Pediatric and Perinatal Autopsy

Why is the external examination especially important in fetal and perinatal autopsies?

Because many congenital syndromes are diagnosed primarily from:

• Body proportions

• Facial features

• Limb abnormalities

• External malformations

• Growth measurements

What benefits does a fetal or perinatal autopsy provide for the family?

Answers regarding cause of death

Emotional closure

Genetic counseling

Information about recurrence risk in future pregnancies

What are the medical benefits of fetal/perinatal autopsies?

Evaluates therapies and diagnostic techniques

Expands knowledge of congenital disease

Improves epidemiologic data

Identifies new disease manifestations

What legal benefits do pediatric autopsies provide?

Detect child abuse

Evaluate malpractice

Monitor public health issues

Determine cause and manner of death

What is pediatric?

Medical care of infants, children, and adolescents

What is fetus?

More than 8 weeks gestation, up to birth

What is a neonate?

Birth to one month

What is an infant?

One month to a year

What is the difference between therapeutic abortion from spontaneous abortion?

Therapeutic abortion: Elective termination for maternal, fetal, or social reasons

Spontaneous abortion: Miscarriage

What is a missed abortion?

Fetal death with retained fetal tissue ("silent miscarriage")

What is the difference between a complete and incomplete abortion?

Complete = all fetal tissue expelled

Incomplete = some fetal tissue remains

What is a stillbirth?

Fetal death after 28 weeks gestation

When is parental consent required for fetal autopsy?

Whenever a death certificate is issued (laws vary by state)

According to Louisiana law discussed in lecture, when is a fetal death certificate issued?

20 weeks gestation

350 g

Why is maternal history important?

It often explains fetal pathology and guides the autopsy examination

What photographs should routinely be obtained?

Entire body (front)

Entire body (back)

Face

Side profile

Any congenital abnormalities or injuries

Why are whole-body radiographs commonly obtained in pediatric autopsies?

Detect skeletal abnormalities

Diagnose syndromes

Evaluate growth

Assess ossification centers

Detect fractures/abuse

Identify foreign bodies

What is Sudden Infant Death Syndrome (SIDS)?

The sudden, unexplained death of an infant <1 year old that remains unexplained after:

• Complete autopsy

• Death scene investigation

• Review of clinical history

Why is SIDS considered a diagnosis of exclusion?

Because every other possible natural and non-natural cause of death must first be ruled out

Which infants are at greatest risk for SIDS?

Male infants

Age 2–4 months

Prematurity

Low birth weight

Young maternal age

Low socioeconomic status

Cigarette exposure

Maternal drug use

Sleeping position (especially prone)

Cold climates

Which age group has the highest incidence of SIDS?

2-4 months

What are the classic autopsy findings in SIDS?

Thymic, pleural petechial, epicardial petechiae — 70-95% of cases

Pulmonary congestion or edema

• Frothy fluid in the tracheobronchial tree

Mild chronic airway inflammation

Brainstem gliosis

Which radiographic views are routinely obtained?

AP

Lateral

What are the key considerations associated with SIDS?

Maternal clinical history

Malformation

Gestation/age

Labor and delivery notes

Legal issues

What is maceration?

Softening of fetal tissues occurring after intrauterine death due to autolysis

How does maceration differ from decomposition?

Maceration	Decomposition
Sterile	Bacterial
In utero	Usually after delivery
Autolysis	Putrefaction

How is fetal autolysis graded?

Mild

• Skin sloughing only

Moderate

• Skin sloughing

• Organ softening (pancreas, liver first)

Marked

• Skin sloughing

• Organ softening

• Joint laxity

What routine measurements are obtained during every fetal/perinatal autopsy?

Weight

Fronto-occipital circumference (FOC)

Chest circumference

Abdominal circumference

Crown-rump length

Crown-heel length

Foot length

Fontanel size

Which fetal measurement is often the best indicator of gestational age?

Foot length

Why are body measurements so important?

Determine gestational age

Evaluate fetal growth

Diagnose syndromes

Compare with prenatal ultrasound

What are the specific fontanelles to note in fetal autopsies?

Sphenoidal

Mastoid

Anterior

Posterior

During the external examination, what should always be assessed besides measurements?

Hair distribution

Facial features

Ear position

Fontanels

Tubes/wires

Congenital abnormalities

Which body openings should be checked for patency?

Nares

Choanae

External auditory canals

Rectum

Which oral structures should always be evaluated?

Philtrum

Palate

What extremity findings should be documented?

Symmetry

Muscle bulk

Mobility

Hand position

Foot position

Digit number

Nail development

Palmar creases

Plantar creases

Which two evisceration methods are most commonly used in pediatric/perinatal autopsies?

Letulle (En Masse) – all organs removed together

Ghon (En Bloc) – organs removed in regional groups

What is the Letulle (En Masse) method?

All organs are removed as a single, combined block (in toto)

What are the advantages of the Letulle method?

Faster body reconstruction

Preserves anatomic relationships

Safer for the prosector

Most dissection occurs outside the body

What is the major disadvantage of the Letulle method?

Organ dissection is more time-consuming

May require assistance

What is the Ghon method?

Removal of organs in regional and functional groups

What is the major advantage of the Ghon method?

Easier for a single prosector

Preserves interrelationship of organs

What is a disadvantage of the Ghon method?

Transection of the esophagus and aorta may interfere with evaluation of:

• Aortic dissection

• Aneurysm

• Esophageal varices

• Esophageal tumors

Why is the inferior vena cava opened during pediatric autopsy?

To evaluate for thrombi

If the kidneys appear congested, what additional structure should be examined?

Renal veins

Why is the descending aorta opened?

To inspect for vascular abnormalities and thrombi

What should always be done with the adrenal glands?

Remove

Weigh

Exam

Where should the bowel be ligated before removal?

Ligament of Treitz

Proximal rectum

What should always be documented for the intestines?

Length

Congenital malformations

How is biliary tree patency assessed?

Express bile from the gallbladder through the ampulla of Vater

Which organs are separated from the gastrointestinal block during dissection?

Liver

Gallbladder

Spleen

Which additional tissues are routinely sampled in pediatric autopsies?

Rib costochondral junction

Vertebral bone

Skin

Subcutaneous tissue

Femoral nerve

Psoas muscle

What should be done if congenital heart disease is suspected?

Perfuse the heart and lungs with formalin overnight

Why are cardiac chambers perfused with formalin?

Distended chambers make congenital abnormalities easier to identify

How are the testes removed?

Through the inguinal ring

How does lung preparation differ between stillborn and liveborn infants?

Stillborn — No airway perfusion, scored

Liveborn — Airway perfusion performed

How are the neck organs examined?

They remain attached to the heart and lungs

How are the airway and esophagus opened?

Esophagus — Posteriorly

Trachea/larynx — Anteriorly

What abnormality should specifically be sought during neck dissection?

Tracheoesophageal abnormalities (e.g., fistula, atresia)

Before opening the pediatric heart, what relationship must be confirmed?

Position of the great arteries

How is the heart opened?

Along the normal direction of blood flow

When should the heart be separated from the trachea and esophagus?

Only after congenital malformations have been excluded

Which cardiac structures should be sampled histologically?

Right atrium

Left atrium

Right ventricle

Left ventricle

AV valves

Coronary artery

Papillary muscles

Why should the lungs remain attached to the heart initially?

To preserve anatomy while evaluating congenital cardiovascular abnormalities

How are the lungs sampled?

One section from each lobe

How are the liver and spleen examined?

Weighed

Bisected along long axis

Umbilical vein examined

Portal sinus examined

Ductus venosus examined

One representative section submitted

How is the stomach handled in infants less than one day old?

Leave closed

Fix first

Section afterward

Why is the neonatal stomach left unopened initially?

To preserve luminal contents for evaluation, especially in suspected infection (e.g., chorioamnionitis)

How is the stomach handled after one day of life?

Open before fixation

How is the pancreas sampled?

Left attached to GI block

Bisected longitudinally

One half submitted

How are pediatric kidneys examined?

Capsule left intact

Hemisected

Weighed individually

Collecting system opened

Cortex, medulla, and pelvis sampled

What should always be assessed in the ureters?

Patency

How is the bladder opened?

Anteriorly

How are the uterus and adnexa sampled?

Sagittal uterus/cervix section

Longitudinal ovaries

Cross-section including fallopian tubes

How are testes examined?

Hemisected

One half submitted

How is the fetal scalp reflected?

Ear-to-ear incision over the crown

Why are fontanelles measured?

To evaluate growth and congenital abnormalities

Why are the cranial sutures opened instead of using a saw?

The skull is incompletely ossified

How is the brain removed?

Cut falx

Cut tentorium

Transect cranial nerves

Support brain

Slowly remove

Transect spinal cord

Why may very soft fetal brains be removed underwater?

To prevent fragmentation

What should be done with severely autolyzed brains?

Place directly into formalin

After fixation, how is the pediatric brain examined?

Similar to the adult brain

What is neonaticide?

Deliberate killing of a newborn, usually by the mother

What are the two most common mechanisms of neonaticide?

Asphyxia

Abandonment

What is one of the first questions that must be answered during a suspected neonaticide investigation?

Was the infant born alive or stillborn?

What findings help determine whether an infant was born alive?

Degree of intrauterine maceration

Lung examination

Presence of aerated alveoli

Histology

Why is the lung flotation ("float") test considered unreliable?

Gas can be introduced by:

• Decomposition

• Artificial ventilation

• Putrefaction

Which microscopic finding indicates the infant breathed?

Diffuse atelectasis

Which microscopic finding suggests the infant never breathed?

Expanded/Open (aerated) alveoli

Which age group has the highest homicide rate?

Children younger than 2 years

What is the most common cause of homicide death during the first year of life?

Craniocerebral injuries

What is the second most common fatal injury?

Blunt abdominal trauma

What are the three major categories of homicide in young children?

1. Battered Child Syndrome

2. Impulse Homicide

3. Gentle Homicide

What findings suggest Battered Child Syndrome?

Multiple bruises

Abrasions

Patterned injuries

Rib fractures

Long bone fractures

Head injuries

Liver injuries

Malnutrition

Delayed medical care

Inconsistent history

Which patterned injuries are highly suspicious for abuse?

Belt

Buckle

Coat hanger

Handprint

Which fractures are particularly suspicious for child abuse?

Rib fractures

Extremity fractures

What intracranial hemorrhages are commonly associated with abusive head trauma?

Subdural hemorrhage

Subarachnoid hemorrhage

Which organ is injured most commonly in abusive abdominal trauma?

Liver (80%)

Approximately what percentage of abused children with abdominal trauma have liver lacerations?

About 80%

True or false — Most children with fatal abdominal abuse have obvious external injuries

False — Approximately 43% have no external injuries

What history from caregivers raises suspicion for abuse?

Story inconsistent with injuries

Delayed EMS call

Changing history

Injury incompatible with developmental age