Neonatal death after hypoxic ischaemic encephalopathy: does a postmortem add to the final diagnoses?

Abstract

a Background Case review after fatal perinatal asphyxia may have medicolegal implications. Accurate diagnosis of cause of death is therefore essential. Objective To determine consent rate and utility of autopsy after fatal grade III hypoxic ischaemic encephalopathy (HIE) presumed to be secondary to birth asphyxia. Design A retrospective clinical review from January 1995 to December 2002.Setting Regional tertiary referral neonatal unit, Wellington, New Zealand.Population Inclusion criteria were gestation 37 weeks, resuscitation after delivery and clinical course of grade III HIE. Exclusions were a recognised major lethal malformation. Methods Review of clinical records including the autopsy report.Main outcome measures Consent for autopsy, change in diagnosis after autopsy.Results Twenty-three infants died during the time period with a major diagnosis of grade III HIE. Three did not meet inclusion criteria. Of the remaining 20, 11 were female. Median gestation at birth was 40 weeks (range 38 -42 weeks) and median birth weight was 3568 g (range 2140-4475 g). In 8/17 of the infants for whom length and head measurements were available, the Ponderal Index suggested intrauterine growth retardation. The 16/20 infants had an autopsy. Four of these were Coroner's cases giving an autopsy rate of 80% with a rate by consent of 60%. In 10 (62.5%) infants, significant new information was added to the clinical diagnoses. Conclusions Neonatal HIE is a symptom rather than a final clinical diagnosis. A full autopsy is required to fully explore the reasons for fatal neonatal HIE and may provide information that is important medicolegally.

Neuronal cell death in neonatal hypoxia‐ischemia

“…165 Magnetic resonance spectroscopy studies of infants at 24 hours of life after perinatal asphyxia reveals abnormalities of neuronal integrity in basal ganglia. 166 Most available postmortem studies of human HIE have focused on “pontosubicular necrosis.” 167 In asphyxic term humans on day 1, neuronal necrosis in striatum is suggested.…”

“…152,164 Neurodegeneration in Newborn Human HIE Assessment of the cellular and molecular pathology seen in newborn human HIE is needed to identify the standard against which experimental observations in animal models should be compared; however, few detailed neuropathological and molecular mechanism-based studies of cell death have been done on pediatric human HIE autopsy brains. 165 Magnetic resonance spectroscopy studies of infants at 24 hours of life after perinatal asphyxia reveals abnormalities of neuronal integrity in basal ganglia. 166 Most available postmortem studies of human HIE have focused on ''pontosubicular necrosis.''…”

A Controversial Medicolegal Issue: Timing the Onset of Perinatal Hypoxic-Ischemic Brain Injury

“…Medicolegal evaluation is certainly much more oriented when dealing with a fatal case so that a judicial autopsy has been disposed. In literature, it is largely represented how full postmortem examination, including a complete autopsy, may provide elements of paramount importance from a quantitative as long as a qualitative point of view [ 27 , 28 ]. Nevertheless, autopsy alone cannot provide all the solutions to the correct decision.…”

Less invasive autopsy: an evidenced based approach

“…Despite this reduction, class I errors continue to be reported in up to 12% and class II errors (ie, major findings, even if known before death, that would not have changed clinical management because the treatment was not available or was being already given) in up to 29% of neonatal and paediatric autopsies, even in recent studies 2 3. One study recorded unexpected iatrogenic injuries at autopsy in 41% of extremely premature babies; in 14% this was the direct cause of death 4.…”