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Improving the uptake of post-mortem after
pregnancy loss
Editor-in-Chief, Dr Michael Marsh, discusses the latest thinking in women’s
health and highlights articles from this issue in an audio podcast available at:
https://soundcloud.com/bjog/may-editorial-2019
Parents who consent to post-mortem
after termination of pregnancy for con-
genital anomaly, stillbirth or neonatal
death usually do so because they feel
that the post-mortem examination helps
‘to explain what had happened’ and
because they would like to know
‘whether future pregnancies would be
affected’ (Rankin et al. BMJ
2002;324:816–8). They are correct in
thinking so; in one-quarter or more of
cases, additional information that
changes the underlying diagnosis or the
information given to parents during
counselling may be acquired from a for-
mal autopsy (Gordijn et al. Pediatr Dev
Pathol 2002;5:480–8). Even when an
abnormality has been identified antena-
tally with ultrasound, where there is
often agreement between prenatal
ultrasound diagnosis and full post-mor-
tem results (Vogt et al. Ultrasound
Obstet Gynecol 2012;39:666–72), post-
mortem adds useful information for a
small proportion of cases.
The most recent MBRRACE-UK Perina-
tal Mortality Surveillance Report (Draper
et al. MBRRACE-UK Perinatal Mortality
Surveillance Report, UK Perinatal Deaths
for Births from January to December
2016. 2018) indicates that although the
offer of a post-mortem to parents was
reported in almost all cases of stillbirths
(98%) and for 81% of neonatal deaths,
the uptake of providing consent for
post-mortem for stillbirth and neonatal
deaths still remain low at 49% and 29%,
respectively. There appears to be varia-
tion in uptake, with some units report-
ing acceptance rates much higher than
the UK average (Rankin et al. BMJ
2002;324:816–8). In the adult setting,
there is good evidence that formal
instruction regarding obtaining permis-
sion for autopsy given to senior
residents may double post-mortem
uptake (Clayton and Sivak Am J Med
1992;92:423–8; Soubani et al. Am J Med
1995;98:418–9), suggesting that there
may be remediable deficiencies in train-
ing of how to obtain consent for these
procedures.
Two common reasons for declining
post-mortem, accounting for more than
half of cases, are the belief that the
baby ‘had already suffered enough’ and
concerns about disfigurement of the
body (Rankin et al. BMJ 2002;324:816–
8). Conventional autopsy involves inva-
sive components such as in situ, macro-
scopic and histological assessments of
the brain and the internal organs and
non-invasive ancillary assessments,
including post-mortem plain-film radiog-
raphy, external examination of the body
and laboratory tests, including genetic,
metabolic and microbiological studies.
The term minimally invasive autopsy
(MIA) has been developed to describe a
range of less-invasive ways of obtaining
post-mortem information without open
dissection of the body. Together with
ancillary assessments, MIA may give suf-
ficient information for a diagnosis to be
made without the need for full autopsy.
Typically, MIA involves sampling tissues
by either needle biopsy through the skin
(percutaneous approach) or keyhole
techniques using endoscopy.
The Magnetic Resonance Imaging
(MRI) Autopsy Study (MaRIAS) (Thayyil
et al. BMC Pediatr 2011;11:120) was a
large prospective study that evaluated
the clinical usefulness of post-mortem
MRI as an alternative to full conven-
tional autopsy in 277 fetuses and 123
children. In this prospective validation
study, pre-autopsy, post-mortem, whole-
body MRI was performed for an unse-
lected population of fetuses (≤24 weeks’
or >24 weeks’ gestation) and children
aged <16 years. MRI findings alone, or
in conjunction with other minimally
invasive post-mortem investigations
were assessed for accuracy in determin-
ing the cause of death or detecting
major pathological anomalies compared
with conventional autopsy as the diag-
nostic gold standard. The cause of death
or major pathological lesion detected by
minimally invasive autopsy was concor-
dant with conventional autopsy in 95%
(95% CI 90.3–97.0%) of 185 fetuses at
24 weeks’ gestation or less, 96% (95% CI
89.3–98.3%) of 92 fetuses at more than
24 weeks’ gestation and 81% (95% CI
66.7–90.0%) of 42 newborns aged 1
month or younger. The authors con-
cluded that MIA autopsy has accuracy
similar to that of conventional autopsy
for detection of cause of death or major
pathological abnormality after death in
fetuses, newborns and infants, and that
if undertaken jointly by pathologists and
radiologists, minimally invasive autopsy
could be an acceptable alternative to
conventional autopsy in selected cases.
A recent study examined the accept-
ability of minimally invasive perinatal/
paediatric autopsy to healthcare profes-
sionals (Ben-Sasi et al. Prenat Diagn
2013;33:307–12) and reported that there
was a general agreement across all pro-
fessionals involved that autopsy was
important in providing additional infor-
mation for future pregnancies and med-
ical research, with MIA being
significantly more acceptable across a
range of ethnic and religious groups
than traditional autopsy. Professionals
also strongly agreed that having the
option of MIA would make discussing
autopsy options easier with parents, and
that it would be useful for parents to be
able to meet with a doctor or
ª2019 Royal College of Obstetricians and Gynaecologists 679
DOI: 10.1111/1471-0528.15364
www.bjog.org
Editorial