1. NEONATAL AUTOPSY TECHNIQUE SPECIAL DISSECTION PROCEDURES

2. MAIN DEFINITIONS AND TERMS IN NEONATOLOGY

3. THE DEATH OF NEWBORN: PERINATAL DEATH: FULL-TERM NEWBORN:
it is a lethal outcome before the 28th day of life
PERINATAL DEATH:
death before delivery, during delivery or during first 7 days of life
FULL-TERM NEWBORN:
newborn delivered between hbd
PREMATURE NEWBORN
newborn delivered hbd
POSTMATURE NEWBORN:
newborn delivered after the 42 hbd
VIABLE FETUS:
fetus delivered with weight over 1000g and length over cm

4. AN INFANT WITH POSTMATURITY SYNDROME IS CALLED ALSO DYSMATURE OR POSTTERM
Postmature infant with characteristic skin changes; the skin is dry, cracking, and desquamating.

5. Apgar Score Rates Respiration, crying Reflexes, irritability
Pulse, Heart rate
Skin color of body and extremities
Muscle tone
A system of evaluating a newborn’s physical condition by assigning a value (0,1,2) to each of five criteria

6. MAIN CAUSES OF DEATH IN INFANCY

7. Cause of Death Natural: immaturity malformation disease of heart
lungs or brain
meconium aspiration
Rh incompatibility

8. Cause of Death Accidental: Criminal: cord prolapse prolonged labor
cord round the neck
placenta previa; death of mother
aspiration of blood
Criminal:
strangulation with cord
drowning in milk or water
omission to feed

9. POSTMORTEM EXAMINATION OF FETUS AND NEWBORN

10. The cause of death should be established on basis of:
obstetrical medical history
clinical examination of child with laboratory tests
postmortem examination:
gross examination,
histological examination
examination of afterbirth

11. EXTERNAL EXAMINATION OF NEWBORN AND FETUS

12. Differences Signs of death:
rigor mortis
livor (hypostatic blotch) putrefaction
Measurements of head, chest, abdominal circumferences, length and weight; facial measurements
Skin-color; elasticity of subcutaneous tissue
Examination of head
pupillary membrane, development of ear and nose cartilage
Umbilical cord
localization, changes of proximal and distal end of umbilical cord

13. External examination of the Newborn and Fetus
Rigor mortis (stiffness of death; caused by chemical change in the muscle after death)
Occurs as ATP is depleted, preventing relaxation of muscle fibers begins to develop several hours after death; rigor initially develops in the jaw,
Followed by upper and lower extremities
in newborn occurs very early (even 20 min after death)
Infection, terminal seizure, electrocution, strenuous exercise or high body temperature may cause rigor to develop more rapidly
In hot weather, rigor dissipates more rapidly; in cold weather, rigor may persist longer

14. Livor
(hypostatic blotch, settling of the blood in the lower portion of the body; intensity of color depends upon the amount of reduced hemoglobin)
Initially, livor is due to blood settling within vessels, and thus can shift with movement of the body and will blanch with pressure later, blood will hemolysis and diffuse out of the vascular space; at this point, livor is fixed; it will not shift with movement of the body and is nonblanchable
Weaker than in adults without possibility of dislocation even after 5 hours after death
Lack of livor in full termed newborn- suspicion of anemia, hemorrhage more intensive livor- in full termed newborn occurs in case of cyanosis in carbon monoxide poisoning, livor is cherry red in color

15. Livor Mortis
Discoloration does not occur in the areas of the body that is in contact with the ground or another object
As the vessel wall become permeable due to decomposition, blood leaks trough them and stains the tissue
fixation of hypostasis

16. External examination of newborn and fetus
Postmortem drying of the tongue and mucosal membranes darkens the tissues, imparting a Pseudohemorrhagic appearance
drying up- lips, ends of fingers, auricles

17. External examination of newborn and fetus
Putrefaction (decomposition of proteins) it results in breakdown of cohesion between tissues
Green discoloration of the lower abdomen, due to overgrowth of colonic bacteria
Green-black discoloration and swelling of the face and neck
Red-brown purge fluid may extrude from the nose and mouth; this should not be confused with blood
Gas formation causes diffuse swelling of the body, most noticeable in the abdomen
Skin slippage and blistering; hair slippage from the scalp
Marbling occurs due to breakdown of hemoglobin within blood vessels
In infants occur very early; firstly near subcutaneous blood vessels and livors

18. Measurement of head, chest, abdominal circumference, length and weight; facial measurement
Head circumference,
Mento-occipitaldiameter,
Fronto-occipital diameter,
Biperietal diameter

19. LENGTH : crown-heel
(from the vertex to heel with feet situated perpendicular)

20. Facial measurement
Persistent pupillary membrane (PPM) is a condition of the eye involving remnants of a fetal membrane that persist as strands of tissue crossing the pupil;
It exists in the fetus as a source of blood supply for the lens
It normally atrophies from the time of birth to the age of four to eight weeks;
PPM occurs when this atrophy is incomplete

21. Umbilical cord-localization, proximal and distal end of cord
The degree of fetal maturity
Wet or dried, smooth, with knots or without
Features of inflammation in proximal end of cord - distal end of cord- regular and uniformly cut
Irregular end of cord-delivery without medical help

22. Internal examination of newborn and fetuses: main differences
Autopsy of head: special techniques opening of scull, caput succedaneum
„collar incision” (y-shaped, with sharp scalpel) with bypass of umbilicus
Opening of trachea in situ
Pulmonary water loading test, gastro-intestinal test
Estimation of abdominal cavity (30-40 ml of blood leads to death)
Estimation of patency of Botall’s duct and foramen ovale

23. Autopsy of Head
CAPUT SUCCEDANEUM (pressure of the presenting part of the scalp against the dilating cervix during delivery; management...)
Description of fontanells
Bones defects of scull (due to injury or congenital abnormalities)
Special techniques opening the scull
Examination of dura mater, cerebral falx, tentorium of the cerebellum, subdural hematoma

24. Caput Succedaneum
An abnormal collection of fluid under the scalp on top of the skull that may or may not cross the suture lines, depending on the size
Pressure on the presenting part of the fetal head against the cervix during labor may cause edema of the scalp
This diffuse swelling is temporary and will be absorbed within 2 or 3 days

25. Different methods opening the scull
„basket” incision
„butterfly” opening of scull
with creating two large bone flaps

26. Butterfly
this method is superb for demonstration of posterior fossa abnormalities

27. WITH CREATING TWO LARGE BONE FLAPS
To preserve the superior sagital sinus
the incision 1 cm lateral on both sides of the midline, preserving sagital sinus between

28. ¨Collar Incision¨ with by pass of umbilicus:
The incision is roughly y-shaped
It begins at the shoulders, anterior to the acromial process
The upper limbs of incision penetrate to the ribs and meet at the level of the xiphoid process
The descending limbs of the incision extends along the midline from the xyphoid process
Above the umbilicus the incision divides towards the inguens

29. Examination of oral cavity and the opening of trachea in situ
The examination and description of oral cavity, pharynx and upper part of larynx (foreign bodies, injures, anatomical abnormalities)
Opening of trachea in situ (we stick knife in the middle of trachea; contents of larynx, trachea)

30. HYDROSTATIC PULMONARY WATER-LOADING TEST
HYDROSTATIC GASTRO-INTESTINAL TEST

31. Still Birth
When child (born after 28 weeks) did not breath or show any sign of life at any time after being expelled from the mother
Common causes are prematurity, anoxia, birth trauma especially intracranial hemorrhage due to excess molding, placental abnormality

32. Dead Birth
When child has died in the utero and shows one of the following signs after complete birth

33. Rigor mortis at delivery
Maceration (aseptic autolysis after 3-4 days in uterus filled with amniotic fluid and no air); the earliest sign of maceration is skin slippage, which can be seen in 12 hours after death in utero; the body of the macerated fetus is soft, flaccid, and flattens out when placed on a level surface; it has a sweetish disagreeable odor.;
Mummification: is the condition in which the fetus dries up, shriveled in the uterus.; it occurs when fetus dies from deficient supply of blood, when the liquor amni is scanty

34. MACERATION OF FETUSES

35. Interuterine Maceration – Softening due to decomposition
iIntrauterine aseptic autolysis of body
fetal tissues get soaked with amniotic fluid, blood serum,
Tissue enzymes and acid properties of calcium soaps in meconium
lack of specific smell of putrefaction
the lesions are located uniformly
advanced lesions- head as fluctuating cyst with palpable separated bones of scull

36. Macerated stillborn fetus
Death was due to a true knot with obstruction of venous return from the placenta 10 cm from the abdomen. Total length was 65 cm. Note the marked congestion of the cord distal to the knot

37. Signs of Live birth Shape of chest
the position of diaphragm- found at the level of 4th or 5th rib; if no
Respiration, 6th or 7th rib after breathing
Lungs- after respiration, volume is increased, margins become rounded, consistency becomes soft, spongy, elastic and crepitant; the hydrostatic test by placing the lung tied at bronchi into water- if floats suggests respiration but an unexpanded lung may float from putrifaction and the expanded lung may sink from disease like acute edema, pneumonia
Stomach- air is swallowed into the stomach during respiration
other signs of live birth- caput succedaneum, air in GI tract, clothed body

38. Pulmonary Water Loading Test
In cases suspected for infanticide; was the child alive after birth ?
After the opening of abdominal cavity we describe the diaphragm,
The appearance of lungs, pleura
We open pericardial sac
Ligation of stomach beneath the diaphragm
Evisceration of thorax with description of surface of the lungs, color of the lungs; gas bubbles, marble-like pattern of the surface
pulmonary water-loading test

39. Put all organs into the water- they sink or float on the surface of the water
Cut the trachea and bronchi (contents)
Cut off the thymus
Estimation of patency of Botall’s duct
Cut off lungs and put them into water
Classical examination of lungs
Cut off each lobe and put into water
Cut the lungs into slices, pieces and put into water

40. False Positive
Putrefaction gas
State after resuscitation

41. False Negative Infanticide when placental circulation is still present
In pre termed newborns- insufficiency of respiratory centers or respiratory muscles
Disruption of placental circulation during delivery with aspiration of amniotic fluid
Congenital abnormalities and obstacle in respiratory tract

42. Gastrointestinal Test
In cases suspected for infanticide
To check if the child was born alive or death
After ligation of stomach, small and large intestine we put into the water
Check which part of gastrointestinal part floats on the water surface

43. Positive result of the test:
Newborn breath after delivery
After resuscitation of newborn
Putrefaction lesions

44. Negative result of test:
Stomach and intestine sink in water – child died before the first breath or delivered dead
POSITIVE RESULT OF GASTROINTESTINAL AND PULMONARY WATER-LOADING TEST child breath after delivery
POSITIVE RESULT OF GASTROINTESTINAL AND NEGATIVE PULMONARY WATER-LOADING TEST – child breath after delivery

45. AUTOPSY IN FAT EMBOLISM

46. The Presence of Fat Emboli Suggest That injury of body was intravital
Fat from the bone marrow and subcutaneous tissue
Fat from organs
Not emulsificated fat from blood serum
during autopsy we take some tissue samples from brain, lungs, myocardium and fix them in formalin
we can’t put them into the alcohol- it dissolves the fat
Fat emboli- requires specialized techniques (frozen sections, SUDAN III staining)

47. Autopsy in Pneumothorax

48. Causes of pneumothorax:
Primary
SPONTANOUS PNEUMOTHORAX
TRAUMATICPNEUMOTHORAX - blunt trauma or penetrating injury to
the chest wall - rib fracture - rupture of esophagus
young slim man congenital sub pleural bull
Secondary:
congenital cystic adenomatoid malformation
chronic obstructive pulmonary disease
neoplasm of pleura
tuberculosis
sarcoidosis
in children, additional causes include measles, inhalation of a foreign body

49. CT scan of the chest showing a pneumothorax on the person's left side
The air-filled pleural cavity (black) and ribs (white) can be seen

50. Complications of pneumothorax:
CT scan of the chest showing a pneumothorax on the person's left side
the air-filled pleural cavity (black) and ribs (white) can be seen
Recurrence- many people who have had one pneumothorax have another, usually within three years of the first
Persistent air leak- air may sometimes continue to leak if the opening in the lung won't close; surgery may eventually be needed to close the air leak
Low blood oxygen levels (hypoxemia)
Cardiac arrest
Respiratory failure
Shock

51. When Pneumothorax is suscpected we do the test
After surgical procedures in the chest in tuberculosis
During preparation of cervical integument and chest we can not cause the injury intercostal space
We preparate integument from the second intercostal space to xiphoid process to form a kind of pocket and we pour water into it
We tap the intercostal spaces with knife and we observe if any gas bubbles get out onto the surface of water
After cutting off the sternum we pour water into pleural cavity in which the pneumothorax was diagnosed
Through the trachea we flow some air and observe where the place of injury is

52. Sudden Infant Death Syndrome SIDS
„sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of death scene, and review the clinical history”

53. Is the leading cause of death between age 1 month and 1 year in developed
Countries „cot death” -cause ???
Recognission after the excluding alternative causes of death

54. SIDS – Postmortem abnormalities detect is cases of sudden unexpected infant death
Multiple petechie on the thymus, viceral and parietal pleura, and epicardium
Pulmonary congestion
Astrogliosis of the brain stem and cerebellum
Hypoplasia of the arcuate nucleus
Extramedullaryhematopoiesis

55. No symptoms
Babies who die of SIDS do not appear to suffer or struggle
Autopsy - not able to confirm a cause of death