Dear Editor,

Wright and Lee's article [1] provides an excellent overview of the options to consider when parents decline the offer of conventional autopsy following perinatal death.

Although a less invasive autopsy (LIA), such as one based on MRI, may be more acceptable to many parents, the provision of such a service could have significant implications, not just with regard to the availability of a scarce resource, in terms of availability of MRI services but also with regard to how such a service should be provided.

Just as perinatal autopsy has largely become a regional specialist service, it could be argued that MRI LIA (if offered) should also be a regional specialist service, as smaller centres are unlikely to acquire the expertise with smaller local numbers of perinatal deaths. In addition, as experience is being acquired, conventional post-mortem should be performed on referrals for MRI autopsy, and therefore probably restricted to research studies, with appropriate informed consent.

If LIA was indeed more acceptable to parents, this would have significant implications for audit and counselling. As Wright and Lee highlight, current evidence suggests that MRI autopsy may not detect clinically significant anomalies in different organ systems including the gastrointestinal tract and the heart. Other abnormalities such as anomalous lung lobation may also go undetected, and the quality of counselling by obstetricians and neonatologists could be reduced. Genetic syndromes may not be recognised, or be misdiagnosed, with false-negative findings.

The loss of the 'gold-standard' autopsy would also have implications for audit within fetal medicine and obstetric ultrasound services.

Although published work on post-mortem MRI of the fetal CNS is encouraging [2], with regard to its specificity and sensitivity, we need more data with which to counsel parents who are seeking a less-invasive autopsy, but also potentially to explain its limitations in the apparent absence of abnormality on MRI (even after one was suspected on antenatal ultrasound, for example). Absence of evidence of abnormality (normal MRI autopsy) cannot be at present equated with evidence of absence of abnormality (normal conventional autopsy), and parents must be aware of this when making choices at this difficult time. Consent for a conventional or less-invasive autopsy, must therefore be sought by a skilled clinician aware of these difficulties, as well as insight into organ and tissue retention issues.

The proposed DoH-funded Less Invasive Autopsy studies [3] will make a welcome contribution to our understanding of this area.

References

(1). Wright, C and Lee, REJ. Investigating perinatal death: a review of the options when autopsy consent is refused Arch. Dis. Child. Fetal Neonatal Ed. 2004; 89: F285-F288

(2). Griffiths, P.D., et al., Postmortem MR imaging of the fetal and stillborn central nervous system. AJNR Am J Neuroradiol, 2003. 24(1): p. 22-7.

(3). http://www.dh.gov.uk/assetRoot/04/07/83/93/04078393.doc