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The Clinicians' View of Fetal and Neonatal Necropsy

  • E. Sarah Cooper
  • Ian A. Laing

In many parts of the developed world the role of the perinatal necropsy has diminished in status, for a number of reasons. There may be a touching faith in the accuracy of noninvasive technology to provide all answers. There may be a suspicion that clinicians wish to experiment on deceased fetuses and newborns. These understandable beliefs may in part have stemmed both from the failure of obstetricians and neonatologists to explain to families the limitations of sophisticated equipment and from secrecy around the process of necropsy. Such secrecy was often well intentioned, and generally stemmed from a misguided wish to protect vulnerable parents from the details of the examination of their baby ' s body. In 2003 the British Medical Journal devoted an issue to the subject of death. It included fi ve editorials and fi ve original articles on mortality: the subject of necropsy was not mentioned once (Anon 2003).

There is an easy path for all clinicians. We can avoid asking for autopsies because the “baby has suffered enough” and suggest that our clinical skills, imaging, phlebotomy, microbiology, and histological capabilities have already given us the complete answer to the causes of the demise of the fetus or neonate. To take this line is to abrogate our responsibilities to the family. It is essential that we as clinicians should persuade our professional colleagues of the high value of necropsy, especially to bereaved families. Professionals should emphasize to parents that it is their opportunity and right to have a necropsy carried out on their baby. Only then can the most appropriate counseling be entered into with accuracy, confi -dence, and in a spirit of trust.

Keywords

Obstet Gynecol Royal College Neonatal Death Fetal Growth Restriction Hypoplastic Left Heart Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. Abdul RH, Khong TY (1995) Perinatal infant postmortem examination. Survey of women ' s reactions to perinatal necropsy. Br Med J 310:870–871.Google Scholar
  2. Airas U, Heinonen S (2002) Clinical signifi cance of true umbilical knots: a population based analysis. Am J Perinatol 19:127–132.PubMedGoogle Scholar
  3. Al-Adnani M, Scheimberg I (2006) How can we improve the rate of autopsies among Muslims?. Br Med J 332:310.Google Scholar
  4. Anderson RE (1977) The autopsy—benefi ts to society. Am J Clin Pathol 69:239–241.Google Scholar
  5. Bakketteig LS (1999) Only a minor part of cerebral palsy cases begin in labour. Br Med J 319:1016– 1017.Google Scholar
  6. Baschat AA (2004) Fetal responses to placental insuffi ciency: an update. Br J Obstet Gynaecol 111:1031–1041.Google Scholar
  7. Battle RM, Pathak D, Humble CG, et al. (1987) Factors infl uencing discrepancies between pre mortem and postmortem diagnoses. JAMA 258:339– 344.PubMedGoogle Scholar
  8. Becher JC, Bell JE, Keeling JW, Mcintosh N, Wyatt B (2004a) The Scottish Perinatal Neuropathology Study: clinicopathological correlation in early neonatal deaths. Arch Dis Child (Fetal Neonatal Ed) 89;F399–407.Google Scholar
  9. Becher JC, Laing IA, Keeling JW, McIntosh N (2004b) Restoring high neonatal autopsy rates. Lancet 364:2019–2020.Google Scholar
  10. Beckwith JB (1989) The value of the paediatric post mortem examination. Pediatr Clin North Am 1:29–36.Google Scholar
  11. Bell R, Parker L, MacPhail S, Wright C (2004) Trends in the cause of late fetal death, 1982–2000 Br J Obstet Gynaecol 111:1400–1407.Google Scholar
  12. Benirschke K, Robb JA (1987) Infectious causes of fetal death. Clin Obstet Gynecol 30:284–294.PubMedGoogle Scholar
  13. Berthrong M (1984) The autopsy as a vehicle for the lifelong education of pathologists. Arch Pathol Lab Med 108:506–509.PubMedGoogle Scholar
  14. Blanch G, Quenby S, Ballantyne ES, Gosden CM, Neilson JP, Holland K. (1998) Embryonic abnormalities at medical termination of pregnancy with mifepristone and misoprostol during fi rst trimester: observational study. Br Med J 316:1712–1713.Google Scholar
  15. Bower S, Schuchter K, Campbell S. (1993) Doppler ultrasound screening as part of routine antenatal screening: prediction of pre-eclampsia and intrau-terine growth retardation. Br J Obstet Gynaecol 100:989–994.PubMedGoogle Scholar
  16. Brodlie M, Laing IA, Keeling JW, McKenzie KJ (2002) Ten years of neonatal autopsies in tertiary referral centre: retrospective study. Br Med J 324:761–763.Google Scholar
  17. Brookes JAS, Hall-Craggs MA, Lees WR, Sama VR (1996) Non invasive perinatal necropsy by magnetic resonance imaging. Lancet 348:1139–1141.PubMedGoogle Scholar
  18. Brown HG (1984) Lay perceptions of autopsy. Arch Pathol Lab Med 108:446–448.PubMedGoogle Scholar
  19. Burrows S (1975) The postmortem examination. Scien-tifi c necessity or folly?. JAMA 233:441–443.PubMedGoogle Scholar
  20. Butler NR, Bonham DG (1963) Perinatal Mortality. The First Report of the 1958 British Perinatal Mortality Survey. Livingstone, Edinburgh.Google Scholar
  21. Carey JK, Rayburn WF (2000) Nuchal cord encirclements and risk of stillbirth. Int J Gynaecol Obstet 69:173–174.PubMedGoogle Scholar
  22. Chiswick M (1995) Perinatal and infant postmortem examination. Br Med J 310:141–142.Google Scholar
  23. Chitty LS, Hunt GH, Moore J, Lobb MO (1991) Effectiveness of routine ultrasonography in detecting fetal structural abnormalities in a low risk population. Br Med J 303:1165–1169.Google Scholar
  24. Clausson N, Cnattingius S, Axelsson O (1999) Outcomes of post-term births: the role of fetal growth restriction and malformations. Obstet Gynecol 94(5 pt 1): 758–762.PubMedGoogle Scholar
  25. Clayton-Smith J, Farndon PA, Mckeowan C, Donnai D (1990) Examination of fetuses after induced abortion for fetal abnormality. Br Med J 300:295–297.Google Scholar
  26. Cole SK, Hey EN, Thomson AM. (1986) Classifying perinatal death: an Obstetric approach. Br J Obstet Gynaecol 93:1204–1212.PubMedGoogle Scholar
  27. Collaborative Low Dose Aspirin Study in Pregnancy Collaborative Group. (1995) Low dose aspirin in pregnancy and early childhood development: fol-lowup of the Collaborative Low Dose Aspirin Study in Pregnancy. Br J Obstet Gynaecol 102:861–868.Google Scholar
  28. Confi dential Enquiry into Maternal and Child Health (2005) Stillbirth, Neonatal and Post-Neonatal Mortality 2000–2003, England, Wales and Northern Ireland. RCOG Press, London.Google Scholar
  29. Cowan F, Rutherford M, Groenendaal F, et al. (2003) Origin and timing of brain lesions in term infants with neonatal encephalopathy. Lancet 361(9359): 736–742.PubMedGoogle Scholar
  30. Craft H, Brazy JE (1986) Autopsy—high yield in neonatal population. Am J Dis Child 140:1260–1262.PubMedGoogle Scholar
  31. Dahms B (1986) The autopsy in pediatrics. Am J Dis Child 4:335.Google Scholar
  32. Department of Health (2006) The Pregnancy Book: Your Health in Pregnancy. Department of Health, London, p. 12.Google Scholar
  33. Dhar V, Perlman M, Vilela MI, Haque KN, Kirpalani H, Cutz E (1998) Autopsy in a neonatal intensive care unit: utilization patterns and associations of clinico-pathologic discordances. Pediatrics 132:75–79.Google Scholar
  34. Duley L, Henderson-Smart D, Knight M, King D (2001) Antiplatelet drugs for prevention of pre-eclampsia and its consequences: systematic review. Br Med J 322:329–333.Google Scholar
  35. Edwards AD, Nelson KB (1998) Neonatal encephalopa-thies: time to reconsider the cause of encephalopa-thies. Br Med J 317:1537–1538.Google Scholar
  36. Faye-Peterson O, Guinn D, Wenstrom KD (1999) Value of perinatal autopsy. Obstet Gynecol 94:915– 920.Google Scholar
  37. Friederici HHR, Sebastian M (1984) An argument for the attendance of clinicians at autopsy. Arch Pathol Lab Med 108:522–523.PubMedGoogle Scholar
  38. Gardosi J, Kady SM, McGeown P, Francis A, Tonks A (2005) Classifi cation of stillbirth by relevant condition at death (ReCoDe): population based cohort study. Br Med J 331:1113–1116.Google Scholar
  39. Geller SA (1984) Religious attitudes and the autopsy. Arch Pathol Lab Med 108:494–496.PubMedGoogle Scholar
  40. Ghanem I (1988) Permission for performing an autopsy: the pitfalls under Islamic law. Med Sci Law 28:241–242.PubMedGoogle Scholar
  41. Gibb RS, Duff P (1991) Progress in pathogenesis and management of clinical intraamniotic infection. Am J Obstet Gynecol 164:1317–1326.Google Scholar
  42. Goldenberg RL, Thompson CT (2003) The infectious origins of stillbirth. Am J Obstet Gynecol 189:861–873.PubMedGoogle Scholar
  43. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M (1983) The value of the autopsy in three medical eras. N Engl J Med 308:1000–1005.PubMedGoogle Scholar
  44. Griffi ths PD, Paley MNJ, Whitby EH (2005) Post mortem MRI as an adjunct to fetal or neonatal autopsy. Lancet 365:1271–1273.Google Scholar
  45. Hall DMB (1989) Birth asphyxia and cerebral palsy. Br Med J 299:279–282.Google Scholar
  46. Hey EN, Lloyd DJ, Wigglesworth JS (1986) Classifying perinatal death: fetal and neonatal factors. Br J Obstet Gynaecol 93:1213–1223.PubMedGoogle Scholar
  47. Hirsch CS (1984) Talking to the family after an autopsy. Arch Pathol Lab Med 108:513–514.PubMedGoogle Scholar
  48. Imperiale TF, Petrulis AS (1991) A meta-analysis of low-dose aspirin for the prevention of pregnancy-induced hypertensive disease. JAMA 266:260–264.PubMedGoogle Scholar
  49. Incerpi MH, Miller DA, Samadi R, Settlage RH, Goodwin TM (1998) Stillbirth evaluation: what tests are needed. Am J Obstet Gynaecol 178:1121–1125.Google Scholar
  50. Italian Study of Aspirin in Pregnancy (1993) Low-dose aspirin in prevention and treatment of intrauterine growth retardation and pregnancy-induced hypertension. Lancet 341:396–400.Google Scholar
  51. Johns N, Al-Salti W, Cox P, Kilby MD (2004) A comparative study of prenatal ultrasound fi ndings and post mortem examination in a tertiary referral centre. Prenatal Diagnosis 24:339–346.PubMedGoogle Scholar
  52. Khare M, Nelson-Piercy C (2003) Acquired thrombo-philias and pregnancy. Best Pract Res Clin Obstet Gynaecol 17:491–507.PubMedGoogle Scholar
  53. Khong TY, Mansor FAW, Staples AJ (1995) Are perinatal autopsy rates satisfactory?. Med J Austr 162:469–470.Google Scholar
  54. Kumar P, Angst DB, Taxy J, Mangurten HH (2000) Neonatal autopsies: a 10-year experience. Arch Pediatr Adolesc Med 154:38–42.PubMedGoogle Scholar
  55. Landefeld CS, Chren MM, Myers A, Geller R, Robbins S, Goldman L (1988) Diagnostic yield of the autopsy in a university hospital and a community hospital. N Engl J Med 318:1249–1254.PubMedGoogle Scholar
  56. Larson JD, Rayburn WF, Crosby S, Thurnau GR (1995) Multiple nuchal cord entanglements and intra-partum complications. Am J Obstet Gynecol 173:1228–1231.PubMedGoogle Scholar
  57. Larson JD, Rayburn WF, Harlan VL (1997) Nuchal cord entanglements and gestational age. Am J Perinatol 14:555–557.PubMedGoogle Scholar
  58. Leitich H, Egarter C, Husslein P, Kaider A, Schemper M (1997) A meta-analysis of low dose aspirin for prevention of intrauterine growth retardation. Br J Obstet Gynaecol 104:450–459.PubMedGoogle Scholar
  59. Lundberg GD (1983) Medical students, truth and autopsies. JAMA 250:1199–1200.PubMedGoogle Scholar
  60. Lyon A (2004) Perinatal autopsy remains the gold standard. Arch Dis Child (Fetal Neonatal Ed) 89:F284.Google Scholar
  61. Maclennan A (1999) A template for defi ning a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. Br Med J 319:1054–1059.Google Scholar
  62. Maleckiene L Nadisauskiene R, Stankeviciene I, Cizaus-kas A, Bergstrom S (2000) A case reference study on fetal bacteraemia and late fetal death of unknown etiology in Lithuania. Acta Obstet Gynaecol Scand 79:1069–1074.Google Scholar
  63. Manchester DK, Pretorius DH, Avery C, et al. (1988) Accuracy of Ultrasound diagnoses in pregnancies complicated by suspected fetal anomalies. Prenatal Diagn 8:109–117.Google Scholar
  64. Maniscalco WVM, Clarke TA (1982) Factors infl uencing neonatal autopsy rate. Am J Dis Child 136:781–784.PubMedGoogle Scholar
  65. Manning FA (1999) Fetal biophysical profi le. Obstet Gynecol Clin North Am 26:557–577.PubMedGoogle Scholar
  66. Manning FA, Platt LD, Sipos L (1980) Antepartum fetal evaluation: development of a fetal biophysical profi le. Am J Obstet Gynecol 136:787–795.PubMedGoogle Scholar
  67. McHaffi e HE (2001) Crucial Decisions at the Beginning of Life. Radcliffe Medical Press. Abingdon.Google Scholar
  68. Mediera A, Norman A, Haslam J, Clayton-Smith J, Donnai D (1994) Examination of fetuses after induced abortion for fetal abnormality—a followup study. Prenatal Diagn 14;381–385.Google Scholar
  69. Meier PR, Manchester DK, Shikes RH, Clewell WH, Stewart M (1986) Perinatal autopsy: its clinical value. Obstet Gynecol 67:349–351.PubMedGoogle Scholar
  70. Moyo SR, Hagerstrand L, Nystrom SA, Tswana J, Blomberg S, Bergstrom J (1996) Stillbirths and intrauterine infection, histological chorioamnionitis and microbiological fi ndings. Int J Gynaecol Obstet 54:115–123.PubMedGoogle Scholar
  71. Nelson CT, Demmler GJ (1997) Cytomegalovirus infection in the pregnant mother, fetus, and newborn infant. Clin Perinatol 24:151–160.PubMedGoogle Scholar
  72. Nelson KB, Leviton A (1991) How much of neonatal encephalopathy is due to birth asphyxia. Am J Dis Child 145:1325–1331.PubMedGoogle Scholar
  73. Nelson-Piercy C (2002) Handbook of Obstetric Medicine, 2nd ed. Martin Dunitz. London.Google Scholar
  74. Out HJ, Kooijman CD, Bruinse HW, Derksen RH (1991) Histopathological fi ndings in placentae from patients with intra-uterine fetal death and antiphospholipid antibodies. Eur J Obstet Gynecol Reprod Biol 41:179– 186.PubMedGoogle Scholar
  75. Porter HJ, Keeling JW (1987) Value of perinatal necropsy examination. J Clin Pathol 40:180–184.PubMedGoogle Scholar
  76. Prutting J (1977) Autopsies—benefi ts for clinicians. Am J Clin Pathol 69:223–259.Google Scholar
  77. Rankin J, Wright C, Lind T (2002) Cross sectional survey of parent ' s experiences and view of the post mortem examination. Br Med J 324:816–818.Google Scholar
  78. Reynolds RC (1977) Autopsies—benefi ts to the family. Am J Clin Pathol 69:220–222.Google Scholar
  79. Rispler-Chaim V (1993) The ethics of postmortem examinations in contemporary Islam. J Med Ethics 19:164–168.PubMedGoogle Scholar
  80. Rowe J, Clyman R, Green C, Mikkelsen C, Haight J, Ataide L (1978) Follow-up of families who experience a perinatal death. Pediatrics 62:166–170.PubMedGoogle Scholar
  81. Royal College of Obstetricians Green Top Guideline (2003) Prevention of Early Onset Neonatal Group B Streptococcal Disease, No. 36. Royal College of Obstetricians and Gynaecologists, London.Google Scholar
  82. Royal College of Obstetricians and Gynaecologists (1998) A consideration of the law and ethics in relation to late termination of pregnancy for fetal abnormality. Royal College of Obstetricians and Gynaecologists, London, p. 19.Google Scholar
  83. Royal College of Obstetricians and Gynaecologists and Royal College of Pathologists (2001) Joint Working Party in Fetal and Perinatal Pathology. RCOG Press, London.Google Scholar
  84. Saller DN, Lesser KB, Harrel U, Rodgers BB, Oyer CE (1995) The clinical utility of the perinatal autopsy. JAMA 273:663–665.PubMedGoogle Scholar
  85. Schaffer L, Burkhardt T, Zimmermann R, Kurmanavi-cius J (2005) Nuchal cords in term and postterm deliveries—do we need to know?. Obstet Gynecol 106:23–28.PubMedGoogle Scholar
  86. Scottish Perinatal and Infant Mortality Report (2001) Information and Statistics Division NHS Scotland, 2000. ISD Scotland Publications, Edinburgh.Google Scholar
  87. Scottish Programme for Clinical Effectiveness in Reproductive Health (2002) Newsletter, Issue 11.Google Scholar
  88. Sepulveda W, Shennan AH, Bower S, Nicolaidis P, Fisk NM (1995) true knot of the umbilical cord: a diffi cult prenatal ultrasonographic diagnosis. Ultrasound Obstet Gynecol 5:106–108.PubMedGoogle Scholar
  89. Shen-Schwartz S, Nelsh C, Hill LM (1989) Antenatal ultrasound for fetal anomalies: importance of perinatal autopsy. Pediatr Pathol 9:1–9.Google Scholar
  90. Shulman LP, Ling FW, Meyers CM, Shanklin DR, Simpson JL, Elias S (1990) Dilatation and evacuation for second trimester genetic pregnancy termination. Obstet Gynecol 75:1037–1040.PubMedGoogle Scholar
  91. Soothill PW, Rodeck CH (1994) First trimester fetal necropsy after ultrasound guided aspiration. Lancet 343;1096–1097.PubMedGoogle Scholar
  92. Stolman CJ, Castello F, Yorio M, Mautone S (1994) Attitudes of paediatricians and paediatric residents toward obtaining permission for autopsy. Arch Pae-diatr Adolesc Med 148:843–847.Google Scholar
  93. Stock SJE, Keeling JW (2006) Changing rates of postmortem examination following stillbirth. Ped Devel Pathol 9:409(A).Google Scholar
  94. Tolockiene E, Morsing E, Holst E, Herbst A, Ljungh A, Svenningsen N (2001) Intrauterine infection may be a major cause of stillbirth in Sweden. Acta Obstet Gynaecol Scand 80:511–518.Google Scholar
  95. Turner J, Raphael B (1997) Requesting necropsies. Br Med J 314:1499–1495.Google Scholar
  96. Valdes-Dapena M (1984) The postautopsy conference with families. Arch Pathol Lab Med 108:497–498.PubMedGoogle Scholar
  97. Van Marter LJ, Taylor F, Epstein ME (1987) Parental and physician-related determinants of consent for neonatal autopsy. Am J Dis Child 141:149–153.Google Scholar
  98. Vyas S, Nicolaides KH, Bower S, Campbell S (1990) Middle cerebral artery fl ow velocity waveforms in fetal hypoxaemia. Br J Obstet Gynaecol 97:797– 803.PubMedGoogle Scholar
  99. Weiner CP (1990) The relationship between the umbilical artery systolic/diastolic ratio and umbilical blood gas measurements in specimens obtained by cordo-centesis. Am J Obstet Gynecol 162:1198–1202.PubMedGoogle Scholar
  100. Weston MJ, Porter HJ, Andrews HS, Berry PJ (1993) Correlation of antenatal ultrasonography and pathological examinations in 153 malformed fetuses. J Clin Ultrasound 21:387–392.PubMedGoogle Scholar
  101. Anon (2003) What is a good death?. Br Med J 327:185– 238.Google Scholar
  102. Whitby EH, Paley MNJ, Sprigg A (2004) outcome of 100 singleton pregnancies with suspected brain abnormalities diagnosed on ultrasound and investigated by in utero MRI imaging. Br J Obstet Gynaecol 111:784–792.Google Scholar
  103. Wigglesworth JS (1980) Monitoring perinatal mortality. A pathophysiological approach. Lancet 2:684–686.Google Scholar
  104. Williams MJ, Perry TM (1977) The autopsy, a beginning, not an end. Am J Clin Pathol 69:215–216.Google Scholar
  105. Woodward PJ, Sohaey R, Jackson DP, Klatt EC, Alexander AL, Kennedy A (1997) Post mortem MR imaging: comparison with fi ndings at autopsy. AJR 168:41–46.PubMedGoogle Scholar
  106. Wright C, Cameron H, Lamb W. (1998) A study of the quality of perinatal autopsy in the former Northern Region. Br J Obstet Gynaecol 105:24–28.PubMedGoogle Scholar
  107. Wright C, Lee REJ (2004) Investigating fetal death: a review of the options when autopsy consent is refused. Arch Dis Child (Fetal Neonatal Ed) 89: F285.Google Scholar
  108. Yudkin P, Johnson A, Clover LM, et al. (1995) Assessing the contribution of birth asphyxia to cerebral palsy in term singletons. Paediatr Perinatal Epidemiol 9:156–170.Google Scholar
  109. Yudkin PL, Wood L, Redman CW (1987) Risk of unexplained stillbirth at different gestational ages. Lancet 1:1192–1194.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2007

Authors and Affiliations

  • E. Sarah Cooper
    • 1
  • Ian A. Laing
    • 2
  1. 1.Department of Obstetrics and GynaecologyRoyal Infi rmary of EdinburghEdinburghUK
  2. 2.Neonatal UnitSimpson Centre for Reproductive Health, Royal Infi rmaryEdinburghUK

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