Sunday, February 28, 2010

Fetal Autopsy

I was sitting in my home away from home in the rural office, the one with a window, when two heads popped in my door. Both lab techs/administrators - there's more job lumping and less splitting in a small town. "Gizabeth? I think there is going to be a fetal autopsy. A stillborn, delivered last night. Do you remember the rules for the cutoff between surgical specimen and autopsy, in a stillborn?"

Damn it, I didn't. And I wasn't in my own office, the one with amazing organized drawers of folders. I knew exactly where to look, there. But I was here, in my partner's office. I glanced up at her array of books, in desperation. No Lester, that I could see. I was stymied.

"Let me call the on call anatomic pathologist, and check. I'll get back to you in a little bit."

"That would be great. I heard it took her all night to deliver the baby. Hadn't heard a heartbeat in a couple of days. Probably pretty traumatic, for mom. They think she was 27 weeks."

I finished up some cases, and called my partner. Looked at my watch. 2:00. I hoped this would happen quickly - I had dinner plans with my parents and kids at 6:30. Autopsies take a while. But patients are more important than dinner plans.

In the meantime, I got a call from the OB. "What can the parents expect to find, from the autopsy?"

"If the baby has been dead for a couple of days, it's probably pretty macerated. There won't be much to see, histologically. Too much autolysis. I'm not trying to discourage anything. We can get samples for cytogenetics, to see if there are any problems there. We can culture the nares and mouth, to look for bacterial etiologies. There's probably a lot of contamination, but if certain culprits are revealed in cultures, we can point to a possible source."

"The baby looked fine, externally. No obvious malformations to suggest a genetic cause. I'll talk to them. In the meantime, find out whatever you can."

I took the task to heart. Called my dad for suggestions - he deals with babies all the time and might have some good insight. Called my partner and confirmed what I was vaguely remembering - the cutoff was 20 weeks for autopsy vs. surgical specimen. So this was definitely a candidate for autopsy. Alerted the gross tech. Set the lab administrators to the task of looking on the ARUP website for the best source to submit for cytogenetics. Got prepared.

4:00 - Surgical cases done. Autopsy still pending. Heard nothing. I decided to press. Wandered into the administrators office, a little sheepishly.

"Have you heard anything, about the fetal autopsy? I don't mean to press, but it is getting late. I hate to call the on call anatomic pathologist, to deal with this in another town, on a Friday night. I understand about bonding with the baby, but we need to know if this is going to happen or not. I'm willing to stay here for as long as it takes, but I'd like some information. Is there someone you can call?"

I was remembering a case I had in residency, on the weekend. I had a fetal autopsy, and the clinicians were worried about a mitochondrial disorder. We needed skin fibroblasts, for culture, and they needed to be fairly fresh. The mom was so distraught, understandably, and wanted to hold the dead baby in order to process her grief. But every minute was taking away opportunities for diagnosis, and we had to put pressure on her. It sucked.

A few phone calls were made, and the administrator came into my office at around 5:00. "Mom wants to bond for a few more hours."

I looked up at his poker face, and believed him. Planned to call my help and rearrange dinner plans.

"Just kidding. They decided to call off the autopsy. The OB was supposed to call you, but forgot. You can go home. Have a great weekend. Here's my card. Call me if you need anything."


Anonymous said...

wow. You know, I've always thought of pathologists as sort of removed from the day to day suffering and misery that the clinicians deal with, but this makes me realize that no matter what you do in medicine everyone has their own gut-wrenching moments to deal with.

rlbates said...

Can I just ditto what sajbat said.

Gizabeth Shyder said...

Dealing with death and autopsies, kids or adults, can get pretty intense. I am glad, in my current job, that we don't get them very often anymore. People can be very reactive and upset in their grief.

I can't imagine carrying a baby for 27 weeks and having to deal with that grief. That has got to be pretty painful.

Anonymous said...

As a father who recently lost a child during birth, I can tell you that when you are put into the situation of deciding weather or not to do the autopsy it is the most gut wrenching decision you will ever have to make. And this decision has to be made shortly after everything happens.

also too doctors will say it's not 100% sure way to find out what happened to cover them selves if they do not find anything. I have asked doctors directly if by doing the autopsy will we know what caused it, and most of them said no, only help prevent this from happening in the future.

Gizabeth Shyder said...

I don't think the doctors are covering themselves - they are telling you the truth. Answers are rarely answered, during a fetal autopsy. I encourage them, and ask for placenta and get cytogenetics, hoping we will get some answers. But in my experience, we usually don't. Usually. I have made a couple of enlightening discoveries.

I am so sorry for your loss. I have two children, and the thought of losing them is unimaginable to me. Good luck coping - I hope you and mom have some good counselors to help you deal with the grief process. I'll put you both on my thoughts/prayer list.