L13 - Post mortem in current practice (Dr Francesca Maggiani)

Question 1

What is the purpose of postmortem examinations in current medical practice?

Answer 1

🏥 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.

Question 2

What is the significance of a death certificate?

Answer 2

📝 A death certificate is a legal document that records the cause of death and ensures proper documentation for legal, financial, and insurance purposes.

Question 3

Who is resonsible for completeing a death certificate

Answer 3

👨‍⚕️ A registered medical practitioner who attended the deceased during their last illness must complete the certificate under the Births and Deaths Registration Act 1953.

Question 4

What are example health professions that can certify a death

Answer 4

health professionals at different levels: e.g. nursing staff, paramedic, or anyone who is competent and gets to the scene of death

Question 5

What must be included when certifying the cause of death

Answer 5

📄 The doctor must state the primary cause of death (“the smoking gun”) and any contributing factors to the best of their knowledge and belief.

Question 6

What is the difference between certifying death and completeing a death certificate?

Answer 6

✅ 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.

Question 7

Who can certify death vs who can issue a death certificate

Answer 7

🏥 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

Question 8

Can multiple people be involved in writing a death certificate?

Answer 8

👥 Yes, doctors may collaborate with other clinicians involved in the patient’s care, and sometimes consult the pathology team.

Question 9

Why is a death certificate legally important?

Answer 9

⚖️ It is needed for legal and financial purposes, such as inheritance, stopping or starting payments, and insurance claims.

Question 10

What are the main sections of a death certificate?

Answer 10

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.

Question 11

How does accurate death certification help public health?

Answer 11

📊 It aids in mortality statistics, epidemiological research, and resource allocation, helping guide funding and prevention strategies.

Question 12

Why are postmortems still commonly used in perinatal pathology

Answer 12

🍼 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.

Question 13

How does filling out a death certificate accurately benefit public health?

Answer 13

📊 It provides data for mortality statistics, helps track disease prevalence, and influences healthcare funding and prevention strategies.

Question 14

How is a cause of death structured in a death certificate?

Answer 14

🏥 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).

Question 15

What are the different types of death certificates for infants

Answer 15

👼 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.

Question 16

Why is distinguishing between neonatal death and stillbirth important?

Answer 16

🔍 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.

Question 17

When should the medical certificate of cause of death be used

Answer 17

🏥 It should be used for any death occurring after 28 days of life.

Question 18

When should the Neonatal death certificate ( Form 65) be used?

Answer 18

👶 It should be used for any death of a live-born infant occurring within the first 28 days of life.

Question 19

When should the Certificate of Stillbirth (Form 34) be used?

Answer 19

🤰 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.

Question 20

What are hospital postmortems, and why are they rarely performed today?

Answer 20

🏥 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.

Question 21

When is a coroner’s postmortem required?

Answer 21

⚖️ 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)

Question 22

Why are postmortems not routinely performed?

Answer 22

💰 They are highly invasive, distressing for families, and expensive, so they are only done when necessary.

Question 23

When is a perinatal postmortem performed?

Answer 23

🔬 It is conducted when a foetus dies in utero, during labor, or shortly after birth to investigate the cause of death.

Question 24

Why is the placenta examined in perinatal pathology?

Answer 24

🌿 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

Question 25

What happens to the placenta after birth?

Answer 25

📦 If no complications arise, it is documented and incinerated. If complications occur, it is examined in detail to determine possible causes.

Question 26

Can a placenta have abnormalities without causing complications?

Answer 26

🏥 Yes, some placentas show areas of infarction, scarring, or other abnormalities without affecting pregnancy. The placenta has reserve potential, meaning functional areas can compensate.

Question 27

Why isn't every placenta examined in detail after birth?

Answer 27

🔬 If the baby and mother are healthy, placental abnormalities are often insignificant. Examining every placenta could lead to unnecessary findings without clinical relevance.

Question 28

Why is a perinatal postmortem offered to bereaved parents?

Answer 28

💔 It provides potential answers about why their baby died, helping with closure and future pregnancy planning.

Question 29

How often do perinatal postmortems identify a cause of death?

Answer 29

📊 22-76% of cases, showing a large gap due to limitations in examination (e.g., maternal factors may not be assessed).

Question 30

What is the UK perinatal mortality rate?

Answer 30

7.4 per 1,000 deliveries (SONS 2010), remaining stable for 10 years, equating to 5,340 deaths per year.

Question 31

Why do perinatal mortality rates vary?

Answer 31

📉 They depend on data collection quality, maternal factors, and healthcare access. Mortality rates can differ by ethnicity and socioeconomic status, highlighting health disparities.

Question 32

what are the common reasons for conducting a perinatal postmortem

Answer 32

🏥 To determine causes of: Stillbirth Pregnancy loss Termination due to fetal anomalies

Question 33

When are routine ultrasounds performed during pregnancy

Answer 33

~ 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

Question 34

Besides ultrasound, how is fetal health assessed?

Answer 34

🩸 Maternal blood tests for infections (TORCH panel: Toxoplasmosis (from cat faeces), Other, Rubella, Cytomegalovirus, and Herpes Simplex.), which can cause fetal abnormalities and death.

Question 35

What is hydrops fetalis?

Answer 35

🌊 A condition where the fetus develops severe edema (swelling) due to fluid buildup.

Question 36

What is the most common cause of hydrops fetalis?

Answer 36

🩸 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.

Question 37

what other factors can cause hydrops fetalis

Answer 37

👶👶 Twin pregnancy complications, fetal infections, genetic conditions, or heart/liver defects.

Question 38

What does unexplained fetal growth retardation indicate for postmortem?

Answer 38

🚼 Unexplained fetal growth retardation may be identified via ultrasound, where lack of fetal movement or other issues might suggest complications such as fetal growth restriction, placental insufficiency, genetic factors, maternal health issues .....

Question 39

What is unexplained fetal loss (sstillbirth) and why is postmortem necessary?

Answer 39

💔 Unexplained fetal loss refers to fetal death : after 12 weeks of gestation, including antepartum (before labour) and intrapartum (during labour) stillbirths, necessitating postmortem to identify the cause.

Question 40

What does antepartum mean

Answer 40

relating to the period before parturition ( before labour)

Question 41

What does intrapartum mean

Answer 41

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)

Question 42

when should a postmortem be performed on malformed fetuses or babies?

Answer 42

🍼 Malformations seen in ultrasound or identified at birth, either in stillbirth or neonatal death, are important postmortem indications.

Question 43

Why is a postmortem necessary after neonatal intensive care?

Answer 43

🏥 If a baby requires intensive care after birth and later dies, a postmortem helps determine if any unseen complications contributed to the death.

Question 44

What does SUDI stand for

Answer 44

Sudden unexplained death in infancy (SUDI - previously called SIDS)

Question 45

When does SUDI occur

Answer 45

🛏️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

Question 46

What measurements are important during the external examination of a fetus?

Answer 46

📐 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.

Question 47

How can you identify growth retardation during external examination?

Answer 47

🧑‍⚕️ 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.

Question 48

What does maceration indicate in a fetus?

Answer 48

🩸 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.

Question 49

What are common abnormal findings during external examination?

Answer 49

⚠️ Abnormal findings include swelling, unusual color (e.g., meconium staining, indicating fetal distress), and abnormal pallor or oedema.

Question 50

What does meconium staining indicate?

Answer 50

🟩 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.

Question 51

What condition is suggested by a fetus with multiple fractures and bent long bones

Answer 51

🦴 Osteogenesis Imperfecta, a genetic disorder affecting collagen production, leading to fragile bones prone to fractures even with minimal trauma.

Question 52

what are the key radiological and histological findings in osteogenesis imperfect?

Answer 52

🩻 Radiology shows multiple fractures, bent bones, and irregular white areas in the ribs, while histology confirms collagen abnormalities and defective bone calcification.

Question 53

What are the key aspects examined in a fetal autopsy?

Answer 53

🏥 Internal examination includes cranial (carefully opening the skill to examine the brain, meninges observed for signs of inflammation) , thoracic (opening the chest - heart, thymus and major blood vessels) , and abdominal cavities (to observe the liver, spleen, kidneys, stomach, intestines, pancreas....) to come up with a detailed description of major organs, their weights, and skeletal abnormalities

Question 54

Why might a pregnancy be terminated in cases of skeletal dysplasia?

Answer 54

❌ 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.

Question 55

How does collagen affect bone development in osteogenesis imperfect?

Answer 55

🏗️ 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.

Question 56

How can genetic tests help confirm osteogenesis imperfect ( OI)

Answer 56

🧬 Mutation analysis can identify defects in COL1A1 or COL1A2 genes, which are responsible for producing type I collogagen (for bone structure and strength). Karyotyping and fibroblast/DNA storage may also aid diagnosis.

Question 58

Why are X-rays mandatory in suspected skeletal dysplasia?

Answer 58

🦴 X-rays confirm fractures, bone deformities, and abnormal ossification, helping to differentiate skeletal dysplasias from other conditions.

Question 59

What special investigations may be performed in a fetal autopsy?

Answer 59

🩺 Tests may include bacteriology (🦠 blood/spleen/lung/CSF), virology (🦠 viral infections), karyotyping (🧬 chromosomal abnormalities), biochemistry (🧪 metabolic disorders), and haematology (🩸 blood disorders).

Question 60

Why is it important to confirm prenatal diagnoses postmortem?

Answer 60

✅ To ensure prenatal findings were correct, as misdiagnoses can happen. This helps future parental counseling and improves diagnostic accuracy.

Question 61

What is the typical gestational range for a full term baby

Answer 61

📆 36-42 weeks is the normal range for full-term birth.

Question 62

why do more premature babies survive today compared to the past?

Answer 62

🏥 Advances in neonatal intensive care allow early-born babies to survive, but they may face developmental abnormalities or still succumb despite medical support.

Question 63

What are the most common obstetric events leading to perinatal deaths?

Answer 63

🩸 Spontaneous preterm delivery and hypertensive disorders cause 28.7% of perinatal deaths.

Question 64

What is the main cause of early neonatal deaths?

Answer 64

🍼 Prematurity accounts for 62% of early neonatal deaths.

Question 65

What percentage of perinatal deaths are linked to fetal abnormalities?

Answer 65

🧬 Only 12% of perinatal deaths are due to fetal abnormalities.

Question 66

Why are chromosomal disorders a common cause of fetal death or termination?

Answer 66

🧪 They can be detected through prenatal testing, cause developmental abnormalities, and often lead to early demise.

Question 67

What are some common chromosomal disorders associated with fetal death?

Answer 67

🧬 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)

Question 68

What are the main methods for detecting chromosomal abnormalities in a fetus?

Answer 68

🩸 Amniocentesis – Invasive, risks infection and pregnancy complications 🧬 Chorionic villus sampling (CVS) – Previously invasive 🩸 Non-invasive prenatal testing (NIPT) – Detects fetal DNA in maternal blood

Question 69

What risks are associated with gestational diabetes?

Answer 69

📏 Macrosomia – Larger baby size, increasing delivery risks ⚠️ Higher perinatal mortality 🧬 Increased malformation risk 🦠 Beta-cell hyperplasia & hyperinsulinemia – Due to fetal overstimulation from excess glucose

Question 70

What is the difference between gestational diabetes and pre-existing diabetes in pregnancy?

Answer 70

🍬 Gestational Diabetes – Develops only during pregnancy, due to impaired glucose metabolism 🩸 Pre-existing Diabetes – Mother already diabetic before pregnancy

Question 71

What is pre-eclampsia

Answer 71

⚠️ A pregnancy complication of unknown cause, characterized by: 📈 High blood pressure (hypertension) 🧪 Proteinuria (protein in urine) 📏 Intrauterine growth restriction (IUGR)

Question 72

why can pre eclampsia cause problems in the baby?

Answer 72

Because it can reduce blood flow to the placenta which affects their development ( limiting the amount of oxygen and nutrients it receives)

Question 73

How is pre-eclampsia monitored during pregnancy

Answer 73

🩸 Blood pressure checks 🧪 Urine protein tests 📏 Ultrasound for fetal growth 📉 Measurement of maternal belly size

Question 74

If a woman has pre eclampsia in one pregnancy, is she at risk in future pregnancies?

Answer 74

⚠️ Yes – There is a higher chance of recurrence in future pregnancies.

Question 75

Besides pre-eclampsia, what conditions can contribute to intrauterine growth restrictions (IUGR)

Answer 75

💊 Maternal drug abuse 🩸 Thrombophilia (blood clotting disorders) 🦠 Autoimmune disorders 🏥 Malformed uterus

Question 76

what are autopsy findings for pre eclampsia

Answer 76

📉 Intrauterine Growth Restriction (IUGR) ⚖️ Asymmetrical fetal growth restriction 🧫 Placental pathology is crucial for diagnosis

Question 77

What are signs of maceration in a foetus?

Answer 77

⚰️ 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

Question 78

What does a brain haemorrhage indicate in a preterm foetus?

Answer 78

🧠 Massive haemorrhage common in prematurity ⚖️ Poorly developed brain – grey and white matter not well separated ⚠️ Can lead to severe neurological damage or death

Question 79

What is anencephaly, and what are its implications?

Answer 79

🧠 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

Question 80

What is spina bifida, and how does it affect the baby?

Answer 80

🦴 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

Question 81

What are the external features of a baby with Reye's syndrome?

Answer 81

👶 Swollen facial features 🩸 Liver and brain swelling due to metabolic dysfunction ⚠️ Can be fatal if not treated promptly

Question 82

What is bowel atresia, and how does it affect the baby?

Answer 82

🫄 Congenital defect where part of the bowel is missing or blocked 🚫 Enlarged bowel due to lack of connection to rectum ⚠️ Requires urgent surgical correction

Question 83

What is oesophageal atresia and why is it dangerous?

Answer 83

🫁 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

Question 84

What is a single palmar crease and what does it indicate?

Answer 84

✋ 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)

Question 85

How does insufficient amniotic fluid affect the foetus?

Answer 85

💧 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

Question 86

why does low amniotic fluid lead to wrinkled skin

Answer 86

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).

Question 87

What is Potter's syndrome and how does it affect the foetus

Answer 87

🩸 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

Question 88

How is placenta position monitored and why is it important?

Answer 88

🖥️ 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

Question 89

what is the ideal placenta position

Answer 89

⚠️ The ideal placenta position is central, but it can sometimes be off-center

Question 90

What are the risks of abnormal placenta position or cord insertion

Answer 90

🩸 Placenta at the periphery increases the risk of detachment and haemorrhage 📍 Abnormal cord insertion can cause complications with blood flow to the foetus

Question 91

What is placental infection, and what condition is it often associated with?

Answer 91

🩸 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

Question 92

What is chorioamnionitis and how does it affect pregnancy?

Answer 92

🦠 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

Question 93

Why is it important to gather as much information as possible during pregnancy monitoring?

Answer 93

📝 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