Autopsy liveborn perinatal protocol



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AUTOPSY - LIVEBORN PERINATAL PROTOCOL

M.C. Fishbein, MD (March 08)


J.D. Goldstein MD and M.C. Fishbein MD (Revised October 2015, May 2017)
UCLA DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE

AUTOPSY SERVICE


[PLEASE USE ADDITIONAL SHEETS AS NEEDED TO FULLY DESCRIBE ABNORMAL FINDINGS]
Note: Please see Table 1 for anthropomorphic data with reference ranges.
The body is that of a small for age/macrosomic/normally developed/dysmorphic male/female infant weighing       g      percentile for gestational/post-natal age). The crown-rump length is       cm and the crown-heel,       cm. The occipito-frontal circumference is       cm.

Rigor is absent/mild/moderate/severe.

Lividity is absent/mild/moderate/severe (state site)

Edema is absent/focal/global (fetal hydrops).

The skin is      .

(Describe any localized skin lesions, generalized discoloration, cyanosis etc.)

(Describe needle punctures, vascular access lines, catheters etc.)
The head is normo/micro/macro cephalic with/without molding or caput succedaneum.

The anterior fontanelle is      x      cm, the posterior fontanelle is      x      cm, and the cranial sutures are overriding/mobile/normal.

The eyes are normally spaced/show hypertelorism; the inner canthal distance is      cm and the outer canthal distance       cm.

The palpebral fissures are normal/upslanted/ downslanted,and the eyelids are separate.

The pupils are equal or unequal and measure       and       on the left and right sides, respectively. [measure only if unequal]

The sclerae are white/icteric /discolored      ; the corneas are clear/cloudy; and the irides are dark/light/. The ears are not low set or posteriorly rotated. The pinna are soft/folded/firm.

The nose is normally formed. There is no choanal atresia

The mouth is edentulous.

The lip and palate are intact.

The philtrum measures 0.       cm.

The thorax appears symmetric/distorted/narrow/broad. The chest circumference is      cm. The internipple distance is       cm.

The abdomen is flat/scaphoid/protuberant/markedly distended. The abdominal circumference is       cm. There is no/an omphalocele or abdominal wall defect. [Measure if present]

The umbilicus is well healed. OR

The segment of umbilical cord, measures      x      cm, and       vessels are identified.

The back appears normal. No exposed neural tube defect or abnormal spinal curvature are present.

The anus is patent/imperforate.

The external genitalia are normally formed for a male/female. The testes are undescended. OR Both/right/left testes/ testis are/is in the scrotum.

Inguinal hernia is absent/present.

Extremities are unremarkable without contractures, syndactyly, polydactyly or clinodactyly. No palmar crease or sandal toe deformity are present. The foot length is __ cm.      .

There are no other findings on external examination or      .

Post-mortem radiographs of       were obtained which show      . OR

No post-mortem radiographs were obtained.

The usual Y-shaped thoracoabdominal incision and U-shaped biparietal scalp incisions are made.


PERITONEAL CAVITY: The peritoneal surfaces are smooth and dusky/glistening.

The peritoneal cavity contains       ml of clear/cloudy/yellow/serosanguineous fluid/or blood.

The liver is normally configured and is anatomically normally situated.

The spleen is normally configured and is anatomically normally situated.

The stomach is externally unremarkable/distended.

The bowel is normally rotated without redundant mesentery such that the small intestine and large intestine are normally situated and the appendix is the in the right lower quadrant/pelvis.


The mesenteric lymph nodes are inconspicuous/unremarkable/diffusely enlarged.
PLEURAL CAVITIES: The visceral and parietal pleural surfaces are smooth and dusky/shiny with/without petechiae.

The right pleural cavity contains       ml of clear/serous/serosanguineous fluid (or blood).

The left pleural cavity contains       ml of clear/serous/serosanguineous fluid (or blood).

The lungs occupy 95% of their respective pleural cavities.

Each lung has a normal number of lobes.
PERICARDIAL CAVITY: The pericardial surfaces are smooth and dusky/shiny.

The cavity is free from adhesions and contains       ml of clear/serous/serosanguineous fluid (or blood).


CARDIOVASCULAR SYSTEM:

HEART: The heart weighs       g.

The viscera-atrial situs is solitus/inversus/ambiguous.

There is a D ventricular loop with the cardiac apex and left ventricle to the left and a solitus relationship of the great arteries with the pulmonary artery anterior and to the right of the aorta.



(If other than "solitus", "D", and "solitus", describe more thoroughly the site of the apex, position and relationship of the ventricles, and great arteries).

The epicardium is smooth without/with a scant amount of adipose tissue.

There are/no epicardial petechiae.

The atria are/do not appear distended.

The foramen ovale is patent/closed.

The septum secundum appears sufficient/fenestrated/deficient over the ostium.

There is no atrial septal defect.

The coronary sinus ostium is normal in size and location.


The mural and valvular endocardium is smooth, shiny and dusky/translucent/white.

The atrioventricular valves are thin and delicate with normal appearing cordae tendinae.

Both semilunar valves contain three cusps.

The ventricular chambers are not dilated.

The myocardium is brown and unremarkable.

There is no ventriculoseptal defect.

The measurements of the heart in cm are as follows:

Tricuspid Valve       cm, Pulmonic Valve       cm, Mitral Valve       cm, Aortic Valve       cm, Right Ventricular Myocardial wall       cm, Left Ventricular Myocardial wall       cm.


The venae cavae enter the right atrium and the ductus venosus is patent/closed.

All four pulmonary veins enter the left atrium; there is no anomalous pulmonary venous connection.


The coronary ostia are in normal position.

The coronary arteries have a right/left dominant or aberrant distribution on the epicardial surface.


The great vessels arise from a left/right sided aortic arch in a normal manner.

The caliber of the ascending aorta is normal, and there is no aortic coarctation.

The ductus arteriosus is patent/closed.

The branch pulmonary arteries arise normally from the pulmonary trunk and are of normal caliber.



RESPIRATORY SYSTEM:

The trachea and major bronchi are lined by smooth/tan/purple/ mucosa, their lumens contain       fluid. There is no tracheal-esophageal fistula.

LUNGS: The weight of the lungs is: right       g; left       g. On section they are firm/fluid filled/foamy/hemorrhagic.

The trachea and major bronchi are lined by shiny/hyperemic mucosa, their lumens contain       fluid.


HEMATOPOIETIC AND LYMPHATIC SYSTEM:

THYMUS: The thymus weighs       g.

The external surface is ivory/rose colored and lobulated without/with petechiae.

The cut surfaces are soft and unremarkable.

SPLEEN: The spleen weighs       g. The capsule is dusky/shiny/”sugar coated”..

On section the parenchyma is soft and deep red without localized lesions.

The malpighian corpuscles are inconspicuous/visible and unremarkable.



LYMPH NODES AND MARROW: The lymph nodes are inconspicuous/tan and soft.

Bone marrow is red.



GASTROINTESTINAL SYSTEM:

The mucosa of the esophagus is shiny/ulcerated/grey with longitudinal folds and its lumen is empty/contains       fluid.

The mucosa of the stomach is unremarkable or       and its lumen contains      .

The length of the small bowel is       cm, the large bowel is       cm.The mucosa of the small intestine is unremarkable and its lumen contains      . There is no Meckel diverticulum.

The mucosa of the large intestine is unremarkable and its lumen contains soft stoolgreen meconium.

LIVER: The liver weighs       g.

The capsule is dull/shiny and smooth/disrupted

On section the parenchyma is homogenous and brown without cysts, other localized lesions or fibrosis.

The bile, which is green/orange, is freely expressed from the gallbladder into the duodenum. No calculi are noted.
PANCREAS: The pancreas is tan and coarsely lobulated. On section, it is light tan and otherwise unremarkable.
ENDOCRINE SYSTEM:

ADRENALS: The weight of the adrenals is: right       g; left       g. They are normally shaped. The cut surfaces reveal bright yellow fetal/thin golden cortex and gray/thin brown central zones.


GENITO-URINARY SYSTEM:

KIDNEYS: The weight of the kidneys is: right       g; left       g.

The renal arteries and veins are free from thrombi. The capsules strip easily from the smooth renal surfaces that exhibit fetal lobulations.

On section the cortex and medulla are clearly demarcated. There are no cysts or localized lesions.

The renal pelves and ureters are lined by grey, translucent mucosa.

BLADDER: The mucosa of the bladder is ivory. The ureteral orifices and urethra at the trigone are normal. The urachus is closed/patent.

GENITALIA: The prostate gland is small, firm and reveals no gross abnormalities. The testes are descended in the scrotum/in the inguinal canal/intra-abdominal.

OR

The vaginal mucosa is unremarkable. The uterus, cervix and fallopian tubes have a normal infantile appearance with an elongated cervix and small fundus. The ovaries are thin with small/without cysts.



ORGANS OF THE NECK: The thyroid and larynx reveal no gross abnormalities.

The submaxillary glands are tan and unremarkable.



# parathyroids are identified.
BRAIN: The soft tissues of the scalp are unremarkable/edematous/hemorrhagic.

The sutures are separated by       cm.

The brain is initially examined fresh; it weighs      . Please see the Neuropathology Report, when issued, for further description.
The dura mater is unremarkable. The dural sinuses are free from thrombi.

The falx cerebri and the tentorium cerebelli are intact. The pia arachnoid is clear.

There is no subarachnoid hemorrhage nor exudate. The convolutions and sulci are approriate for gestational age.

The middle ears are not examined.

A segment of the thoracoabdominal spinal cord is removed by the anterior approach and reveals no gross abnormalities.

The pituitary gland is unremarkable.


MUSCULO-SKELETAL SYSTEM:

BONES: The vertebral bodies are normally formed, the joint spaces are unremarkable, and the marrow space is deep red. No other bones are examined.
ADDITIONAL AREAS OF DISSECTION OR SPECIAL STUDIES:

Placental Examination (S     ):


PHOTOGRAPHS:
MICROSCOPIC BLOCKS TAKEN:
AUTHOR:Typist

Date


Table 1.WEIGHTS AND MEASUREMENTS WITH REFERENCE RANGES
(Paste in the table from the Gestational Age Anthropometry Website; values applicable up to 1 year of age.)
Reference range data generated from the Gestational Age Anthropometry Website

Copyright © 2013 University of Alabama at Birmingham.


Matthew D. Cain, Joseph R. Siebert, Egiebade Iriabho, Alexander Gruneberg, Jonas S. Almeida, and Ona Marie Faye-Petersen (2015) Development of Novel Software to Generate Anthropometric Norms at Perinatal Autopsy. Pediatric and Developmental Pathology: May/June 2015, Vol. 18, No. 3, pp. 203-209.





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