Fetopsy in third trimester and stillbirth

Author: Mikael Häggström
Autopsy of a fetus in the third trimester (from 27 or 28 weeks of gestational age), as well as intrapartum stillbirth.

There are many variants, with the following being a suggestion:

Comprehensiveness

Factors supporting a relatively more comprehensive autopsy and/or report, particularly in the inclusion of negated findings:

• Lack of explanation from existing evidence. On the other hand, for example, upon finding an obvious aortic rupture, the rest of the autopsy is less relevant and may be relatively short.
• Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed, because the doctor who will do the double-reading then knows that you have looked at those locations.
• Highly suspected locations, such as given from the referral.

On this resource, the following formatting is used for comprehensiveness:

• Minimal depth
• (Moderate depth)
• ((Comprehensive))

Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Organs or important regions are in bold in the report example, but does not need to be in an actual report.

Preparations

• Read the autopsy referral.
• Confirm that there is a consent from the next of kin to perform the autopsy.
• (Go through the mother's medical records, at least if necessary aspects are not included in the referral. The most important aspects are:

• Maternal age/date of birth
• Relevant medical and family history, including consanguinity
• Maternal ((height, weight and)) BMI
• Previous pregnancies and deliveries:

• Previous pregnancy losses and any pathology results thereof
• Any malformations, growth restrictions or other complications

• History of current pregnancy, including:

• Gestational age
• Any antenatal infection screening results
• Any abnormal findings from ultrasound or other antenatal investigations
• Any hypertension, bleeding, fever or membrane rupture
• Most recent events leading up to intrauterine death and/or delivery
• Time of delivery, and first recorded absence of fetal heartbeat such as ultrasound
• Delivery: Mode, complications and any instrumentation used
• Any attempted resuscitation.)

{{Apply X-ray or CT if skeletal dysplasia is suspected.}}

In the autopsy room, before starting examination:

• Bring a camera to document relevant findings.
• Use protective wear, generally according to local practice. Do any knots before putting on gloves for better dexterity.
• Confirm the identity of the fetus, often by the mother's identity details.

External examination

Components:

• Measure body weight, crown-rump length, crown-heel length, foot length and occipito-frontal circumference.
• Determine nutritional status/soft tissue and muscle bulk
• Inspect skin for any maceration, local/generalised oedema, pallor, meconium staining
• Determine any overall dysmorphic features, evidence of trauma or other lesions
• Orifices for patency, including choanae
• Confirm palatal fusion

Internal examination

• Make a longitudinal skin incision on the front of the body, typically T- or Y-shaped.
• Measurement the thickness of the subcutaneous fat over the sternum.

Central nervous system (CNS)

The skull is opened by a median posterior or transverse scalp incision. Components:

• Inspect falx and venous sinuses for injury and/or meningeal hemorrhage (especially in intrapartum

death)

• Look for any skull fracture or occipital osteodiastasis (at least in intrapartum death)
• Look for any spinal injury by a posterior approach (at least in intrapartum death)
• If a CNS malformation is suspected, examine the posterior fossa structures by a posterior approach.
• Inspect the gyral pattern

• ((Remove the brain under water and perhaps in dura (especially with marked autolysis), for weighing and further assessment of the gyral pattern.))

Other internal organs

Including:

• Umbilical arteries and vein, and ductus venosus
• Heart and great vessels, by initial in situ examination
• Thoracic and abdominal organs, by initial in situ examination.
• Dissect along the diaphragm to detect any organ herniation.
• ((Dissect up to the larynx to inspect the thyroid and detect any tracheoesophageal fistulas.))
• Weigh internal organs (minimum: thymus, heart, lungs, liver, kidneys, adrenals, spleen and brain)
• The placenta:

• Trimmed weight (without extraplacental membranes and cord)
• Dimensions of the placenta (width in two planes and thickness)
• Fetal surface: appearance, any thrombosis of chorionic vessels
• Maternal surface: completeness, craters
• Slicing at approximately 1 cm intervals to evaluate parenchyma for color and focal changes.

• The umbilical cord

• Measure length, diameter, and number of vessels.
• Note the insertion into the placental disc

Look for any coiling or lesions

• Membranes

Main page

• Main page of Patholines