S2 E7: Where would we be without perinatal pathology?

In this episode, RCPA Vice President, Associate Professor, Trishe Leong, speaks with anatomical pathologist, Professor Jane Dahlstrom OAM, and specialist obstetrician and gynaecologist, Dr Farah Sethna, to discuss perinatal pathology and its role in trying to give answers to women, their families and the treating team when there has been an adverse outcome of a pregnancy. 

Transcript

00:00:01:22 - 00:00:12:19
Prof Jane Dahlstrom
A lack of perinatal pathologists means that we may not be able to provide the high quality comprehensive service across our country that we currently do.

00:00:12:21 - 00:00:25:06
Dr Farah Sethna
Why did this happen? Why me? And what a perinatal pathologist can offer these families is absolutely invaluable.

00:00:25:08 - 00:00:35:14
A/Prof Trishe Leong
I'm Associate Professor Trishe Leong, the vice president of the Royal College of Pathologists of Australasia.

00:00:35:16 - 00:00:56:18
A/Prof Trishe Leong
Hello, everyone, and welcome to this RCPA podcast on Perinatal Pathology. During this podcast, we're going to shine a light on this important area of pathology and hopefully encourage trainees to consider a career in this special discipline. For those of you who don't know me, I'm Associate Professor Trishe Long, the Vice president of the Royal College of Pathologists of Australasia.

00:00:56:20 - 00:01:29:17
A/Prof Trishe Leong
And today, I'm looking forward to speaking to one of Australasia's most eminent anatomical pathologists, Professor Jane Dahlstrom OAM. Professor Dahlstrom is currently a senior staff specialist at ACT Pathology Canberra Health Services, and she's the chair and Professor of Pathology at Australian National University School of Medicine and Psychology. Jane's in the midst of a very distinguished career, including publishing important research in perinatal pathology and placental pathology to help families who lose babies or encounter problems during a pregnancy.

00:01:29:19 - 00:01:48:01
A/Prof Trishe Leong
Later on, we'll also be joined by Dr. Farah Sethna, specialist, obstetrician and gynecologist who works alongside Jane as lead of the perinatal loss Clinic at the Canberra Hospital. But for now, I'd like to extend a warm welcome to Professor Jane Dahlstrom. Hi, Jane. Thanks for joining us today.

00:01:48:03 - 00:01:53:15
Prof Jane Dahlstrom
Yes, thank you, Trishe, for the opportunity for us to chat to you today.

00:01:53:17 - 00:02:27:00
A/Prof Trishe Leong
So this is a very special area of pathology because it's got such significance to families, the death of a baby or the interruption of a pregnancy. It's a really difficult time for many families. And in this situation, pathology provides important information for not only the family, also the clinical team, and sometimes the wider community as well. Can you maybe tell us a bit more about what perinatal pathology is and also who it impacts, in your opinion?

00:02:27:02 - 00:03:06:16
Prof Jane Dahlstrom
Perinatal pathology is the study of diseases of the placenta and baby in the perinatal period. Now, the perinatal period is classically defined as the time immediately before and after birth. There are, in fact, different time cutoffs across the world. But in Australia, the perinatal period is from 20 weeks gestation to 28 days or four weeks after birth. Most perinatal pathologists are, however, experts in diseases throughout the pregnancy and into the neonatal period.

00:03:06:18 - 00:03:33:01
Prof Jane Dahlstrom
In answer to the second part of your question. Perinatal pathology is an area of medicine where we're trying to give answers to women, their families and the treating team. When there's been an adverse outcome of a pregnancy, including stillbirth. You may be aware that in Australia there are in fact over 3000 perinatal deaths per year.

00:03:33:03 - 00:03:54:05
Prof Jane Dahlstrom
Every day in Australia, six babies are stillborn and two die within 28 days of birth. It's said that at least 60 lives are touched by each of these deaths, so that over 175,000 people are being affected every year by a stillbirth.

00:03:54:07 - 00:04:19:21
A/Prof Trishe Leong
So pregnancy loss and stillbirth is often not straightforward. The answers are often quite complex. And my recollection from the brief time that I was working in this area was that it's a really multi disciplinary kind of area. So maybe, Jane, can you elaborate a little bit more on what areas and disciplines of pathology, perinatal pathology encompasses?

00:04:19:23 - 00:04:55:21
Prof Jane Dahlstrom
Yes. Look, a perinatal pathologist, if we look at that particular discipline first, they examine tissues of pregnancy, including the placenta, embryos and fetuses. So it's a branch of anatomical pathology. When a baby is stillborn or there's a neonatal death. A perinatal pathologist is also trained in performing autopsies or post-mortems to discover why a baby died, if this problem could recur in another pregnancy.

00:04:55:23 - 00:05:36:19
Prof Jane Dahlstrom
And perhaps what could be done differently next time. With autopsy investigations, we often also need to work very closely with other areas of pathology, like microbiology, if we're thinking about infection as a cause of a preterm birth or death of a baby. Genetics to rule out problems within the chromosomes and, on occasions, immunology, biochemistry and haematology related to different diseases that can cause problems with the placenta and result in an adverse outcome in pregnancy.

00:05:36:21 - 00:06:03:13
A/Prof Trishe Leong
So I guess to call out the elephant in the room, I'm sure there are some of our listeners out there are thinking, oh my God, dealing with, you know, tragic circumstances, dead babies on a daily basis. What a career, what a job. What led you into into a career perinatal pathology, Jane. And you know, what do you actually love about what you do?

00:06:03:15 - 00:06:32:19
Prof Jane Dahlstrom
It's a it's a good question. And what I'm I'm often asked about. Look, I think the reason I chose perinatal pathology is I've always had an inquiring mind. And I do enjoy finding answers to difficult questions. I also realised as an anatomical pathology trainee that I could make a difference to so many as a perinatal pathologist. I chose to do additional training interstate in perinatal pathology.

00:06:33:00 - 00:06:59:23
Prof Jane Dahlstrom
Once I completed my initial pathology fellowship, really to try and be the best I could be and explore whether this was a career that suited me. The perinatal pathology community across Australia and New Zealand is a really supportive group and I think it helped me gain my confidence as a junior consultant to be able to connect with more experienced perinatal pathologists.

00:07:00:00 - 00:07:24:00
Prof Jane Dahlstrom
I try now to give back to others who are interested in perinatal pathology through mentoring or providing second opinions. One more thing that I think attracted me to perinatal pathology was it's an area of pathology which involves working in a multidisciplinary team, including with colleagues like Farah, who you're going to talk to and families. And I really enjoy this.

00:07:24:02 - 00:07:29:22
Prof Jane Dahlstrom
I'm certainly a great believer that working together is better for our patients.

00:07:29:24 - 00:07:53:22
A/Prof Trishe Leong
I think you're quite right that this is an area of pathology where we can really make a difference. But, despite that, and I guess despite the the professional and sort of personal benefits does have job satisfaction that might come from working in this area, we've still got a shortage of perinatal pathologists in Australia. So can you explain what the implications of that might be?

00:07:53:24 - 00:08:19:03
Prof Jane Dahlstrom
Well, probably the main two implications is that a lack of perinatal pathologists means that we may not be able to provide the high quality, comprehensive service across our country that we currently do, and there just may not be enough perinatal pathologists to train the next generation of perinatal pathologists. This is certainly already a problem in some other countries.

00:08:19:05 - 00:09:11:03
Prof Jane Dahlstrom
This might not only mean not been able to provide answers to a family that suffers a perinatal loss now, but also might mean other families may suffer a perinatal loss that perhaps could have even been prevented. Because through perinatal autopsies and studying the placenta, we have advanced our understanding of many diseases. But there's still so much to do, and I think this was really highlighted during the COVID-19 pandemic when worldwide perinatal pathologists decided to set up a study group as they felt it was important to study the placenta to see whether the virus infected the placenta, which it did, and what effects it could have on the baby and its development.

00:09:11:05 - 00:09:41:20
Prof Jane Dahlstrom
And I think this enabled the obstetricians and neonatalogists to have informed discussions with women who became infected with the various strains of coronaviruses. You know, it's interesting. We all needed a placenta to come into the world, and we still know so little about it. So there's a lot of opportunity to do research on the placenta to better understand its function in health and disease, to benefit future generations.

00:09:41:22 - 00:10:04:21
A/Prof Trishe Leong
Yeah, as you say without people working in the area, we'll never know what we don't know. So thanks, Jane. I might move on now. As I mentioned earlier, we also have Dr Farah Sethna joining us today. So, Farah, you worked closely with Jane in your role as specialist obstetrician and gynecologist at the Canberra Hospital. Can you explain how how you worked together?

00:10:04:23 - 00:10:37:06
Dr Farah Sethna
Yes. Thank you for inviting me, Trishe. So Jane and I work closely together on many fronts. Despite our specialties and work environments being vastly different from each other. Primarily, we work together clinically to provide answers for parents who may have experienced a pregnancy complication or an unexpected or adverse pregnancy outcome following which examination of the placenta or a postmortem examination is undertaken.

00:10:37:08 - 00:11:14:03
Dr Farah Sethna
So the types of situation that may arise in is obviously pregnancy loss be it a miscarriage, stillbirth or neonatal death. We may unexpectedly encounter a baby born in an unexpectedly compromised condition where information available from the placenta can provide insights into the antepartum or antenatal events that can explain what happened and provide some prognostic information for the health of that baby.

00:11:14:05 - 00:11:47:14
Dr Farah Sethna
It may be a case of a suspected maternal or fetal infection. Not infrequently, we find an answer to explain growth restriction when we look in the placenta, and that may have implications for a mother's future, subsequent pregnancy. Likewise, in the case of preterm birth. But it's not just about health problems with the baby. We will care for many mothers who have health problems themselves, and the placenta examination can then be informative.

00:11:47:15 - 00:12:21:11
Dr Farah Sethna
So, for example, in mums who may have experienced a malignancy in pregnancy, assessing the pregnancy for metastatic malignancy is important. Or we may be have a mum with severe pre-eclampsia where information on how the placenta has sort of adapted to that pregnancy may offer the opportunity for preventative intervention in a future pregnancy. Likewise, in cases of multiple pregnancy, we might want to know the chorionicity or, indeed, assess the complications.

00:12:21:13 - 00:12:51:07
Dr Farah Sethna
Where Jane and her team can then be helping us sort of better understand, for example, twin–twin transfusion or TAP sequence. But also for those families who make the very difficult decision of interrupting a pregnancy for a fetal abnormality. It's very important that we're actually able to sort of correlate findings seen at postmortem with that sort of appreciated antenatal on ultrasound or MRI.

00:12:51:09 - 00:13:34:22
Dr Farah Sethna
Not only as a quality control issue that have we actually identified all the anomalies possible and innately but also in refining the diagnosis and making sure we're giving the best advice moving forward. Certainly, these examinations, when properly undertaken and reported, are very helpful, but it requires clinical input. I would never assess a clinical presentation of abdominal pain without clinical context, and I can't expect Jane and her colleagues to sort of provide meaningful information to me and my colleagues without also providing clinical context for them.

00:13:34:24 - 00:14:09:21
Dr Farah Sethna
In other aspects, we work closely together at multidisciplinary education events and forums alongside neonatologists, sonographers, geneticists. And this offers us an opportunity to discuss the presentation and management of complicated pregnancies. These meetings and clinical review sessions provide an opportunity for learning in a safe and constructive manner. Jane and I also work closely in a quality improvement and audit point of view.

00:14:10:00 - 00:14:40:17
Dr Farah Sethna
So we review and correctly classify all the stillbirths and neonatal deaths within the territory so that statistics are accurate when they're fed into local and national reports. As you know, having accurate data informs trends and, more importantly, can lead to practice improvement opportunities. But I think both of us would agree that one aspect of our job that both gives us joy is education and training.

00:14:40:19 - 00:15:19:11
Dr Farah Sethna
We want to sort of improve knowledge amongst our colleagues, and so we collaborate closely and teach medical students in clinical pathological sessions when we cover conditions like pre-eclampsia. And I think that's very helpful for those students. But we also teach collaboratively in postgraduate settings, both locally, territory wide and nationally. And, certainly, one of the initiatives we both teach on is a program called IMPROVE, which is about improving perinatal mortality review outcomes through education.

00:15:19:11 - 00:15:41:17
Dr Farah Sethna
It's teaching practitioners how to have conversations and with parents, but also the importance of investigating pregnancy loss and how to interpret the findings. And I think I'm very privileged to work in a hospital with trained and accessible, knowledgeable perinatal pathologists like Jane.

00:15:41:19 - 00:15:43:08
Prof Jane Dahlstrom
Thanks Farah. You've.

00:15:43:08 - 00:15:54:22
A/Prof Trishe Leong
Probably already touched on this in your previous answer with some of the examples you gave, but can you elaborate a little bit more on why is this area of medicine important to you?

00:15:54:24 - 00:16:25:13
Dr Farah Sethna
So, as Jane mentioned earlier, every day in Australia, six babies are stillborn, two babies die within 28 days of birth and, sadly, to this day, some of these deaths remain unexplained as they may have been suboptimally investigated. And these families never receive an answer to the question they asked most, which is why? Why did this happen? Why me?

00:16:25:15 - 00:17:05:06
Dr Farah Sethna
And what a perinatal pathologist can offer these families is absolutely invaluable. I appreciate sometimes, despite the gold standard investigations, we can't always find an explanation, but still being able to inform these parents of what it was not is equally powerful. And due to a lack of perinatal pathologists in Australia in certain states and territories, some families who've chosen to have postmortem investigations following a pregnancy loss have to wait up to a year to receive these results.

00:17:05:12 - 00:17:38:21
Dr Farah Sethna
I wish this wasn't the case because I'd see firsthand how this delay can negatively impact on their wellbeing and sometimes care provision in the subsequent pregnancy. I'd like to take this podcast actually as an opportunity to thank and acknowledge the time and care perinatal pathologists take when they're crafting the commentary section of their postmortem report. The impact of a well written report in language easily understood by families is so, so very important.

00:17:38:23 - 00:18:13:07
Dr Farah Sethna
But as you know, as an obstetrician, I request many more placental histopathological examinations than I do post-mortems. And again, here I see a huge difference in the quality and detailed information provided from this examination when it's been conducted by a patthologist with general training or somebody like Jane with a special interest in perinatal pathology. And it makes such a difference to the families I encounter and the recommendations I make.

00:18:13:09 - 00:18:41:13
Dr Farah Sethna
I think I'd like to end by saying this area of medicine is so important to me because as an obstetrician I wish to see a reduction in the number of preterm births, stillbirths and neonatal deaths in Australia. And this can only happen through ongoing multi-professional collaboration and learning. And to achieve this goal, we ultimately need more trained perinatal pathologists.

00:18:41:15 - 00:19:07:01
A/Prof Trishe Leong
Thanks, Farah. It's really great to see you two obviously have a very close and very effective collaborative relationship that I can I can tell from how you describe your work together. So just on that last note that you touched on, I might throw back to Jane for the final question, which is what would you say to someone, Jane, that perhaps hasn't considered perinatal pathology as a career?

00:19:07:03 - 00:19:35:21
Prof Jane Dahlstrom
Well, I think I'd say to them it's an ideal time to become a perinatal pathologist. I think there's lots of good career opportunities at the moment. And some of this actually has come about because of the Senate select inquiry that happened in to stillbirths in 2019 and the subsequent 16 recommendations that the government has actually committed some $52 million in this space.

00:19:35:23 - 00:20:09:10
Prof Jane Dahlstrom
And this includes funding to increase the number of perinatal pathologists in Australia. I also believe that being a perinatal pathologist is an incredibly rewarding career for a medical practitioner. Over the last 20 years, it's enabled me to give closure to many families as to why their baby died and I hope also assisted with the management of their next pregnancy if that's what they wanted.

00:20:09:12 - 00:20:33:18
A/Prof Trishe Leong
All right. Well, I think we're going to wrap it up there. Thank you, Jane and Farah, for your time and expertise talking about this very important area of pathology today. I'm certain it's given our listeners an insight into the area and also hopefully spark some interest out there in a career, potentially in perinatal pathology or, if not, perhaps being an obstetrician.

00:20:33:18 - 00:20:40:14
A/Prof Trishe Leong
You never know. So thank you both very much and thank you as well to our listeners. We'll see you next time.