Value of perinatal autopsy

Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set

BACKGROUND

A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority.

OBJECTIVES

To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth.

SEARCH STRATEGY

Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021.

SELECTION CRITERIA

Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention.

DATA COLLECTION AND ANALYSIS

Interventions, outcomes reported, definitions and outcome measurement tools were extracted.

MAIN RESULTS

Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome.

CONCLUSIONS

Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system

OBJECTIVE

Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary maternity unit in England with a perinatal pathology service.

POPULATION

Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken.

METHODS

A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification.

MAIN OUTCOME MEASURES

Inter-rater, intra-rater, inter-disciplinary agreement and cause of death.

RESULTS

Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins.

CONCLUSIONS

This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins.

TWEETABLE ABSTRACT

New classification system for #twin cause of death 'CoDiT' shows high rater agreement.

Causes and risk factors for singleton stillbirth in Japan: Analysis of a nationwide perinatal database, 2013-2014

Over 80% of perinatal mortality in Japan is due to stillbirths after 22 weeks of gestation, with one in 300 families experiencing fetal loss every year. This study aimed to assess causes and risk factors for singleton stillbirth in Japan. A retrospective cross-sectional study was conducted using the Japan Society of Obstetrics and Gynecology Perinatal Database from January 2013 to December 2014. A total of 379,211 births including 2,133 stillbirths were analyzed. Causes of death were classified into eight categories. A multi-level Poisson regression model was used to assess the relationship between stillbirth and key covariates. Causes of death were unknown in 25–40% of stillbirths across gestational age. Placental abnormality accounted for the largest proportion of known causes, followed by umbilical cord abnormality. Stillbirth risk was increased among small-for-gestational-age infants (adjusted relative risk [ARR]: 3.78, 95% confidence interval [CI]: 3.31–4.32) and nulliparous women (ARR: 1.19, 95% CI: 1.05–1.35). Maternal underweight, pregnancy-induced hypertension and oligohydramnios showed a protective effect. Our finding suggests that stillbirths occurring among women with known complications are likely already being prevented. Further reduction in stillbirths must target small-sized fetuses and nulliparous women. Improved recording of the causal pathways of stillbirths is also needed.

Provider Adherence to Syphilis Testing Recommendations for Women Delivering a Stillbirth

OBJECTIVE

To assess overall adherence to Centers for Disease Control and Prevention and American College of Obstetrics and Gynecology recommended guidelines for syphilis testing among women who delivered a stillbirth and compare it with other tests recommended for stillbirth evaluation.

METHODS

We used MarketScan claims data with 40 million commercially insured and 8 million Medicaid enrollees annually to estimate prenatal care and follow-up testing among women who had stillbirths between January 1, 2013, and December 24, 2013. Stillbirth was identified if women had any International Classification of Disease, Ninth Revision codes related to a stillbirth outcome. Among women with stillbirths, we estimated the proportions of women who received prenatal care and prenatal syphilis testing within 280 days before stillbirth, and testing at the time of stillbirth (syphilis testing, complete blood count, placental examination and autopsy) using Physician's Current Procedural Terminology codes.

RESULTS

We identified 3672 Medicaid-insured women and 6023 commercially insured women with stillbirths in 2013. Approximately, 61.7% of Medicaid-insured women and 66.0% of commercially insured women had claims data indicating prenatal syphilis testing. At the time of stillbirth, Medicaid-insured and commercially insured women had similar rates of syphilis testing (6.5% vs 9.3%), placental examination (61.6% vs 57.8%), and complete blood count (31.9% vs 37.6%). Autopsies were too infrequent to be reported. Approximately, 34.6% of Medicaid-insured women and 29.7% of commercially insured women had no syphilis testing either prenatally or at the time of stillbirth.

CONCLUSIONS

Syphilis testing among women after stillbirth was less than 10%, illustrating limited adherence to Centers for Disease Control and Prevention and American College of Obstetrics and Gynecology recommendations. Such low prenatal and delivery syphilis testing rates may impact the number of stillbirth cases identified as congenital syphilis cases and reported to the national surveillance system. Our results emphasize the need to improve syphilis testing to improve diagnosis of syphilitic stillbirths, identify women with syphilis infection, and provide treatment to these women to avoid syphilis-related adverse outcomes.

Causes of antepartum stillbirth in women of advanced maternal age

OBJECTIVES

To breakdown the causes of antepartum stillbirth by maternal age.

STUDY DESIGN

Observational study.

SETTING

UK.

SAMPLE

Anonymised national data on 2850 cases of antepartum stillbirth in 2009.

STATISTICAL ANALYSIS

The association between cause of stillbirth and maternal age was examined using an adjusted multinomial logistic regression model. Risk ratios were calculated relative to stillbirth due to haemorrhage.

MAIN OUTCOME MEASURES

Antepartum stillbirths classified by the Centre for Maternal and Child Enquiries (CMACE) classification.

RESULTS

Stillbirths in women aged 35 years and over are more likely to be due to major congenital anomalies (relative risk ratio (RRR) 2.0, 95% CI 1.3-3.0), mechanical causes (RRR 1.6, 95% CI 1.0-2.6), maternal disorders (RRR 2.1, 95% CI 1.2-3.6) or associated obstetric factors (RRR 2.1, 95% CI 1.1-3.9) than women less than 35. Women aged 35 years and over have a statistically significant increased risk of stillbirth due to major congenital anomalies (OR relative to live birth 1.6, 95% CI 1.3-1.9) and maternal disorders (OR 1.7, 95% CI 1.2-2.4) than younger women. Women aged 35 years and over were 30% more likely to experience a term stillbirth than women <35 years (OR 1.3, 95% CI 1.1-1.5). Stillbirth due to congenital anomaly was statistically significantly more likely in women ≥ 35 years.

CONCLUSIONS

Advanced maternal age is a significant risk factor for antepartum stillbirth particularly at term. Attention should be given to stillbirth due to mechanical causes, maternal disorders and associated obstetric factors in such women.

A pathologist׳s perspective on the perinatal autopsy

The perinatal autopsy is an important tool in the investigation of fetal and neonatal death, and a complete understanding of its risks and benefits is necessary for providers of perinatal care. This review, from the perspective of a perinatal pathologist, reports the details of the autopsy procedure, its goals, its value to individual patients and the health care system in general, and its alternatives. Even with new emerging technologies, the conventional perinatal autopsy remains the gold standard for determining the cause of death and the final summary of all pathologic findings. Therefore, the information provided in this review can help providers properly convey information about perinatal autopsy to bereaved families.

Foetal autopsy-categories and causes of death

INTRODUCTION

Intrauterine death(IUD)/ Stillbirth forms a major part of perinatal mortality which thereby is a good indicator of pregnancy wastage as well as quality of healthcare available. The key objectives of autopsy examination are to know the cause(s) of death, elucidation of pathogenic mechanism and quality control of clinical management. The aim of this study was to identify the prevalent causes of IUD, thereby taking appropriate measures to prevent them and decrease the perinatal mortality rate.

MATERIALS AND METHODS

The study included 14 cases of IUD received for autopsy in the Department of Pathology over a period of five years. Autopsies were performed as per standard protocol and included full anthropometric profile, external examination, gross and microscopic evaluation of different organs and placenta.

RESULTS

Total number of 14 fetal autopsies were performed over a period of 5 years. The causes were broadly classified as fetal, maternal and placental. Placental causes were seen in majority of cases (48.57%) followed by fetal (35.72%) and then maternal (21.42). Most prevalent cause of death was congenital anomalies (28.6%) followed by placental insufficiency (21.4%) and chorioamnionitis (14.2%).

CONCLUSION

Determination of causes of fetal death would prove beneficial to the clinicians and parents for better management and care in future pregnancies as well as in genetic counseling.

Placental findings in singleton stillbirths

OBJECTIVE

To compare placental lesions for stillbirth cases and live birth controls in a population-based study.

METHODS

Pathologic examinations were performed on placentas from singleton pregnancies using a standard protocol. Data were analyzed overall and within gestational age groups at delivery.

RESULTS

Placentas from 518 stillbirths and 1,200 live births were studied. Single umbilical artery was present in 7.7% of stillbirths and 1.7% of live births, velamentous cord insertion was present in 5% of stillbirths and 1.1% of live births, diffuse terminal villous immaturity was present in 10.3% of stillbirths and 2.3% of live births, inflammation (eg, acute chorioamnionitis of placental membranes) was present in 30.4% of stillbirths and 12% of live births, vascular degenerative changes in chorionic plate were present in 55.7% of stillbirths and 0.5% of live births, retroplacental hematoma was present in 23.8% of stillbirths and 4.2% of live births, intraparenchymal thrombi was present in 19.7% of stillbirths and 13.3% of live births, parenchymal infarction was present in 10.9% of stillbirths and 4.4% of live births, fibrin deposition was present in 9.2% of stillbirths and 1.5% of live births, fetal vascular thrombi was present in 23% of stillbirths and 7% of live births, avascular villi was present in 7.6% of stillbirths and 2.0% of live births, and hydrops was present in 6.4% of stillbirths and 1.0% of live births. Among stillbirths, inflammation and retroplacental hematoma were more common in placentas from early deliveries, whereas thrombotic lesions were more common in later gestation. Inflammatory lesions were especially common in early live births.

CONCLUSIONS

Placental lesions were highly associated with stillbirth compared with live births. All lesions associated with stillbirth were found in live births but often with variations by gestational age at delivery. Knowledge of lesion prevalence within gestational age groups in both stillbirths and live birth controls contributes to an understanding of the association between placental abnormality and stillbirth.

LEVEL OF EVIDENCE

II.

Sharing experiences to improve bereavement support and clinical care after stillbirth: report of the 7th annual meeting of the International Stillbirth Alliance

Stillbirth remains a global health challenge which is greatly affected by social and economic inequality, particularly the availability and quality of maternity care. The International Stillbirth Alliance (ISA) exists to raise awareness of stillbirth and to promote global collaboration in the prevention of stillbirth and provision of appropriate care for parents whose baby is stillborn. The focus of this ISA conference was to share experiences to improve bereavement support and clinical care. These issues, relevant throughout the globe, are not discrete but closely interrelated, with both similarities and differences depending on the specific country and cultural context. Counting stillbirths and understanding the causes of stillbirth are essential not only for providing optimal care and support to parents whose babies die, but also for reducing the future burden of stillbirth. This summary highlights novel work from obstetricians, midwives, psychologists, parents and peer support organizations that was presented at the ISA meeting. It covers topics including the bereavement process, peer support for parents, support and training for staff, evidence for clinical care, and the need for accurate data on stillbirths and perinatal audits. Representatives from the maternity services of the region presented their outcome data and shared their experiences of clinical and bereavement care. Data and developments in practice within stillbirth and bereavement care must be widely disseminated and acted upon by those responsible for maternity care provision, both to prevent stillbirths and to provide high-quality care when they do occur.

The stillbirth collaborative research network postmortem examination protocol

After reviewing the state of knowledge about the scope and causes of stillbirth (SB) in a special workshop sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the participants determined that there is little guidance regarding the best use of postmortem examination (PM) to address the pathogenesis of stillbirth. In this report, we describe the PM procedure designed and used in the NICHD-supported Stillbirth Cooperative Research Network (SCRN). Perinatal pathologists, clinicians, epidemiologists, and biostatisticians at four tertiary care centers, a data coordinating center, and NICHD developed a standardized approach to perinatal PM, which was applied to a population-based study of stillbirth as part of the SCRN. The SCRN PM protocol was successfully instituted and used at the four medical centers. A total of 663 women with stillbirth were included: 620 delivered a single stillborn infant, 42 delivered twins, and one delivered triplets for a total of 676 stillborn infants. Of these women, 560 (84.5%) consented to PM (572 stillborn infants) that was conducted according to the SCRN protocol. A standardized PM protocol was developed to evaluate stillbirth consistently across centers in the United States. Novel testing and approaches that increase the yield of the PM can be developed using this model.

Noninvasive investigation of asymmetrically conjoined tripus twins with features of rachipagus, parapagus dicephalus, and cephalopagus

A hypothetical mechanism for conjoined twinning postulated by Spencer ([2003] Developmental Malformations and Clinical Implications, Baltimore: Johns Hopkins University Press, p 1-476) suggests that, after separation, monovular twins fuse in one of eight predictable homologous sites. The tripus fetal specimen under study embodies characteristics of three types therefore preventing it from classification into a simple variant of any one of the eight twin types described by Spencer. The aim of this study was to reveal internal structural anomalies of the fetal specimen by using magnetic resonance imaging and computerized tomography. Dorsally appended to the primary twin is a secondary head mass (brain tissue and ocular globe) and two spinal columns converging at T4/T5, suggesting rachipagus twinning. The ventral orientation of the secondary twin's (right lateral) lower limb suggests parapagus twinning. The caudal divergence of the spinal columns and the presence of a secondary hemipelvis, separate from the primary pelvis, suggest cephalopagus twinning. Measurements of the long bones indicate a gestational age of ∼20-23 weeks. Secondary malformations of the primary fetal body include anencephaly, cleft palate, renal agenesis, decreased left ventricular outflow, and a prematurely terminating descending aorta. This study demonstrates the possibility of using current imaging techniques to study very old, formalin-preserved human material for documentation and scientific discussion without destroying the specimen, thus keeping it intact for posterity.

Evidence of maternal platelet activation, excessive thrombin generation, and high amniotic fluid tissue factor immunoreactivity and functional activity in patients with fetal death

OBJECTIVE

Fetal death can lead to disseminated intravascular coagulation or fetal death syndrome. However, currently it is not clear what are the changes in the coagulation system in patients with a fetal death without the fetal death syndrome. This study was undertaken to determine: (1) whether fetal death in the absence of fetal death syndrome is associated with changes in hemostatic markers in maternal plasma and amniotic fluid; and (2) whether maternal hypertension or placental abruption are associated with further changes in the hemostatic profile of these patients.

METHODS

A cross-sectional study included the following: (1) determination of changes in markers of coagulation and platelet activation in patients with a normal pregnancy (n = 71) and patients with fetal demise (FD) without disseminated intravascular coagulation (n = 65); (2) determination of the amniotic fluid (AF)-tissue factor concentration and activity, as well as the concentrations of thrombin-antithrombin III (TAT) complexes in patients with a normal pregnancy (n = 25) and those with a FD (n = 36) who underwent amniocentesis. Plasma and AF concentrations of TAT complexes and TF (an index of thrombin generation), as well as maternal plasma concentrations of sCD40L (a marker of platelet activation), tissue factor pathway inhibitor (TFPI) and prothrombin fragments (PF) 1 + 2 (also an indicator of in vivo thrombin generation) were measured by ELISA. TF and TFPI activity were measured using chromogenic assays.

RESULTS

(1) patients with FD without hypertension had a higher median maternal plasma sCD40L concentration than normal pregnant women (P < 0.001); (2) patients with FD had a higher median maternal plasma TAT III complexes than women with a normal pregnancy (P < 0.001); (3) the median AF-TF concentration and activity were higher in the FD group than in the normal pregnancy group (P < 0.001 for both); (4) patients with preeclampsia and FD had a higher median maternal plasma immunoreactive TF concentration than both normotensive patients with FD and women with normal pregnancies (P < 0.001 and P = 0.001, respectively); (5) the median plasma TF activity was higher in patients with preeclampsia and FD than that of women with normal pregnancies (P = 0.003); (6) among patients with a FD, those with placental abruption had a higher median AF-TAT complexes concentration than those without abruption (P = 0.0004).

CONCLUSIONS

Our findings indicate that: (1) mothers with a FD have evidence of increased in vivo thrombin generation and platelet activation than women with normal pregnancies; (2) patients with a FD and hypertension had a higher degree of TF activation than those with fetal death but without hypertension; (3) the AF of women with a FD had a higher median TF concentration and activity than that of normal pregnant women. AF can be a potential source for tissue factor and it participates in the development of fetal death syndrome in patients with a retained dead fetus.

Placental findings contributing to fetal death, a study of 120 stillbirths between 23 and 40 weeks gestation

BACKGROUND

Intrauterine fetal death is an agonizing, often unpredictable event. Autopsies of stillborn fetuses, including placentas, are performed to clarify the cause of death. Autopsy results are not always easily understood by the patients or their healthcare providers.

OBJECTIVE

To evaluate placental causes of death in stillbirths based on autopsy and placental findings that are related to maternal underperfusion, fetal underperfusion, or inflammatory etiologies in hierarchical order.

METHODS

Retrospective review of 120 autopsy reports of singleton stillborn fetuses and placentas from 23 to 40 weeks of gestation.

RESULTS

Among the placental causes of death there were 54(51%) cases with direct cause or major contributor to death in the etiology of maternal vascular supply abnormalities, 28(26%) cases in the etiology of fetal vascular supply abnormalities and 13(12%) in the etiology of inflammatory lesions. Maternal vascular supply abnormalities were more common in preterm stillbirths and fetal vascular supply abnormalities were more common among term stillbirths. In 88% of stillbirths, the direct cause or a major contributor to death was found in the placentas. The incidence of unexplained death was 8%.

CONCLUSIONS

Pathological analysis of the placenta is essential for clarifying causes of stillbirths. Using specific simplified categories for abnormal placental findings may increase the benefits of the autopsy report.

Stillbirth recurrence in a population of relatively low-risk mothers

We sought to estimate the risk of stillbirth recurrence among relatively low-risk women, a group defined as maternal age <35 years; absence of congenital anomalies; gestational age range of 20-44 weeks inclusive; singleton births; and non-smokers. The Missouri maternally linked data containing births from 1978 to 1997 were used for the study. We identified the study group (low-risk gravidae who experienced a stillbirth in the first pregnancy) and a comparison group (low-risk gravidae who delivered a live birth in their first pregnancy) and compared the stillbirth risks in the second pregnancy between both groups. Analysis was based on 261 384 women with information on first and second pregnancies [1050 (0.5%) women with stillbirth]. Of the 947 cases of stillbirth in the second pregnancy, 20 cases occurred in women with a history of stillbirth (stillbirth rate 19.0 per 1000 births) and 927 in the comparison group (stillbirth rate 3.6 per 1000 births; P<0.001). The adjusted risk of stillbirth was almost six times higher in women with a prior stillbirth (hazard ratio [HR] 5.8, [95% CI 3.7, 9.0]). Analysis by stillbirth subtype in the second pregnancy showed that history of stillbirth conferred greater risk for subsequent early (fetal deaths between 20 and 28 weeks) (HR 10.3, [95% CI 6.1, 17.2]) than late stillbirths (fetal deaths at >or=29 weeks) (HR 2.5, [95% CI 1.0, 6.0]); and for intrapartum (HR 12.2, [95% CI 4.5, 33.3]) than antepartum (HR 4.2, [95% CI 2.3, 7.7]) stillbirths. Among relatively low-risk women, history of stillbirth was associated with increased recurrence, with substantial heterogeneity by timing of stillbirth.

The perinatal autopsy: Pertinent issues in multicultural Western Europe

Western Europe is in a demographic transition with increasing multicultural societies. Health professionals have to understand the background, religious and cultural aspects of parents to counsel them regarding an autopsy in the event of a perinatal loss. Autopsy rates have declined over the past decades, the major limiting factor being the granting of permission for an autopsy, possibly because of adverse publicity or reluctance of doctors to obtain consent. Autopsy has proved its value in revealing unsuspected findings. The public can be convinced of this utility by means of good information notwithstanding their religious or cultural background.

Work-up of stillbirth: a review of the evidence

Despite improvements in antenatal and intrapartum care, stillbirth, defined as in utero fetal death at 20 weeks of gestation or greater, remains an important, largely unstudied, and poignant problem in obstetrics. More than 26,000 stillbirths were reported in the United States in 2001. Although several conditions have been linked to stillbirth, it is difficult to define the precise etiology in many cases. This paper reviews known and suspected causes of stillbirth including genetic abnormalities, infection, fetal-maternal hemorrhage, and a variety of medical conditions in the mother. The proportion of stillbirths that have a diagnostic explanation is higher in centers that conduct a defined and systematic evaluation. The evidence for recommended diagnostic tests for stillbirth are discussed. The ongoing work of the National Institute of Child Health and Human Development Stillbirth Collaborative Research Network, a consortium of 5 academic centers in the United States that are studying the scope and causes of stillbirth, is presented.

Identification of the causes of intrauterine death during 310 consecutive autopsies

OBJECTIVE

Evaluation of causes of death in stillborn infants.

METHODS

During a five-year period, 310 consecutive autopsies of stillborn infants were performed using a standardized protocol with systematic examination of all major cranial, thoracic and abdominal organs including microscopic examination.

RESULTS

In 71%, the intrauterine death (ID) occurred up to the end of the 37th week of gestation. Thirty-seven percent (115/310) stillbirths represented with maceration and about one-half with minor or major malformations. Thirty-one percent (53/171) of them were responsible for intrauterine death. In 83% (44/53), the intrauterine death of the malformed fetus occurred before the end of 37th week of gestation, most of them (48/53, 90.6%) were small for gestational age infants. In 75.5% (234/310), the placental villous tree and the umbilical cord represented pathologic conditions. In 191 cases (61.1%), utero-placental pathology was responsible for intrauterine death. Intrauterine infections and traumatic lesions were accompanied by intrauterine death in 2.2 and 1.3%, respectively. In 15.2%, unexplained intrauterine death (because of severe maceration, the placenta was not available for autopsy or insufficient clinical data) occurred.

CONCLUSIONS

Perinatal autopsy may be valuable in three ways: the confirmation of ante-mortem diagnoses; the identification of unexpected disorders; and exclusion of other (perhaps inheritable) conditions which might be have caused the intrauterine death. Clinically valuable information, obtained from the autopsy, can be improved by high autopsy rate and performing perinatal necropsies by specially trained pathologists.

Magnetic resonance imaging: an alternative to autopsy in neonatal death?

Magnetic resonance imaging (MRI) represents a non-invasive alternative to full autopsy in neonatal death if parents refuse classical full autopsy. MRI offers high resolution images of the entire neonate without disrupting the integrity of the child. Neonatal malformations or pathologies that are responsible for the death of the neonate can be identified. A major disadvantage of MR-autopsy is the lack of tissue sampling. Chromosomal, histological or microbiological analyses are consequently missing. MR-autopsy has proven to be especially helpful in the evaluation of the central nervous system but is limited in complex cardiac malformations. The limitations and possibilities of MR-autopsy are discussed.

Quality of fetal, perinatal and infant autopsy reports. An audit of all reports of postmortem examinations following fetal, perinatal and infant death in Rogaland County, Western Norway, 1997-1999

The aim of the present study was to investigate the quality of fetal, perinatal and infant (< 12 months of age) autopsy reports. One hundred and thirty-six reports were scored for seven major categories (History, External description, Internal examination, Histology report, Other investigations, Placenta, Conclusions/Commentary) derived from "Guidelines for post mortem reports" published by the Royal College of Pathologists. The time taken for the final reports to be issued was also investigated. Of the 136 reports, 31 failed to reach a minimum standard of a 50% score. The one major category clearly falling below the recommended standard was Conclusions/Commentary. Other major categories such as History, External description and Histology report were also in need of improvement. Only three final reports were issued within the Department of Pathology's goal of 4 weeks. Although 77% of the reports fulfilled a minimum standard of a 50% score, the audit clearly showed that the standardised report form used was in need of revision and that many reports failed to give the clinicians an evaluation of the data presented in the autopsy reports. Based on the present findings, a number of measures have been implemented in order to improve the quality of future fetal, perinatal and infant autopsy reports.

Genetic counselling in prenatally diagnosed non-chromosomal fetal abnormalities

Advances in technology and skills have resulted in the improved detection of fetal ultrasound abnormalities by ultrasound. In addition, the development of new diagnostic methods has resulted in major advances in our ability to detect microscopic and submicroscopic chromosome abnormalities as well as single gene disorders. This often enables us to provide the family with accurate information regarding the aetiology, prognosis, the risk of recurrence and the prenatal diagnosis options available in future pregnancies. Genetic counselling is important because this information should be communicated to the family in simple language, with care and sensitivity, so that the family can make decisions that are fully informed.