Jc Hutchinson

Stillbirth and intrauterine fetal death: factors affecting determination of cause of death at autopsy

There have been several attempts to classify cause of death (CoD) in stillbirth; however, all such systems are subjective, allowing for observer bias and making comparisons between systems challenging. This study aimed to examine factors relating to determination of CoD using a large dataset from two specialist centers in which observer bias had been reduced by classifying findings objectively and assigning CoD based on predetermined criteria.

Stillbirth and intrauterine fetal death: role of routine histopathological placental findings to determine cause of death

Placental abnormalities are a common cause of death in stillbirth, ranking second only to unexplained deaths, though there is wide variation in the proportion attributed to placental disease. In clinical practice, interpretation of the significance of placental findings is difficult, since many placental features in stillbirths overlap with those in live births. Our aim was to examine objectively classified placental findings from a series of > 1000 autopsies following intrauterine death in order to evaluate the role of placental histological examination in determining the cause of death.

Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal growth restriction at autopsy

According to the classification system used, 15–60% of stillbirths remain unexplained, despite undergoing recommended autopsy examination, with variable attribution of fetal growth restriction (FGR) as a cause of death. Distinguishing small‐for‐gestational age (SGA) from pathological FGR is a challenge at postmortem examination. This study uses data from a large, well‐characterized series of intrauterine death autopsies to investigate the effects of secondary changes such as fetal maceration, intrauterine retention and postmortem interval on body weight.

Postmortem research: innovations and future directions for the perinatal and paediatric autopsy

Postmortem examination remains an important investigation in perinatal, infant and child deaths, with additional findings provided in 30–40%.1 Though additional investigations, including genetic testing, are now available, until recently the autopsy procedure had evolved little over centuries. However, the combination of advances in imaging technology, development of less-invasive sampling techniques and expansion of ‘omic’ approaches for fluid and tissue samples, together with reduction in parental acceptance of traditional autopsy are likely to change the way paediatric deaths are investigated.2 It is important that clinicians are aware of changes to postmortem practice, since requests for minimally invasive approaches from bereaved parents and religious communities are likely to become increasingly common. The aim is to appropriately consent for the investigation after death that will best answer the clinical question while being acceptable to parents. This article summarises current and future areas of paediatric autopsy research, including postmortem imaging, molecular biology and discovery-based laboratory approaches such as proteomics and transcriptomics. Current trends in autopsy research focus on improving acceptability of the postmortem examination, empowering parents who do not accept traditional autopsy for various reasons. Postmortem MRI (PMMRI) shows the greatest promise, as part of a minimally invasive approach; PMMRI with placental examination and other adjunctive investigations (without incisions) …

Stillbirth and intrauterine fetal death: role of routine histological organ sampling to determine cause of death

Guidelines for the investigation of intrauterine death and sudden unexpected death in infancy (SUDI) recommend, based on expert opinion, autopsy procedures and tissue sampling strategies for histological analysis. Although stillbirth is much more common than SUDI, there have been no large‐scale studies published which evaluate the usefulness of histological evaluation of specific organs in stillbirth for determining cause of death. Our aim was to evaluate the use of macroscopic and microscopic assessment of internal organs to determine cause of intrauterine death.

Current issues in postmortem imaging of perinatal and forensic childhood deaths

Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected non-accidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.

Organ weights and ratios for postmortem identification of fetal growth restriction: utility and confounding factors

The postmortem fetal brain:liver weight ratio is commonly used as a marker of nutrition for diagnosis of fetal growth restriction (FGR). However, there are limited data regarding the effects of intrauterine retention, fetal maceration and postmortem interval on organ weights and their ratios at autopsy. Our aims were to examine the relationships between gestational‐age‐adjusted and sex‐adjusted fetal organ weights at autopsy, cause of intrauterine death and effects of intrauterine retention, and to determine whether the brain:liver weight ratio is a reliable marker of FGR in intrauterine death.

Stillbirth and intrauterine fetal death: contemporary demographic features of >1000 cases from an urban population

Of 780 000 births annually in the UK, around 3300 are stillborn, a rate of approximately 4 per 1000 births. Traditional epidemiological associations are based on historic data. The aim of this study was to document contemporary demographic findings in a large series of > 1000 deaths in utero in London and compare these with national datasets.

Novel usage of microfocus computed tomography (micro‐CT) for visualisation of human embryonic development—Implications for future non‐invasive post‐mortem investigation

Whats already known about this topic? Accurate pathological assessment of small gestational age fetuses is challenging. Dating an embryo/fetus is essential to recognise expected human developmental stages and prevent misdiagnosis. What does this study add? Micro‐CT offers a non‐destructive, digital method for dating human embryos. The micro‐CT imaging here is of the earliest gestation human embryo published to date with corresponding pathology. It can provide an alternative to autopsy even at early stages of development.

“We might get a lot more families who will agree”: Muslim and Jewish perspectives on less invasive perinatal and paediatric autopsy

Background Perinatal and paediatric autopsy rates are at historically low levels with declining uptake due to dislike of the invasiveness of the procedure, and religious objections particularly amongst Muslim and Jewish parents. Less invasive methods of autopsy including imaging with and without tissue sampling have been shown to be feasible alternatives. We sought to investigate attitudes including religious permissibility and potential uptake amongst members of the Muslim and Jewish communities in the United Kingdom. Methods Semi-structured interviews with religious and faith-based authorities (n = 16) and bereaved parents from the Jewish community (n = 3) as well as 10 focus groups with community members (60 Muslim participants and 16 Jewish participants) were conducted. Data were analysed using thematic analysis to identify key themes. Findings Muslim and Jewish religious and faith-based authorities agreed that non-invasive autopsy with imaging was religiously permissible because it did not require incisions or interference with the body. A minimally invasive approach was less acceptable as it still required incisions to the body, although in those circumstances where it was required by law it was more acceptable than a full autopsy. During focus group discussions with community members, the majority of participants indicated they would potentially consent to a non-invasive autopsy if the body could be returned for burial within 24 hours, or if a family had experienced multiple fetal/pregnancy losses and the information gained might be useful in future pregnancies. Minimally invasive autopsy was less acceptable but around half of participants might consent if a non-invasive autopsy was not suitable, with the exception of the Jewish Haredi community who unanimously stated they would decline this alternative. Conclusions Our research suggests less invasive autopsy offers a viable alternative to many Muslim and Jewish parents in the UK who currently decline a full autopsy. The findings may be of importance to other countries with significant Muslim and/or Jewish communities as well as to other religious communities where concerns around autopsy exist. Awareness-raising amongst religious leaders and community members will be important if these methods become routinely available.