Reference & Suggested Readings:

01. https://www.myindiamyglory.com/2018/08/21/ancient-indians-knew-science-of-fertilization-without-
microscope-wow-facts/
02. Jaiman S. Placental evaluation in unexplained intrauterine fetal death: O1-8. APMIS : acta
pathologica, microbiologica, et immunologica Scandinavica. 2013;121.
03. Textbook of Fetal and Perinatal Pathology. Editors: Jonathan S. Wigglesworth, Don B. Singer
United Kingdom: Blackwell Scientific Publications, 1991.
04. Encha-Razavi F, Gonzalès M, Laquerrière A, Martinovic J, Sinico M, Allias F, et al. A practical
approach to the examination of the malformed fetal brain: impact on genetic counselling.
Pathology. 2008;40:180-7.
05. Nahmias AJ. The TORCH Complex. Hospital Practice. 1974;9(5):65-72.
Fetal Autopsy procedure and intergration of Genetic workup

Technique of fetal autopsy and its role in syndromic diagnosis

Dr. Asaranti Kar, Secretary, IAPM

Associate Prof., Pathology, SCB Medical College, Cuttack

Intrauterine fetal demise or termination for malformation are rare adverse obstetric outcomes,
agonizing for the parents and frustrating for health care providers. These events are often unpredictable
and investigation necessary are not only the evaluation of the fetus/neonate but also the
placenta/umbilical cord. In recent times, with extensive advances in the pediatric specialty, the
significance and requirements for perinatal autopsy have also multifolded. Perinatal autopsy is
considered as the gold standard in evaluation of perinatal deaths. Out of several types of autopsy, we
will be discussing clinical/ pathological autopsy. As all are aware, there are different methods for doing
autopsy and removing organs from body. Whatever may be the method, it’s necessary to perform the
1st few essential steps like documenting maternal and fetal demographic factors, anthropometry which
includes weight of fetus and placenta, measurements of CRL, CHL, HC, CC and foot length and external
examination to find out the congenital anomalies. This is followed by skin incision (usually an inverted
“Y” shaped incision) and examination of internal organs for any abnormality. Organs can be removed in
several ways: The first is the en masse technique of Letulle whereby all the organs are removed as one
large mass. Thoracic, cervical, abdominal, and pelvic organs are removed en masse (as a whole) and
subsequently dissected into organ blocks. Rokitansky method is an in situ examination of viscera, in part
combined with en bloc removal. In the Virchow technique, the organs are removed one by one and
dissected as removed. The en bloc method of Ghon or en bloc removal of viscera into functionally
related blocks is a compromise between the Virchow and en masse techniques. The choice of technique
is made at the time of the autopsy by the prosector with the intent to obtain the maximum information
possible. En bloc removal of organs in perinatal autopsy has become popular recently. In this method
the whole mass is divided into four groups of organs thoracic, cervical, abdominal and urogenital
allowing the prosector to retain a continuity in organ architecture during the subsequent dissection.
Neck organs include thymus, trachea, thyroid, thoracic organs- esophagus, heart, thoracic aorta and
lungs, abdominal organs- intestines, liver, gallbladder and bile duct system, pancreas, spleen, adrenal
glands, kidneys, pelvic or urogenital organs-ureter, urinary bladder, uterus and ovaries (male genital
organs).

En bloc technique: A large and deep Y-shaped incision is made starting at each mastoid process and
running down the front of the chest, meeting at the lower point of the sternum (breastbone). the incision
then extends all the way down to the umbilicus encircling it on left side and moving still down till
symphysis pubic bone. Skin and muscles are reflected. The neck organs are exposed like trachea, thymus
and thyroid and removed as one bloc. The thoracic cavity is entered by first incising the sternoclavicular
joints and then cutting the ribs 4 mm from the costochondral junction Cut through the ribs on the costal
cartilage is done, to allow the sternum to be removed. After removing the sternum from the soft tissue
that attaches it to the mediastinum, the heart and lungs can be seen in situ and that the heart, in
particular, the pericardial sac is not damaged or disturbed from opening. The great vessels like aorta,
ductus arteriosus, and the pulmonary trunk and the pulmonary veins examined.Cardiothoracic ratio is
recorded and the thoracic situs determined.
The abdominal cavity is opened by the side of the umbilical vein, finger inserted under the umbilicus and
the umbilical arteries. The abdominal organs are usually examined first commencing with recording of
the situs. The position of parts of intestine and the mesenteric attachment are inspected. The domes of
the diaphragm are inspected. The liver, its visceral surface along with gall bladder, portahepatis, and the
lesser omentum are examined. Visual inspection of the spleen, splenic artery, and the pancreas can be
done by displacing the stomach and transverse colon. This can also help in inspection of right kidney and
associated organs. The descending colon can be retracted medially along with the peritoneum to
visualize left kidney, left supra renal gland, and the left ureter. The presence of anomalies is documented.
Uterus, ovaries, and fallopian tubes in the female and testes in the male are identified. Depending on
anomalies present or on the pathologist, slices can be taken from different organs and subjected to HP
study.

Syndromic diagnosis:

Congenital anomalies are broadly categorised into isolated, sequence, multiple anomalies, association
and syndromes. Pattern of multiple anomalies are thought to be pathologically related either due to
genetic/ environmental causes or gene-environment interactions. Two syndromes diagnosed by autopsy
(one with genetic confirmation, second without) are discussed here.

Meckel Gruber syndrome-Meckel–Gruber syndrome (MGS) is a rare lethal congenital malformation not
compatible with life; affecting 1 in 13,250–140,000 live births. This is autosomal recessive in inheritance;
characterized by the classical triad of multicystic dysplasia of kidney, occipital encephalocele, and
polydactyly, which are observed in 100%, 90%, and 83.3% cases, respectively. Besides the clinically
recognized classic malformations, it can be variably associated with oral clefting, central nervous system
(CNS) malformations such as anencephaly, holoprosencephaly, polymicrogyria, cerebellar hypoplasia,
pulmonary hypoplasia, and hepatic fibrosis.
A 23-year-old primigravida with nonconsanguineous marriage presented with 20 weeks of gestation for
routine antenatal examination. There was no antenatal history of any infection, teratogenic drug intake,
hypertension, diabetes mellitus, or radiation exposure to the mother. Routine USG showed features of
anencephaly with bilateral multicystic kidneys and amniotic fluid index of 4.0 ml. With the consent of
parents, the pregnancy was terminated, and the fetus was sent for neonatal autopsy .

The weight of the fetus was 350 g; the CRL was 18 cm, CHL 33.5cm, HC 16 cm, CC 18 cm, and foot length
was 3cm. External examination of head and neck revealed encephalocele through posterior fontanelle,
low-set, deformed right ear , microcephaly microphthalmia, orbital hypertelorism , micrognathia, cleft
lip and palate, flat nose with broad nasal bridge. lobulated tongue and neonatal teeth (upper and lower
lateral incisors). Both upper limbs and right foot showed postaxial polydactyly with right side club foot.
The internal examination was done after giving Y shaped incision. Both thorax and abdomen were
opened. The heart was dissected out of the thorax and after opening revealed bifid apex with left atrial
thrombus. The liver was enlarged showing surface congestion. Microscopic examination of the liver
showed features of hepatic fibrosis, lymphocytic infiltration, and reactive bile ductular proliferation.
Both kidneys were found to be enlarged each measuring 5.5 cm × 3.5 cm × 3 cm. On cut section, multiple
minute cysts of various sizes were detected, with bilateral adrenal agenesis. Histopathological
examination revealed multiple cystically dilated spaces lined by flattened epithelium with severely
deficient nephrons. Other viscera were normal both in the gross and microscopic examination. Based on
the presence of above classical features, a diagnosis of MGS was suggested. The parents of the baby did
not give consent for genetic analysis.
Edward syndrome: Trisomy 18 (either full, mosaic trisomy, or partial trisomy 18q) is an autosomal
chromosomal disorder accounting for 1 in 3600 to 1 in 10,000 live births. Prevalence of this lethal
condition is increasing over last years due to advance maternal age. These are characterized by both
major and minor anomalies of multiple systems including heart, kidney and intestine with craniofacial
features.
32 year old female with 29 weeks of gestation without antenatal check up presented to Gynec OPD with
loss of fetal movements. She belonged to low socioeconomic group, didn’t have history of diabetes,
hypertension, addiction and consanguineous marriage. Ultrasonography showed intrauterine death of
fetus with cleft lip and palate, absence of intestinal loops, single umbilical artery. It was subsequently
delivered vaginally. After obtaining informed consent, autopsy was done. Weight of fetus was 1050 gms.
External examination revealed multiple anomalies like bilateral cleft lip, cleft palate, short neck, swollen
abdomen, imperforate anus and ambiguous genitalia. Internal examination showed collapsed lungs,
absence of spleen, intestine, ascites, agenesis of right kidney and streak gonads which was confirmed by
histopathology. Sections from other organs didn’t reveal any abnormality.2 ml of cord blood was
collected in heparin vial during delivery and sent immediately to genetic lab and a diagnosis of Edward
syndrome was confirmed with an extra copy of chromosome 18 in karyotype.

There needs to be a methodical approach for detection of all birth defects so that an accurate
diagnosis can be done which will provide scope for recurrent risk counselling of parents and proper
management decisions can be taken for both the ongoing and future pregnancies. In these cases, a
meticulous autopsy is necessary to document complete anomalies and syndrome diagnosis.
-x-
 Neuropathology in the Fetal and Perinatal Period

Dr. Uttara Chatterjee,

MD (Pathology)
Professor (Pathology), IPGME&R, Kolkata, India
uttarac1@gmail.com

Abnormalities of the CNS are an important cause of fetal loss and perinatal deaths. The prevalence of
CNS abnormalities is approximately 5-10/1000 births. CNS malformations are seen in about 15% of
infants dying due to causes associated with birth defects and 75% of fetal deaths are attributed to
structural abnormalities of the CNS. Most of these are structural abnormalities of the CNS. However, a
smaller portion show changes pertaining to prematurity, infections and even congenital tumors. The
abnormalities of the CNS are of diverse morphology and etiology. Genetic defects, infections, teratogens,
irradiation, maternal diseases or medications have been implicated in these malformations. Different
entities result from a complex interaction between different genes and poorly understood environmental
factors. Congenital CNS malformations are broadly divided in descriptive terms such as neural tube
defects(NTDs), segmentation and cleavage abnormalities, abnormalities of sulcation, organization,
migration and posterior fossa abnormalities. Of these, NTDs are the commonest in all reported series.
An understanding of the embryology of CNS is essential to an understanding of its malformation. The
brain and spinal cord are formed through a complex series of embryologic stages which include dorsal
induction, ventral induction, neuronal proliferation, migration, organisation and myelination.
Neural tube defects are the most frequent CNS malformation and comprise a wide spectrum varying in
severity and location. The defects can range from anencephaly/craniorachichisis, the most severe form
to spina bifida occulta with no symptoms at all. NTDs affect 0.5-2 per 1000 pregnancies, world-wide and
are the second commonest group of birth defects, after congenital heart defects.Abnormalities of
gastrulation gives rise to neuroenteric cysts and split cord malformation, abnormalities of primary
neurulation give rise to the open NTDs, non-disjunction of mesoderm gives rise to limited dorsal
myeloschisis, dermal sinuses, premature dysjunction gives rise to dorsal spinal lipomas and abnormalities
of secondary neurulation gives rise to lipomas (complex), thickened filum, myelocystocele, caudal
regression and retained spinal cord. The risk of recurrence is 2-5% in siblings. USG can detect anencephaly
from 12 weeks and spina bifida from 16-20 weeks.However, small spina bifidas particularly in the lumbo-
sacral region can be missed. Clinical methods have been developed and refined for the prenatal diagnosis
and in-utero surgical repair of NTDs.
Disorders of cortical development include microcephaly which can be because of genetic or non-genetic
causes and megalencephaly. The neuronal migration defects include agyria –pachygyria, lissencephaly,
neuronal heterotropias and polymicrogyrias. These are often associated with epilepsy, autism and
schizophrenia. Disorders of regionalisation include holoprosencephaly. Depending upon the severity, a
range of morphologies can be seen. The severity of face and brain abnormalities go hand in hand and
50% are associated with trisomy 13 or 18.
Foetal & Perinatal Infections
Foetal & Perinatal Infections

Dr Sunil Jaiman MBBS; MD; DipRCPath (UK); FCAP (USA)

Assistant Professor & Section Head Placental Lab

Department of Pathology, Wayne State University School of Medicine

Perinatology Research Branch NICHD, NIH
4 Brush/3990 John R/Detroit/MI 48201 USA
sjaiman@med.wayne.edu (o)

jaiman.sunil@yahoo.dk (pers)

Human pathogens can damage the developing nervous system in utero or perinatally is a concept
that has been appreciated for over a century. Although numerous infectious agents are encountered during
pregnancy, relatively few pathogens cross the placenta and cause intrauterine fetal infections. In the 1970s
investigators at Emory University and the Centers for Disease Control and Prevention (CDC) coined the
term TORCH, an acronym underscoring Toxoplasma gondii, Rubella virus, Cytomegalovirus, and
Herpesviruses as important, potential causes of congenital infection (1). TORCH, organisms constitute a
modest number of human pathogens that cross the placenta and infect the fetus.

Due to the immaturity of the immune system, congenital and perinatal infections represent major
causes of permanent disability worldwide and the newborn infants are at risk for postnatally acquired
infections with certain viruses and several bacteria. These pathogens, along with the emergence of Zika
virus remain important causes of cerebral palsy, epilepsy, and intellectual disability.

Evidence of SARS-CoV-2 vertical transmission is scarce. At present, the influence of SARS-CoV-

2 as a cause of late pregnancy loss is not clear. Increases in stillbirth rates have been reported during the
pandemic; however, only a few cases of late pregnancy loss have been deemed to be related to SARS-
CoV-2 infection (2). Early postnatal transmission has been described more frequently with most infected
newborns remaining asymptomatic or with mild symptoms that evolve well during follow-up (3).
Maternal characteristics predisposing infants to neonatal infection have not been described as yet (3).
Although vertical transmission has been rarely observed in SARS-CoV-2 to date, given the potential for
profound maternal immune activation (MIA), impact on the developing fetal brain has been suggested (4)

Features of congenital infections

Great majority of infected fetuses show hydrops, hepatosplenomegaly and are macerated. Fetal
hydrops in previable fetuses varies from mild to severe. The most common infections of the fetus
associated with fetal hydrops are cytomegalovirus, toxoplasmosis, and parvovirus infection. The hydrops
is usually caused by a combination of different factors such as hemolytic anemia, hypoalbuminemia
caused by liver disease, and myocardial infection (5).