Advertisement

The Perinatal Postmortem from a Clinician’s Viewpoint

  • Alexander HeazellEmail author
  • Alan Fenton

Abstract

The perinatal postmortem examination is one investigation offered to parents after they experience the death of their child. From both the parents’ and clinicians’ perspective, the postmortem examination aims to determine what was or was not the cause of death and to identify any relevant associated factors. For parents, appropriate explanation of these findings can facilitate the process of grieving and aid in planning future pregnancies. For professionals, in addition to information for the parents, these data can provide population-level information about why babies die, which are key components of audit and ensuring safety of care. Despite these benefits the rate of perinatal postmortem examination is decreasing in many settings. We review the evidence for perinatal postmortem (and associated) examination in cases of stillbirth and neonatal deaths. We consider the consent process and feedback of information to parents and how this affects whether parents give consent for a postmortem examination. Finally, we consider what the likely developments in perinatal postmortem examination may be and how these will affect clinicians and parents.

Keywords

Stillbirth Perinatal death Neonatal death Classification systems Consent process Autopsy Necropsy Placenta Genetic examination 

References

  1. 1.
    Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011;377:1319–30.CrossRefGoogle Scholar
  2. 2.
    UNICEF, World Health Organization, The World Bank, United Nations. Levels and trends in child mortality report: 2013. New York: UNICEF; 2013.Google Scholar
  3. 3.
    Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: the way forward in high-income countries. Lancet. 2011;377:1703–17.CrossRefGoogle Scholar
  4. 4.
    Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384:347–70.CrossRefGoogle Scholar
  5. 5.
    Alderliesten ME, Stronks K, Bonsel GJ, Smit BJ, van Campen MM, van Lith JM, et al. Design and evaluation of a regional perinatal audit. Eur J Obstet Gynecol Reprod Biol. 2008;137:141–5.CrossRefGoogle Scholar
  6. 6.
    Dahl LB, Berge LN, Dramsdahl H, Vermeer A, Huurnink A, Kaaresen PI, et al. Antenatal, neonatal and post neonatal deaths evaluated by medical audit. A population-based study in northern Norway – 1976 to 1997. Acta Obstet Gynecol Scand. 2000;79:1075–82.PubMedGoogle Scholar
  7. 7.
    Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin SK, et al. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynaecol Obstet. 2009;107:S113–21, S121–112.CrossRefGoogle Scholar
  8. 8.
    Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce A. Stages of change: a qualitative study on the implementation of a perinatal audit programme in South Africa. BMC Health Serv Res. 2011;11:243.CrossRefGoogle Scholar
  9. 9.
    Pattinson RC, Bergh AM. Implementing recommendations arising from confidential enquiries into maternal deaths. Best Pract Res. 2008;22:477–87.CrossRefGoogle Scholar
  10. 10.
    Royal College of Obstetricians and Gynaecologists. Green-top guideline 55 – late intrauterine fetal death and stillbirth. London: Royal College of Obstetricians and Gynaecologists; 2010.Google Scholar
  11. 11.
    American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 102: management of stillbirth. Obstet Gynecol. 2009;113:748–61.CrossRefGoogle Scholar
  12. 12.
    Flenady V, King J, Charles A, Gardener G, Ellwood D, Day K, et al. PSANZ clinical practice guideline for perinatal mortality. Version 2.22009.Google Scholar
  13. 13.
    Heinonen S, Kirkinen P. Pregnancy outcome after previous stillbirth resulting from causes other than maternal conditions and fetal abnormalities. Birth. 2000;27:33–7.CrossRefGoogle Scholar
  14. 14.
    Reddy UM. Prediction and prevention of recurrent stillbirth. Obstet Gynecol. 2007;110:1151–64.CrossRefGoogle Scholar
  15. 15.
    Rankin J, Wright C, Lind T. Cross sectional survey of parents’ experience and views of the postmortem examination. BMJ. 2002;324:816–8.CrossRefGoogle Scholar
  16. 16.
    Heazell A, McLaughlin MJ, Schmidt E, Cox P, Flenady V, Khong T, et al. A difficult conversation? The views and experiences of parents and professionals on the consent process for perinatal postmortem after stillbirth. BJOG. 2012;119:987–97.CrossRefGoogle Scholar
  17. 17.
    Stock SJ, Goldsmith L, Evans MJ, Laing IA. Interventions to improve rates of post-mortem examination after stillbirth. Eur J Obstet Gynecol Reprod Biol. 2010;153:148–50.CrossRefGoogle Scholar
  18. 18.
    Ptacek I, Sebire NJ, Man JA, Brownbill P, Heazell AE. Systematic review of placental pathology reported in association with stillbirth. Placenta. 2014;35:552–62.CrossRefGoogle Scholar
  19. 19.
    Faye-Petersen OM, Guinn DA, Wenstrom KD. Value of perinatal autopsy. Obstet Gynecol. 1999;94:915–20.PubMedGoogle Scholar
  20. 20.
    Kock KF, Vestergaard V, Hardt-Madsen M, Garne E. Declining autopsy rates in stillbirths and infant deaths: results from Funen County, Denmark, 1986–96. J Matern Fetal Neonatal Med. 2003;13:403–7.PubMedGoogle Scholar
  21. 21.
    Cartlidge PH, Dawson AT, Stewart JH, Vujanic GM. Value and quality of perinatal and infant postmortem examinations: cohort analysis of 400 consecutive deaths. BMJ. 1995;310:155–8.CrossRefGoogle Scholar
  22. 22.
    Cernach MC, Patricio FR, Galera MF, Moron AF, Brunoni D. Evaluation of a protocol for postmortem examination of stillbirths and neonatal deaths with congenital anomalies. Pediatr Dev Pathol. 2004;7:335–41.CrossRefGoogle Scholar
  23. 23.
    Saller Jr DN, Lesser KB, Harrel U, Rogers BB, Oyer CE. The clinical utility of the perinatal autopsy. JAMA. 1995;273:663–5.CrossRefGoogle Scholar
  24. 24.
    Gordijn SJ, Erwich JJ, Khong TY. Value of the perinatal autopsy: critique. Pediatr Dev Pathol. 2002;5:480–8.CrossRefGoogle Scholar
  25. 25.
    Rodriguez MM, Chaves F, Romaguera RL, Ferrer PL, de la Guardia C, Bruce JH. Value of autopsy in nonimmune hydrops fetalis: series of 51 stillborn fetuses. Pediatr Dev Pathol. 2002;5:365–74.CrossRefGoogle Scholar
  26. 26.
    Alderliesten ME, Peringa J, van der Hulst VP, Blaauwgeers HL, van Lith JM. Perinatal mortality: clinical value of postmortem magnetic resonance imaging compared with autopsy in routine obstetric practice. BJOG. 2003;110:378–82.CrossRefGoogle Scholar
  27. 27.
    Peres LC. Review of pediatric autopsies performed at a university hospital in Ribeirao Preto, Brazil. Arch Pathol Lab Med. 2006;130:62–8.PubMedGoogle Scholar
  28. 28.
    Hefler LA, Hersh DR, Moore PJ, Gregg AR. Clinical value of postnatal autopsy and genetics consultation in fetal death. Am J Med Genet. 2001;104:165–8.CrossRefGoogle Scholar
  29. 29.
    Hickey L, Murphy A, Devaney D, Gillan J, Clarke T. The value of neonatal autopsy. Neonatology. 2012;101:68–73.CrossRefGoogle Scholar
  30. 30.
    Elder DE, Zuccollo JM. Autopsy after death due to extreme prematurity. Arch Dis Child Fetal Neonatal Ed. 2005;90:F270–2.CrossRefGoogle Scholar
  31. 31.
    Becher JC, Bell JE, Keeling JW, McIntosh N, Wyatt B. The Scottish perinatal neuropathology study: clinicopathological correlation in early neonatal deaths. Arch Dis Child Fetal Neonatal Ed. 2004;89:F399–407.CrossRefGoogle Scholar
  32. 32.
    Elder DE, Zuccollo JM, Stanley TV. Neonatal death after hypoxic ischaemic encephalopathy: does a postmortem add to the final diagnoses? BJOG. 2005;112:935–40.CrossRefGoogle Scholar
  33. 33.
    Boyd PA, Tondi F, Hicks NR, Chamberlain PF. Autopsy after termination of pregnancy for fetal anomaly: retrospective cohort study. BMJ. 2014;328:137.CrossRefGoogle Scholar
  34. 34.
    Rodriguez MA, Prats P, Rodriguez I, Cusi V, Comas C. Concordance between prenatal ultrasound and autopsy findings in a tertiary center. Prenat Diagn. 2014;34:784–9.CrossRefGoogle Scholar
  35. 35.
    Johns N, Al-Salti W, Cox P, Kilby MD. A comparative study of prenatal ultrasound findings and post-mortem examination in a tertiary referral centre. Prenat Diagn. 2004;24:339–46.CrossRefGoogle Scholar
  36. 36.
    Kumari N, Pradhan M, Shankar VH, Krishnani N, Phadke SR. Post-mortem examination of prenatally diagnosed fatal renal malformation. J Perinatol. 2008;28:736–42.CrossRefGoogle Scholar
  37. 37.
    Hayati AR, Khong TY, Zainul R. The usefulness of limited placental sampling in stillbirths. Malays J Pathol. 1998;20:99–102.PubMedGoogle Scholar
  38. 38.
    Horn LC, Langner A, Stiehl P, Wittekind C, Faber R. Identification of the causes of intrauterine death during 310 consecutive autopsies. Eur J Obstet Gynecol Reprod Biol. 2004;113:134–8.CrossRefGoogle Scholar
  39. 39.
    Heazell AE, Martindale EA. Can post-mortem examination of the placenta help determine the cause of stillbirth? J Obstet Gynaecol. 2009;29:225–8.CrossRefGoogle Scholar
  40. 40.
    Rayburn W, Sander C, Barr Jr M, Rygiel R. The stillborn fetus: placental histologic examination in determining a cause. Obstet Gynecol. 1985;65:637–41.PubMedGoogle Scholar
  41. 41.
    Tellefsen CH, Vogt C. How important is placental examination in cases of perinatal deaths? Pediatr Dev Pathol. 2011;14:99–104.CrossRefGoogle Scholar
  42. 42.
    Ogunyemi D, Jackson U, Buyske S, Risk A. Clinical and pathologic correlates of stillbirths in a single institution. Acta Obstet Gynecol Scand. 1998;77:722–8.CrossRefGoogle Scholar
  43. 43.
    Incerpi MH, Miller DA, Samadi R, Settlage RH, Goodwin TM. Stillbirth evaluation: what tests are needed? Am J Obstet Gynecol. 1998;178:1121–5.CrossRefGoogle Scholar
  44. 44.
    VanderWielen B, Zaleski C, Cold C, McPherson E. Wisconsin stillbirth services program: a multifocal approach to stillbirth analysis. Am J Med Genet. 2011;155A:1073–80.CrossRefGoogle Scholar
  45. 45.
    Bonetti LR, Ferrari P, Trani N, Maccio L, Laura S, Giuliana S, et al. The role of fetal autopsy and placental examination in the causes of fetal death: a retrospective study of 132 cases of stillbirths. Arch Gynecol Obstet. 2011;283:231–41.CrossRefGoogle Scholar
  46. 46.
    Heazell AEP, Byrd LM, Cockerill R, Whitworth MK. Investigations following stillbirth – which tests are most valuable? Arch Dis Child Fetal Neonatal Ed. 2011;96:Fa135.CrossRefGoogle Scholar
  47. 47.
    Vergani P, Cozzolino S, Pozzi E, Cuttin MS, Greco M, Ornaghi S, et al. Identifying the causes of stillbirth: a comparison of four classification systems. Am J Obstet Gynaecol. 2008;199:319.e311–4.Google Scholar
  48. 48.
    Flenady V, Froen JF, Pinar H, Torabi R, Saastad E, Guyon G, et al. An evaluation of classification systems for stillbirth. BMC Pregnancy Childbirth. 2009;9:24.CrossRefGoogle Scholar
  49. 49.
    Michalski ST, Porter J, Pauli RM. Costs and consequences of comprehensive stillbirth assessment. Am J Obstet Gynecol. 2002;186:1027–34.CrossRefGoogle Scholar
  50. 50.
    Gold KJ, Sen A, Xu X. Hospital costs associated with stillbirth delivery. Matern Child Health J. 2013;17:1835–41.CrossRefGoogle Scholar
  51. 51.
    Mistry H, Heazell AE, Vincent O, Roberts T. A structured review and exploration of the healthcare costs associated with stillbirth and a subsequent pregnancy in England and Wales. BMC Pregnancy Childbirth. 2013;13:236.CrossRefGoogle Scholar
  52. 52.
    Royal College of Obstetricians and Gynaecologists, Royal College of Pathologists. Joint working party report on fetal and perinatal pathology. London; 1988.Google Scholar
  53. 53.
    Royal College of Obstetricians and Gynaecologists, Royal College of Pathologists. Fetal and perinatal pathology: report of a joint working party. London; 2001.Google Scholar
  54. 54.
    Khong TY. A review of perinatal autopsy rates worldwide, 1960s to 1990s. Paediatr Perinat Epidemiol. 1996;10:97–105; discussion 106–9.CrossRefGoogle Scholar
  55. 55.
    Omoniyi-Esan GO, Omonisi AE, Bakare B, Kuti O, Adejuyigbe E. Perinatal autopsies in a tertiary health facility in southwestern Nigeria: a retrospective evaluation of 14 consecutive cases. Niger J Med. 2014;23:153–6.PubMedGoogle Scholar
  56. 56.
    Confidential enquiry into maternal and child health. Perinatal mortality 2008: England, Wales and northern Ireland. London: Centre for Enquiries into Maternal and Child Health; 2010.Google Scholar
  57. 57.
    Bishop KL, Dupuis C, Nanton P, Clarke K, Bolt C, Chin-See C. Perinatal autopsy rates at the university hospital of the West Indies: 2002–2008. West Indian Med J. 2013;62:35–8.PubMedGoogle Scholar
  58. 58.
    Swinton CH, Weiner J, Okah FA. The neonatal autopsy: can it be revived? Am J Perinatol. 2013;30:739–44.CrossRefGoogle Scholar
  59. 59.
    Confidential enquiry into maternal and child health. Perinatal mortality 2009: England, Wales and northern Ireland. London: Centre for Enquiries into Maternal and Child Health; 2011.Google Scholar
  60. 60.
    Holste C, Pilo C, Pettersson K, Radestad I, Papadogiannakis N. Mothers’ attitudes towards perinatal autopsy after stillbirth. Acta Obstet Gynecol Scand. 2011;90:1287–90.CrossRefGoogle Scholar
  61. 61.
    Breeze AC, Statham H, Hackett GA, Jessop FA, Lees CC. Perinatal postmortems: what is important to parents and how do they decide? Birth. 2012;39:57–64.CrossRefGoogle Scholar
  62. 62.
    Meaney S, Gallagher S, Lutomski JE, O’Donoghue K. Parental decision making around perinatal autopsy: a qualitative investigation. Health Expect. 2014. DOI:  10.1111/hex.12305CrossRefGoogle Scholar
  63. 63.
    Downe S, Kingdon C, Kennedy R, Norwell H, McLaughlin MJ, Heazell AE. Post-mortem examination after stillbirth: views of uk-based practitioners. Eur J Obstet Gynecol Reprod Biol. 2012;162:33–7.CrossRefGoogle Scholar
  64. 64.
    Horey D, Flenady V, Heazell AE, Khong TY. Interventions for supporting parents’ decisions about autopsy after stillbirth. Cochrane Database Syst Rev (Online). 2013;(2):CD009932.Google Scholar
  65. 65.
    Downe S, Schmidt E, Kingdon C, Heazell AE. Bereaved parents’ experience of stillbirth in uk hospitals: a qualitative interview study. BMJ Open. 2013;3:e002237.CrossRefGoogle Scholar
  66. 66.
    Rose C, Evans M, Tooley J. Falling rates of perinatal postmortem examination: are we to blame? Arch Dis Child Fetal Neonatal Ed. 2006;91:F465.CrossRefGoogle Scholar
  67. 67.
    Henley A, Schott J. The sands audit tool for maternity services – caring for parents whose baby has died. London: Sands – Stillbirth and Neonatal Death Charity; 2011.Google Scholar
  68. 68.
    Sebire NJ, Weber MA, Thayyil S, Mushtaq I, Taylor A, Chitty LS. Minimally invasive perinatal autopsies using magnetic resonance imaging and endoscopic postmortem examination (“keyhole autopsy”): feasibility and initial experience. J Matern Fetal Neonatal Med. 2012;25:513–8.CrossRefGoogle Scholar
  69. 69.
    Cohen MC, Paley MN, Griffiths PD, Whitby EH. Less invasive autopsy: benefits and limitations of the use of magnetic resonance imaging in the perinatal postmortem. Pediatr Dev Pathol. 2008;11:1–9.CrossRefGoogle Scholar
  70. 70.
    Taylor AM, Sebire NJ, Ashworth MT, Schievano S, Scott RJ, Wade A, et al. Postmortem cardiovascular magnetic resonance imaging in fetuses and children: a masked comparison study with conventional autopsy. Circulation. 2014;129:1937–44.CrossRefGoogle Scholar
  71. 71.
    Thayyil S, Sebire NJ, Chitty LS, Wade A, Chong W, Olsen O, et al. Post-mortem mri versus conventional autopsy in fetuses and children: a prospective validation study. Lancet. 2013;382:223–33.CrossRefGoogle Scholar
  72. 72.
    Ben-Sasi K, Chitty LS, Franck LS, Thayyil S, Judge-Kronis L, Taylor AM, et al. Acceptability of a minimally invasive perinatal/paediatric autopsy: healthcare professionals’ views and implications for practice. Prenat Diagn. 2013;33:307–12.PubMedGoogle Scholar
  73. 73.
    Reddy UM, Page GP, Saade GR, Silver RM, Thorsten VR, Parker CB, et al. Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med. 2012;367:2185–93.CrossRefGoogle Scholar
  74. 74.
    Harris RA, Ferrari F, Ben-Shachar S, Wang X, Saade G, Van Den Veyver I, et al. Genome-wide array-based copy number profiling in human placentas from unexplained stillbirths. Prenat Diagn. 2011;31:932–44.CrossRefGoogle Scholar
  75. 75.
    Crotti L, Tester DJ, White WM, Bartos DC, Insolia R, Besana A, et al. Long qt syndrome-associated mutations in intrauterine fetal death. JAMA. 2013;309:1473–82.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing 2015

Authors and Affiliations

  1. 1.Maternal and Fetal Health Research CentreInstitute of Human Development, University of ManchesterManchesterUK
  2. 2.St. Mary’s Hospital, Central Manchester University Hospitals NHS Foundation TrustManchesterUK
  3. 3.Newcastle Neonatal ServiceRoyal Victoria InfirmaryNewcastle upon TyneUK

Personalised recommendations