Value of the Perinatal Autopsy: Critique

Abstract

In consenting to a perinatal autopsy, the primary motive of parents may be to find the exact cause of death. A critical review on the value of perinatal autopsies was performed to see whether parents could be counseled regarding their main motive. A literature search was performed in MEDLINE, EXCERPTA MEDICA, and the Cochrane library. We evaluated the value of the autopsy by comparing the clinical and autopsy diagnoses in stillbirths, neonatal deaths, and therapeutic terminations. Clinicopathologic concordance was divided into four categories: (1) change in diagnosis, (2) additional findings, (3) complete confirmation, and (4) inconclusive. We sought information on factors that may influence the value of perinatal autopsies: the type and definitions of perinatal loss; autopsy rate; level of hospital; expertise of pathologists; autopsy protocol used; whether patients were inborn or referred; and antenatal diagnosis. From the 27 articles that met our review criteria, the autopsy revealed a change in diagnosis or additional findings in 22% to 76% of cases. If confirmation of clinical findings is included, then the value of the perinatal autopsy was as high as up to 100%. Factors that could influence this rate were reported variably by investigators. When centers report their experience of the value of the perinatal autopsy, information on the factors that may influence their reports should be provided as well. Clinicians can confidently advise parents of the usefulness of the perinatal autopsy in ascertaining the cause of death or for counseling their future pregnancies.

Evaluation of 1025 fetal deaths: proposed diagnostic workup

“…7 In accordance with others, [15][16][17] we cannot overemphasize the value of autopsy. Earlier studies also provided evidence that after IUFD routine macroscopic and histological examination of the placenta is a necessary complement to autopsy confirming clinical and/or autopsy findings.…”

Canada’s pregnancy-related mortality rates: doing well but room for improvement

“…Autopsy findings may change the clinical diagnosis of the cause of death, as well as yield new information, in up to 75% of stillbirth cases [52]. The development of an accurate classification system for still-births, based on the cause of death and other information, is crucial for the reduction of perinatal mortality.…”

Minimally invasive fetal postmortem examination using magnetic resonance imaging and computerised tomography: current evidence and practical issues

“…Perinatal autopsy findings are reported to broadly agree with the prenatal clinical diagnosis in 30 to 90% of the cases, depending on the population studied, but change the final diagnosis in 10 to 40%, with additional findings that do not change the clinical diagnosis reported in up to an additional 25% of postmortem examinations. Overall, therefore, in around 30% of the perinatal postmortem examinations, some additional information is obtained from autopsy which changes either the underlying diagnosis or information given to parents during counselling (Gordijn et al, 2002;Amini et al, 2006;Sankar and Phadke, 2006;Akgun et al, 2007;Gordijn et al, 2007). The likelihood of gaining such information is also related to the specialist status of the pathologist, with significantly more findings reported when the autopsy is performed by paediatric specialist, compared to general, histopathologists, and other factors such as the length of time between death and autopsy (Vujanic et al, 1998;Gordijn et al, 2002).…”

“…Nevertheless, discrepancy between prenatal USS and postmortem findings still occurs in a significant minority of cases, particularly in relation to specific neurological and cardiac abnormalities, such as ventriculomegaly or posterior fossa defects, and cardiac specific malformations (Gordijn et al, 2002).…”

“…While there are several reasons for this decline in autopsy rates, one major factor is likely to be lack of parental agreement to the procedure based on concerns, primarily regarding disfigurement of the body and organ retention (DoH 2000;Gordijn et al, 2002). In addition, clinicians may not appreciate the continued potential beneficial information which autopsy can provide, may not like discussing postmortem examination, and may be less likely to discuss autopsy if they feel that this could cause parental distress (Epstein, 2008).…”