PPT on pediatric autopsy

1. ‘Oh Death Where is Thy Victory
Oh Death Where is Thy Sting.’
(I Corinthians 15:55)
PRESENTED BY : MAJ PRERNA GULERIA
GUIDE : COL V SRINIVAS

2. INTRODUCTION
 Pediatric age group: birth to 18 yrs of
age
 Perinatal & Neonatal
 Infant (1 yrs) to 2 yrs of age
 > 2 yrs: similar to adults

3. PURPOSE OF THE AUTOPSY
 Establishing the definitive cause and manner of death
 Detect deviations in growth and development
 Recognize organ and tissue pathology
 Explain clinical events and make clinicopathological
correlation

4. PURPOSE OF THE AUTOPSY
 The efficacy and safety of new diagnostic or
therapeutic interventions
 Identification of genetic conditions or obstetric
factors that may be of relevance to the
management of future pregnancies
 Monitor health care, provide education, direct
research and determine health care policy

5. PREPARATION FOR AUTOPSY
 Check the type of consent given
 Confirmation of the identity of the child
 Medical case sheet
 Consultation with clinicians
 Desirable studies
 Diagnosis considered in life
 Potential iatrogenic hazards
 Any atypical features
 Measures to prevent infection

6. IMAGING
Radiograph of the whole body help to
determine
 Ossification centers
 In skeletal dysplasias
 Metaphysitis of the long bones
 congenital infections such as syphilis
 Documentation of pneumothorax
 Location of lines and tubes

7. MRI
 Used for detecting malformations and
diseases of the central nervous system
 When consent for an autopsy is
refused, it provides a good alternative
 Potential tool in neonatal autopsy
 May replace conventional post mortem
in future

8. PHOTOGRAPHY
 Full body, face and facial profile photographs help
in diagnosis and can be used for consultation
 Black and white prints can be kept with the
paperwork providing for easy comparison with
reference books
 Photographs of malformations are essential

9. EQUIPMENT NEEDED
 Set of scales – giving
accurate weight to 1gm
 Measuring board –fixed
head and movable foot
 Autopsy instruments
 Appropriate size
 Scissors with tapered tines
 Forceps without teeth
 Small probes

10. EXTERNAL EXAMINATION

11.  Facial measurements
 Weight of the neonate
 Comparison with standard
charts available
MORPHOMETRY

12. MORPHOMETRY

13. MORPHOMETRY
 Crown rump length = 2/3 of crown heel length
 Crown rump length and head circumference do not differ by
more than 1 cm
 Foot length useful in
 Fetus of early gestational age
 Severely macerated fetus
 Anencephaly
 D&E specimens
 Facial, ear, hand and other organ measurement in cases of
suspected dysmorphology
 The infant can be classified as small, appropriate and large for
gestational age according to its weight

14. HEAD & SKULL
 Examination of hair and any abnormal hair patterns or
whorls
 Shape and size of skull
 Examine for abrasions, cephalhaematoma or
subaponeurotic hemorrhage
 Bulging fontanelles indicate intracranial disorder
 The presence of additional fontanelles or defects of the
skull: possibility of a chromosomal defect or Meckel–
Gruber syndrome

15. HEAD & SKULL
 Splayed sutures
hydrocephalus
 Premature fusion of the
sutures
craniosynostosis

16. FACE
 Facial symmetry
 Any dysmorphism
 Position and flexibility of ear lobe
 Choanal atresia :
CHARGE syndrome (coloboma, heart
disease, atresia choanae, and retarded
growth and development)

17. FACE
 Cleft lip and palate
 Macroglossia
 Beckwith Weidemann syndrome
 With abnormalities of the CNS
 Micrognathia, retrognathia or
agnathia
 Aneuploidy
 A horizontal crease on the chin
 Renal disease

18. SKIN
 Appearance
 Length of toe nails and finger nails
 Findings of meconium staining,
abnormal nutrition, deviations of
hydration and edema
 Skin lesions
 Multiple haemangiomas suggest Osler-
Rendu-Weber syndrome
 Leaf-shaped cafe´au lait spots suggests
tuberous sclerosis

19. SKIN
 Bullae, pustules or scaling
lesions
 Congenital varicella zoster
 Congenital syphillis
 Hemorrhages or blueberry
muffin
 Haematological condition
 Congenital infection
 hypoxia

20. SKIN
 Ichthyosis vs maceration: If in
doubt, take a skin biopsy
 Amount of lanugo should be
assessed in a newborn
 Needle puncture marks and
intact catheters

21. NECK
 Lateral skin webbing
 monosomy X (XO)
 multiple pterygium syndrome
 Postnuchal cystic hygroma
 XO
 Trisomy 21and 18
 A groove around the neck with
congestion of the face
 strangulation by the umbilical cord

22. CHEST
 A small abnormally shaped
chest with short ribs
 skeletal dysplasias
 A bell-shaped chest
 pulmonary hypoplasia occuring
with anhydramnios

23. CHEST
 Asymmetrical bulge
 diaphragmatic hernia
 Pneumothorax
 Size of the breast bud
 Palpable crepitus
 following difficult ventilation

24. ABDOMEN
 Abdominal distention due to
 ascites
 organomegaly
 gaseous distension of the bowel
 intestinal obstruction
 rarely, a tumor
 Defects of the body wall may be
related to a short umbilical cord

25. ABDOMEN
 Localized defect near the umbilicus
 gastroschisis
 Failure of the bowel to return into
the abdomen during development
 omphalocoele
OMPHALOCOELE
GASTROSCHISIS

26. GENITALIA
The external genitalia
 Descent of testes in males
 Extent of scrotal rugation
 Maturity , malformations and
ambiguity
 Vagina in females is probed
 Associated renal and anal anomalies
Male
Female

27. BACK
 Scoliosis
 Defects of the neural tube
 Pigmented lesions
 Abnormal tufts of hair
 Midline masses
MENINGOMYELOCOELE

28. EXTREMITIES
 A simian crease: Trisomy 21
 Polydactyly : Trisomy 13 and some
skeletal dysplasias
 Overgrowth of a digit: Proteus
syndrome
 Syndactyly of the third and fourth
digits: Triploidy

29. EXTREMITIES
Arthrogryposis
Rockerbottom
Trisomy 18
Amnion bands

30. INTERNAL EXAMINATION

31. SKIN INCISION
 Y or T- shaped incision used
 Arms of the Y to the top of the
shoulders
 Vertical incision in the midline from
xiphoid process to pubic symphysis
 Deviation around the umbilicus: to
remove it in continuity with umbilical
arteries and veins

32.  Girls > 5 years: incision extended only to axillary line
 With well developed breasts : initial incision to lie above
the breast tissue
 If genitourinary or anal abnormality suspected, incision
extended around the perineum to include external
genitals and anus
SKIN INCISION

34. BEFORE DISSECTION
 Suspected cases of pneumothorax, haemothorax, or
pleural effusion
 Look for air bubbles
 Attempt to aspirate fluid
 If present, amount aspirated measured accurately

35. THE ABDOMEN
 In situ examination : colour, size and relationship of organs
 Inflammation, infarction, ascites, pneumoperitoneum and
surgical wounds
 Anomalies to look for
 Malrotation
 Strictures
 Atresia
 Hernia
 Ectopic tissue
 Levels of hemidiaphragm

36. THE ABDOMEN
 Liver examined for symmetry
 Spleen for multiplicity
 Bladder for distention
 Stomach and gall bladder for location
 Greater omentum for transparency
 State of lymph nodes

37. THE ABDOMEN
 Examine kidneys, ureters, adrenals and
internal genitalia
 Look for :
 Bladder hypertrophy
 Hydronephrosis
 Renal dysplasia
 Note testicular descent
 In females, uterus, fallopian tubes and
ovaries to be identified
Lower urinary tract obstruction

38. THORACIC CAVITY
 Removing the chest wall
 Assessing the hemidiaphragm
 Observe position of chest tubes
 Mediastinal emphysema
 Cultures of lung tissue, pleural
fluid and heart blood

39. THORACIC CAVITY
 Thymus
 Atrophy : prolonged stress
 Petechial haemorrhages
 Phrenic nerve on either side
 Absence : DiGeorge syndrome
 Extent of lung distention and
pleural content
 Measure cardio-thoracic ratio

40. THORACIC CAVITY
 Expose great vessels by removing
pericardium and thymus
 Taussig maneuver to assess
pulmonary venous connection in
situ:
 If the heart can be lifted from the
chest without moving the lungs,
there is an anomalous
pulmonary venous connection

41. THORACIC CAVITY
 Evaluation of congenital anomalies : better if heart
opened in situ
 Dissection of heart and blood vessels follows the
course of blood
 Conduction system dissection : in case of arrythmias
 Ligation of arteries
 Done in older children, not required in newborns
 Right and left carotids
 Subclavian
 Common iliacs

42. SCALP
 Scalp incision from one pinna to another
in the vicinity of the posterior fontanelle
 Reflection of anterior and posterior flaps
 Question mark incision
 Fontanelles to be measured
 Examine sutures for orientation and
movability

43. OPENING OF SKULL
 Incision given along the suture
lines
 Incision kept about 1/4th inch
away from mid line to avoid
damage to falx and sinuses
 Bone flaps are reflected
downwards to expose cerebral
hemisphere (flower petal
incision)
 Inspect brain, falx and tentorium
 Falx removed along with sagittal
sinus

44. OPENING OF SKULL

45. REMOVAL OF BRAIN
 Head is tilted to let the brain fall
 All attachments are freed from front to back
 Cervical cord is cut as far caudally as possible
 Brain slides out into the prosector’s hand
 Suspended in 10 times its volume of 10% buffered
formalin (5% glacial acetic acid may be added to
promote hardening)
 Dural sinuses to be examined for thrombi
 Pituitary to be removed
 Markedly macerated or hydrocephalic brain to be
removed under water

46. EARS AND EYES
 Middle ears to be inspected and cultured
 Petrous temporal to be incised and ossicles and drum
inspected in situ
 Remove and process if anomalies of the ear suspected
 Remove eyes: h/o prolonged exposure to oxygen
 By removing base of anterior fossa
 Exteriorly with an ophthalmology retractor

47. SPINAL CORD
 Removed by anterior approach : if opisthotonic position
 Posterior approach: if Arnold-Chiari malformation
present
 Remove 1-2 lower lumbar vertebrae, then cut along on
each side in the cranial direction
 Dura is cut in the midline, tranversely at the filum
terminale and stripped of progressively cranially
 In meningomyelocoele, vertebral bodies removed along
with the cord

48. LIMBS
 Indicated only in few instances
 Hip dissection undertaken in severe talipes to confirm
dislocation
 Suspected congenital neuromuscular disorders
peripheral muscles should be sampled and examined

49. EXAMINATION OF PLACENTA
 Initially examined in unfixed state with membranes
and blood clot
 Site of rupture of sac
 Membranes are clear or cloudy
 Offensive odor &staining with meconium
 Length, site of attachment, appearance of umbilical cord
 Weight of placenta

50. SECTIONS FROM PLACENTA
RECOMMENDED SECTIONS
•Two sections of cord
•Membrane roll (Swiss Roll)
•Two full-thickness non-marginal normal
disc
•Areas of Abnormalities

51. PLACENTA
 Hypercoiling of the umbilical cord :
hypoxia
 Chorioamnionitis : most common
placental lesion associated with cerebral
palsy in term and preterm infants
 Extensive placental infarction
 ischaemic cerebral injury
 periventricular white matter necrosis in
stillbirths.

53. DISSECTION OF ORGANS

54. DISSECTION OF ORGANS
 Organs preferrably removed ‘en mass’
 Block of organs stretched longitudinally over a suitable
surface
 Examination of tongue
 Remnants of thyroglossal duct
 Pharynx opened first
 Inspection of tonsillar pillars, soft palate, uvula, hyoid
bone

55. DISSECTION OF ORGANS
 Incision proceeds caudally through the midline of
oesophagus to the level of the diaphragm close to the
oesophago-gastric junction
 Look for ectopic gastric mucosa
 Tracheo-esophageal fistula (TOF): trachea to be opened
anteriorly
 Separate oesophagus and pharynx to expose the
posterior wall of pericardium

56.  Interior of larynx inspected:
 Inflammation
 Ulceration
 Foreign bodies
 Level of endotracheal tube, if present
 Neck organs cut away en bloc from the main unit
 Tonsils removed with a cuff of surrounding mucosa
 Tongue with hyoid bone fixed as a whole
 Larynx, trachea and thyroid : fixed as a single unit
DISSECTION OF ORGANS

57.  Abdominal aorta opened: longitudinally in the midline
upto the bifurcation of the common iliac arteries
 Renal arteries, coeliac and superior mesenteric arteries
inspected
 Thoracic organs separated by cutting across IVC close
to the diaphragm
DISSECTION OF ORGANS

58.  If no congenital anomalies present, heart separated
from the lungs; aortic arch and thoracic aorta left
attached to the heart
 Note: sizes of the chambers, epicardial surface, valves,
state of the myocardium and thickness of the
ventricular walls
 In newborns, diameter of ascending aorta, ductus
arteriosus and pulmonary trunk measured
DISSECTION OF ORGANS: HEART

59.  Assess pattern of lobulation, distribution of major
bronchial branches
 Inflate the lungs with 10% buffered formalin through
the main bronchus
 Lung dissected by slicing on cutting board or opening
along pulmonary arteries
DISSECTION OF ORGANS : LUNGS

60. DISSECTION OF ORGANS
 IVC and renal veins opened
 Diaphragm removed with the crura in one piece
 Each adrenal removed and periadrrenal renal tissue
inspected

61.  Each kidney freed, hemisected in the coronal plane
and capsule removed
 Observe number and colour of pyramids, size and
shape of the pelvis
 Ureter opened from pelvis to bladder
 Bladder opened from outlet to the dome
 Inspect trigone
 Orifices
 Bladder wall thickness
DISSECTION OF ORGANS : GUT

62.  Remove entire intestinal tract: begin with the ligament
of Tietz and proceed distally by cutting the mesenteric
attachment
 Measure length of small and large bowel
 Bowel contents observed
 Examine serosal, muscular and mucosal surfaces,
lymphoid follicles and Peyer’s patches
DISSECTION OF ORGANS : GIT

63.  In suspected cases of Hirschprung’s disease, biopsy is
taken 2cm from anal verge in neonates and 3cm in
older children
 Explore biliary tree by
 Removing gall bladder from its bed
 Opening the first part of duodenum to display ampulla
of Vater
 Expressing bile by compressing the gall bladder
 Normal saline injected into the gall bladder to
demonstrate patency
DISSECTION OF ORGANS : GIT

64.  Duodenohepatic ligament severed to separate liver
 Examine portal and hepatic veins
 Liver sliced at 0.5 cm intervals to examine parenchyma
 Pancreas to be separated from the duodenum and
spleen, serial sectioning to be done and fixed
DISSECTION OF ORGANS : GIT

65.  If multiple spleens present, determine whether they lie
on each side or one side of the dorsal mesogastrium
 Linear incision of the oesophagus to be extended
along the greater curvature of the stomach
 Finally, separation of the female internal genitalia from
the urinary bladder.
DISSECTION OF ORGANS : GIT

66. SPECIMENS

67. SPECIMENS
 Specimens for Microbiology
 Heart blood, lung, liver and spleen swabs
 Aspirates from gastric, middle ear and CSF
 Viral cultures, if relevant
 Specimen for Hematology
 Hydrops foetalis: Coomb’s test
 Foetomaternal haemorrhage: Kleihauer-Betke test
 Biochemistry
 Inborn errors of metabolism
 Cytogenetic
 Chromosome analsysis can be performed on white blood cells, if
autopsy is performed within 12 hrs
 Culture of fibroblast from skin – Upto 3 days

68. SPECIMENS FOR HISTOLOGY
 Lungs - At least 1 block needed from each of the major
lobes
 Heart - One section is taken to include left atrium mitral
valve, left ventricle and papillary muscle
 Liver - Blocks of left and right lobes are taken
 Spleen - One block is taken
 Thymus - One block is needed
 Pancreas and umbilical cord - One block is needed

69. STILL BIRTHS

70. CLINICAL HISTORY
 Maternal age.
 Relevant medical and family history.
 Obstetric history
 History of current pregnancy:
 estimated delivery date
 antenatal infection screen, including HIV
 abnormal findings from ultrasound or other antenatal
investigations
 hypertension/bleeding/pyrexia/membrane rupture
 events leading up to intrauterine death and/or delivery
 delivery: mode, complications and use of instrumentation.

71. PATHOLOGY ENCOUNTERED
 Hypoxia:
 visceral petechial haemorrhages
 inhaled amniotic material
 hypoxic-ischaemic injury of brain and other internal
organs
 Growth restriction: symmetric, asymmetric
(nutritional)
 Infection:
 amniotic fluid infection (chorioamnionitis, funisitis,
pneumonia)
 haematogenous infection (including villitis)

72.  Malformation
 Trauma: cranial, extracranial
 Blood loss, e.g. cord, feto-maternal, internal
 Hydrops
 Maternal disease, e.g. diabetes, hypertension and pre-
eclampsia
PATHOLOGY ENCOUNTERED

73.  Placental and cord disease, including:
 pathology of fetoplacental and uteroplacental
circulations (e.g. fetal vessel thrombosis, placental
haemorrhage/thrombosis, placental infarction)
 features of amniotic fluid infection
(chorioamnionitis/funisitis)
 Villitis
 abnormal cord insertion, cord knots.
 Changes in the baby and placenta secondary to intrauterine
death (e.g. maceration, placental vascular involution)
PATHOLOGY ENCOUNTERED

74. AUTOPSY
 Measurements valuable in determining gestational age
 Foot length valuable if gestational age < 23 wks
 Macerated stillbirths : degree of maceration suggests
time since death
 <=8 hrs - Skin reddened but intact
 8 to 48-72 hrs - Skin slippage with detachment of epidermis
 >72 hrs – severe skin slippage, discoloration of internal
organs, serosanguineous effusion in the body spaces

75.  Spontaneous second trimester abortions :
 Infections, anomalies or abnormal karyotype
 Microscopy and culture of fetal lungs to rule out
infections
 Therapeutic abortions :
 evaluate clinical basis of termination of pregnancy
 Detect other abnormalities that may have been missed
 Assess whether death due to intrinsic abnormality or
external factors
AUTOPSY

76.  Lung hypoplasia :
 Compare observed with expected lung weight
 Expected ratio of lung weight with body weight
 IUGR – primary or acquired :
 Most common secondary to maternal diseases –
hypertension and diabetes mellitus
 Brain growth and development normal if cause is
maternal
 Brain growth adversely affected in primary or
constitutional IUGR
AUTOPSY

77.  Normally, liver weight : brain weight is < 1:2.8, in
secondary growth retardation ratio is > 1:3
 Macrosomia with visceromegaly in infants of mothers
with gestational diabetes mellitus
 Significant external dysmorphism: fibroblast culture
 Fetal skin in nonmacerated cases
 Achilles tendon or placental amnion or chorion in
macerated cases
 Minor malformations may have predictive value for
major anomaly complexes
AUTOPSY

78. PERINATAL DEATHS

79. CAUSES
 Prematurity
 Sepsis
 Complex malformations
 Acute and chronic pulmonary disease
 Infection
 Necrotising enterocolitis
 Intracranial haemorrhage
 Ischaemic encephalopathy

80. AUTOPSY
 Systematic sampling of baby and placenta
 Tissue sampling helpful in detection of toxoplasmosis,
CMV, HSV, syphillis, enterovirus and parvovirus
 Hydrops : severe circulatory failure
Rh factor incompatibility
arrhythmias
 Dysmorphic neonate : photographs, whole body
radiographs, fibroblast culture

81.  Careful examination and sampling of brain required
for delineation of acquired perinatal brain diseases
 All lines and tubes of neonatal ICU to remain in place
until their location and related complications
delineated
 Appropriate samples for neonatal sepsis :
 E. coli
 Pseudomonas aeruginosa
 Grp B streptococcus
 Staph aureus and epidermidis
 Listeria, candida, viruses
AUTOPSY

82. OLDER INFANTS

83. CAUSES
 Sequelae of perinatal diseases
 Acute infections
 Isolated malformations
 Neoplasms
 Metabolic/genetic diseases
 Accidental trauma
 Child abuse
 Sudden infant death syndrome

84.  History from birth
 Cultures for bacteria and viruses
 Examination for drugs or toxins
 If h/o previous unexplained crises – metabolic studies
 Retain materials for follow up studies – urine, serum,
muscle and liver
 Familial sudden deaths require biochemical evaluation
 Defects in lipid metabolism
AUTOPSY

85. AUTOPSY
 In suspected infections :
 Appropriate cultures to be obtained
 Responsible agent to be characterized
 In neoplasias :
 Evaluation of the extent of tumor
 Effects and complications of therapy
 Autopsy –derived tissue culture, DNA extracts or fresh
frozen tissue provide valuable resource

86.  In metabolic/genetic diseases :
 Determination of the extent of prior investigations and
questions to be addressed
 Expeditious collection of appropriate tissue samples
 Tissue for DNA extraction, tissue culture and
ultrastructural study
 Sudden infant death syndrome :
 Diagnosis of exclusion
 History from death scene – position of baby, bedding
materials and ambient temperature
AUTOPSY

87. CHILDREN > 2 yrs

88. CAUSES
 Trauma : a major cause
 Natural causes :
 Overwhelming infections in previously well children
 Pneumonia in children with genetic or acquired
disorders
 Unsuspected cardiac diseases – stenotic bicuspid aortic
valve, genetic cardiomyopathy
 Complications of complex cardiac , brain or intestinal
anomalies
 Neoplasms
 Diverse genetic or metabolic disorders

89.  Intracranial haemorrhage – vascular malformations
 Asthma
 Poorly controlled seizures
 Sudden death in child receiving medications – wrong
drug dosage and errors should be ruled out
CAUSES

90. AUTOPSY
 Similar to that of adults
 Thorough medical history including
 family history
 Recent medical history
 Circumstances of death
 Representative sectioning and proper sampling

91. REFERENCES
 Stoker J T, MacPherson T A. The Pediatric Autopsy. Pediatric Pathology;
2nd edition: 5-17.
 Bove K E and Autopsy Committee of the College of American
Pathologists. Practice guidelines for autopsy pathology – The perinatal
and pediatric autopsy. Arch Pathol Lab Med 2007; 121: 368-76.
 Gilbert-Barness E, Debich-Spicer DE. Handbook of pediatric autopsy
pathology. Humana press Totowa New Jersey, 2005.
 Cohen MC, Paley MN, Griffiths PD, Whitby EH. Less invasive autopsy:
benefits and limitations of the use of magnetic resonance imaging in the
perinatal postmortem. Pediatric Dev Pathol 2008; 11(1): 1-9.
 The Working Party on Autopsy of the Specialist Advisory Committee on
Histopathology. Guidelines on Autopsy Practice Scenario 9: Stillborn
infant (singleton). The Royal College of Pathologists 2006; 1: 1-5.
 Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. W
B Saunders Company USA, 2000.

92. THANK YOU