Int. Med J Vol. 6 No 2 December 2007

A study of autopsy findings on stillbirths in Shahid Motahary hospital of Urmia- Iran (10 months)

M. Taghizadieh, M.D. ¹, F. Noroozinia, M.D. ² R. Didevar, M.D.³_, F. Ghavam, M.D. ⁴, A.R. Jhantabi⁵, A. Ghazanchaei

¹Dr. Mohammad Taghizadieh, Assisstant Prof. in Pathology, Urmia University of Medical Sciences, Urmia, Iran. Mohammadtaghizadieh@yahoo.com, Tel. Mobile: 0098 914 316 5783

² Dr. Farahnaz Noroozinia, Assisstant Prof. in Pathology, Urmia University of Medical Sciences, Urmia, Iran. Tel. Mobile: 0098 914 441 3947

³Dr. Reza Didevar, Phathologist, Urmia University of Medical Sciences, Urmia, Iran. Tel. Mobile: 0098 914 351 0129

⁴Dr. Farrokh Ghavam, Professor in Pathology, Urmia University of Medical Sciences, Urmia, Iran. Tel. Mobile: 0098 914 141 6009

⁵Ali Reza Jahantabi, MSc in Medical Bacteriology,. Mobile: 0098 914 400 5921

⁶Ardavan Ghazanchaei: MSc in Medical Parasitology, Tabriz University Of medical Sciences, Tabriz, Iran. Tel: 0098 914 311 3455

ABSTRACT

Perinatal death complicated 1.5% of all births. Such loss is often difficult for families to understand and cope with self-recrimination and criticisms of the physician are common. An autopsy can provide the explanation for the loss, often to the relief of the  parents and physician. It may reveal a specific disorder for which recurrence risks or strategies for prevention may be taken. Objective: Autopsy findings documentation on stillbirths in Shahid Motahary hospital of Urmia from October 2003 to September 2004 (A ten months study). Material and Methods: All stillbirths with consent for an autopsy examination were submitted for autopsy. Two pathology residents under supervision of a pathology staff performed the autopsies. Results: There were seventy-three fetal deaths in the study period. Consent for an autopsy was granted for 31 of them (42%). Abnormalities likely to be the cause of death were identified in 26 of cases (84%). Seventeen subjects (55%) did not have structural abnormalities. In 6 cases (19%) previously unsuspected pathology were detected and in three cases (10%) no abnormal findings were detected. Fourteen cases (45%) had structural anomalies. Severe maceration was present in 2 cases. Asphyxia and CNS malformations were the most frequent causes of death in this series. Conclusion:  The cause of fetal death was determined by autopsy in 84% of cases in this study. The importance of perinatal routine ultrasound screening and perinatal autopsy is emphasized.

KEY WORDS: Autopsy, Stillbirth, Perinatal, Structural Anomaly and Asphyxia

INTRODUCTION

Autopsy has served medicine in numerous ways. Human dissections were known to have been advocated as early as 1000 B.C. An autopsy was ordered when Pope Alexander died unexpectedly in 1410. Carl Von Rokitansky (1804-1878) as important as he was to the establishment of anatomic pathology as a discipline and as skillful as he was in gross pathologic studies attempted to make pathophysiologic correlations based on gross findings alone, but these findings were insufficient to explain disease processes¹.

Virchow drew relationships between gross and microscopic findings and the relationships to the clinical picture. In the twentieth century, William Osler thorough correlations between clinical course of disease and his personal observations made at autopsy examination and reflected the autopsy as a key process in medical education¹. Perinatal death complicated 1.5% of all births ². Still birth is sometimes difficult for families to cope with and understand, accept, and may provoke self recrimination and criticism of the attend physician ³.

A couple, who has experienced a neonatal death, is likely to have serious concerns about future recurrence. A perinatal autopsy can provide an explanation for neonatal death that often relieves the family and physician of blame. Often those perinatal autopsies may not be offered by the physician to families. Strategies to improve the availability, use, and standardization of perinatal autopsy as well as additional data directly comparing accuracy of antenatal or neonatal diagnosis with postmortem findings, are needed³.

MATERIALS AND METHODS

This is a non-randomized descriptive perspective study. All fetal intrauterine death after the 20th week of pregnancy delivered at the Department of Obstetrics and Gynecology of the Shahid Motahary hospital of Urmia from October 2003 to September 2004 is included. Consent for an autopsy examination from parents was obtained by the O&G specialist. Maternal medical and obstetrical history, sonographic studies, family history and delivery records of all cases were reviewed. Two pathology residents under supervision of a pathology staff performed the autopsies. Results of the autopsy finding are discussed with the physicians for counseling the parents. The cause of death, precipitating factors, recurrence risks and strategies to improve future pregnancy outcome are discussed with the parents. Histological specimens were studied from all internal organs and umbilical cord of the fetus. In severely macerated fetuses the histological study was restricted to the extra fetal tissues ^{2, 4}.

RESULTS

During the 10 months period of this study, 2576 births were recorded, seventy three (2.8%) of them were stillbirths. Consent for an autopsy examination was granted for 31 of them (42.5%). The male to female ratio of the stillbirth infants was 1:2.  There were ambiguous genitalia in one case, which turned out to be Prune-belly syndrome.

Eight of the thirty-one pregnant women (26%) had background medical morbidities which complicated the course of the pregnancy as listed in table 1 below:

Table 1 morbidities complicating the pregnancy

Autopsy findings identified the cause of death in twenty-six (84%) cases. Fourteen (45%) of the stillbirths had structural anomalies, CNS malformation was the most frequent finding. Seventeen fetuses (55%) were structurally normal. Autopsy findings in the stillbirth fetuses are shown in table 2.

Table 2 Autopsy findings in stillborn fetuses

Fetal maceration hampered the assessment of conditions leading to fetal death. Intrauterine meconium aspiration, petechiae on the serous membranes and cerebral intraventricular hemorrhages has been classified as asphyxia.

The most common causes of stillbirths were intrauterine asphyxia and major malformations. Other include maceration only (n=2), subdural hematoma (n=2), diaphragmatic hernia (n=1), complete situs inversus (n=1), fetal erythroblastosis (n=1), omphalocele (n=1). In three cases no abnormal finding were detected.

Fourteen (45%) of the stillbirth fetuses had antenatal ultrasonographic examination. The comparison of antenatal ultrasound diagnosis and postmortem diagnosis is listed in table 3.

Table 3 Comparison of Antenatal ultrasound diagnosis and Postmortem diagnosis

In ten cases (32%) ultrasound diagnosis were compatible with postmortem diagnosis. In seventeen (55%) the autopsy confirmed the antenatal diagnosis .In six cases (19%) the postmortem diagnoses differ from the antenatal diagnosis. In the test of the cases, the autopsy findings confirmed the antenatal diagnosis but also identified additionalabnormalities. The complication related to the placenta and umbilical cords were seen in eleven cases (35.5%). The most common abnormalities were a single umbilical artery (Table 4).

Table 4 – Complications related to the placenta

In three cases (10%) major structural defects were not detected by ultrasound. There were renal defects (n=2) and diaphragmatic hernia (n=1). Autopsy evaluation allowed for detailed important data to be obtained and hence made postmortem counseling possible. The cause of death or major contributing factors in twenty-six cases (84%) is listed in Table 5 below:

Table 5 Comparison of Antenatal and Postmortem diagnosis

In three cases (10%) no pathologic findings were seen. Severe maceration was present in two cases (6.45%). Histological study was restricted to the extra fetal tissues. One fetus with 13-trismoy was diagnosed by morphological criteria including encephalomyelocele, bilateral dysplastic cystic kidney, low set deformed ears, polydactyly, cleft palate and bicornate uterus. In two cases with single umbilical artery, the final diagnosis was Prune-belly syndrome and asphyxia respectively.

DISCUSSION

Determination the cause of death is an important assert in stillbirth and neonatal demise. Not only does this information facilitate emotional and psychological recovery for the parents, but also for diagnosis and prognosis of substantial recurrence risk. This allows better counseling and future pregnancy planning⁵.

A carefully performed autopsy is the single most useful step in identifying the cause of fetal death and includes pathologic examination of both fetus and placenta. However as several studies shows only a portion of fetal or neonatal deaths (33%) are evaluated by autopsy.

Failure to request a perinatal autopsy may be due to many factors including the patient’s religious beliefs or sometimes the status of the parents. Some physicians may assume that the diagnosis determined by antenatal ultrasound or neonatal examination is adequate. The widespread use of obstetric sonography and the increasing sophistication of ultrasound equipment have made it possible to make fairly specific antenatal diagnosis before birth. In the RADIUS study, only 16.6% of major congenital anomalies were detected before 24 weeks gestation in the routine ultrasound-screening group³.

The patient’s habits, fetal position and oligohydromnious may preclude clear visualization of anatomic structures. Some structural abnormalities develop over time (i.e. flow related cardiac defects, contractures, pulmonary hypoplasia) and thus may not be clearly visible during a second-trimester examination. Another problem is that ultrasound diagnoses are broad by nature. For example, saying that a fetus has hydrocephaly is somewhat analogous to saying a patient has cancer; it represents a class of pathology but indicates very little about cause or prognosis. Furthermore, the diagnosis of a genetic syndrome, which is essential for accurate counseling and pregnancy planning, often depends on the presence of additional small features not visible by even the most sophisticated sonographic examination.

Perinatal death complicated 1.5% of all births. In this study, the rate of perinatal death was 2.8%. Because this study was performed in a referral center, this may explain our higher rate of perinatal mortality compared with the cited rates. In this study, autopsy was vital for clarifying the diagnosis of hydrops fetalis in one case, oligohydramnious in two, oligohydramnious and genitourinary malformation in one. Postmortem examination is also very important in fetuses and neonates without obvious structural defects. In this study, for definite diagnosis of bilateral pulmonary agenesis in one case, subdural hematoma in two, diaphragmatic hernia in one, 13-trisomy in one and kidney defects in three, autopsy was necessary.

In a similar study, success of the autopsy in determining the cause of death in 94% of cases is likely related to the fact that all autopsies at that center were performed by one specially trained perinatal pathologist, in close consultation with clinicians and other specialists³. The cause of stillbirth was determined by autopsy in 84% of cases in this study. Complicated pregnancies due to maternal diseases in 8 cases (26%) of which eclampsia and maternal diabetes mellitus were the most common.

The most common causes of stillbirth were intrauterine asphyxia in eight cases (26%), CNS malformations in seven (22%) renal malformations and subdural hematoma respectively. One stillbirth fetus with 13-trisomy was diagnosed by morphological criteria including encephalomyelocele, bilateral dysplastic cystic kidney, low set deformed ears, cleft palate, polydactyly and bicornate uterus. The most common form of the CNS malformations was encephalocele in 3 cases (10%). In three cases (10%), the cause of death could not be identified that may be due to placental and cord complications and/or TORCH infections.  In this study, the cause of the stillbirth changed after autopsy in 19% of cases.

SUGGESTIONS

It is better to evaluate placenta and fetus together. Viral and bacterial cultures are recommended. In these studies, cytogenetic evaluations must be done. Chromosome anomalies found in 11.5% of macerated and in 4.5% of fresh stillborn infants⁷.

In this study, because of limited tests and instruments, placental evaluation, cultures and cytogenetic studies did not performed. The importance of routine ultrasound and complete autopsy for the detection of unrecognized stillbirth death causes is emphasized.

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