L13 - Post mortem in current practice (Dr Francesca Maggiani) Flashcards
- Understanding the difference between death certificate and certifying death - Explaining the role of post mortem in 2021 - Perinatal pathology
What is the purpose of postmortem examinations in current medical practice?
🏥 Postmortems help identify the cause of death and contribute to medical knowledge. They provide insights into disease processes, improve healthcare, and guide future treatments by understanding what went wrong.
What is the significance of a death certificate?
📝 A death certificate is a legal document that records the cause of death and ensures proper documentation for legal, financial, and insurance purposes.
Who is resonsible for completeing a death certificate
👨⚕️ A registered medical practitioner who attended the deceased during their last illness must complete the certificate under the Births and Deaths Registration Act 1953.
What are example health professions that can certify a death
health professionals at different levels: e.g. nursing staff, paramedic, or anyone who is competent and gets to the scene of death
What must be included when certifying the cause of death
📄 The doctor must state the primary cause of death (“the smoking gun”) and any contributing factors to the best of their knowledge and belief.
What is the difference between certifying death and completeing a death certificate?
✅ Certifying death means declaring that a person has died. It can be done by paramedics, nursing staff, or competent individuals at the scene. 📄 Issuing a death certificate documents the cause of death to the best of the persons knowledge and must be done by a health professional who knew the patient.
Who can certify death vs who can issue a death certificate
🏥 Health professionals such as nurses, paramedics, or other competent individuals who arrive at the scene can certify death.
📄 A health professional who knew the patient, such as a GP or a hospital doctor who cared for them, usually a registrar rather than a senior staff member can issue a death certificate
Can multiple people be involved in writing a death certificate?
👥 Yes, doctors may collaborate with other clinicians involved in the patient’s care, and sometimes consult the pathology team.
Why is a death certificate legally important?
⚖️ It is needed for legal and financial purposes, such as inheritance, stopping or starting payments, and insurance claims.
What are the main sections of a death certificate?
Part 1: The immediate cause of death (e.g., hemorrhagic stroke) and its antecedent cause (e.g., atrial fibrillation).
Part 2: Other contributing conditions (e.g., diabetes, hyperlipidemia) that may have played an indirect role.
How does accurate death certification help public health?
📊 It aids in mortality statistics, epidemiological research, and resource allocation, helping guide funding and prevention strategies.
Why are postmortems still commonly used in perinatal pathology
🍼 Perinatal postmortems provide valuable insights into conditions affecting newborns. Since causes of death in infants are sometimes unclear, postmortems help identify preventable factors and improve neonatal care.
How does filling out a death certificate accurately benefit public health?
📊 It provides data for mortality statistics, helps track disease prevalence, and influences healthcare funding and prevention strategies.
How is a cause of death structured in a death certificate?
🏥 The cause of death follows a logical sequence, starting with the immediate event (e.g., hemorrhagic stroke) and tracing back to underlying conditions (e.g., atrial fibrillation → myocardial infarction → atherosclerosis).
What are the different types of death certificates for infants
👼 Neonatal Death Certificate: Issued for babies who die within the first 28 days of life.
🤰 Stillbirth Certificate: Issued for babies who die in the womb or during labor.
Why is distinguishing between neonatal death and stillbirth important?
🔍 It helps determine if the death occurred before labour, during delivery, or due to a medical issue, influencing healthcare policies and improvements in perinatal care.
When should the medical certificate of cause of death be used
🏥 It should be used for any death occurring after 28 days of life.
When should the Neonatal death certificate ( Form 65) be used?
👶 It should be used for any death of a live-born infant occurring within the first 28 days of life.
When should the Certificate of Stillbirth (Form 34) be used?
🤰 It should be used for any infant who dies after the 24th week (6 months) of pregnancy and does not breathe or show signs of life after birth.
What are hospital postmortems, and why are they rarely performed today?
🏥 Hospital postmortems investigate the cause of death in a controlled hospital setting. They are rarely performed because many patients have well-documented conditions, and their decline is usually expected.
When is a coroner’s postmortem required?
⚖️ A coroner’s postmortem is needed when the cause of death is unclear, such as:
- No known medical conditions
- Sudden or unexplained deterioration
- Death after surgery
- Unclear circumstances (does not necessarily mean foul play)
Why are postmortems not routinely performed?
💰 They are highly invasive, distressing for families, and expensive, so they are only done when necessary.
When is a perinatal postmortem performed?
🔬 It is conducted when a foetus dies in utero, during labor, or shortly after birth to investigate the cause of death.
Why is the placenta examined in perinatal pathology?
🌿 The placenta is stored for a period after birth to:
✅ Check for abnormalities
✅ Ensure full removal (preventing retained placenta)
✅ Investigate complications affecting mother or baby
What happens to the placenta after birth?
📦 If no complications arise, it is documented and incinerated. If complications occur, it is examined in detail to determine possible causes.
Can a placenta have abnormalities without causing complications?
🏥 Yes, some placentas show areas of infarction, scarring, or other abnormalities without affecting pregnancy. The placenta has reserve potential, meaning functional areas can compensate.
Why isn’t every placenta examined in detail after birth?
🔬 If the baby and mother are healthy, placental abnormalities are often insignificant. Examining every placenta could lead to unnecessary findings without clinical relevance.
Why is a perinatal postmortem offered to bereaved parents?
💔 It provides potential answers about why their baby died, helping with closure and future pregnancy planning.
How often do perinatal postmortems identify a cause of death?
📊 22-76% of cases, showing a large gap due to limitations in examination (e.g., maternal factors may not be assessed).
What is the UK perinatal mortality rate?
7.4 per 1,000 deliveries (SONS 2010), remaining stable for 10 years, equating to 5,340 deaths per year.
Why do perinatal mortality rates vary?
📉 They depend on data collection quality, maternal factors, and healthcare access. Mortality rates can differ by ethnicity and socioeconomic status, highlighting health disparities.
what are the common reasons for conducting a perinatal postmortem
🏥 To determine causes of:
Stillbirth
Pregnancy loss
Termination due to fetal anomalies
When are routine ultrasounds performed during pregnancy
~ at 11 to 14 weeks to confirm the number of fetuses and placental location
~ between 18 and 21 weeks of pregnancy to assess the morphology and detect fetal abnormalities
Besides ultrasound, how is fetal health assessed?
🩸 Maternal blood tests for infections (TORCH panel: Toxoplasmosis, Rubella, Cytomegalovirus, etc.), which can cause fetal abnormalities and death.
What is hydrops fetalis?
🌊 A condition where the fetus develops severe edema (swelling) due to fluid buildup.
What is the most common cause of hydrops fetalis?
🩸 Rh factor incompatibility (mother Rh-negative, fetus Rh-positive). If the mother was previously sensitised, her antibodies attack fetal red blood cells, causing anaemia and fluid accumulation.
what other factors can cause hydrops fetalis
👶👶 Twin pregnancy complications, fetal infections, genetic conditions, or heart/liver defects.
What does unexplained fetal growth retardation indicate for postmortem?
🚼 Unexplained fetal growth retardation may be identified via ultrasound, where lack of fetal movement or other issues might suggest complications.
What is unexplained fetal loss and why is postmortem necessary?
💔 Unexplained fetal loss can occur after 12 weeks of gestation, including antepartum (before labour) and intrapartum (during labour) stillbirths, necessitating postmortem to identify the cause.
What does antepartum mean
relating to the period before parturition ( before labour)
What does intrapartum mean
relating to the period of time between the start of labour and the birth of the baby and the expulsion of the placenta ( during labour)
when should a postmortem be performed on malformed fetuses or babies?
🍼 Malformations seen in ultrasound or identified at birth, either in stillbirth or neonatal death, are important postmortem indications.
Why is a postmortem necessary after neonatal intensive care?
🏥 If a baby requires intensive care after birth and later dies, a postmortem helps determine if any unseen complications contributed to the death.
What does SUDI stand for
Sudden unexplained death in infancy (SUDI - previously called SIDS)
When does SUDI occur
🛏️Sudden unexplained death in infancy (SUDI) occurs when a seemingly healthy baby dies suddenly, usually during sleep (cot death) and often requires a postmortem to investigate the cause
What measurements are important during the external examination of a fetus?
📐 Important measurements include body weight, head circumference, crown-to-heel length, crown-to-rump length, and foot length to compare development with the gestational age.
How can you identify growth retardation during external examination?
🧑⚕️ If the fetus is smaller than expected for its gestational age (e.g., a 28-week fetus appearing smaller), it may indicate growth retardation or earlier death.
What does maceration indicate in a fetus?
🩸 Maceration occurs when a fetus shows signs of skin breakdown, often with a translucent appearance and visible internal organs, suggesting the fetus may have been deceased for a longer period.
What are common abnormal findings during external examination?
⚠️ Abnormal findings include swelling, unusual color (e.g., meconium staining, indicating fetal distress), and abnormal pallor or oedema.
What does meconium staining indicate?
🟩 Meconium staining suggests fetal distress, where the fetus releases meconium (dark green substance / first stool) during delivery, which can stain the skin, placenta, and membranes.
What condition is suggested by a fetus with multiple fractures and bent long bones
🦴 Osteogenesis Imperfecta, a genetic disorder affecting collagen production, leading to fragile bones prone to fractures even with minimal trauma.
what are the key radiological and histological findings in osteogenesis imperfect?
🩻 Radiology shows multiple fractures, bent bones, and irregular white areas in the ribs, while histology confirms collagen abnormalities and defective bone calcification.
What are the key aspects examined in a fetal autopsy?
🏥 Internal examination includes cranial, thoracic, and abdominal cavities, a systematic description of major organs, their weights, and skeletal abnormalities
Why might a pregnancy be terminated in cases of skeletal dysplasia?
❌ If the bone abnormalities are severe (e.g., lethal Type II Osteogenesis Imperfecta), the fetus may not survive to term or would have severe deformities incompatible with life.
How does collagen affect bone development in osteogenesis imperfect?
🏗️ Collagen is a key component of osteoid, the organic matrix of bone. If collagen is defective, the bone cannot calcify properly, leading to brittle, easily fractured bones.
How can genetic tests help confirm osteogenesis imperfect ( OI)
🧬 Mutation analysis can identify defects in COL1A1 or COL1A2 genes, which are linked to OI. Karyotyping and fibroblast/DNA storage may also aid diagnosis.
Why are X-rays mandatory in suspected skeletal dysplasia?
🦴 X-rays confirm fractures, bone deformities, and abnormal ossification, helping to differentiate skeletal dysplasias from other conditions.
What special investigations may be performed in a fetal autopsy?
🩺 Tests may include bacteriology (🦠 blood/spleen/lung/CSF), virology (🦠 viral infections), karyotyping (🧬 chromosomal abnormalities), biochemistry (🧪 metabolic disorders), and haematology (🩸 blood disorders).
Why is it important to confirm prenatal diagnoses postmortem?
✅ To ensure prenatal findings were correct, as misdiagnoses can happen. This helps future parental counseling and improves diagnostic accuracy.
What is the typical gestational range for a full term baby
📆 36-42 weeks is the normal range for full-term birth.
why do more premature babies survive today compared to the past?
🏥 Advances in neonatal intensive care allow early-born babies to survive, but they may face developmental abnormalities or still succumb despite medical support.
What are the most common obstetric events leading to perinatal deaths?
🩸 Spontaneous preterm delivery and hypertensive disorders cause 28.7% of perinatal deaths.
What is the main cause of early neonatal deaths?
🍼 Prematurity accounts for 62% of early neonatal deaths.
What percentage of perinatal deaths are linked to fetal abnormalities?
🧬 Only 12% of perinatal deaths are due to fetal abnormalities.
Why are chromosomal disorders a common cause of fetal death or termination?
🧪 They can be detected through prenatal testing, cause developmental abnormalities, and often lead to early demise.
What are some common chromosomal disorders associated with fetal death?
🧬 Trisomy 21 (Down Syndrome) – 1 in 800-1,000 births
🧬 Trisomy 18 (Edward’s Syndrome)
🧬 Trisomy 13 (Patau’s Syndrome)
🧬 Triploidy
🧬 Turner Syndrome (45,X0)
What are the main methods for detecting chromosomal abnormalities in a fetus?
🩸 Amniocentesis – Invasive, risks infection and pregnancy complications
🧬 Chorionic villus sampling (CVS) – Previously invasive
🩸 Non-invasive prenatal testing (NIPT) – Detects fetal DNA in maternal blood
What risks are associated with gestational diabetes?
📏 Macrosomia – Larger baby size, increasing delivery risks
⚠️ Higher perinatal mortality
🧬 Increased malformation risk
🦠 Beta-cell hyperplasia & hyperinsulinemia – Due to fetal overstimulation from excess glucose
What is the difference between gestational diabetes and pre-existing diabetes in pregnancy?
🍬 Gestational Diabetes – Develops only during pregnancy, due to impaired glucose metabolism
🩸 Pre-existing Diabetes – Mother already diabetic before pregnancy
What is pre-eclampsia
⚠️ A pregnancy complication of unknown cause, characterized by:
📈 High blood pressure (hypertension)
🧪 Proteinuria (protein in urine)
📏 Intrauterine growth restriction (IUGR)
why can pre exclampsia cause problems in the baby?
Because it can reduce blood flow to the placenta which affects their development ( limiting the amount of oxygen and nutrients it receives)
How is pre-eclampsia monitored during pregnancy
🩸 Blood pressure checks
🧪 Urine protein tests
📏 Ultrasound for fetal growth
📉 Measurement of maternal belly size
If a woman has pre eclampsia in one pregnancy, is she at risk in future pregnancies?
⚠️ Yes – There is a higher chance of recurrence in future pregnancies.
Besides pre-eclampsia, what conditions can contribute to intrauterine growth restrictions (IUGR)
💊 Maternal drug abuse
🩸 Thrombophilia (blood clotting disorders)
🦠 Autoimmune disorders
🏥 Malformed uterus
what are autopsy findings for pre eclampsia
📉 Intrauterine Growth Restriction (IUGR)
⚖️ Asymmetrical fetal growth restriction
🧫 Placental pathology is crucial for diagnosis
What are signs of maceration in a foetus?
⚰️ Maceration occurs when a foetus has been retained in utero after death
🫀 Softening and discoloration of tissues due to autolysis
🦴 No fractures or abnormalities may be visible
⚠️ Risk of complications for the mother if not removed
What does a brain haemorrhage indicate in a preterm foetus?
🧠 Massive haemorrhage common in prematurity
⚖️ Poorly developed brain – grey and white matter not well separated
⚠️ Can lead to severe neurological damage or death
What is anencephaly, and what are its implications?
🧠 Absence of brain formation due to neural tube defect
⚰️ Incompatible with life – most affected foetuses do not survive long after birth
📅 Can be diagnosed prenatally and may lead to pregnancy termination
What is spina bifida, and how does it affect the baby?
🦴 Neural tube defect causing incomplete spine closure
📊 Spectrum of severity:
Mild cases – minimal impact on daily life
Severe cases – paralysis from the waist down
⚠️ Can lead to mobility issues and neurological complications
What are the external features of a baby with Reye’s syndrome?
👶 Swollen facial features
🩸 Liver and brain swelling due to metabolic dysfunction
⚠️ Can be fatal if not treated promptly
What is bowel atresia, and how does it affect the baby?
🫄 Congenital defect where part of the bowel is missing or blocked
🚫 Enlarged bowel due to lack of connection to rectum
⚠️ Requires urgent surgical correction
What is oesophageal atresia and why is it dangerous?
🫁 Oesophagus fails to connect to stomach
🔗 May be attached to trachea instead (tracheoesophageal fistula)
🥛 Newborns can inhale milk into lungs, leading to aspiration pneumonia
⚠️ Requires immediate surgery for survival
What is a single palmar crease and what does it indicate?
✋ Normally, two palmar creases are present, but in this instant there will be only one
🧬 A single palmar crease is associated with Down syndrome
⚠️ Historically referred to as the ‘Simian line’ (outdated and offensive)
How does insufficient amniotic fluid affect the foetus?
💧 Low amniotic fluid leads to wrinkled skin, most noticeable on fingers
🦾 Can be a sign of Potter’s syndrome due to kidney malformations
🚱 The foetus can’t produce enough urine, reducing amniotic fluid
why does low amniotic fluid lead to wrinkled skin
because the foetus doesn’t have enough fluid to keep its skin properly hydrated and smooth ( amniotic fluid typically serves to cushion the foetus and maintain the skin’s moisture).
What is Potter’s syndrome and how does it affect the foetus
🩸 Caused by kidney malformations that prevent the foetus from producing urine
🚱 Results in low amniotic fluid and can cause skin wrinkling
⚠️ Can lead to underdeveloped lungs and other complications
How is placenta position monitored and why is it important?
🖥️ Ultrasound tracks placenta location for complications
📍 Placenta is ideally positioned at the top of the uterus
⚠️ A low-lying placenta can complicate delivery and cause bleeding
what is the ideal placenta position
⚠️ The ideal placenta position is central, but it can sometimes be off-center
What are the risks of abnormal placenta position or cord insertion
🩸 Placenta at the periphery increases the risk of detachment and haemorrhage
📍 Abnormal cord insertion can cause complications with blood flow to the foetus
What is placental infection, and what condition is it often associated with?
🩸 A placental infarction is an area of dead tissue in the placenta
⚠️ Common in pre-eclampsia, which can put the mother at risk
🔍 The placenta has functional reserves, so some infarctions may not affect the pregnancy
What is chorioamnionitis and how does it affect pregnancy?
🦠 Chorioamnionitis is an infection of the amniotic membranes
⚠️ It can lead to preterm labour and foetal infection
🔬 Infections can come from the bloodstream or lower genital tract
Why is it important to gather as much information as possible during pregnancy monitoring?
📝 Detailed tracking of pregnancies improves outcomes
⚠️ Confusion or lack of information from doctors and trusts can affect care
👩⚕️ Organized prenatal care and visits are key for avoiding complications
