Autopsy findings of fetal death.
ABSTRACT To study the autopsy findings associated with fetal death in the division of reproductive pathology.
Descriptive study of 35 fetal deaths with placentas after postmortem examinations in the division of reproductive pathology between January 2005 and December 2005. The fetal deaths and placentas were examined by a perinatal pathologist in the surgical pathology room, Department of Pathology and Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University. The demographic data of the mothers, the gestational age from obstetric information, diagnosis before abortus or delivery. The postmortem examinations including abnormal macroscopic or microscopic findings were analyzed.
The associated pathologies of fetal death could be identified 87.5% for groups of fetal weight less than 500 grams and in 77.8% for groups of fetal weight 500 grams or more. The most common associated pathology of fetal death in both groups was congenital anomaly, was 50% and 25.9% respectively. Macerated fetuses were found in 48.2% of all cases. Causes of macerated groups were identified in 66.7% of cases. Hydropic fetuses were 14.3% (5 cases) of all fetal deaths in which the cause of death was identified before delivery in two cases and was identified in postmortem examination in one case. Thus, the identified causes of fetal death in hydrops fetalis were 60%.
Most common associated pathology of fetal deaths is congenital anomaly.
- [show abstract] [hide abstract]
ABSTRACT: The underlying causes of 80% of perinatal deaths were identified in a study of 53,518 pregnacies in the United States: 17% of the deaths were due to amniotic fluid infections, 11% to abruptio placentae, 10% to premature rupture of the membranes, 9% to congenital anomalies, 6% to large placental infarcts, and the rest to more than 20 other specific disorders.JAMA The Journal of the American Medical Association 08/1977; 238(3):228-9. · 29.98 Impact Factor
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ABSTRACT: A large number of district general hospitals have access to diagnostic ultrasonography and other methods of prenatal diagnosis, resulting in an increased supply of freshly terminated malformed fetuses to general histopathology departments, and there is now more open discussion of malformation and greater concern over fetal wastage. General pathologists are therefore under greater pressure to produce complete and detailed descriptions of a wide range of often complex anomalies. The dismissal of specimens as "multiple congenital anomalies" is becoming increasingly unacceptable to couples who wish to embark on further pregnancies and to their medical attendants. As in other fields an understanding of the methods and terminology in clinical use and a consistent diagnostic approach should help pathologists to extract sufficient information for accurate counselling.Journal of Clinical Pathology 11/1986; 39(10):1049-65. · 2.44 Impact Factor
- Quality assurance programs for necropsy. 1190-3..
J Med Assoc Thai Vol. 90 No. 1 200721
Correspondence to : Kleebkaow P, Department of Obstetrics
and Gynecology, Faculty of Medicine, Khon Kaen University,
Khon Kaen 40002, Thailand.
Autopsy Findings of Fetal Death
Pilaiwan Kleebkaow MD*,
Thawalwong Ratanasiri MD*, Ratana Komwilaisak MD*
* Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen
Objective: To study the autopsy findings associated with fetal death in the division of reproductive pathology.
Material and Method: Descriptive study of 35 fetal deaths with placentas after postmortem examinations in
the division of reproductive pathology between January 2005 and December 2005. The fetal deaths and
placentas were examined by a perinatal pathologist in the surgical pathology room, Department of Pathology
and Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University. The demographic
data of the mothers, the gestational age from obstetric information, diagnosis before abortus or delivery. The
postmortem examinations including abnormal macroscopic or microscopic findings were analyzed.
Results: The associated pathologies of fetal death could be identified 87.5% for groups of fetal weight less
than 500grams and in 77.8% for groups of fetal weight 500 grams or more. The most common associated
pathology of fetal death in both groups was congenital anomaly, was 50% and 25.9% respectively. Macerated
fetuses were found in 48.2% of all cases. Causes of macerated groups were identified in 66.7% of cases.
Hydropic fetuses were 14.3% (5 cases) of all fetal deaths in which the cause of death was identified before
delivery in two cases and was identified in postmortem examination in one case. Thus, the identified causes of
fetal death in hydrops fetalis were 60%.
Conclusion: Most common associated pathology of fetal deaths is congenital anomaly.
Keywords: Postmortem examinations, Fetal death, Associated pathology, Autopsy
Several studies have been conducted to
demonstrate the value of the postmortem examinations
of fetal death as a means of clinical audit and quality
control(1). Special attention has been focused on the
perinatal postmortem examination(2).
The widespread use of ultrasound screening
for congenital anomalies, the almost universal use of
maternal serum α-fetoprotein screening, and the in-
creasing use of amniocentesis, chorionic villous sam-
pling and cordocentesis, for prenatal detection of spe-
cific abnormalities in families at risk, has placed a spe-
cial responsibility upon the pathologist receiving cases
from obstetric units. The importance of detailed exami-
nation of any fetus after termination of pregnancy for
congenital anomaly has been repeatedly emphasized(3).
The objectives of the postmortem examina-
tion are composed of information to the family of a
dead fetus, information to clinicians caring for the
family, information to enable quality control and audit
of management practices, accurate epidemiological data,
stimulation of research and medicolegal evidence(4).
Several aspects of placental examination are
worth emphasizing in the context of perinatal death.
The placenta should always be submitted in as fresh a
condition as possible, without fixative and without
undue handling or stripping of membranes, particu-
larly of twin placentas(4). The mortality rate of low birth
weight infants is eight times greater than normal-weight
infants(5). The prevalence of placental pathology in
low birth weight infants in Srinagarind Hospital was
Srinagarind Hospital, the division of repro-
ductive pathology has started the postmortem exami-
nations of all fetuses from the department of Obstet-
rics and Gynecology since 2002. Almost all fetuses were
sent from the labor room. In 2005, the perinatal death
was 17.36 per 1000 live births. The limitation is that it
J Med Assoc Thai 2007; 90 (1): 21-5
Full text. e-Journal: http://www.medassocthai.org/journal
22J Med Assoc Thai Vol. 90 No. 1 2007
did not include late neonatal deaths. All fetuses weighed
500grams or more(7). The postmortem examinations
were performed in 26 of 46 fetuses (56.5%). The remain-
ing fetuses are those who had postmortem examina-
tion performed at another division or the parents did
not give consent.
There are many classifications of causes of
fetal deaths such as Aberdeen clinicopathological
classification, British necropsy classification, Wiggles-
worth classification, Nordic-Baltic classification and
placental and fetal pathology classification of Naeye(8).
Classification of causes of fetal death in the present
study followed the classification of Naeye(9).
Material and Method
The authors included all fetuses from fetal
deaths from the departments of Obstetrics and Gyne-
cology after obtaining a signed informed consent from
their parents. All fetuses were postmortem examined
by one perinatal pathologist, fellows and residents from
the division of maternal fetal medicine, Department of
Obstetrics and Gynecology. Fetuses with no consent
forms and incomplete postmortem examinations were
excluded. Between January 2005 and December 2005,
35 fetuses weighing between 40 and 2,340 grams aborted
or delivered at Srinagarind Hospital were included
After receiving written informed consent, the
data were collected from 1) request forms; 2) labor
records; and, 3) postmortem records (i.e. demographic
and baseline variables of age, gestational age by ob-
stetric information, timing of death, characteristics of
fetuses, prenatal investigation and pre and postmor-
The fetuses and placentas were stored at 6? C
to ensure ‘fresh state’ pathological examination. A few
fetuses were formalin-fixed from miscommunication of
the staff. Macroscopic studies included: 1) clinical pho-
tography, 2) body weight, 3) measurements of fetal
parameters and 4) placenta examinations. Microscopic
studies were performed on the tissue samples taken from
each organ and placentas. Baby grams, microbiology
and electron microscopy were performed in selected
cases. All samples were stained with hematoxylin
and eosin. Sections of bones were fixed with EDTA
The causes of fetal death were post-mortem
examined (Naeye, 1977) according to placental and
fetal pathology, as follows: 1) acute amniotic fluid
infection syndrome, 2) abruptio placentae, 3) premature
rupture of membranes, 4) congenital anomalies, 5) large
placental infarcts, 6) intervillous thrombi of placenta,
7) umbilical cord compression, 8) cord knots, 9) placen-
tal growth retardation, 10) placenta previa, 11) rhesus
erythroblastosis, 12) birth trauma, 13) polyhydramnios,
14) cesarean section, 15) marginal syndrome, 16) severe
fetal undernutrition, 17) uterine rupture, 18) post ma-
turity, 19) congenital syphilis, 20) other disease and
21) unexplained(9). The associated pathologies of fetal
deaths, demographics and baseline variables were
presented as percentages.
The demographic and baseline data of 35
fetal deaths enrolled in the present study are presented
in Table 1. Maternal age was between 20-35 years old
in 70.6%, mostly abortion and delivery in the labor room
(91.4%) and gestational age from 22 to < 37 weeks by
obstetrics record (65.7%). One woman had twins. The
fetuses were equal in sex and showed one unidentified
sex (in one limb body wall complex). The 77.1% fetuses
Age of 34 mothers (years)*
Place of abortion or delivery
Gestational age by obstetric data
< 22 wks or < 500 g
> 22 - < 37wks
> 37 wks
Sex of fetuses
Timing of fetal deaths
Early neonatal death
Table 1. Demographic data of the studying groups (n = 35
* One mother had twins
J Med Assoc Thai Vol. 90 No. 1 200723
weighed 500 g or more. Fetal deaths during the an-
tepartum period were 42.8%. The fetuses revealed
non-maceration in 57.1% and fresh status in 82.8%
In the present study, 57.1% were identified
associated pathologies of death before delivery or
abortion and 80% with postmortem examination. The
unexplained causes were 20% (Table 3).
According to Naeye’s classification, most
common causes of fetal deaths were congenital ano-
malies (31.4%) (Table 4). One case was detected with
postmortem in groups of hydrops fetalis (Fig. 1).
The macerated groups were 66.67% of iden-
tified causes. The unexplained causes were 33.3%
(Table 5). One macerated fetus of an unexplained
group was severe maceration with one survived mono-
zygotic twin at term.
Causes of deaths in hydrops fetalis were
identified in only three of five cases (60%) although
the electron microscopy was performed. The two un-
explained fetuses were anemia, cardiomegaly, hepato-
spleenomegaly and placentomegaly.
The authors selected Naeye’s classification
due to complete details of clinical and pathological
findings. Most common associated pathologies of
fetal and neonatal deaths in United States of America
were amniotic fluid infection in 17.7%, congenital
anomalies in 9.5% and unexplained causes in 13.8%(10).
In Durban, South Africa, causes of fetal deaths were
amniotic fluid infection in 26%, congenital anomalies
in 4.9% and unexplained in 1.5%. In the present study,
more unexplained causes and no amniotic fluid infec-
Fresh or formalin-fixed
Table 2. Characteristics of fetal deaths (n = 35 cases)
Before postmortem examination
After postmortem examination
Before postmortem examination
After postmortem examination
Table 3. Associated pathologies of fetal deaths before and
after postmortem examinations (n = 35 cases)
Twin twin transfusion syndrome
PROM with chorioamnionitis
Placental growth retardation
Severe fetal undernutrition
Umbilical cord compression
Bart hydrops fetalis
- Hydrops fetalis
- Idiopathic polyhydramnios
Table 4. Details of associated pathologies of fetal deaths
after postmortem examinations (n = 35 cases)
Twin twin transfusion syndrome
Single fetal death of twins
Table 5. Associated pathologies of fetal deaths in macer-
ated groups (n = 15 cases)
24J Med Assoc Thai Vol. 90 No. 1 2007
Most unexplained causes of deaths in the
present study were in hydrops fetalis. One case con-
genital diaphragmatic hernia was detected (Fig. 1).
There were many limitations in the present study
groups; therefore, the investigation should be done to
improve the cause of fetal death identification.
The strength of the present study was good
obstetric data and good quality of post mortem exami-
nations. The weakness was the small sample size
because of only preliminary report in one year. The
authors could not perform postmortem examinations
in early neonatal death in the pediatric ward, because
there were incomplete microbiologic studies, such as
anaerobe. No tissue culture or cytogenetic study was
performed in the authors’ faculty.
The usefulness of the present study was the
preliminary data to improve the data collection, coun-
seling parents, and improved quality of prenatal diag-
In conclusion, the identified causes of fetal
death were rather high (80.7%). The most common cause
was congenital anomaly (31.4%). Postmortem examina-
tion is very useful for obstetrician practice. Available
antepartum data and placental examinations improved
identification of the causes of fetal deaths.
1. Harrison M, Hounhane DOB. Quality assurance
programs for necropsy. J Clin Pathol 1989; 42:
2. Russell GA, Berry PJ. Postmortem audit in a paedi-
atric cardiology. J Clin Pathol 1989; 42: 912-8.
3. Knowles S. Examination of products of concep-
tion terminated after prenatal investigation. J Clin
Pathol 1986; 39: 1049-65.
4. Chamber HM. The perinatal autopsy: a contempo-
rary approach. Pathology 1992; 24: 45-55.
5. Sohl B, Moore T R. Abnormalities of fetal growth.
In: Taeusch HW, Roberta AB, editors. Avery’s
disease of the newborn. 7th ed. Philadelphia: WB
Saunders; 1998: 90-101.
6. Kleebkaow P, Limdumrongchit W, Ratanasiri T,
Komwilaisak R, Seejorn K. Prevalence of placental
pathology in low birthweight infants. J Med
Assoc Thai 2006; 89: 594-9.
7. World Health Organization. Manual of the inter-
national statistical classification of disease, inju-
ries and causes of death vol1, 9th Rev ed, Geneva:
tion were found due to not included early neonatal
death in pediatric units. There were 42.8% of macer-
ated groups that caused difficulty in finding out the
etiology. In recent times, the prenatal diagnosis is
worldwide then congenital anomalies as cause of fetal
According to Wigglesworth classification, a
review of southeast Thames perinatal statistics from
1988-1995, showed antepartum fetal death in 41% of
the cases and malformation in 14%(8). The rate of
antepartum fetal deaths is similar to the present study.
The malformation in the present study was lower due
to the different cases of prenatal diagnosis. In the
present study, the authors found a case of limb body
wall complex with amniotic band and a case of anen-
cephaly in 41 weeks of gestational age. The latter case
was undiagnosed by ultrasound in the first half of
antepartum period. One case of skeletal dysplasia was
detected in the antepartum period.
Case of macerated hydrops fetalis with diagnosis of
congenital diaphragmatic hernia and pulmonary
hypoplasia on postmortem examination (big pointer
at left lobe of liver in left chest and small pointer at
left lung hypoplasia)
J Med Assoc Thai Vol. 90 No. 1 200725
8. Golding J. Epidemiology of fetal and neonatal
death. In: Keeling JW, editor. Fetal and neonatal
pathology. 3rd ed. London: Springer; 2001: 175-90.
9. Naeye RL. Causes of perinatal mortality in the US
collaborative perinatal project. JAMA 1997; 238:
10. Ross SM, MacPherson TA, Naeye RL, Khatree
MHD, Wallace IA. Causes of fetal and neonatal
mortality in a South African black community. S
Afr Med J 1982; 12: 905-8.
พิไลวรรณ กลีบแก้ว, ถวัลย์วงค์ รัตนสิริ, รัตนา คำวิลัยศักดิ์
วัตถุประสงค์: เพื่อศึกษาพยาธิสภาพที่พบร่วมกับการตายของทารก หลังจากได้ตรวจพิสูจน์ทางพยาธิวิทยา จากสาขา
วัสดุและวิธีการ: เป็นการศึกษาแบบพรรณนา ของทารกตายและรกที่ได้ทำการตรวจพิสูจน์ทางพยาธิวิทยา ใน
ระหว่าง 1 มกราคม พ.ศ. 2548 ถึง 31 ธันวาคม พ.ศ. 2548 จำนวน 35 ราย โดยทำการตรวจที่ ห้องตัดชิ้นเนื้อ
ภาควิชาพยาธิวิทยา และ สาขาพยาธิวิทยาการเจริญพันธุ์ ภาควิชาสูติศาสตร์และนรีเวชวิทยา คณะแพทยศาสตร์
มหาวิทยาลัยขอนแก่น โดยพยาธิแพทย์ปริกำเนิดทำการตรวจ รวบรวมข้อมูลต่าง ๆ ของมารดาได้แก่ ลักษณะ
ประชากร อายุครรภ์ทารกที่ประเมินจากข้อมูลทางสูติศาสตร์ การตรวจวินิจฉัยก่อนแท้งหรือคลอด วิเคราะห์ผล
การตรวจ จากการตรวจของทารกและรก ทั้งมหกายวิภาคหรือทางจุลพยาธิวิทยา
ผลการศึกษา: พบพยาธิสภาพร่วมกับการตายของทารก ร้อยละ 87.5 ในกลุ่มทารกน้ำหนักน้อยกว่า 500 กรัม และ
ร้อยละ 77.8 ในกลุ่มทารกน้ำหนักตั้งแต่ 500 กรัมขึ้นไป พยาธิสภาพที่พบบ่อยที่สุดเป็น ความพิการ ของทารกแต่กำเนิด
พบร้อยละ 50 และ ร้อยละ 25.9 ตามลำดับ ในทารกทั้ง 2 กลุ่มพบทารกมีลักษณะเปื่อยยุ่ย ร้อยละ 42.8 ในจำนวนนี้
พบมีสาเหตุการตาย ร้อยละ 66.7 นอกจากนั้นพบทารกที่มีอาการบวมน้ำจำนวน 5 ราย คิดเป็นร้อยละ 14.3
พบพยาธิสภาพก่อนคลอด 2 ราย พบสาเหตุเพิ่มจากการตรวจพิสูจน์ทางพยาธิวิทยา 1 ราย คิดเป็นพบสาเหตุรวม