The Value of Pathologic Evaluation in Stillbirth

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This presentation will review the most important tests in the postmortem work-up of stillbirth and their value to clinicians and families. Important autopsy and placental findings associated with stillbirth will be presented. The current pathology techniques and emerging techniques will be discussed.
 
Dr Linda Ernst is currently an Associate Clinical Professor and the director of Perinatal Pathology at NorthShore University HealthSystem. She is board certified in AP-CP and Pediatric Pathology having trained at Yale University for her residency and the Children’s Hospital of Philadelphia for fellowship. She has devoted her career to Perinatal Pathology with clinical expertise in Placental Pathology and Perinatal Autopsy. One of her greatest contributions to the field is the beautiful Color Altas of Human Fetal and Neonatal Histology. She has also had an active research career with over 90 peer-reviewed publications on subjects related to fetal and placental pathology. She is currently the Vice Chair for Research in her department, and is currently a co-investigator on 3 NIH-funded research projects to evaluate the importance of placental pathology in poor pregnancy outcomes.

Dr. Ernst has disclosed that she does not have any real or perceived conflicts of interest in making this presentation.

This presentation was part of the Stillbirth Summit 2021.   This individual lecture will be awarded .75 hours of continuing education credit to include viewing the lecture and completing evaluation and post-test.  Once received a certificate will be emailed to the address you provide in the post-test.  If you did not register for the Summit WITH Continuing Education, you can purchase the continuing education by clicking here.  This purchase will provide you access to all Stillbirth Summit 2021 lectures including continuing education credit. There is no charge for viewing the presentation.

To receive continuing education credit for this lecture, the participant must complete the evaluation and post-test.

Please feel free to ask questions of the presenter.  We will obtain their answers/comments and provide them here as received.  

19 Responses

  1. Anna Vick: Why would an OB doctor discourage autopsy? She mentioned the baby being cut into, also that many families have to pay and don’t always get any answers from it.

    1. Dr. Ernst’s reply:
      As I mentioned in my talk, there are lots of barriers to getting an autopsy in SB. Obstetricians sometimes feel uncomfortable asking for autopsy because they don’t understand the value of it and/or the process. Clinicians usually don’t actively discourage autopsies, but they may present it in a way that doesn’t express its benefits in the best light. For instance, a clinician saying something like “we usually don’t get an answer from the autopsy” is one way to subtlety discourage an autopsy. See question below. Other barriers include those regarding family beliefs and pathologists beliefs.

  2. Angelica Kovach
    When we had our stillbirth, the physician offered us an autopsy, but told us that he didn’t suggest one based on my son’s otherwise normal external assessment. He said there was nothing more that we could glean from an autopsy. There still is no known cause for his death. Is it common for physicians to suggest that a family not do an autopsy?

    1. As above, I don’t think it is common practice to discourage autopsy, but I do not have any data. The ACOG recommendations are now very clear. An autopsy should be offered in all cases. I hope that everyone will become aware of the benefits of autopsy for their patients, and I continue to strive to educate.

  3. Aubrey Kitchel:
    If there is a way to get the autopsy FAQ sheet she was just describing I would love that!

  4. Delice:
    Is there a time limit on when a placental exam can be done? (How many hours after delivery should it be done)

    1. Dr. Ernst’s Reply: Placentas are pretty hearty organs. They can be stored in the refrigerator for up to a week and still be fine for examination. At our institution, no placenta is discarded after delivery. They are all saved for 7 days in case something abnormal comes up with mom or baby.

  5. Shaylee Dave
    Does is matter where the fetal autopsy is done? Like at a community hospital vrs academic center?

    1. Dr. Ernst’s reply: Yes, I think so. The best is to have perinatal autopsies done by people with lots of experience in perinatal pathology. Unfortunately, this kind of pathologist is not always available. This is a problem that is hard to solve until the field of perinatal pathology is treated with the same importance as oncologic pathology.

  6. Annie Kearns
    Do you know of any cost analyses comparing “virtual autopsy” techniques with histologic examination? I worry about hospitals avoiding these due to expense.

    1. Dr. Ernst’s Reply: I don’t off hand know of any cost analyses. Your concerns are warranted.

  7. Angelica Kovach
    How do you guide your families who express guilt and regret for not performing an autopsy? Especially if they do not have answers regarding their baby’s death…

    1. Dr. Ernst’s Reply: This is not a scenario that I run into too often, but I am sure that folks who talk to loss patients do experience this. I know of at least one social worker who knows this sort of reaction in her patients and encourages the parents at the time of delivery and decision about autopsy to consider how they will feel in 6 weeks after their SB. Will they want more answers? Will they be ok not knowing more? This does make folks think about the decision more carefully.

  8. Annie Kearns
    What do we do if there are no perinatal pathologists available? I believe all my hospital’s autopsies are sent elsewhere, and I don’t think the receiving organization has any pathologists specifically trained in perinatal autopsy. Should I be advocating for perinatal cases to get sent elsewhere? If so, any East Coast suggestions?

    1. Dr. Ernst’s Reply: This is a problem, and may not be one that is easily solved in all cases. There are not enough folks with expertise in perinatal pathology to cover all perinatal autopsies. Regional centers of excellence might be one future solution. However, right now that does not exist. Consultation with experts can be requested, but does increase the hassle of transport and potential cost. As a clinician, I always suggest advocating for what you need. Pathology does all kinds of things because the clinicians want it. I encourage you to request, demand, advocate for what you need.

  9. Anonymous: could you talk a little about the evaluation of a stillborn baby with a knot in the umbilical cord?

    1. Sure. A true knot of the umbilical cord can be seen in SB. Usually it is a tight knot which constricts blood flow through the cord. One can see the tightness of the cord on the gross exam and assess its effect on fetal blood flow by looking for changes in vascular caliber (dilation), evidence of blood flow stasis (thrombosis) and evidence of loss of blood supply to more distant portions of the placenta (avascular villi). When these things are present one can say the cord knot is the probable cause of death. The main reason the knot causes death is by restricting blood flow between the placenta and fetus and reducing delivery of oxygen and nutrients to the baby.

  10. Anonymous – Dr. Jason Collins talks about a type A and type B nucal cord and the danger levels of each – is this commonly discussed in the autopsy findings. I realize that those circumstances are gone once a baby is delivered and the cord removed from the wraps around the baby. For that reason are immediate photographs at delivery useful?

    1. Dr. Ernst’s Reply: I have never heard of type A or B nuchal cords. And you are right! At autopsy, I cannot diagnose nuchal cord except in rare circumstances where I see a furrowed area of pallor around the neck which suggests a tight nuchal cord. As with cord knots above, evidence of vascular dilation, thrombosis and avascular villi could support a “cord accident” as a cause of death. Certainly pictures, if possible, are always helpful. I always check the delivery note for notation of presence of nuchal cord at delivery.

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