The autopsy after an intrauterine death

by Claudia Ravaldi
CiaoLapo Onlus
CiaoLapo Onlus

Interview with Gaetano Bulfamante

by Claudia Ravaldi, psychotherapist , founder and president of CiaoLapo Onlus,

Gaetano Bulfamante is Associate Professor of Pathological Anatomy , University of Milan, Section Director of Pathological Anatomy, Department of Health Sciences, University of Milan; Director of the UOC of Pathological Anatomy, Cytogenetics and Molecular Pathology, AO San Paolo in Milan.

Prof Gaetano Bulfamante

Prof Gaetano Bulfamante

Since 2007 CiaoLapo has been actively involved in the medical aspects of stillbirth, promoting the training of Italian staff, the updating of gynecologists and obstetricians, and collaborating in Italy and abroad with the most prestigious research centers on high-risk pregnancy and on perinatal death.
An example among many of our commitment, the participation in the Lancet monographic work on death in utero, the presence by invitation as speakers at various congresses on the subject (in Milan, with the Vita in Culla association and the Lino Rossi center, La Spezia with those who deal with SIDS SIUDS and ALTE, in Bergamo in a recent and interesting specific conference on this issue).
The goal, in accordance with international guidelines, is to implement the WHO (World Health Organization) proposals to lower the frequency of stillbirths by at least 20% in Italy and in high-development countries, i.e. to save one child out of five, and therefore about 400 children every year.
For these purposes, we believe it is essential to provide information and clarify the scientific and legal aspects that govern this field too often ignored or neglected in the daily routine of Italian hospitals. At our request, a parliamentary question last year raised the problem, and Minister Balduzzi essentially replied by citing a text published by the ministry in 2006 and distributed in all birth centers (see documents section of this site); as parents and professionals dedicated to this particular sector, we would like to understand how much and how this text has been received, and if there are national regulations that hospitals should refer to.
To this end, today we interview Prof. Bulfamante on a delicate but extremely important issue for families and for research, about which little is known and often in a confused way. Let’s talk about the autopsy and postmortem histological examination and the laws that regulate them in Italy.

Professor, is there a national law that regulates the autopsy on stillborn babies?

The legislation on the request for an autopsy is governed by a state law, therefore valid throughout the national territory. This Law is the “Mortuary Police Regulations”, made applicable by DPR 10.09.1990, n ° 285.

Can the regions decide independently? And the companies?

It should be remembered that in the context of regional autonomies regarding health care, many Regions and also various Municipalities have issued their own texts relating to some application aspects of the aforementioned Law (which, as a Law, cannot be eliminated except through an act repeal or a new comprehensive law on the matter); however the changes are substantially related (and could not do otherwise) to the funerary aspects (rules for the construction of cemeteries, transport of the body, rules relating to burial, cremation, etc.) or epidemiological (office responsible for the registration of death, etc.) leaving unchanged the part relating to diagnostic investigations.

What is the autopsy for the Italian law?

According to the Mortuary Police Regulations, the request for an autopsy for diagnostic confirmation (i.e. the one performed by the anatomopathologist to define the causes of death – modalities and diseases / conditions that produced it -, which is different from the judicial autopsy performed by the coroner and ordered by the Magistrate with the aim of answering specific questions relating to an alleged intentional or negligent context) is “a medical act”, a free choice of the carer who is not subject to the approval of the relatives of the deceased (which differentiates our legislation from the Anglo-Saxon one, for which the execution of the diagnostic check must be approved by the parents – if minor or unmarried and they are still living – or by the spouse or by the children if widowed). It should be remembered that in hospital care the “caregiver” is any doctor of the facility who has participated in the diagnostic / therapeutic process. In summary, on the basis of this law it is the doctor who autonomously decides whether or not to carry out an autopsy for diagnostic verification. It should be borne in mind that in the spirit of the law this provision was formulated to facilitate the execution of the diagnostic test, in a historical moment in which in the common Italian sentiment this practice was often experienced as an “insult to the deceased”, particularly in the immediacy of the death.

Are there any differences in the case of stillborn babies?

In 1999 this general law was supplemented by a specific rule for “stillborn” (DPC of 22.07.1999 n ° 170): an autopsy is made compulsory for them. It should be emphasized here that for the Italian legislation a new directive or “particular” law (which deals with a specific aspect within a general law) improves the previous text and imposes the new procedure in the specific case. In summary, in Italy it is mandatory to carry out an autopsy for the diagnosis of “stillborn” fetuses, regardless of the will of the treating physician.

So the autopsy, as a diagnostic confirmation of the causes that caused the death in utero of the gestating baby, should always be done?

Here are a number of issues to date. Unfortunately, the DPC n ° 170 did not give the definition of “stillborn”, and therefore the week of gestation to be used to differentiate stillbirth (MEF) from late abortion is not univocal (a condition that still falls within the addresses of DPR 10.09. 1990, n ° 285 and is not exempt from the possibility of an autopsy). For many years the WHO (World Health Organization) has defined that a fetus that died in utero and given birth at a gestational age equal to or greater than 22 weeks (21 weeks + 7 days) or, if not gestational age can be defined with certainty, with a weight equal to or greater than 500 grams.

What happens in Italy in this regard?

The various states continue to apply the most varied criteria: in Italy, in the absence of specific legislation, a little of everything happens and mostly it refers to the criterion used by ISTAT which places 180 days of pregnancy (25 weeks and 5 days) the limit to distinguish an abortion (subject if born unable to survive and legally “part of the mother”, so much so that it is registered as a “fetus of …..”) from a “stillborn” subject (subject if born capable of survival and legally recognized as an Italian citizen “stillborn”, so much so that he acquires his father’s surname – when recognized by him – and a series of specific legal rights). It is evident that this time limit is anachronistic today, given that thanks to medical treatment, even live births of low gestational age or low weight have a good chance of survival and therefore the use of the “survival capacity” criterion to differentiate abortion from MEF appears weak to justify “rod positioning” at 180 days of pregnancy. Also a more recent Italian law (n ° 31 of 02.02.2006) relating to “SIDS and the unexpected death of the fetus aged over 25 weeks” for example (although it is in its “non-applicative” phase, lacking its implementation protocol), gives a late time indication of the MEF, far from the WHO definition. Therefore the Italian law, as formulated, in the absence of a clear definition of stillbirth, currently covers only a part of the cases that could necessarily benefit from the diagnostic investigation.

What could we say to parents affected by perinatal bereavement, considering that the autopsy for cultural and emotional reasons is still an “emotionally” difficult act to accept?

The execution of the autopsy for diagnostic verification should be the first treatment and the first interest of the doctor, both to understand how and why the death occurred, and to concretely manifest to the child’s family their empathic interest in what happened. Furthermore, even if it is not Law, not doing everything that is reasonably possible to do (and a fetal autopsy is not an act with unreasonable costs or difficulties) violates one of the fundamental rights of the patient: the right to the best possible definition of the diagnosis. This right becomes even stronger in the event that the disease can affect subsequent pregnancies or other family members.
I am aware of the emotional impact on parents of the news of an autopsy being carried out on their son, but this examination must be brought out of the collective imagination of a “profanatory act” that has surrounded him for centuries in Latin countries. There is nothing different from surgery: it is a highly complex medical procedure aimed at the highest purpose, that of trying to make the most complete diagnosis possible. While in the countries of Austro-Hungarian culture this concept has “passed” for centuries (all the deceased, even those who died at home, were subjected to autopsy to defend collective health, monitoring the spread of diseases and promptly identifying the outbreaks of infectious ones ), in Italy the legislation of the early 1900s imposed that the autopsy could not be subjected, among others, to “solvent” patients, which made it identify, as well as an irreverent act towards the deceased, also a an act that, reserved for the “poor”, was also infamous to his social condition. Personally I think that from this point of view “a lot of water has passed under the bridges”: today, rightly so, more and more parents want the diagnostic check to be performed, in the belief that it represents a crucial step to prevent what happened from happening again.

Thank you Professor!

You can download the CiaoLapo brochure on the role of autopsy in perinatal death in the Documents section

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