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Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Options for less invasive postmortem investigations

While a full autopsy remains the diagnostic method of choice for most perinatal deaths,42-44,47,49 non-invasive or minimally invasive approaches should be offered to parents who decline a full autopsy. Offering alternatives to full autopsy reduced the proportion of Māori women in Aotearoa New Zealand who had no investigations for their babies.20

Less invasive autopsy options include a limited autopsy (where only specific organs are examined) and minimally invasive tissue sampling.50 Non-invasive options include imaging (babygram, ultrasound, magnetic resonance imaging [MRI] and computed tomography [CT]) and external examination by a pathologist.47,49,80,81

In a review of imaging in investigating perinatal deaths,47 MRI performed better than ultrasound irrespective of the state of maceration, except for the abdomen, for which there was no significant difference between imaging techniques when the baby was macerated. Microfocus computed tomography (micro-CT) is a promising approach for imaging babies. The authors proposed a stepwise diagnostic approach for fetal examination, where imaging is undertaken prior to a decision about autopsy, which may reduce the need for autopsy.47 However, further research is needed to test this application in routine practice.47 Imaging decision trees have been proposed to guide the use of imaging and autopsy for perinatal death49,82,83 and may prove helpful.

The systematic review from the Dutch postmortem imaging guideline group included a practice-based flowchart for radiology in non-forensic fetal and neonatal deaths.49 The authors concluded that MRI is the imaging modality of choice for perinatal deaths. Postmortem MRI can provide valuable diagnostic information for perinatal deaths particularly for brain and spinal cord anomalies with advantages over conventional autopsy in the presence of maceration.47,49,83 MRI should be undertaken within three days of the death and optimally within 24 hours where practicable.83 When termination of pregnancy because a suspected brain malformation is planned, a fetal MRI may provide more information than postmortem MRI alone.84

Postmortem imaging techniques cannot replace the value of histology results in all cases. Tissue sampling (with parental consent) may be required in addition to imaging and is best achieved by image-guided laparoscopic tissue sampling; however, this may be difficult for small babies. Image-guided needle tissue biopsy can overcome this limitation,85 where appropriate services are available. In selected cases, when combined with imaging and other core investigations, the addition of targeted tissue sampling may provide similar results to full autopsy.27,50.

Due to the complex nature of many perinatal deaths, the optimal approach to alternative investigations should ideally be developed by a multidisciplinary team.47,85

Evidence-based recommendation 6.30

Evidence quality: Moderate confidence

Where a full autopsy is declined by the parents, alternative options of less or minimally invasive investigations should be offered and an explanation provided of the value in their circumstances following a multidisciplinary discussion including the obstetrician, and neonatologist/paediatrician pathologist, radiologist, and geneticist as required. In addition to all core investigations, the following should be offered to parents who decline a full autopsy:

  • limited autopsy or minimally invasive tissue sampling (where available)
  • external examination by the pathologist   
  • full body X-ray imaging of the baby (also known as a ‘babygram’)  
  • postmortem MRI (where available).

Consensus-based recommendation 6.31

A postmortem MRI, where available, should be offered to parents as an adjunct to autopsy or in place of an autopsy where this is declined.

  • Ideally, MRI should be performed within 24 hours of stillbirth.
  • MRI has been shown to be helpful in identifying brain and spinal cord anomalies, particularly in macerated stillborn babies.
Core investigations
Additional investigations in specific clinical scenarios
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