International Journal of Legal Medicine

, Volume 133, Issue 2, pp 483–489 | Cite as

Parameters for estimating the time of death at perinatal autopsy of stillborn fetuses: a systematic review

  • Mariano Paternoster
  • Mauro Perrino
  • Antonio TravaglinoEmail author
  • Antonio Raffone
  • Gabriele Saccone
  • Fulvio Zullo
  • Francesco Paolo D’Armiento
  • Claudio Buccelli
  • Massimo Niola
  • Maria D’Armiento



Stillbirth is defined by the WHO as birth of a fetus with no vital signs, at or over 28 weeks of pregnancy age. The estimation of time of death in stillbirth appears crucial in forensic pathology. However, there are no validated methods for this purpose.


To perform a systematic review of the available literature regarding the estimation of the time of death in stillborn fetuses, in terms of hours or days.


Electronic databases were searched from their inception to August 2018 for relevant articles. Macroscopic, histologic, and radiologic parameters were evaluated.


Nine studies with 664 stillborns were included. The evaluation of extent and location of fetal maceration signs showed good accuracy in estimating the time of death; by contrast, a dichotomous assessment of maceration (present vs absent) was found to be unreliable in a subsequent study. Histologic assessment of the loss of nuclear basophilia in fetal and placental tissues showed excellent accuracy; an “autolysis equation” was proposed to achieve an even higher accuracy in fetuses who had been dead for < 24 h. Magnetic resonance imaging of the lung parenchyma, pleural fluids, and brain parenchyma could estimate the death-to-autopsy time, but the results appeared weak and conflicting.


Pathologic examination, based on the assessment of maceration, and even more of the loss of nuclear basophilia, may be a reliable method to estimate the time of death in stillborn fetuses. Further studies should be encouraged to validate these results. Imaging techniques have not yet found application in this field.


Stillbirth Intrauterine death Fetal death Autopsy Maceration Perinatal pathology 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    World Health Organization (2004) International statistical classification of diseases, and related health problems, 10th revision (ICD-10). World Health Organization, GenevaGoogle Scholar
  2. 2.
    Tavares Da Silva F, Gonik B, McMillan M et al (2016) Stillbirth: case definition and guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine 34:6057–6068CrossRefGoogle Scholar
  3. 3.
    World Health Organization (2017) Epidemiology, monitoring and evaluation - maternal, newborn, child and adolescent health – stillbirths Accessed 21 July 2018
  4. 4.
    Moher D, Shamseer L, Clarke M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4:1CrossRefGoogle Scholar
  5. 5.
    Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM, QUADAS-2 Group (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536CrossRefGoogle Scholar
  6. 6.
    Genest DR (1992) Estimating the time of death in stillborn fetuses: II. Histologic evaluation of the placenta; a study of 71 stillborns. Obstet Gynecol 80:585–592Google Scholar
  7. 7.
    Kim JH (2013) Histologic estimation of intrauterine retention time after fetal death. Kor J Leg Med 37:191–197CrossRefGoogle Scholar
  8. 8.
    Gold KJ, Abdul-Mumin AR, Boggs ME, Opare-Addo HS, Lieberman RW (2014) Assessment of “fresh” versus “macerated” as accurate markers of time since intrauterine fetal demise in low-income countries. Int J Gynaecol Obstet 125:223–227CrossRefGoogle Scholar
  9. 9.
    Arthurs OJ, Price GC, Carmichael DW, Jones R, Norman W, Taylor AM, Sebire NJ (2015) Diffusion-weighted perinatal postmortem magnetic resonance imaging as a marker of postmortem interval. Eur Radiol 25:1399–1406CrossRefGoogle Scholar
  10. 10.
    Genest DR, Williams MA, Greene MF (1992) Estimating the time of death in stillborn fetuses: I. Histologic evaluation of fetal organs; an autopsy study of 150 stillborns. Obstet Gynecol 80:575–584Google Scholar
  11. 11.
    Barber JL, Hutchinson JC, Sebire NJ, Arthurs OJ (2016) Pleural fluid accumulation detectable on paediatric post-mortem imaging: a possible marker of interval since death? Int J Legal Med 130:1003–1010CrossRefGoogle Scholar
  12. 12.
    Shelmerdine SC, Main C, Hutchinson JC, Langan D, Sebire NJ, Arthurs OJ (2018) The use of whole body diffusion-weighted post-mortem magnetic resonance imaging in timing of perinatal deaths. Int J Legal Med 132:1735–1741CrossRefGoogle Scholar
  13. 13.
    Carroll R and American Society for Healthcare Risk Management (ASHRM) (2010) Risk management handbook for health care organizations. Jossey-Bass, New York CityGoogle Scholar
  14. 14.
    Papadopoulou L, Langan D, Sebire NJ, Jacques TS, Arthurs OJ (2016) Diffusion-weighted post-mortem magnetic resonance imaging of the human fetal brain in situ. Eur J Radiol 85:1167–1173CrossRefGoogle Scholar
  15. 15.
    Genest DR, Singer DB (1992) Estimating the time of death in stillborn fetuses: III. External fetal examination; a study of 86 stillborns. Obstet Gynecol 80:593–600Google Scholar
  16. 16.
    Keller S, Schmidt TM, Kim AC, Fischer R, Heinemann A, Adam G, Yamamura J (2018) Postmortem MR diffusion-weighted imaging of the liver: time-behavior of the hepatic apparent diffusion coefficient in the early death interval. Int J Legal Med 132:263–268CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Mariano Paternoster
    • 1
  • Mauro Perrino
    • 1
  • Antonio Travaglino
    • 2
    Email author
  • Antonio Raffone
    • 3
  • Gabriele Saccone
    • 3
  • Fulvio Zullo
    • 3
  • Francesco Paolo D’Armiento
    • 2
  • Claudio Buccelli
    • 1
  • Massimo Niola
    • 1
  • Maria D’Armiento
    • 4
  1. 1.Legal Medicine Unit, Department of Advanced Biomedical Sciences, School of MedicineUniversity of Naples Federico IINaplesItaly
  2. 2.Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of MedicineUniversity of Naples Federico IINaplesItaly
  3. 3.Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of MedicineUniversity of Naples Federico IINaplesItaly
  4. 4.Pathology Unit, Department of Public Health, School of MedicineUniversity of Naples Federico IINaplesItaly

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