Miller Emily S, Minturn Lucy, Linn Rebecca, Weese-Mayer Debra E, Ernst Linda M
Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
Am J Obstet Gynecol. 2016 Jan;214(1):115.e1-6. doi: 10.1016/j.ajog.2015.08.049. Epub 2015 Aug 28.
The American Congress of Obstetricians and Gynecologists places special emphasis on autopsy as one of the most important tests for evaluation of stillbirth. Despite a recommendation of an autopsy, many families will decline the autopsy based on religious/cultural beliefs, fear of additional suffering for the child, or belief that no additional information will be obtained or of value. Further, many obstetric providers express a myriad of barriers limiting their recommendation for a perinatal autopsy despite their understanding of its value. Consequently, perinatal autopsy rates have been declining. Without the information provided by an autopsy, many women are left with unanswered questions regarding cause of death for their fetus and without clear management strategies to reduce the risk of stillbirth in future pregnancies. To avoid this scenario, it is imperative that clinicians are knowledgeable about the benefit of autopsy so they can provide clear information on its diagnostic utility and decrease potential barriers; in so doing the obstetrician can ensure that each family has the necessary information to make an informed decision.
We sought to quantify the contribution of placental pathologic examination and autopsy in identifying a cause of stillbirth and to identify how often clinical management is modified due to each result.
This is a cohort study of all cases of stillbirth from 2009 through 2013 at a single tertiary care center. Records were reviewed in a stepwise manner: first the clinical history and laboratory results, then the placental pathologic evaluation, and finally the autopsy. At each step, a cause of death and the certainty of that etiology were coded. Clinical changes that would be recommended by information available at each step were also recorded.
Among the 144 cases of stillbirth examined, 104 (72%) underwent autopsy and these cases constitute the cohort of study. The clinical and laboratory information alone identified a cause of death in 35 (24%). After placental pathologic examination, 88 (61%) cases had a probable cause of death identified. The addition of autopsy resulted in 78 (74%) cases having an identifiable probable cause of death. Placental examination alone changed clinical management in 52 (36%) cases. Autopsy led to additional clinical management changes in 6 (6%) cases.
This stepwise assessment of the benefit of both placental pathological examination and autopsy in changing probable cause of death beyond traditional clinical history and laboratory results emphasizes the need to implement more comprehensive evaluation of all stillbirths. With the aim of providing a cause of stillbirth to the parents, and to prevent future stillbirths, it behooves health care professionals to understand the value of this more comprehensive approach and convey that information to the bereaved parents.
美国妇产科医师学会特别强调尸检是评估死产最重要的检查之一。尽管有尸检的建议，但许多家庭会基于宗教/文化信仰、担心孩子遭受更多痛苦，或认为无法获得额外信息或信息无价值而拒绝尸检。此外，许多产科医护人员表示，尽管他们了解围产期尸检的价值，但存在诸多障碍限制他们推荐进行围产期尸检。因此，围产期尸检率一直在下降。由于没有尸检提供的信息，许多女性对于胎儿的死因仍有疑问，并且没有明确的管理策略来降低未来妊娠中死产的风险。为避免这种情况，临床医生必须了解尸检的益处，以便他们能够提供关于其诊断效用的明确信息并减少潜在障碍；这样产科医生可以确保每个家庭都有必要的信息来做出明智的决定。
我们试图量化胎盘病理检查和尸检在确定死产原因方面的贡献，并确定每种结果导致临床管理改变的频率。
这是一项对2009年至2013年在单一三级医疗中心发生的所有死产病例的队列研究。记录以逐步方式进行审查：首先是临床病史和实验室结果，然后是胎盘病理评估，最后是尸检。在每个步骤中，对死因和该病因的确定性进行编码。还记录了每个步骤可获得的信息所建议的临床改变。
在检查的144例死产病例中，104例（72%）接受了尸检，这些病例构成了研究队列。仅临床和实验室信息确定了35例（24%）的死因。胎盘病理检查后，88例（61%）病例确定了可能的死因。加上尸检后有78例（74%）病例确定了可识别的可能死因。仅胎盘检查在52例（36%）病例中改变了临床管理。尸检导致另外6例（6%）病例的临床管理发生改变。
这种对胎盘病理检查和尸检在改变可能死因方面的益处进行的逐步评估，超出了传统临床病史和实验室结果，强调了对所有死产实施更全面评估的必要性。为了向父母提供死产原因，并预防未来的死产，医疗保健专业人员理应了解这种更全面方法的价值，并将该信息传达给失去亲人的父母。
