RU2577454C1 - Method of differential diagnosis of stillbirths and neonatal deaths after birth - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for the differential diagnosis of a stillborn birth and death carried out magnetic resonance tomography study of the body of a dead child in T2-weighted sagittal projection mode. On the obtained scans the optical density of the lung tissue submarine and shoulder muscles PM. Calculate the rate of breathing by the formula: PL×PM/100. When the breath rating is more than 700 stillbirth is diagnosed, with the breath rating is no more than 700 death after birth is diagnosed.

EFFECT: method allows rapid and objective non-invasive differential diagnosis of antenatal and intrapartum fetal death with the postnatal death of the newborn.

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Description

The invention relates to medicine, namely to obstetrics and gynecology, pathological anatomy and forensic medical examination. It is associated with the development of a method for differential diagnosis of stillbirth and postnatal death of a newborn.

The most important task facing obstetricians is to reduce perinatal mortality, including stillbirth. The level and structure of antenatal and intrapartum mortality reflect the quality of obstetric care, including separately for antenatal care and maternity hospital.

In this regard, pathological autopsy of the bodies of fetuses and newborns, which make it possible to conduct a systematic analysis of the causes of death, is of particular importance. The primary task of an autopsy study is to determine the fact of stillbirth or live birth, which determines the need to develop unambiguous objective differential diagnostic criteria. This is of particular importance when conducting a forensic medical examination [A. Kovalev et al., 2014].

The most commonly used method for determining live births during autopsy is the conduct of so-called life tests (pulmonary and gastrointestinal tests) [Khrushchelevsky E. et al., 1962: Siebert J.R., 2008].

Pulmonary swimming test consists of several sequentially performed actions. Lobes of the lung are cut off at the root, immersed in a vessel with clean, cool water, and whether they are floating or not. Then the lung tissue is examined in sections, after which the lungs are divided into lobes and each of them is immersed in water. Finally, the lobes of the lung are cut into small pieces, dipped into water and determined by their ability to float before and after squeezing under water.

A pulmonary hydrostatic test is considered positive if the lungs or parts of them float on the surface of the water. A negative breakdown is considered when all parts of the lungs sink when immersed in water. A positive pulmonary test indicates the presence of air in the lungs, that is, indicates that the baby was born alive and breathed after birth. However, without a detailed microscopic examination of the lungs, this sample is not sufficient. Moreover, it should be noted the possibility of spreading the lungs of a stillborn and, accordingly, obtaining a positive lung test as a result of mechanical ventilation [Khrushchelevsky E. et al., 1962].

A gastrointestinal test is performed as follows. During the opening, the esophagus is ligated over the entrance to the stomach and the esophagus is cut over the ligature. After that, the intestines are separated from the mesentery and the stomach is removed along with the lower segment of the esophagus and the entire intestine. The recovered complex is immersed in a vessel with water and it is determined whether it is swimming or drowning, and if it is swimming, then all or some of its parts. If the whole complex is swimming, then most likely this child was born alive and breathed for some time. Although after mechanical ventilation, a gastrointestinal test may also be positive.

A promising method of non-invasive post-mortem diagnosis of pathological processes in fetuses and deceased newborns is a full-body radiation study. S.S. Guddat et al. [2013] provide descriptions of four cases of forensic examination of the bodies of newborns. In three observations during a post-mortem CT scan, the authors noted signs of airiness over the entire area of the lungs, on the basis of which a conclusion was made in favor of breathing lungs and, accordingly, live births. This was later confirmed in a police investigation. In one observation, it was a question of antenatal fetal death, where there were no signs of airiness of the lungs after post-mortem computed tomography. However, the authors themselves note a small number of studies, subjectivity in evaluating data, and the possibility of obtaining false conclusions in the development of putrefactive changes in organs and tissues.

Another way of differential diagnosis of bodies of stillbirths and dead livebirths is the determination of lung aeration by magnetic resonance imaging [Barber J.L. et al., 2015]. Based on a study of 19 bodies of deceased newborns and 23 stillbirths, the authors found that the sign of lung aeration has 89.5% sensitivity and 95.6% specificity for differential diagnosis. However, the authors point to false positive and false negative results, as a result of which the agreement between the findings of the post-mortem MRI study and autopsy data was 92.9%. In addition, this study is based on a subjective assessment of lung aeration (airiness).

The purpose of the invention is the development of an objective non-invasive method for the differential diagnosis of stillbirths and dead live births.

The goal is achieved by conducting magnetic resonance imaging of the body of a dead stillborn, the scans determine the optical density of lung tissue and shoulder muscles, which are used to calculate the respiratory rate and conduct differential diagnosis.

The method is as follows. Conduct a magnetic resonance imaging of the body of a stillborn in a T2-weighted mode in a sagittal projection, determine the optical density of lung tissue and shoulder muscles, based on them calculate the respiratory rate by the formula:

PL × PM / 100,

where PL is the value of the optical density of lung tissue on the scan, PM is the value of the optical density of the muscles of the shoulder on the scan.

If the obtained value of the respiratory rate is more than 700, a stillbirth is diagnosed less, if the value of the respiratory rate is not more than 700, the newborn's death after birth is diagnosed.

Example 1. Pregnant B., 29 years old, was admitted on an emergency basis in the first period of II childbirth for a period of 36-37 weeks. During the examination, head prevalence, pronounced polyhydramnios and bilateral diaphragmatic hernia in the fetus were established. After 3 hours and 50 minutes, spontaneous delivery occurred in the anterior view of the occipital presentation. A live full-term boy was born with a mass of 2969 g and a length of 48 cm (Apgar score 1/3).

At birth, the condition of the baby is severe due to manifestations of respiratory and cardiovascular failure. Intracheal intubation, mechanical ventilation, endotracheal adrenaline, zones in the stomach were performed in the delivery room. In the intensive care unit, the child was transferred to high-frequency oscillatory artificial ventilation of the lungs in severe conditions, inhalation of nitric oxide, and infusion through an umbilical catheter began. Cardiotonic, hemostatic, antibacterial and analgesic therapy was performed. However, the condition of the baby worsened, and biological death was observed 23 hours 15 minutes after birth.

After stating death, a magnetic resonance imaging study is performed in a T2-weighted mode in a sagittal projection. The obtained scans determine the optical density in the lung tissue (PL = 124) and shoulder muscles (PM = 246). According to the formula, the respiration rate is calculated: PL × PM / 100 = 124 × 246/100 = 305, on the basis of which it is concluded that we are talking about the death of a living (breathing) newborn.

With a subsequent pathological and anatomical opening of the child's body, the skin is bluish-reddish without detachment of the epidermis. With a microscopic study of drugs, the structure of internal organs corresponds to 37 weeks of gestation. Based on the revealed macroscopic and histological signs, it was concluded that the death of a newborn boy occurred 23 h 15 min after birth due to a congenital malformation - false bilateral diaphragmatic hernia. The immediate cause of death was pulmonary heart failure.

Example 2. Pregnant B., 27 years old, gestational age 38 weeks, was admitted for the absence of fetal movement during the day. During the examination, antenatal fetal death was diagnosed. After 20 hours, timely spontaneous birth occurred in the pelvic presentation by a dead male fetus weighing 2980 g and a length of 55 cm.

Conduct a magnetic resonance imaging study of the body of a stillborn boy in a T2-weighted mode in a sagittal projection. The obtained scans determine the optical density in the lung tissue (PL = 490) and shoulder muscles (PM = 340). According to the formula, the respiration rate is calculated: PL × PM / 100 = 490 × 340/100 = 1666, on the basis of which a conclusion is made about the absence of signs of respiration and, accordingly, stillbirth.

With a subsequent pathological and anatomical opening of the body of a stillborn boy, the skin is bluish-pink, moist, with symptoms of desquamation of the epidermis in an area of 5%. With a microscopic study of drugs, the structure of internal organs corresponds to 38 weeks of gestation. There is a loss of basophilia by the nuclei of cardiomyocytes of the external and internal half of the myocardium and by the nuclei of hepatocytes.

A placenta with signs of moderate preplacental hypoxia and multiple small infarcts of the villous tree. An undeveloped umbilical cord (IIP 0) with marginal attachment to the placental disc with the presence of acute thrombosis of its vessels and their chorial branches. Based on the revealed macroscopic and histological signs, the prescription of intrauterine death is at least 24 hours.

Example 3. Pregnant Y., 25 years old, gestational age 37 weeks, was admitted for examination and further delivery. During the examination, pregnancy is 37 weeks 3 days, headache, severe polyhydramnios, type I diabetes (diabetic retinal angiopathy, polyneuropathy), congenital heart disease in the fetus (transposition of the main arteries). 3 days after admission, taking into account the decompensation of diabetes mellitus and the presence of heart disease in the fetus, a planned labor stimulation has begun. An early amniotomy was performed. After the birth of the head, signs of dystocia of the shoulders were noted, and corresponding allowances were made. 8 minutes after the birth, a dead full-term male fetus weighing 4800 g and a length of 61 cm was born.

Conduct a magnetic resonance imaging study of the body of a stillborn boy in a T2-weighted mode in a sagittal projection. The obtained scans determine the optical density in lung tissue (PL = 414) and shoulder muscles (PM = 285). According to the formula, the respiration rate is calculated: PL × PM / 100 = 414 × 285/100 = 1180, on the basis of which a conclusion is drawn about the absence of signs of respiration and, accordingly, stillbirth.

With the subsequent pathological and anatomical opening of the body of a stillborn male weighing 4772 g and a length of 61 cm, it was found that death occurred during childbirth (intrapartum death of the fetus), due to hypoxia due to dystocia of the shoulders, and congenital heart disease (transposition of the great vessels, simple form) .

The proposed method for differential diagnosis of stillbirths and death after birth, characterized by objectivity and high information content, can significantly improve the results of the diagnosis, and therefore help to clarify the circumstances and the specific cause of death.

The diagnostic capabilities of the proposed method were tested by comparing the results of magnetic resonance imaging and a comprehensive pathological study of the bodies of 12 fetuses that died at gestational ages of 18-21 weeks, 20 stillbirths that died at gestational periods of 22-40 weeks (17 antenatal and 3 intranatally), 19 bodies of newborns who died at the age of 2 hours - 36 days, and 7 live newborns at the age of 1-7 days. Based on the comparisons, it was found that this method allows us to clearly differentiate the intrauterine (antenatal and intrapartum) fetal death and the death of a living (breathing) newborn.

Bibliography

- Kovalev A.V., Pletyanova I.V., Fetisov V.A. Legal and forensic problems of establishing the viability of fetuses and newborns in modern conditions // Forensic medical examination, 2014, No. 4, p. 4-7.

- Khrushchelevsky E., Sperl-Zeyfridova G. Section of corpses of fruits and newborns. M .: Medgiz, 1962.

- Barber J.L., Sebire N J., Chitty L.S., Taylor A.M., Arthurs O.J. Lung aeration on post-mortem magnetic resonance imaging is a useful marker of live birth versus stillbirth // Int. J. Legal. Med. 2015. Vol. 129. P. 531-6.

- Guddat S.S., Gapert R., Tsokos M., Oesterhelweg L. Proof of live birth using postmortem multislice computed tomography (pmMSCT) in cases of suspected neonaticide: advantages of diagnostic imaging compared to conventional autopsy // Forensic Sci. Med. Pathol. 2013. Vol. 9. P. 3-12.

- Siebert JR Perinatal, fetal and embryonic autopsy // Gilbert-Barness E. (ed): Potters's pathology of the fetus and infant. 2 ^nd edition. Philadelphia: Mosby Elsevier, 2007, p. 695-740.

Claims (1)

A method for differential diagnosis of a stillborn and death after birth, characterized in that they perform magnetic resonance imaging of the body of a dead child in a T2-weighted mode in a sagittal projection, on the obtained scans, the optical density of lung tissue of the lung PL and shoulder muscles PM is determined, based on which the indicator is calculated breathing according to the formula: PL × PM / 100, with a respiration rate of more than 700, stillbirth is diagnosed, with a respiration of not more than 700, death after birth is diagnosed Eden.