenic causes for the family. After reviewing cases and literature with duplications within this genomic region, we found that they are extremely rare and most of the cited cases were too small for comparison. The disturbance of the BMP2 gene could explain BDD, but the other clinical presentations in the mother and fetus are not yet fully understood.

Conclusion

This study provides important evidence for the current understanding of genotype–phenotype association of this 6.3 Mb size duplication in the 20p13p12.2 region. This duplication is a unique CNV occurring so far only in this family. Further cases and research are needed to understand the discordance in the phenotypes between the mother and fetus and establish the relationship between BMP2 gene and BDD.

Diagnostic value of virtual autopsy using pm-MRI at 3T on malformed second trimester fetuses vs classic autopsy

Objective

To determine the diagnostic value of virtual autopsy using post mortem-MRI (pm-MRI) at 3Tesla (T) compared to classic autopsy for the confirmation of fetal structural anomalies and secondly to establish which cases of termination of pregnancy would benefit mostly from a virtual autopsy.

Methods

In each of 32 fetuses included in the study, 32 anatomical structures were assessed, after termination of pregnancy in the second trimester. All cases were evaluated by prenatal ultrasonography, virtual autopsy and classic autopsy, and then divided into four groups: Cerebral Group, Cardiac Group, Renal Group and Other Group (miscellaneous group). The concordance of virtual autopsy with classic autopsy was calculated overall and for each group and each structural item. Also, the concordance between the two methods was assessed using a diagnostic error score (DgE_score), calculated as the absolute value of the difference between the number of malformations detected by classic autopsy per case (CA score) and the number of malformations detected at virtual autopsy per case (VA score).

Results

Overall virtual autopsy demonstrated a diagnostic sensitivity (Se) compared to classic autopsy of 67.33% [95% CI 57.28–76.33], with a specificity (Sp) of 98.37% [95% CI 97.33–99.09], a positive predictive value (PPV) of 81.93% [95% CI 71.95–89.52], a negative predictive value (NPV) of 96.49% [95% CI 95.11–97.57] achieving a diagnostic accuracy of 95.31% [95% CI 93.83–96.52]. Overall, no statistic significant correlation was demonstrated between DgE_score and the gestational age of the fetuses or between DgE_score and the weight of the fetuses, but a significant correlation was revealed between the virtual autopsy and classic autopsy score. The diagnostic utility of virtual autopsy using pm-MRI at 3 T as compared to classic autopsy for each category of termination of pregnancy revealed in the Cerebral Group a Se of 80.00% [95% CI 28.36–99.49], with a 96.30% [95% CI 81.03–99.91], a PPV of 80.00% [95% CI 35.75–96.64] a NPV of 96.30% [95% CI 81.81–99.34], with a diagnostic accuracy of 93.75% [95% CI 79.19% to 99.23] and a Cohen’s Kappa coefficient of 0.76 [95% CI 0.4494–1.0765]; in the Renal Group a Se and Sp of 100%, but in the Cardiac Group the Se was only 60.00% [95% CI 26.24–87.84], Sp 75% [95% CI 34.91–96.81], the PPV 75.00% [95% CI 44.92–91.69], NPV 60% [95% CI 38.87–77.96], with a diagnostic accuracy of 66.67% [95% CI 40.99–86.66] and a Cohen’s Kappa coefficient of 0.32 [95% CI -0.07–0.76].

Conclusions

The results support virtual autopsy using pm-MRI at 3T as a reliable alternative to classic autopsy for the non-forensic analysis of second trimester fetuses. Analyzing the diagnostic utility of virtual autopsy using pm-MRI at 3 T for the confirmation of prenatal ultrasound findings in second trimester fetuses as compared to classic autopsy, the best results were obtained in the Cerebral and Renal Group. Reserved results were found in the Cardiac Group. Therefore, for the pregnancies with termination of pregnancy for cerebral or renal abnormalities, virtual autopsy by pm-MRI at 3T can be taken into consideration as a first-line investigation to confirm the prenatal findings.

Pathologist's role in identifying cardiac defects-a fetal autopsy series

AIMS

Major cardiac abnormalities can lead to miscarriages and is also an important indication of medical termination of pregnancy. The present study aims: (1) To determine the spectrum of cardiac anomalies in fetal autopsies, (2) To correlate the autopsy findings with prenatal imaging studies.

METHODS

Fetal autopsies with cardiac anomalies were retrospectively analyzed over a period of five years. Autopsy diagnoses were correlated with prenatal ultrasound and echocardiogram findings.

RESULTS

Of the 177 fetal autopsies, 40 (22.5%) cases with cardiac defects were identified. Among these cases, 11 (27.5%) showed only cardiac defects and associated extracardiac malformations were seen in 29 cases (72.5%). Septal defects (45%) were the most frequent cardiac defect followed by left ventricular outflow tract obstruction. Agreement with prenatal imaging and autopsy findings was seen in 65% of cases. There was 100% concordance between autopsy and echocardiogram wherever available.

CONCLUSION

Cardiac malformation forms a significant subset of fetal congenital anomalies. Meticulous examination and following sequential segmental analysis during autopsy are essential in identifying complex cardiac and additional extra cardiac defects in the fetuses. Fetal autopsy plays a vital role in confirming and/or refuting the imaging findings and could be the steppingstone in understanding the pathogenesis of cardiac abnormalities.

The Spectrum of Congenital Central Nervous System Anomalies Among Stillborn: An Autopsy Based Study

Background:

Congenital central nervous system (CNS) anomalies are the structural or functional abnormalities of the brain and spinal cord that occur during the intrauterine developmental process.

Purpose:

The present study aims to detect the prevalence of congenital CNS anomalies among stillborn fetuses, the association between congenital anomalies and maternal factors, and also the association between autopsy and ultrasound findings.

Methods:

This study was conducted on 50 stillborn fetuses, obtained from the Department of Obstetrics and Gynecology at JSS Medical College and Hospital, Mysuru. The fetuses were fixed in 10% formalin and autopsies were performed as per the standard fetal autopsy protocol. The congenital CNS anomalies were studied in detail.

Results:

CNS anomalies were the most common congenital anomalies observed. Out of the total 50 stillborn fetuses studied, CNS anomalies were found in 17 fetuses and their occurrence was more common among male stillborn than females. Meningomyelocele was the most common anomaly, followed by anencephaly. The other anomalies documented were meningocele, encephalocele, meningoencephalocele, agenesis of the corpus callosum, craniorachischisis, bifid cerebellum with hypoplastic vermis, holoprosencephaly, and sirenomelia.

Fisher’s exact test showed a significant association between maternal hypothyroidism and congenital CNS anomalies (P < .05). The autopsy confirmed the ultrasound findings in 40 (80%) fetuses. There were significant additional findings observed in seven (14%) fetal autopsies and ultrasound diagnosis completely changed in three (6%) cases, after the final autopsy procedure.

Conclusion:

The fetal autopsy is the single most directly evident investigation, which gives information that changes or significantly improves the clinical diagnosis. A multidisciplinary holistic approach toward pregnancy will help to detect any kind of abnormality in the fetus and thus to take a timely decision toward the management.

Second-trimester fetal autopsy: A morphological study with prenatal USG correlations and clinical implications

OBJECTIVES:

The objective of this study is to analyze the second-trimester fetal autopsies and to reemphasize the role of autopsy by comparing autopsy findings with prenatal ultrasound observations.

MATERIALS AND METHODS:

Retrospective analysis of second-trimester fetal autopsies over a period of 7.5 years (January 2009–June 2016). A standard protocol of autopsy procedure was followed, which included external examination with photography, X-ray, internal examination, and histopathological examination. In fetuses with congenital malformations (CMs), the findings of prenatal ultrasonogram and autopsy examination were compared.

RESULTS:

We analyzed a total of 66 fetuses, which includes 17 intrauterine fetal death, 49 terminations for CM, and increased risk for chromosomal abnormality. In fetuses with CM, multiple anomalies were more common than a single anomaly. The most common anomalies were seen involving central nervous system (neural tube defect) followed by the genitourinary system. Autopsy confirmed prenatal ultrasound findings in all cases except three. Complete agreement between USG findings and autopsy were seen in 17 cases (39.7%). Additional findings on autopsy were noted in 25 cases (62.2%). Among these, 15 cases had a significant change of recurrence risk due to altered initial ultrasound diagnosis.

CONCLUSION:

Fetal autopsy plays an important role in arriving at the final diagnosis and detecting the cause of death. This information is very essential for the clinicians, in genetic counseling of the parents, and management of future pregnancies.

Congenital fetal heart defect - an agreement between fetal echocardiography and autopsy findings

AIMS

To determine the frequency of pregnancy terminations due to prenatal congenital heart defect (CHD) and assess the agreement fetal echocardiography (FECHO) and autopsy findings.

METHODS

The data were retrospectively assessed between 2008 and 2017 in a population of 116 698 live births. The correlations between the FECHO and autopsy findings were classified into five levels of agreement: complete, partial, altered diagnosis, disagreement, and unfeasible autopsy.

RESULTS

Totally, 293 CHDs were identified and 49% of families (143/293) decided to terminate the pregnancy. In 1% (2/143) of cases, the autopsy could not be performed, for the other 99% (141/143), the pathologist confirmed the presence of CHDs. Complete agreement between FECHO and autopsy was achieved in 85% (122/143). In 10% (14/143) of cases, the pathologist found minor findings, which were not described in the FECHO. In 4% (5/143) of cases, the pathologist changed the main diagnosis.

CONCLUSION

Altogether, the results indicated that FECHO is a highly sensitive method for the prenatal detection of CHD but is incapable of detecting the complete spectrum of cardiac defects. Autopsies verified the diagnosis, confirmed the overall impairment in the fetus, and provided data for further counselling of the affected family.

Is traditional perinatal autopsy needed after detailed fetal ultrasound and post-mortem MRI?

OBJECTIVE

To determine the additional yield from autopsy following prenatal ultrasound and post-mortem magnetic resonance imaging (PMMR) for structural abnormalities.

METHOD

PMMR was performed on consecutive fetuses over a 6-year period. Prenatal ultrasound and PMMR findings were categorised as concordant, partially concordant or discordant findings. The yield of new and clinically significant information from autopsy was assessed. Diagnostic accuracies for both modalities were calculated, using autopsy as reference standard.

RESULTS

Our study consisted of 81 fetuses. PMMR and prenatal ultrasound findings were concordant in 44/81 (54.3%), partially concordant in 26/81 (32.1%) and discordant in 11/81 (13.6%) cases. In 19/81 cases (23%), autopsy provided additional information, which appeared clinically significant in 12 cases. In 10 of those 12 cases, there was discordance between PMMR and ultrasound. In only 2 of 44 cases where ultrasound and PMMR were concordant, did autopsy provide clinically significant information. Diagnostic accuracy rates for ultrasound were sensitivity of 76.8% (66.6%, 84.6%), specificity of 92.5% (88.9%, 95.0%). For PMMR the sensitivity was 79.0% (68.9%, 86.5%), specificity 97.9% (95.5%, 99.0%). PMMR had a significantly higher concordance rate with autopsy than ultrasound (89.0 vs 93.8%; P < .001).

CONCLUSION

Where PMMR and ultrasound are concordant, there is little additional yield from autopsy.

Postmortem examination of human fetuses: comparison of two-dimensional ultrasound with invasive autopsy

OBJECTIVE

To assess the diagnostic accuracy of postmortem ultrasound performed by operators blinded to prenatal findings and to invasive autopsy results in fetuses at different gestational ages and to investigate the effect of various parameters on its diagnostic success.

METHODS

We performed postmortem two-dimensional ultrasound examination, blinded to clinical details, on 163 fetuses at 13-42 weeks' gestation. Logistic regression analysis was used to investigate the effect of: (i) gestational age at postmortem ultrasound, (ii) presence of maceration and (iii) mode of death, on whether the exam succeeded or failed to reach a diagnosis. In 123 cases in which invasive autopsy was available, the diagnostic accuracy of ultrasound in detecting major organ abnormalities was evaluated, using invasive autopsy as the gold standard.

RESULTS

For the fetal brain, postmortem ultrasound exam was non-diagnostic in significantly more fetuses with maceration (39.5%; 17/43) vs those without maceration (20.0%; 24/120) (P = 0.013). For the fetal thorax, the exam was non-diagnostic in 34.1% (15/44) of fetuses < 20 weeks of gestation and in 10.9% (13/119) of fetuses ≥ 20 weeks (P < 0.001). For the heart and abdominal organs, there was no association between non-diagnostic postmortem ultrasound and the variables tested. For fetuses < 20 weeks, specificity of postmortem ultrasound examination was 83.3% for detection of anomalies of the brain, 68.6% for the thorax and 77.4% for the heart. For fetuses ≥ 20 weeks, sensitivity and specificity were, respectively, 61.9% and 74.2% for detection of anomalies of the brain, 29.5% and 87.0% for the thorax and 65.0% and 83.1% for the heart. For the fetal abdominal organs, sensitivity was 60.7% and specificity 75.8%, and postmortem ultrasound was particularly useful for detection of abnormalities of the kidneys, irrespective of gestational age.

CONCLUSION

Although maceration may lead to failure of postmortem ultrasound examination in some cases, this technique achieves diagnostically acceptable levels of accuracy for fetal brain and abdominal organs, compared with conventional autopsy. It may therefore play a role as a first-line examination before other virtual autopsy techniques are indicated. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Role of Autopsy in Elective Termination of Pregnancy for Fetal Anomaly (ETOPFA): A Study from a Tertiary Care Hospital in India

OBJECTIVE

To evaluate the fetal anomalies in all the patients who underwent elective termination of pregnancy for fetal anomalies (ETOPFA) before 20 weeks of gestation and to compare prenatal diagnosis with final diagnosis made after autopsy.

METHODOLOGY

Prospective study done in a tertiary care hospital in India over a period of two years which include 252 women who underwent ETOPFA. The prenatal diagnosis was compared with final diagnosis made after autopsy.

RESULTS

In 75.4% of cases autopsy findings were concordant with prenatal diagnosis where as in 21.6% of cases, additional findings were added. In 2.9 % of cases prenatal diagnosis was not confirmed by autopsy and found to be discordant.

CONCLUSIONS

Autopsy plays an important role in completing the final diagnosis along with verification of prenatal diagnosis. To avoid discrepancy especially in cases of severe oligohydramnios, MRI or amnioinfusion could be offered for conformation of the diagnosis before offering ETOPFA.

Trends in Referral Pattern of Antenatally Diagnosed Surgical Abnormalities in a Tertiary Care Center in North India

Aim:

Pregnant women with antenatally diagnosed surgical abnormalities of the fetus are often referred for pediatric surgical consultation for likely outcome and prognosis. In this study, we analyzed the gestational age at referral to see the benefits of the same in decision-making and also looked for any change in trends of referral pattern over a period with the increasing availability of ultrasonography (USG).

Materials and Methods:

Records of pregnant women referred for antenatal counselling over an eight year period were analyzed. This was an observational study conducted in the Pediatric surgery outpatient department of a tertiary care centre from 2008-2015. All pregnant women referred for antenatal counseling were included, with the diagnosis of fetal abnormalities being based on USG. Abnormalities were classified by system involved. Comparison of data before and after the year 2012 was done to look for change in trends. Patients with poor prognostic outcome were further analyzed.

Results:

A total of 1211 women were analyzed, with 490 (40.7%) presenting between 2008 and 2011 and 719 (59.3%) between 2012 and 2015. Overall, in those with likely poor prognostic outcome (n = 482), 189 (39.2%) patients presented at <20 weeks gestation, 106 (22%) between 21 and 24 weeks gestation, and 187 (38.8%) after 24 weeks of gestation. Genitourinary abnormalities (n = 220; 46%) accounted for the most common poor prognostic outcome group in all gestational ages.

Conclusion:

Nearly two-thirds (61%) of the patients with poor outcome were referred after 20 weeks of gestation, i.e., beyond the permissible time for termination. Fetal sonography expertise between 16 and 20 weeks should be improved as a priority by the government in peripheral centers.

Spectrum of prenatally detected central nervous system malformations: Neural tube defects continue to be the leading foetal malformation

Background & objectives:

Prenatal diagnosis of malformations is an important method of prevention and control of congenital anomalies with poor prognosis. Central nervous system (CNS) malformations amongst these are the most common. The information about the prevalence and spectrum of prenatally detected malformations is crucial for genetic counselling and policymaking for population-based preventive programmes. The objective of this study was to study the spectrum of prenatally detected CNS malformations and their association with chromosomal abnormalities and autopsy findings.

Methods:

This retrospective study was conducted in a tertiary care hospital in north India from January 2007 to December 2013. The details of cases with prenatally detected CNS malformations were collected and were related with the foetal chromosomal analysis and autopsy findings.

Results:

Amongst 6044 prenatal ultrasonographic examinations performed; 768 (12.7%) had structural malformations and 243 (31.6%) had CNS malformations. Neural tube defects (NTDs) accounted for 52.3 per cent of CNS malformations and 16.5 per cent of all malformations. The other major groups of prenatally detected CNS malformations were ventriculomegaly and midline anomalies. Chromosomal abnormalities were detected in 8.2 per cent of the 73 cases studied. Foetal autopsy findings were available for 48 foetuses. Foetal autopsy identified additional findings in eight foetuses and the aetiological diagnosis changed in two of them (4.2%).

Interpretation & conclusions:

Amongst prenatally detected malformations, CNS malformations were common. NTD, which largely is a preventable anomaly, continued to be the most common group. Moreover, 60 per cent of malformations were diagnosed after 20 weeks, posing legal issues. Chromosomal analysis and foetal autopsy are essential for genetic counselling based on aetiological diagnosis.

Lethal Congenital Malformations in Fetuses-Antenatal Ultrasound or Perinatal Autopsy

BACKGROUND

Congenital malformations (CMF) are major causes of fetal demise which can be detected antenatally by Ultrasonography (USG).

METHODS

We studied 100 perinatal autopsies for CMF. Sensitivity of USG was determined and accuracy of USG with that of autopsy was compared.

RESULTS

At Autopsy 134 individual CMF were seen in 40 cases. The sensitivity of USG in detecting major CMF was 54.47%. A complete agreement between autopsy and USG findings was seen in 13/40 (32.5%) and partial agreement in 17/40 (42.5%) fetuses while autopsy completely changed antenatal diagnosis in 10/40 (25%) fetuses. Major findings were added in all 17 fetuses with partial agreement. In 2 cases, CMF suspected on USG were not detected on autopsy due to fetal maceration.

CONCLUSION

Autopsy significantly adds to the prenatal USG diagnosis and may help in predicting the probability of recurrence, and thus counseling the affected couple to prevent any such future event.

Correlation between fetal autopsy and prenatal diagnosis by ultrasound: A systematic review

The objective of this study was to review literature about the correlation between fetal autopsy and ultrasound findings of fetal malformations. Search in PubMed, Medline, EMBASE, Clinicl trials.org, reference list was performed. Inclusion criteria for studies selection were: fetal autopsy performed after termination of pregnancy (TOP) or stillbirth, TOP for fetal anomalies, prenatal diagnosis of malformations, data reported as proportional rates.

EXCLUSION CRITERIA

case reports, non English language, data reported in graphs or percentage. From each article: sample size, type of malformation, indication for TOP, autopsy findings. Fetal anomalies were grouped in central nervous system (CNS), genitourinary (GU), congenital heart defects (CHD), gastrointestinal (GI), thorax, limbs, skeleton, genetics (TOP for abnormal karyotype), multiples (TOP for multiple severe malformations for which a single indication for TOP/stillbirth could not be identified). Correspondence between autopsy and ultrasound was defined as agreement (same diagnosis), additional (additional findings undetected by ultrasound), unconfirmed (false positive and false negative ultrasound). PRISMA guidelines were followed. From 19 articles, 3534 fetuses underwent autopsy, which confirmed prenatal ultrasound in 2401 (68.0%) fetuses, provided additional information in 794 (22.5%) fetuses, and unconfirmed prenatal ultrasound in 329 (9.2%) fetuses. The latter group consisted of 3.2% false positive and 2.8% false negative cases. The additional findings changed the final diagnosis in 3.8% of cases. The most frequent indication for TOP/stillbirth was CNS anomalies (36.3%), whereas thorax anomalies represented the less frequent indication (1.7%). The highest agreement between autopsy and prenatal ultrasound was observed in CNS (79.4%) and genetics (79.2%), followed by GU anomalies (76.6%), skeleton (76.6%), CHD (75.5%), thorax (69.7%); GI (62.6%), multiple (37.0%), limbs (23.3%). In spite of the high agreement between prenatal ultrasound and autopsy, fetal examination is mandatory because in a minority of cases it discloses additional findings or changes the final diagnosis and genetic counselling.

Correlation between prenatal ultrasound and postmortem findings in 1029 fetuses following termination of pregnancy

OBJECTIVE

A prenatal ultrasound examination and a postmortem examination provide the basis for correct diagnosis in fetuses terminated due to congenital anomalies. The aim of this study was to correlate fetal anomalies detected by ultrasound examination with those identified at autopsy following termination of pregnancy (TOP) over a 30-year period, and to evaluate the correlation between findings at different gestational ages and assess these trends over time.

METHODS

The study group consisted of 1029 TOPs performed over a 30-year period, from 1985 to 2014. The gestational age ranged between 11 and 33 weeks. Prenatal ultrasound examinations were performed at the National Center for Fetal Medicine, St Olavs Hospital, Trondheim, Norway. Autopsies were performed at the Department of Pathology and Medical Genetics at the same hospital or a collaborating hospital.

RESULTS

There was full agreement between ultrasound and autopsy findings in 88.1% (907/1029) of TOPs, and the main diagnosis was correct in 97.9% (1007/1029). When comparing the 15-year period of 2000-2014 with that of 1985-1999, the difference in the rates of full agreement and agreement in the main diagnosis was statistically significant. In 1.3% (13/1029) of cases, ultrasound findings were not confirmed at autopsy. There were no false-positive diagnoses leading to TOP. Throughout the 30-year period, there was an increase in early TOPs, whereas late TOPs declined.

CONCLUSIONS

Our study demonstrates that there is a clear correlation between ultrasound and autopsy findings, which is continuously improving. Despite this high correlation, there is reason to continue the practice of validation to ensure the safety of the diagnostic process leading to TOP. The trend towards an earlier termination emphasizes the necessity of such a practice. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is the diagnostic yield influenced by the indication for fetal autopsy?

The utility of fetal autopsy to corroborate antenatal ultrasound findings and to aid genetic counseling is well known. However, the ability to identify an underlying cause for the common indications for which it is performed is not well studied. This study aimed to determine if the diagnostic yield of fetal autopsy in identifying the underlying cause is determined by the indication of the autopsy. Five groups of fetuses were defined based on the indication for the autopsy performed in 903 cases: (i) malformations, (ii) intrauterine death (IUD), (iii) cystic hygroma and hydrops fetalis, (iv) isolated abnormalities of amniotic fluid, and (v) intrauterine growth restriction (IUGR). The highest diagnostic yield was in fetuses with isolated abnormalities of amniotic fluid (77%), followed by those with IUGR (75%), with IUD (69.6%), those in group five (55.2%) and lowest (45%) in fetuses with malformations (P < 0.001). A cause was identified in 77.8% fetuses with multiple malformations compared to 37.5% with isolated malformations (P < 0.001), with chromosomal abnormalities in 31.8% versus 9.9% respectively (P < 0.001) and malformation syndromes in 42.5% versus 26.3% (P < 0.001). Placental examination provided the highest yield in IUD, IUGR, and oligohydramnios (43.1%; P < 0.003) whereas chromosomal analysis was most useful in cystic hygroma/NIHF (28.9%; P < 0.001). This information on the diagnostic yield in fetal autopsy related its common indications, can be utilized to counsel families of the utility of autopsy to establish cause and recurrence risks and thereby assist then to make an informed decision to consent for the procedure. © 2016 Wiley Periodicals, Inc.

What does fetal autopsy unmask in oligohydramnios?

OBJECTIVE

We aimed to determine the value of autopsy in fetuses with antenatally diagnosed oligohydramnios.

PATIENTS AND METHODS

We evaluated all fetal losses over a period of 6.5 years. Those with oligohydramnios on antenatal scan were critically analyzed. Oligohydramnios was defined as amniotic fluid index of less than five objectively or as an obvious lack of liquor at subjective assessment. A detailed postmortem examination was carried out in all the fetuses after obtaining an informed consent.

RESULTS

Fetal autopsy was conducted in 255 cases. Fifty-five (21.5%) fetuses were diagnosed to have oligohydramnios on antenatal ultrasonography. On analysis of antenatal causes of oligohydramnios, maternal/placental factors were noted in 18%, ultrasound findings known to affect amniotic fluid in 27% while cause remained unidentified in 54.5% of cases. On autopsy, fetal malformations were noted in 61.8% cases, intrauterine growth retardation in 21.8% fetuses and no obvious malformations in 16.3% fetuses. Renal anomalies were noted in 40% cases and non-renal malformations in 21.8% cases.

CONCLUSION

The postmortem examination helped us to identify the cause of fetal loss in 46 (83.6%) fetuses with antenatal oligohydramnios. A working diagnosis could not have been established without autopsy in 19 (34.5%) cases.

Termination of pregnancy for renal malformations

BACKGROUND

We studied the correlation between prenatal diagnosis and postmortem investigations in pregnancies terminated for renal malformations.

METHODS

Over a 5-year period, 77 cases of termination of pregnancy (TOP) for renal malformations were reviewed. Chromosomal anomalies (n = 9) and cases without conventional or virtual autopsy were excluded (n = 15). In 53 cases, prenatal ultrasound diagnosis and conventional autopsy findings were compared. In addition, we compared the accuracy of conventional and virtual autopsy findings in 17 cases.

RESULTS

Full agreement was observed in 60.4% (32/53) of cases. In 26.4% (14/53) of the cases, the presence of additional malformations did not alter the final diagnosis. However, in 11.3% (6/53) the final diagnosis was adjusted because of major additional findings. One case showed a total disagreement. Conventional and virtual autopsy were in full agreement in 52.9% (9/17). Postmortem magnetic resonance imaging (MRI) description and detection of malformations was less complete and failed to correctly diagnose 5/17 cases (29.4%). In 17.6% (3/17) of the cases, postmortem MRI revealed malformations not confirmed by conventional autopsy.

CONCLUSIONS

A high correlation between prenatal ultrasound and postmortem investigations was observed. Conventional autopsy remains the gold standard to reveal additional major and minor malformations, leading to a correct final diagnosis. The added value of virtual necropsy for renal pathology was limited.

Establishing National Neonatal Perinatal Database and birth defects registry network - need of the hour!

Early detection and prevention of birth defects is necessary to further reduce neonatal morbidity and mortality. A birth defect registry or surveillance system is necessary to assess the exact magnitude, profile and modifiable risk factors for birth defects. We review the existing efforts and suggest possible options for addressing this important issue. Connecting birth defects registry with the pre-existing programs such as National Neonatal Perinatal Database could be one of the option.

Post-mortem MRI as an alternative to non-forensic autopsy in foetuses and children: from research into clinical practice

Although post-mortem MRI (PMMR) was proposed as an alternative to conventional autopsy more than a decade ago, the lack of systematic validation has limited its clinical uptake. Minimally invasive autopsy (MIA) using PMMR together with ancillary investigations has now been shown to be as accurate as conventional autopsy in foetuses, newborns and infants and is particularly useful for cerebral, cardiac and genitourinary imaging. Unlike conventional autopsy, PMMR provides a permanent three-dimensional auditable record, with accurate estimation of internal organ volumes. MIA is becoming highly acceptable to parents and professionals, and there is widespread political support and public interest in its clinical implementation in the UK. In the short to medium term, it is desirable that a supraregional network of specialist centres should be established to provide this service within the current National Health Service framework.

Foetal autopsy-categories and causes of death

INTRODUCTION

Intrauterine death(IUD)/ Stillbirth forms a major part of perinatal mortality which thereby is a good indicator of pregnancy wastage as well as quality of healthcare available. The key objectives of autopsy examination are to know the cause(s) of death, elucidation of pathogenic mechanism and quality control of clinical management. The aim of this study was to identify the prevalent causes of IUD, thereby taking appropriate measures to prevent them and decrease the perinatal mortality rate.

MATERIALS AND METHODS

The study included 14 cases of IUD received for autopsy in the Department of Pathology over a period of five years. Autopsies were performed as per standard protocol and included full anthropometric profile, external examination, gross and microscopic evaluation of different organs and placenta.

RESULTS

Total number of 14 fetal autopsies were performed over a period of 5 years. The causes were broadly classified as fetal, maternal and placental. Placental causes were seen in majority of cases (48.57%) followed by fetal (35.72%) and then maternal (21.42). Most prevalent cause of death was congenital anomalies (28.6%) followed by placental insufficiency (21.4%) and chorioamnionitis (14.2%).

CONCLUSION

Determination of causes of fetal death would prove beneficial to the clinicians and parents for better management and care in future pregnancies as well as in genetic counseling.

Evaluation of Fetal Central Nervous System Anomalies by Ultrasound and Its Anatomical Co-relation

INTRODUCTION

Central nervous system anomalies are often severe and are the most common indications for therapeutic abortions. Ultrasound examination helps to identify and evaluate them well before birth.

OBJECTIVES

Present study was undertaken to evaluate the incidence of central nervous system anomalies in utero by ultrasound and to confirm them by autopsy or postnatal examination.

METHOD

Ultrasound screening of 7485 pregnant women was performed. Pregnancy with ultrasound findings of central nervous system anomalies were followed up. Prenatal ultrasound findings were confirmed by autopsy in cases of therapeutic abortions and fetal losses. In case of live birth postnatal findings were noted.

RESULTS

Ultrasound detected central nervous system malformations in 24 fetuses. Ultrasound findings were matching in 83% on autopsy. Autopsy and postnatal findings together were matching with ultrasound in 85.7%. Two cases had additional minor findings on autopsy.

CONCLUSION

The incidence of central nervous system malformations on ultrasound was 0.31%. Autopsy and postnatal examination showed high degree of correlation with ultrasound findings.

The Frequencies of the Urinary Anomalies which were Detected in a Foetal Autopsy Study

AIM

The detection of foetal urinary abnormalities in the antenatal period will help in an adequate post natal management and it will also have a bearing on the decision of the termination of the pregnancy. The purpose of the present study was to detect urinary anomalies in the antenatal period by doing autopsies of the aborted foetuses.

SETTINGS AND DESIGN

A cross-sectional study.

METHODS AND MATERIAL

A total of 226 aborted foetuses were autopsied. The urinary anomalies which were related to the renal parenchyma, the pelvi-ureteral system and the urinary bladder were recorded. The associated anomalies of the other organ systems were also noted. The incidences of the different urinary anomalies among the aborted foetuses were calculated. The gestational ages at which the various anomalies were detected were also studied.

RESULTS

Twenty nine of the 226 fetuses were detected to have 34 urinary anomalies. Renal agenesis was the single most common anomaly. Overall, the anomalies which were related to the renal parenchyma accounted for 67.65 % of all the urinary anomalies, while the anomalies of the pelvi-ureteral system and the bladder constituted 20.59% of the detected urinary anomalies. The anomalies of the renal parenchyma (renal agenesis and horse-shoe and polycystic kidneys) were more frequently seen in the foetuses with a shorter gestational age as compared to the gestational ages of the foetuses which showed pelvi-ureteral anomalies. The cumulative incidence of the foetuses with urinary anomalies by 30 weeks of gestation was 12.83%.

CONCLUSIONS

A significant proportion of the aborted foetuses was detected to have urinary anomalies. An early antenatal detection of these and associated anomalies has significance, as this may help in an early postnatal diagnosis and management. The degree and the extent of the detected anomalies could also help in the decision making regarding the therapeutic abortions and the future pregnancies.

Congenital malformations in perinatal autopsies - a study of 100 cases

BACKGROUND

Congenital malformations remain a common cause of perinatal deaths and even though ultrasonogram can give fairly accurate diagnosis, perinatal autopsy is essential to confirm the diagnosis and look for associated malformations.

OBJECTIVES

To emphasize the importance of perinatal autopsy in diagnosing congenital malformations and to compare the same with the prenatal ultrasound findings.

METHODS

The present study comprises 100 consecutive perinatal autopsies conducted after obtaining the approval from the Institutional Ethics Committee. In cases where prenatal ultrasound findings were available they were compared with the autopsy findings.

RESULTS

Out of 100 perinatal autopsies, 44 cases were congenital anomalies with M:F = 1:1.5. Majority of the fetuses with congenital malformations (36.36%) were therapeutically terminated, Cental nervous system malformations being the commonest indication. The most common timing of therapeutic termination being 20 -24weeks. Congenital malformations were common between 35-39 weeks gestational age and birth weight range 350- 1000g. The malformations involving the central nervous system were commonest, seen in 15 cases (34.09%) followed by renal anomalies in 9 cases (20.45%) and multiple malformations in 7cases ( 15.91%). Autopsy confirmed the prenatal ultrasound findings in 50% of the cases, added to diagnosis in 29.54%, while it completely changed the primary diagnosis in 9.09% of the cases.

CONCLUSION

This study highlights the importance of perinatal autopsy in confirming the diagnosis of congenital anomalies by prenatal ultrasound findings.

Comparison between prenatal ultrasound and postmortem findings in fetuses and infants with developmental anomalies

OBJECTIVE

To determine if postmortem examinations of fetuses and infants change the diagnosis obtained at prenatal ultrasound and affect counseling of future pregnancies, and if there has been a change over recent years in the accuracy of prenatal ultrasound diagnosis.

METHODS

This was a retrospective review of 455 autopsies of fetuses and infants with developmental anomalies performed at Trondheim University Hospital between 1995 and 2004 and with a prenatal ultrasound examination performed at a tertiary referral center. The routine ultrasound examinations were performed by specially trained midwives and obstetricians, referral scans by fetal medicine experts and autopsies by consultant pathologists with experience in perinatal pathology. The results of this study were also compared with those of a previous similar study performed between 1985 and 1995, with fetuses and infants coming from the same population and diagnosed at the same center.

RESULTS

Of all cases analyzed during the study period, there was complete agreement between prenatal ultrasound and postmortem findings in 84% (384/455), i.e. prenatal ultrasound diagnoses were supplemented by postmortem examinations in 16% (71/455). Autopsy findings in four of these cases influenced further counseling. There was agreement regarding the main diagnosis in 98% (445/455) of cases. In the previous 10-year period, there was complete agreement in 75% and the main diagnosis was correct in 90% of cases. These differences between the two time periods were statistically significant (P = 0.0004 and P < 0.0001, respectively). The most frequent defects involved the central nervous system, heart and urinary tract. For these defects, detection rates for the main diagnoses were significantly better in 1995-2004 compared with in the previous 10-year period (P = 0.0125, P = 0.0111 and P = 0.0241, respectively).

CONCLUSION

The accuracy of prenatal sonographic detection of developmental anomalies has increased in recent years. However, postmortem examination is still necessary to verify or improve the prenatal diagnosis and may influence future counseling.

Fetopathologic examination for early termination of pregnancy: dogma or necessity?

OBJECTIVE

Our objective was assessment of fetopathological examination after termination of pregnancy (TOP) for fetal anomalies with normal karyotype <17 weeks of gestation.

STUDY DESIGN

This was a multicenter retrospective study. Records of TOP for fetal anomalies with normal karyotype were analyzed. Primary outcomes were modifications of genetic counseling and management of next subsequent pregnancies. Medical TOPs were compared with surgical TOPs.

RESULTS

In all, 59 pregnancies were included (30 aspirations, 29 inductions). Fetopathological examination modified genetic counseling for 22 patients: 62% for the medical induction group vs 13% in the vacuum aspiration group (P < .001). Management of subsequent pregnancies was modified in 17% in the medical induction group vs 3% in the aspiration group (P = .06).

CONCLUSION

Fetopathological examination for early TOP with normal karyotype is relevant, especially when an intact fetus is examined. Thanks to it, genetic counseling is often modified, as is management of the next pregnancy. Medical procedures should be preferred to surgical procedures.

Accuracy of prenatal diagnosis in elective termination of pregnancy: 385 cases from 2000 to 2007

Objective. To evaluate the quality of prenatal results in all cases of termination of pregnancy (TOP) due to fetal abnormalities in a tertiary prenatal diagnosis center. Material and Methods. Retrospective analysis of the 385 TOP performed on our department due to fetal abnormalities between January 1, 2000, and December 31, 2007. We compared all data for agreement between the ultrasound, genetic, and postmortem findings, regarding the abnormalities identified in the etiological diagnosis and its prognosis. Results. Chromosome abnormalities were the most common indication for TOP (39%), followed by abnormalities of CNS (20%), monogenic disorders (11%), sequences (9.6%), polimalformative syndromes (5.2%), and isolated congenital heart diseases (4%). Total agreement was 21%. Further abnormalities were identified in 79%. The data collected after TOP changed the etiologic diagnosis in 21% but the prognosis was changed in only one fetus. Discussion. This study corroborates the necessity of a multidisciplinary team in prenatal diagnosis centers. Their work remarkably improves the genetic counseling and represents an important aspect in quality control of the information given to a couple previously to a TOP.

Post-mortem examination of human fetuses: a comparison of whole-body high-field MRI at 9.4 T with conventional MRI and invasive autopsy

BACKGROUND

Conventional whole-body MRI at 1.5 T does not provide adequate image quality of small fetuses, thus reducing its potential for use as an alternative to invasive autopsy. High-field whole-body MRI at 9.4 T provides good images of small animals. We therefore compared the diagnostic usefulness of high-field MRI with conventional MRI for post-mortem examination of human fetuses.

METHODS

We did whole-body MRI at 9.4 T and 1.5 T on 18 fetuses of less than 22 weeks' gestation, using three-dimensional T(2)-weighted fast-spin echo sequences, before doing invasive autopsy. Images obtained with MRI for each system were compared with the findings of invasive autopsy in a blinded manner. Tissue contrast of 14 different regions was compared on 1.5 T and 9.4 T images that were provided by paediatric radiologists separately and in a random order, and image quality was scored on a four-point scale. The primary endpoint was diagnostic accuracy.

FINDINGS

Spatial resolution, tissue contrast, and image quality of all organ systems were much better with high-field MRI than with conventional MRI. All structural abnormalities that were detected with invasive autopsy and internal examination of visceral organs were also detected with high-field MRI, whereas conventional MRI was not diagnostically useful in 14 (78%) cases.

INTERPRETATION

Whole-body high-field MRI is a feasible option for post-mortem examination of human fetuses, and can provide good tissue characterisation even in small fetuses (5 g). The use of MRI at 9.4 T might be helpful in the development of a minimally invasive perinatal autopsy system.

FUNDING

Department of Health Policy Research Programme, British Heart Foundation, National Institute of Health Research, Higher Education Funding Council for England, Biotechnology and Biological Sciences Research Council, Engineering and Physical Sciences Research Council, Great Ormond Street Hospital, University College London (UCL) Institute of Child Health, UCL Hospital, and UCL.

Hypertext atlas of fetal and neonatal pathology

Hypertext atlas of fetal and neonatal pathology is a free resource for pregraduate students of medicine, pathologists and other health professionals dealing with prenatal medicine. The atlas can be found at . The access is restricted to registered users. Concise texts summarize the gross and microscopic pathology, etiology, and clinical signs of both common and rare fetal and neonatal conditions. The texts are illustrated with over 300 images that are accompanied by short comments. The atlas offers histological pictures of high quality. Virtual microscope interface is used to access the high-resolution histological images. Fetal ultrasound video clips are included. Case studies integrate clinical history, prenatal ultrasonographic examination, gross pathology and histological features. The atlas is available in English (and Czech) and equipped with an active index. The atlas is suitable both for medical students and pathologists as a teaching and reference tool. The atlas is going to be further expanded while keeping the high quality of the images.

Palliative care for the family carrying a fetus with a life-limiting diagnosis

Prenatal diagnosis of a lethal anomaly is a monumental moment in a family's life. It requires extensive team counseling and planning about complex neonatal and obstetric medical management. The construct of palliative care with its focus on emotional, spiritual, social, and symptom support can provide a model for caring for these families.