Degree of post-mortem investigation following perinatal loss

Degree of post-mortem investigation following perinatal loss

Matthew A Nestander (1), Kathryn Berryman (2), Robert Brady (3), James Aiden (4), Gayle Haischer-Rollo (1)

(1) Department of Pediatrics, Neonatal Division, Brooke Army Medical Center; (2) Department of Obstetrics, Division of Maternal-Fetal Medicine, Brooke Army Medical Center; (3) Department of Pathology, Brooke Army Medical Center; (4) Department of Graduate Medical Education, Brooke Army Medical Center

Background:
Perinatal death, defined as intrauterine fetal death at ≥20 weeks gestation, plus neonatal deaths within the first 7 days of life, rates have remained stable in the United States over the last decade. The American College of Obstetricians and Gynecologists have published guidelines for the post-mortem evaluation of stillbirths, with autopsy recommended. However, autopsy rates continue to decline. Less invasive post-mortem imaging has been suggested, but it is unclear if this has been incorporated into practice. Additionally, it is not known what evaluation early neonatal deaths receive and if it differs from stillbirths.

Methods:
We conducted a single center retrospective review of all perinatal deaths from 2011-2017. We sought to determine the frequency and degree of post-mortem investigation to include autopsy, imaging, laboratory, and genetic studies.

Results:
Over a 7 year period there were 97 perinatal deaths, with 54 stillbirths (56%) and 43 neonatal deaths (44%). The majority of deaths occurred between 20-25 weeks (stillbirths, n=31; neonatal deaths, n=30). 91 cases had placental pathology completed (94%) and 29 deaths had autopsy performed (30%). Stillbirths were significantly more likely to receive autopsy (p=0.013) and post-mortem genetic testing (p=0.0004) when compared to neonatal deaths. Parvo virus (p=0.0001), anti-phospholipid antibody (p=0.003), and kleihauer-betke (p=0.005) testing were all more likely in stillbirth post-mortem investigation than neonatal deaths. Neonatal deaths were more likely to have a documented physical exam (p=0.002) and be seen by a neonatologist or pediatrician (p=0.0001). Nearly a third of all deaths had no evaluation beyond placental pathology. There was only one case utilizing less invasive post mortem imaging.

Conclusion:
Investigation following perinatal death is more likely in stillbirths than neonatal deaths and there is very limited use of less invasive methods. Stillbirths were more likely than neonatal deaths to receive post-mortem investigation, yet all neonatal deaths were seen by a pediatrician or neonatologist. This suggests pediatricians and neonatologist may have room for improvement following perinatal death.

Ethics Statement:
This study was reviewed and approved by the local investigational review board. A case number was assigned (C.2018.143d). Appropriate measures were taken to ensure all protected health information was secure. All authors contributed to the project and meet the requirements for authorship.

Keywords: Stillbirth, Perinatal Death, Autopsy, Post-mortem exam, Non-invasive autopsy

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