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Re: Comparison between prenatal ultrasound and postmortem findings in fetuses and infants with developmental anomalies

In their study, Vogt et al.1 review retrospectively 455 autopsies of fetuses and infants with developmental abnormalities, as performed at Trondheim University Hospital, Norway, between 1995 and 2004. For each autopsy, the authors compare the postmortem findings with those yielded from the corresponding antenatal ultrasound scan. In order to do so, they measure the ‘agreement’ between the ultrasound and autopsy findings. Finally, the paper comments on the implications of this ‘agreement’, with reference to the utility of postmortem examinations for patients. The paper finds that of the 455 autopsies studied, only four (< 1%) yielded additional information that influenced patient counseling. Several specialists at the Women’s and Children’s Hospital (WCH), South Australia, were surprised by this low figure. This prompted us to conduct a brief analysis of our own autopsies in the past year. We reviewed the reports of 58 autopsies performed in 2012 following second-trimester terminations. We excluded terminations indicated for maternal health reasons, and ‘external only’ autopsies. Each case was examined and sorted according to whether the autopsy revealed new information or merely confirmed the findings of the antenatal ultrasound exam. This was determined in a case-by-case fashion. The data were further categorized according to whether or not the findings of the autopsy altered patient counseling. Findings were deemed to have influenced counseling if they changed an abnormality’s recurrence risk, if they led to a new diagnosis, or if they confirmed a diagnosis suggested hesitantly on ultrasound (but not if they confirmed one made confidently.) We found that 53% (31/58; 95% CI, 13%) of autopsies found significant new information and that 45% (26/58; 95% CI, 13%) affected counseling. This result differs significantly from that found by Vogt et al.1. Several different factors are hypothesized to contribute towards this marked discrepancy. Firstly, the two departments may have adopted different definitions: it is unknown precisely how the authors defined ‘influence patient counseling’. It is also not known what constituted ‘additional findings’. For example, perhaps if a diagnosis postulated tentatively in an antenatal ultrasound report were then to be corroborated definitively by postmortem findings, Vogt et al. would not consider the autopsy as having provided further information, whereas our team would. Furthermore, the WCH routinely makes use of numerous resources in its postmortem examination process, including magnetic resonance imaging, DNA microarray testing, histology and microbiology. When consent is obtained, the placenta and fetus are always examined grossly and histologically. In addition, every case is presented to at least one multidisciplinary advisory meeting. Vogt et al.1 do not disclose whether their autopsies feature more than general radiography and gross fetal examination. The paper concludes that, while antenatal imaging is rapidly improving, there are still cases in which postmortem findings alter the diagnosis and patient counseling. We agree with this conclusion; however, we posit that the extent to which this can be true may have been underrepresented by this study, especially when considering the scope of diagnostic facilities and multidisciplinary expertise available at specialist institutions like the WCH.