Hutchinson, John Ciaran; (2019) Development of the minimally invasive paediatric & perinatal autopsy. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Introduction Perinatal autopsy contributes useful clinical information to patient management in approximately 40% of cases but remains poorly accepted due to parental concerns regarding disfigurement. Post-mortem imaging is an alternative, but 1.5 T MRI lacks resolution below 18 gestational weeks. Additionally, the Royal College of Pathologists autopsy guidelines recommend extensive tissue sampling as part of the investigation of fetal loss, which imaging alone cannot provide. Possible mitigating strategies include micro-CT for phenotyping small fetuses and laparoscopic techniques to obtain tissue samples. Interrogation of the evidence base for tissue sampling in different clinical scenarios is necessary to develop evidence-based practice and recommendations. Methods Minimally Invasive Autopsy with Laparoscopy (MinImAL) was performed in 103 cases. Micro-CT was optimised in extracted organs and the diagnostic accuracy evaluated in 20 fetuses. The Great Ormond Street Autopsy Database was retrospectively interrogated to investigate the yield of internal examination and visceral histology to the cause of death in 5,311 cases. Results MinImAL examination is reliable (97.8% successfully completed, 91/93) with good tissue sampling success rates (100% in lung, kidney, heart). Micro-CT offers an accurate method of scanning small fetuses (97.5% agreement with autopsy, 95% CI, 96.6-98.4) with fewer non-diagnostic indices than standard autopsy in < 14 weeks gestation (22/440 vs 48/348 respectively; p<0.001). Histology of macroscopically normal viscera is valuable in the investigation of infant and childhood deaths. However, it provides almost no useful information relevant to cause of death or main diagnosis (<1%) in fetal cases. Conclusions MinImAL examination offers a reliable method of internal examination and tissue sampling, which may be acceptable when standard autopsy is declined. Micro-CT provides an accurate, non-invasive method for phenotyping early gestation fetal anatomy. Histological sampling of macroscopically normal visceral organs is valuable when investigating infant or child deaths but of limited value in fetal loss and hence should not be routinely performed.

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