Falling rates of perinatal postmortem examination: are we to blame?

Comparison of prenatal central nervous system abnormalities with postmortem findings in fetuses following termination of pregnancy and clinical utility of postmortem examination

OBJECTIVES

In this study, we aimed to compare prenatal ultrasound (USG) and postmortem examination findings of central nervous system (CNS) abnormalities in fetuses following termination of pregnancy (TOP).

METHODS

A total of 190 fetuses with USG-confirmed fetal CNS abnormalities of terminated pregnancies between January 2001 and January 2017 were retrospectively analyzed and USG and postmortem examination findings were compared.

RESULTS

The most frequent CNS abnormalities were acrania/anencephaly (n=45, 24%), spina bifida (n=43, 23%), and ventriculomegaly (n=35, 18%). In 144 of the 190 (76%) cases, there was total agreement between USG and postmortem examination diagnosis. Postmortem examination provided minor findings which did not change the major clinical diagnosis in two (1%) cases with spina bifida and ventriculomegaly. In six (3%) cases, the diagnosis changed after postmortem examination. In 25 of the 190 (13%) cases with multiple abnormalities as evidenced by USG, CNS abnormality was unable to be confirmed at postmortem examination.

CONCLUSIONS

Our study results show an overall high agreement (76%) between USG and postmortem examination findings for CNS malformations. Due to autolysis and fluid structure, USG-confirmed CNS diagnosis cannot be always confirmed by postmortem examination. This potential discrepancy should be explained to patients before considering TOP. Postmortem examination is the gold standard to confirm prenatal diagnosis.

Inter-center variation in autopsy practices among regional neonatal intensive care units (NICUs)

OBJECTIVE

To characterize infants who underwent autopsy in regional neonatal intensive care units (NICUs) and examine inter-center variability in autopsy completion.

STUDY DESIGN

Retrospective cohort study of infants who died between 2010 and 2016 from 32 participating hospitals in the Children's Hospital Neonatal Database (CHND). Maternal/infant demographics and hospital stay data were collected, along with autopsy rates by center, year, and region. Data analysis utilized bivariate and multivariable statistics.

RESULT

Of 6299 deaths, 1742 (27.7%) completed autopsy. Infants who underwent autopsy had higher median birth weight (2 124 g vs. 1 655 g) and gestational age (34 vs. 32 weeks). No differences were seen in sex, length of stay, or primary cause of death. Marked inter-center variability was observed, with 17-fold adjusted difference (p < 0.001) in autopsy rates.

CONCLUSION

Patient characteristics do not account for variability in autopsy practices across regional NICUs. Factors such as provider practices and parental preferences should be investigated.

Differences in Postmortem Investigation Following Perinatal Death

OBJECTIVE

 The study aimed to describe the postmortem investigation patterns for perinatal deaths and compare the degree of investigation between stillbirths and early neonatal deaths.

STUDY DESIGN

 We conducted a single-center retrospective review of all perinatal deaths from 2011 to 2017. Perinatal death was defined as intrauterine fetal death at ≥20 weeks' gestation, plus neonatal deaths within the first 7 days of life. Rates of postmortem investigation were compared.

RESULTS

 There were 97 perinatal deaths, with 54 stillbirths (56%) and 43 neonatal deaths (44%). Stillbirths were significantly more likely to receive autopsy (p = 0.013) and postmortem genetic testing (p = 0.0004) when compared with neonatal deaths. Maternal testing was also more likely in stillbirths than neonatal deaths. A total of 32 deaths (33%) had no postmortem evaluation beyond placental pathology.

CONCLUSION

 Investigation following perinatal death is more likely in stillbirths than neonatal deaths. Methods to improve postmortem investigation following perinatal death are needed, particularly for neonatal deaths.

KEY POINTS

· Investigation into perinatal death is recommended.. · Rates of investigation remain low.. · Neonatal deaths with less investigation than stillbirths..

"Why didn't we do it"? Reproductive loss and the problem of post-mortem consent

Informed consent has been a much debated topic within the social sciences. It often forms a central feature of discussions on research in medical settings and in social research methods more broadly. While sympathetic to its' underlying principles of autonomy and choice, social scientists have tended to argue that these are seldom enacted in research or clinical practice. Rather, such principles are often circumscribed by wider social structures and by a culture of medical dominance. Drawing on data from a qualitative study on perinatal post-mortem, this paper explores informed consent in the emotionally charged clinical arena of perinatal pathology. Our in-depth analysis will provide fresh insight into post-mortem decision-making in the sensitive arena of baby loss. Our findings show how parents often found it difficult to give consent for post-mortem, and also for professionals to take consent from parents. It was also not uncommon for parents to experience regret over non-consent later on. One of our key findings, however, related to the sense of emotional and diagnostic closure often afforded by post-mortem when consent had been given. We conclude by arguing that, although we cannot resolve the tension between the principles of consent and their enactment in practice, we can develop a reflexive approach with which to navigate the process. In doing so, the paper contributes to wider sociological discussions on the meaning and use of informed consent in various settings beyond medical contexts.

Impact of sociodemographic and clinical factors on offer and parental consent to postmortem following stillbirth or neonatal death: a UK population-based cohort study

OBJECTIVE

To identify factors associated with the offer of and consent to perinatal post-mortem.

DESIGN

National population-based cohort study SETTING: The UK.

POPULATION

26 578 perinatal deaths born between 1 January 2013 and 31 December 2017.

MAIN OUTCOME MEASURES

Postmortem offer by clinical staff; parental consent to post-mortem.

RESULTS

Postmortem offer rates were high but varied significantly with time of death from 97.8% for antepartum deaths to 88.4% for neonatal deaths following neonatal admission. Offer rates did not significantly vary by gestation, year of birth, mother's socioeconomic deprivation, ethnicity or age. Only 44.5% of parents consented to a postmortem. Mothers from the most deprived areas were less likely to consent than those from the least deprived areas (relative risk (RR)=0.76, 95% CI 0.71 to 0.80). Consent rates were similar for mothers of white, mixed, Asian Indian, black Caribbean and black African ethnicity (43%-47%), but significantly lower for mothers of Asian Pakistani (20%) and Asian Bangladeshi (18%) ethnicity. Consent increased with increasing gestation (p<0.001) and was lower for deaths following neonatal unit admission than for antepartum death (RR 0.71, 95% CI 0.67 to 0.75).

CONCLUSIONS

The current profile of cause of perinatal deaths in the UK is likely to be biased with less postmortem information available for babies dying in the neonatal period and those born to mothers from deprived areas and of Asian Pakistani or Asian Bangladeshi ethnicity. Such bias severely limits the design of effective strategies for reducing mortality in these high-risk groups. These findings have implications for high-income countries seeking to explore and improve the understanding of perinatal deaths.

Professionals' Practices and Views regarding Neonatal Postmortem: Can We Improve Consent Rates by Improving Training?

BACKGROUND

In the UK, rates of neonatal postmortem (PM) are low. Consent for PM is required, and all parents should have the opportunity to discuss whether to have a post-mortem examination of their baby.

OBJECTIVES

We aimed to explore neonatal healthcare professionals' experiences, knowledge, and views regarding the consent process for post-mortem examination after neonatal death.

METHOD

An online survey of neonatal healthcare providers in the UK was conducted. Responses from 103 healthcare professionals were analysed, 84 of whom were doctors. The response rate of the British Association of Perinatal Medicine (BAPM) members was 11.7%.

RESULTS

Perceived barriers to PM included cultural and religious practices of parents as well as a lack of rapport between parents and professionals. Of the respondents, 69.4% had observed a PM; these professionals had improved satisfaction with their training and confidence in counselling (p < 0.001 and p < 0.001) but not knowledge of the procedure (p = 0.77). Healthcare professionals reported conservative estimates of the likelihood that a PM would identify significant information regarding the cause of death.

CONCLUSIONS

Confidence of neonatal staff in counselling could be improved by observing a PM. Training for staff in developing a rapport with parents and addressing emotional distress may also overcome significant barriers to consent for PM.

Learning From Investigation After Death

OBJECTIVES

The acceptability of traditional postmortem examination to bereaved families, coupled with a misguided professional view about their limited utility, has led to decrease in this ultimate investigation. Research recurrently demonstrates that postmortem examination provides clinically relevant information despite ever-improving diagnostic techniques. This review examines postmortem examination for children who die in PICU-whether consented or nonconsented (legally mandated). It explores how such investigations might provide useful information and suggests that PICU and pathology teams work together to provide information for bereaved families to either enable them to consent to postmortem interventions or understand necessary forensic processes. Newer technologies such as postmortem imaging and laparoscope-assisted/ultrasound-guided tissue sampling are reviewed, with the hope that greater acceptability to families may lead to a welcome resurgence in postmortem information for clinicians, tempered by realization that widespread acceptance of their equivalence to standard techniques by most forensic services is awaited.

DATA SOURCES

Literature review.

STUDY SELECTION

Journal articles describing practices in pediatric and adult postmortem examination.

DATA EXTRACTION

Not available.

DATA SYNTHESIS

Not available.

CONCLUSIONS

The PICU team have a duty to help bereaved parents understand what postmortem investigations are available, or might be mandated, after the death of their child. A thoughtful, unhurried, and compassionate discussion should be arranged with expert pathology teams and any specialists who have cared for the child to explain how investigations can provide information about what is involved-including availability and suitability of newer techniques. This should include information about when a child's body, organs, or tissues will be available for the funeral, necessary legal procedures and how and when results will be explained to them.

Interventions for investigating and identifying the causes of stillbirth

BACKGROUND

Identification of the causes of stillbirth is critical to the primary prevention of stillbirth and to the provision of optimal care in subsequent pregnancies. A wide variety of investigations are available, but there is currently no consensus on the optimal approach. Given their cost and potential to add further emotional burden to parents, there is a need to systematically assess the effect of these interventions on outcomes for parents, including psychosocial outcomes, economic costs, and on rates of diagnosis of the causes of stillbirth.

OBJECTIVES

To assess the effect of different tests, protocols or guidelines for investigating and identifying the causes of stillbirth on outcomes for parents, including psychosocial outcomes, economic costs, and rates of diagnosis of the causes of stillbirth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (15 May 2017).

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. We planned to include studies published as abstract only, provided there was sufficient information to allow us to assess study eligibility. We planned to exclude cross-over trials.Participants included parents (including mothers, fathers, and partners) who had experienced a stillbirth of 20 weeks' gestation or greater.This review focused on interventions for investigating and identifying the causes of stillbirth. Such interventions are likely to be diverse, but could include:* review of maternal and family history, and current pregnancy and birth history;* clinical history of present illness;* maternal investigations (such as ultrasound, amniocentesis, antibody screening, etc.);* examination of the stillborn baby (including full autopsy, partial autopsy or noninvasive components, such as magnetic resonance imaging (MRI), computerised tomography (CT) scanning, and radiography);* umbilical cord examination;* placental examination including histopathology (microscopic examination of placental tissue); and* verbal autopsy (interviews with care providers and support people to ascertain causes, without examination of the baby).We planned to include trials assessing any test, protocol or guideline (or combinations of tests/protocols/guidelines) for investigating the causes of stillbirth, compared with the absence of a test, protocol or guideline, or usual care (further details are presented in the Background, see Description of the intervention).We also planned to include trials comparing any test, protocol or guideline (or combinations of tests/protocols/guidelines) for investigating the causes of stillbirth with another, for example, the use of a limited investigation protocol compared with a comprehensive investigation protocol.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility independently.

MAIN RESULTS

We excluded five studies that were not RCTs. There were no eligible trials for inclusion in this review.

AUTHORS' CONCLUSIONS

There is currently a lack of RCT evidence regarding the effectiveness of interventions for investigating and identifying the causes of stillbirth. Seeking to determine the causes of stillbirth is an essential component of quality maternity care, but it remains unclear what impact these interventions have on the psychosocial outcomes of parents and families, the rates of diagnosis of the causes of stillbirth, and the care and management of subsequent pregnancies following stillbirth. Due to the absence of trials, this review is unable to inform clinical practice regarding the investigation of stillbirths, and the specific investigations that would determine the causes.Future RCTs addressing this research question would be beneficial, but the settings in which the trials take place, and their design, need to be given careful consideration. Trials need to be conducted with the utmost care and consideration for the needs, concerns, and values of parents and families. Assessment of longer-term psychosocial variables, economic costs to health services, and effects on subsequent pregnancy care and outcomes should also be considered in any future trials.

Diagnostic value of perinatal autopsies: analysis of 486 cases

AIM

Autopsy is a beneficial procedure to determine the cause of death and the frequency of anomalies in perinatal losses. Even in the event of an autopsy not providing any additional information, completion of the procedure confirming the clinical diagnoses gives reassurance to both clinicians and parents. Here we present a 15-year archival study based on findings of perinatal autopsies.

DESIGN AND METHODS

Four hundred and eighty-six cases from our archive were reviewed and according to the findings they were divided into three subcategories; (1) miscarriages (MCF); (2) fetuses terminated (FTA) for vital anomalies detected by prenatal ultrasonography; (3) premature or term newborns died within first month of life (neonates: NN). Autopsies were documented and classified according to week/age of cases, anomalies and causes of abortion or death.

RESULTS

Two hundred and twenty-six of 486 cases (46.5%) were in MCF group while 227 (46.7%) and 33 (6.8%) were of them in FTA and NN groups, respectively. In FTA group, the most frequent anomaly detected was neural tube defects. In NN group, prematurity related complications were the most common cause of death. The autopsy process was found valuable in 39.7% of all cases.

CONCLUSIONS

We suggest that autopsy procedure is diagnostically valuable even in situations when there is USG findings that are confirming FTAs or there is no important major fetal or placental anomaly detected in MCFs.

Conventional vs virtual autopsy with postmortem MRI in phenotypic characterization of stillbirths and fetal malformations

OBJECTIVE

To compare virtual autopsy using postmortem magnetic resonance imaging (MRI) with conventional autopsy with respect to phenotypic characterization of stillbirths and malformed fetuses, and acceptability to parents.

METHODS

This was a prospective diagnostic evaluation study, conducted from June 2013 to June 2015, including stillbirths and pregnancies terminated owing to fetal malformation at ≥ 20 weeks' gestation, for which parental consent to both conventional autopsy and postmortem MRI was obtained. Cases of maternal and obstetric cause of fetal demise were excluded. Whole-body postmortem MRI (at 1.5 T) was performed prior to conventional autopsy. Taking conventional autopsy as the diagnostic gold standard, postmortem MRI findings alone, or in conjunction with other minimally invasive prenatal and postmortem investigations, were assessed and compared for diagnostic accuracy.

RESULTS

Parental consent for both conventional autopsy and postmortem MRI was obtained in 52 cases of which 43 were included in the analysis. In 35 (81.4%) cases, the final diagnosis based on virtual autopsy with postmortem MRI was in agreement with that of conventional autopsy. With conventional autopsy as the reference standard, sensitivity, specificity, positive and negative predictive values of postmortem MRI were, respectively: 77.7%, 99.8%, 97.4% and 98.0% for whole-body assessment; 93.1%, 99.0%, 87.1% and 99.5% for the nervous system; 61.0%, 100.0%, 100.0% and 96.7% for the cardiovascular system; 91.1%, 100.0%, 100.0% and 98.0% for the pulmonary system; 80.6%, 99.8%, 96.7% and 98.7% for the abdomen; 96.2%, 99.7%, 96.2% and 99.7% for the renal system; and 66.7%, 100.0%, 100.0% and 97.2% for the musculoskeletal system. Virtual autopsy was acceptable to 96.8% of families as compared with conventional autopsy to 82.5%.

CONCLUSIONS

Virtual autopsy using postmortem MRI and other minimally invasive investigations can be an acceptable alternative to conventional autopsy when the latter is refused by the parents. Postmortem MRI is more acceptable to parents and can provide additional diagnostic information on brain and spinal cord malformations. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Factors influencing the uptake of neonatal bereavement support services - Findings from two tertiary neonatal centres in the UK

BACKGROUND

Research on perinatal bereavement services is limited. The aim of the study was to compare the uptake of bereavement support services between two tertiary neonatal units (NNU), and to investigate influencing factors.

METHOD

The medical and bereavement records of all neonatal deaths were studied from January 2006 to December 2011. Data collected included parent and baby characteristics, mode of death, consent for autopsy and bereavement follow-up. The categorical data were compared by chi-square or Fisher's exact test and continuous data by Wilcoxon signed-rank test; a multivariable regression analysis was performed using STATA 12.0.

RESULTS

The neonatal deaths of 297 babies (182 in NNU1 and 115 in NNU2) with full datasets were analysed. Baby characteristics were similar between units except for lower median gestational age in NNU1 (p = 0.03). Significantly more NNU1 parents were non-Caucasian (p < 0.01), from lower socio-economic status (p = 0.01) and had previous stillbirth/miscarriage (p = 0.03). More babies had care withdrawn in NNU2 (p < 0.01). A significantly higher proportion of parents from NNU1 (61 %) attended bereavement follow-up compared to NNU2 (34 %; p < 0.01). On multivariable analysis, significantly more parents who were married or co-habiting (p = 0.02) and consented for an autopsy (p = 0.01) attended bereavement services.

CONCLUSION

Uptake of bereavement services varied between the two NNUs, which could be due to differences in the ethnic and socio-economic mix of the population. Significantly more parents who were married or co-habiting, or consented for autopsy, attended bereavement follow up services.

Interventions for supporting parents' decisions about autopsy after stillbirth

BACKGROUND

Stillbirth remains one of the least understood areas of infant death and accurate data on the causes of stillbirth are the cornerstone of stillbirth prevention. An autopsy examination remains the gold standard post-mortem investigation for stillbirth. However, decisions about post-mortem investigations, particularly autopsy are difficult. The purpose of this review is to examine the effectiveness of methods to help parents who have experienced a stillbirth decide whether to have post-mortem investigations, including whether to have an autopsy performed.

OBJECTIVES

The primary objectives were a) to examine the effectiveness of interventions to support parents' decisions about autopsy consent after a stillbirth on outcomes for parents, and b) to determine autopsy rates. Secondary objectives were to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE (1966 to 24 July 2012) and EMBASE (1980 to 24 July 2012), Current Controlled Trials metaRegister (mRCT) (18 September 2012) and the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (18 September 2012). We also searched the websites of the Stillbirth and Neonatal Death Charity (SANDS) and International Stillbirth Alliance (ISA) (18 September 2012) and then subsequently searched the websites of all the ISA member organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions designed specifically to support parents who have experienced a stillbirth make decisions about their options for post-mortem investigations including all investigations after stillbirth compared with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations against the selection criteria. 

MAIN RESULTS

No studies meeting the review inclusion criteria were identified. A search of 40 websites associated with supporting parents who experience stillbirth also found little reference to, or information about autopsy or other post-mortem examinations.

AUTHORS' CONCLUSIONS

Support for parents making decisions about autopsy or other post-mortem examinations after stillbirth must rely on the ad hoc knowledge and experience of those involved at the time.

Decision influences and aftermath: parents, stillbirth and autopsy

BACKGROUND

Stillbirth, among the most distressing experiences an adult may face, is also a time when parents must decide whether an autopsy or other post-mortem examinations will be performed on their infant. Autopsies can reveal information that might help explain stillbirth, yet little is known about how people make this difficult decision.

OBJECTIVES

This study examines the influences on decisions about autopsy after stillbirth among Australian parents.

DESIGN

The study involved secondary analysis of transcripts of three focus groups using qualitative content analysis.

PARTICIPANTS AND SETTING

Seventeen parents of 14 stillborn babies participated in consultations around the revision of a perinatal mortality audit guideline.

RESULTS

Parents shared the decision making. Four decision drivers were identified: parents' preparedness or readiness to make decisions; parental responsibility; concern for possible consequences of an autopsy and the role of health professionals. Each decision driver involved reasons both for and against autopsy. Two decision aftermath were also present: some parents who agreed to an autopsy were dissatisfied with the way the autopsy results were given to them and some parents who did not have an autopsy for their infant expressed some form of regret or uncertainty about the choice they made.

CONCLUSIONS

To make decisions about autopsy after stillbirth, parents need factual information about autopsy procedures, recognition that there might be fear of blame, an environment of trust, and health services and professionals prepared and skilled for difficult conversations.

Post-mortem examination after stillbirth: views of UK-based practitioners

OBJECTIVES

Worldwide, around four million stillbirths occur annually. The UK was recently ranked as 33rd out of 35 developed nations for stillbirth rates. The reasons for many stillbirths remain unexplained. Post-mortem examination (PME) can provide information for grieving families, and for future pregnancies. Rates of consent for PME are decreasing in the UK. The views of professionals may influence their approach to bereaved families, and, therefore, rates of consent. Arguably, obtaining qualitative insights into emotive areas such as PME from large numbers of practitioners is increasingly possible as electronic surveys become more sophisticated. Therefore we aimed to describe, using electronic media, the views of UK obstetricians, midwives and perinatal pathologists about PME for stillbirth.

STUDY DESIGN

10,000 UK midwives, 1136 UK obstetricians and all 40 UK perinatal pathologists received a link to an Internet survey via their professional organizations. A box was included for free-text responses. Iterative thematic analysis generated five themes and a 'line of argument' synthesis.

RESULTS

683 midwives, 98 obstetricians, and 11 perinatal pathologists provided open comments, generating five themes and the following line of argument: both professional views and family decision-making about postmortem after stillbirth are affected by the education and training of staff, local resources, and the quality of information available. All of these structural issues are interpreted by individual staff, women and families through personal beliefs and emotions, and professional and social discourses.

CONCLUSIONS

Internet-based surveys can generate valuable qualitative data. Effective decision-making for post-mortem after stillbirth may be improved by the introduction of user-friendly information and consent procedures, and staff training that takes account of existing innovations, and of the emotions and prior experiences of both staff and parents.

Perinatal postmortems: what is important to parents and how do they decide?

BACKGROUND

Falling consent rates for postmortems, regardless of age of death, have been widely reported in recent years. The aim of this study was to explore parental attitudes to, and decision-making about, a perinatal postmortem after termination for fetal abnormality, late miscarriage, or stillbirth.

METHODS

A prospective self-completion questionnaire was given to 35 women and their partners. The participants had experienced second or third trimester pregnancy loss in a single fetal medicine and delivery unit in the United Kingdom and were making decisions about having a postmortem. They were asked to complete a questionnaire about their attitudes to, and expectations of, a perinatal postmortem.

RESULTS

Thirty-one questionnaires were received from parents of 17 babies (49% of those asked; 16 from mothers, 15 from fathers). Parents of nine babies (53%) said they would agree to a full postmortem, of three babies to a limited postmortem, and of four babies to an external examination only; one couple were undecided. The most important issues for the parents in this study that related to their decisions about a postmortem centered on the need for information, both for future planning and about what had happened. Moderately important issues related to altruism, which is, improving medical knowledge and helping other parents experiencing similar bereavement. Among the lowest scoring issues were potential barriers, such as concerns about cultural or religious acceptability of a postmortem, funeral delays, and what would happen to the baby's body.

CONCLUSIONS

Bereaved parents who participated in this study, where postmortem consent rates were relatively high, thought that their need for knowledge eclipsed assumed barriers when deciding whether or not to have a postmortem for their baby.

The value of neonatal autopsy

BACKGROUND AND OBJECTIVE

Neonatal autopsy rates were in decline internationally at the end of the last century. Our objective was to assess the current value of neonatal autopsy in providing additional information to families and healthcare professionals.

METHODS

We conducted a review of neonatal autopsies performed in a tertiary perinatal centre over an 11-year period. Primary outcomes measured were the annual neonatal autopsy rates and concordance rates between clinical and autopsy diagnoses of the primary cause of death. Secondary outcomes were the clinical, genetic and audit value of the examinations. Findings were used to inform the consent process, and the effect this had on institutional post-mortem rates was assessed over the subsequent 5-year period.

RESULTS

There was a marked decline in the annual neonatal autopsy rate from 73% in 1994 to 48% in 2004. 164 cases met the inclusion criteria for review. Complete concordance for cause of death was reached in 91% of cases. Previously unsuspected or unconfirmed clinical conditions, other than the primary cause of death, were uncovered at autopsy in 85 cases. Detailed information on inheritable conditions was obtained in 45 cases. Findings with perceived 'audit value' for clinical practice were identified in 29 cases. The dissemination of this information to staff and families contributed to the stabilisation of the consent rate in the following 5-year period.

CONCLUSION

Neonatal autopsy remains a valuable diagnostic tool as it provides critical clinical and audit information for healthcare professionals and families.

Investigation of the role of computed tomography as an adjunct to autopsy in the evaluation of stillbirth

INTRODUCTION

The number of parents agreeing to autopsy following stillbirth is declining, which has undermined clinicians' ability to assess causes of intrauterine death and can impact counselling regarding recurrence. Post-mortem radiological imaging is a potential alternative method of investigating perinatal loss. The aim of this study was to assess the role of multi-detector computed tomography (MDCT) in the investigation of stillbirth.

STUDY DESIGN

Following ethical approval and written consent, parents were offered MDCT of the stillborn infant. MDCT was performed with 3D reconstruction, and images were analysed for image quality, anthropomorphic measurements and pathologic findings. Body part and organ-specific measurements were performed; including head, chest and abdominal circumferences, and muscle and liver mass was also measured. Findings were correlated with obstetric history, post-mortem skeletal survey (plain radiography), and formal autopsy.

RESULTS

Fourteen third-trimester stillborn infants were scanned. Image quality was moderate to excellent for most body structures. CT was better than plain radiography for imaging skeletal structures and large solid organs and demonstrated a range of pathologies including renal vein thrombosis, mesenteric calcification and skeletal hyperostosis that were not seen on plain radiographs. MDCT did not overlook autopsy findings and provided some additional information.

CONCLUSION

This study confirms the feasibility of MDCT in the investigation of third trimester stillbirth. MDCT image quality is acceptable and the examination can demonstrate a range of anatomic and pathologic findings. Initially, its value may be as an important adjunct to conventional autopsy.

Minimally-invasive fetal autopsy using magnetic resonance imaging and percutaneous organ biopsies: clinical value and comparison to conventional autopsy

OBJECTIVES

Autopsy is an important investigation following fetal death or termination for fetal abnormality. Postmortem magnetic resonance imaging (MRI) can provide macroscopic information of comparable quality to that of conventional autopsy in the event of perinatal death. It does not provide tissue for histological examination, which may limit the quality of counseling for recurrence risks and elucidation of the cause of death. We sought to examine the comparability and clinical value of a combination of postmortem MRI and percutaneous fetal organ biopsies (minimally invasive autopsy (MIA)) with conventional fetal autopsy.

METHODS

Forty-four fetuses underwent postmortem MRI and attempted percutaneous biopsy (using surface landmarks) of major fetal organs (liver, lung, heart, spleen, kidney, adrenal and thymus) following fetal death or termination for abnormality, prior to conventional autopsy, which was considered the 'gold standard'. We compared significant findings of the two examinations for both diagnostic information and clinical significance. Ancillary investigations (such as radiographs and placental histology) were regarded as common to the two forms of autopsy.

RESULTS

In 21 cases conventional autopsy provided superior diagnostic information to that of MIA. In two cases the MIA provided superior diagnostic information to that of conventional autopsy, when autolysis prevented detailed examination of the fetal brain. In the remaining 21 cases, conventional autopsy and MIA provided equivalent diagnostic information. With regard to clinical significance, however, in 32 (72.7%) cases, the MIA provided information of at least equivalent clinical significance to that of conventional autopsy. In no case did the addition of percutaneous biopsies reveal information of additional clinical significance.

CONCLUSIONS

Although in some cases MRI may provide additional information, conventional perinatal autopsy remains the gold standard for the investigation of fetal death. The utility of adding percutaneous organ biopsies, without imaging guidance, to an MRI-based fetal autopsy remains unproven. Postmortem MRI, combined with ancillary investigations such as placental histology, external examination by a pathologist, cytogenetics and plain radiography provided information of equivalent clinical significance in the majority of cases.

The role of autopsy following pregnancy termination for fetal abnormality

OBJECTIVE

To review the frequency of autopsy following pregnancy termination for fetal anomaly and its contribution to subsequent counselling.

METHODS

All medical pregnancy terminations for fetal anomaly performed after 14 weeks gestation from January 1997 to December 2006 were identified and the frequency of autopsy ascertained. The prenatal diagnosis prompting the termination was then compared with the autopsy data, and a diagnostic valuation was determined. The potential autopsy value ranged from no additional information provided, minor added value, significant added value, major added value to non-confirmation of the prenatal findings.

RESULTS

During the ten-year study period, there were 1012 consecutive terminations for fetal abnormality. The principal indications for termination were: karyotypic (38.4%); neural tube defects (16.1%); cardiac (10.3%) and cerebral anomalies (7.5%). Autopsy was performed in 809 cases (79.9%). The autopsy rate progressively declined from 95.1% in 1997 to 67.5% in 2006 (P<0.001). Women declining autopsy were older (31 years (26,35) vs 32 years (27,37), P=0.005) and more likely to have a fetal chromosomal abnormality (30.6% vs 69.9%, P<0.001) (autopsy vs no-autopsy). In euploid cases, autopsy confirmed the prenatal diagnosis with no additional information in 63.5% (357 of 562). In 1.1% (six cases), autopsy added major diagnostic information, and in 15.1% (85 cases), significant information was provided.

CONCLUSIONS

Although contemporary prenatal testing has improved the recognition of fetal abnormalities, autopsy remains a valued tool by providing diagnosis or clarification of some prenatal findings in 16% of cases. Fetal autopsy rates are declining and this trend may lead to a loss of diagnostic and recurrence risk-counselling information.