The complementary role of radiology in pathology investigations in cases of perinatal loss

In this episode of our mini-series on perinatal pathology, RCPA President, Associate Professor Trishe Leong is joined by anatomical pathologist Dr Nick Manton and paediatric radiologist Dr Ajay Taranath who work together at The Women's and Children's Hospital, Adelaide.

 Together, Dr Manton and Dr Taranath shed light on the critical role of radiology in the perinatal autopsy process, highlighting the nuanced collaboration between radiologists and pathologists in unravelling the mysteries of perinatal deaths. 

Transcript

00:00:02:08 - 00:00:18:15

Dr Nick Manton

Perinatal autopsies are not just performed for academic interest or closure, although that’s important. But to provide information for that crucial question of will this happen to me again, next time? And it really is a very rewarding area in which to work. For that reason.

00:00:18:17 - 00:00:29:00

Dr Ajay Taranath

I believe that radiology has a lot to learn from the traditional autopsy and the imaging and the histopathology images that come.

00:00:29:02 - 00:00:38:05

A/Prof Trishe Leong

I’m Associate Professor Trishe Leong, the President of the Royal College of Pathologists of Australasia.

00:00:38:07 - 00:01:02:00

A/Prof Trishe Leong

Hello everyone, and welcome to this RCPA podcast series on perinatal pathology. I’m Associate Professor Trishe Leong and I’m the President of the Royal College of Pathologists of Australasia. So throughout the series we’ve been speaking to perinatal pathologists and their colleagues across Australia in a bid to shine a light on this important area of pathology and to hopefully encourage Trainees to consider it as a career option.

00:01:02:02 - 00:01:17:20

A/Prof Trishe Leong

In today’s episode, I have the pleasure of being joined by anatomical pathologist Dr Nick Manton and paediatric radiologist Dr Ajay Taranath, who work together at the Women’s and Children’s Hospital in Adelaide. Thank you, Ajay and Nick, for both joining us today.

00:01:17:22 - 00:01:20:00

Dr Nick Manton

Good to be here with you, Trishe.

00:01:20:02 - 00:01:22:04

Dr Ajay Taranath

Thank you, Trishe.

00:01:22:06 - 00:01:36:08

A/Prof Trishe Leong

So, kicking off, Nick, you’re under the spotlight first. Your department provides a full perinatal and paediatric pathology service. So can you tell me a little bit more about that and what your role in it is?

00:01:36:10 - 00:02:06:20

Dr Nick Manton

Sure. We have 3.6 FTE pathologists in our department. About half our workload is autopsy based, which is predominantly perinatal, and the other half is surgical pathology based, which is kind of a mixture of paediatric, obstetric and gynaecological pathology. And we serve the whole state of South Australia. We also get cases from the Northern Territory, Alice Springs, Darwin.

00:02:06:22 - 00:02:42:04

Dr Nick Manton

We sometimes get cases from Broken Hill as well. Our perinatal autopsy service handles cases from about as early as 12 to 13 weeks gestation right through to the neonatal period, and these could be fetal deaths from delivery to pre-viable gestation or intrauterine fetal deaths, terminations of pregnancy for fetal malformations or genetic disorders or third trimester stillbirths. So they are kind of the categories of cases that we look at in our perinatal autopsy service. We also perform coronial autopsies, not so many of them.

00:02:42:04 - 00:03:11:07

Dr Nick Manton

And usually in the setting of early neonatal death following intrapartum asphyxia. So they are the older children, community deaths are really done by the Forensic Science Centre. We also always have a pathologist on call and we also, when needed, perform autopsies out of hours, occasionally in the setting, for example, of a death from a suspected metabolic disorder where certain tissue samples have to be taken and frozen down within a couple of hours of death occurring.

00:03:11:10 - 00:03:30:15

Dr Nick Manton

And sometimes we will perform perinatal autopsies out of hours and on weekends for cultural or religious reasons. If there is a request for an autopsy to be done at short notice to facilitate observances around burials, etc. So that’s kind of a summary of how our service works.

00:03:30:17 - 00:03:50:15

A/Prof Trishe Leong

So 50% surgical pathology, 50% perinatal autopsies. The perinatal autopsies, a significant component of what you do. When you took up this position – you didn’t come into it blind – you kind of knew what you were in for, what appealed to you about a career like this? So a career in perinatal pathology?

00:03:50:17 - 00:04:10:11

Dr Nick Manton

I think we all come into perinatal pathology in different ways, really. I know I was working as the paediatric RMO in this hospital. I wasn’t quite sure what I wanted to do at that stage, and pathology was always superbly taught at my university when I was a medical student. There’s not as much pathology in medical student teaching these days, but it was very well taught when I was a medical student.

00:04:10:11 - 00:04:47:05

Dr Nick Manton

I loved pathology as a medical student and there happened to be a job here in our hospital. We only had one registrar at the time in our service, and that’s how I came into it. But in terms of what is appealing about perinatal pathology, I think it’s a very unique field of pathology to work in. You work in a close-knit team, not just with your pathology colleagues, but also with obstetric and maternal fetal medicine specialists, geneticists, radiologists working as a team to try to find answers for families regarding their pregnancy loss.

00:04:47:07 - 00:05:15:24

Dr Nick Manton

I think in contrast to adult postmortems, there’s a time pressure to finalise reports because families need to be able to move on and plan their next pregnancy and they come back to clinic in our hospital within about six weeks of their pregnancy loss occurring. And one of the main goals of perinatal autopsy, which I think is what makes it so interesting, is trying to identify any disorders in the baby or the placenta that might recur in the next pregnancy or the one after that.

00:05:16:01 - 00:05:43:14

Dr Nick Manton

And identifying these can directly influence many aspects of managing the next pregnancy, whether it’s, you know, increased ultrasound surveillance, early genetic testing or medication treatment during the pregnancy. And I think even in cases where no cause of death or abnormality in the baby of the placenta is identified, this can still be reassuring because the investigation will have excluded a number of conditions that could potentially recur in future pregnancies.

00:05:43:14 - 00:06:11:19

Dr Nick Manton

And the parents can be counselled whether a recurrence risk of this happening again should be fairly low. So I’ve kind of learned over time to be comfortable with the negative autopsy where despite everyone’s best efforts, you just don’t come up with anything. So I think perinatal autopsies are not just performed for academic interest or closure, although that’s important. But to provide information for that crucial question of will this happen to me again, next time?

00:06:11:19 - 00:06:16:20

Dr Nick Manton

And it really is a very rewarding area in which to work. For that reason.

00:06:16:22 - 00:06:40:03

A/Prof Trishe Leong

I think you’re absolutely right. There is that kind of immediate usefulness to the answers that a perinatal autopsy can provide that do make it different to the adult autopsy, which, as you say, sometimes the answers that provided a bit more academic so related to closure and giving people information rather than ‘is it safe for me to get pregnant again?’

00:06:40:05 - 00:06:45:19

Dr Nick Manton

Yes, still important, obviously. But it’s just a different setting.

00:06:45:21 - 00:07:08:08

A/Prof Trishe Leong

So, as you say, it’s very important for the parents. They are thinking about future pregnancies but, at the same time, you know, the families are often very concerned about the remains being treated respectfully, which of course we do. But also, you know, they may not be comfortable with some investigations. So, with respect to that, is there more than one type of perinatal autopsy that you can offer?

00:07:08:16 - 00:07:42:15

Dr Nick Manton

Definitely. There’s a number of different options available to parents. And I mean, obviously, the gold standard investigation is the full autopsy where we examine the whole body, including all the internal organs. We sample tissue for genetic testing. We send tissue off for microbiology in certain cases to look for infection. We perform autopsies. Sometimes we might do other imaging, such as an MRI scan, which is particularly useful when there’s suspected abnormalities of the brain or the central nervous system and the quality of the images we see now are quite amazing.

00:07:42:17 - 00:08:08:09

Dr Nick Manton

Ajay will talk about that in a minute. But, you know, when you’ve got radiologists like him with particular expertise in this area and an expertise in interpreting them, it’s incredibly useful. New technology also, especially in the area of genetics, is now becoming available as well. Our geneticists have the ability to perform more in-depth genetic testing now with what’s become known as genomic autopsy.

00:08:08:11 - 00:08:40:11

Dr Nick Manton

And this is where with the family’s consent, whole genome or whole exome sequencing is able to be performed in an attempt to identify the cause of unexplained congenital anomalies. And we’ve found that in about 50% of these types of cases, genomic testing has identified a genetic cause for those congenital abnormalities. So that’s kind of the full autopsy. But if parents would prefer not to request a full autopsy, we can do a limited autopsy, which can be really limited in any way the family wishes.

00:08:40:13 - 00:09:04:16

Dr Nick Manton

Some families only request an external examination with an X-ray and photographs. Sometimes we’re allowed to take a skin sample for genetics. Sometimes they don’t want any cuts on the baby at all. And that’s absolutely fine. Some parents are uncomfortable with the cranial cavity being examined, so they might say you can do everything else, but we don’t want you to touch the head of our baby.

00:09:04:16 - 00:09:27:21

Dr Nick Manton

And that’s absolutely fine as well. Or if there’s a particular abnormality suspected in particular organs such as a congenital heart defect or a kidney abnormality, they might request examination just confined to examine of that particular organ or that particular body cavity. So we can do that as well. We follow very carefully the parent’s wishes as specified on the consent form.

00:09:27:21 - 00:09:52:08

Dr Nick Manton

Our consent forms quite detailed. It’s the same form that’s used for adult postmortem. So there are some questions on there that are probably not relevant, but it does allow them to lay out exactly what they are consenting to and what they’re asking us to do, and we follow that very closely. But counselling, obviously, around autopsy is extremely important and should be done really, in our view, by experienced obstetric staff.

00:09:52:12 - 00:10:19:14

Dr Nick Manton

It shouldn’t be delegated to junior staff because the more you limit the autopsy, the more you potentially compromise the information that can be obtained from the examination. And so counselling is certainly really important around that, particularly in the setting of unexpected stillbirth. I think you really want to be counselling as much as you can for a full autopsy where you’ve got an unexpected, you know, third trimester stillbirth, where no one really knows what happened.

00:10:19:14 - 00:10:22:14

Dr Nick Manton

You just don’t know what you’re dealing with.

00:10:22:16 - 00:10:26:23

A/Prof Trishe Leong

The more opportunity to get as much information as possible, the better.

00:10:27:00 - 00:10:29:01

Dr Nick Manton

Yeah, absolutely.

00:10:29:03 - 00:10:45:16

A/Prof Trishe Leong

So you mentioned how you have been very fortunate to have some specialists, radiologists, people who can interpret the imaging, like Ajay. So, can you maybe talk a little bit more about how you and Ajay work together in this process? And what do you enjoy about working together as a team?

00:10:45:18 - 00:11:12:04

Dr Nick Manton

Well, he’s a fun guy to work with. He’s so humble, he’s so humble. He’s very, very approachable and he’s extremely knowledgeable. So, when you’ve got someone with those characteristics that you work closely with, it’s very rewarding to be able to do that. Ajay has an RCPA Fellowship in postmortem imaging. He’s an extremely important member of the team investigating perinatal loss in our organisation.

00:11:12:06 - 00:11:47:05

Dr Nick Manton

As I said before, his knowledge, particularly of the imaging characteristics of fetal brain development and in diagnosing fetal brain malformations, as well as the imaging characteristics of birth trauma, hypoxic brain injury, his knowledge of those areas is hugely beneficial to us and therefore to the families. We have a meeting each week, an MDT meeting with not just the pathologists, but the maternal fetal medicine specialists and geneticists where we discuss all our cases before final sign out of the final report.

00:11:47:07 - 00:12:20:22

Dr Nick Manton

Ajay is always at that meeting, even when he knows there are cases at the meeting that do not necessarily have radiology input. So he’s also got a good understanding, I think, of all of the issues involved in perinatal loss and all the information that can be gleaned from perinatal autopsies. Certainly, in the area of CNS abnormalities, he really provides the macroscopic assessment of the brain for us when we’re looking at the histology, because often fetal brains are extremely delicate structures to handle and it can be tricky to extract them intact.

00:12:20:24 - 00:12:29:10

Dr Nick Manton

And if you’ve got that MRI scan with those lovely images of whatever’s there, you know that’s where we rely on him quite heavily.

00:12:29:12 - 00:12:37:09

A/Prof Trishe Leong

Thank you, Nick. So over to you then, Ajay. Why do you think this area of medicine is so important?

00:12:37:11 - 00:13:08:01

Dr Ajay Taranath

Thank you, Trishe. And thank you, Nick, for all those kind words. There is a global decline, Trishe, in conventional autopsy rates. There is a lack of parental consent, as Nick was talking about earlier. Sometimes they let you know only the head or only the organ in question. So there is a parental consent that is either due to religious factors surrounding the death or due to the perceived invasive nature of the traditional autopsy.

00:13:08:03 - 00:13:27:06

Dr Ajay Taranath

So postmortem imaging has emerged as a complementary modality to traditional autopsy. And sometimes it is the only way parents would allow something to happen post-death and allow us to get the information and take the investigations forward.

00:13:27:08 - 00:13:31:17

A/Prof Trishe Leong

So, what does a typical day look like for you then, Ajay?

00:13:31:19 - 00:13:58:11

Dr Ajay Taranath

A typical day for me involves reporting X-rays, ultrasound, CT scans, MRIs, whatever comes through on the day. Supervising registrars. And this is not only just the sick children, but also the postmortem imaging. The registrars don’t take an active role in postmortem imaging. It’s predominantly the consultants, and in postmortem imaging we are using MRI more than CT scans.

00:13:58:13 - 00:14:22:03

Dr Ajay Taranath

Occasionally, we do CT scans when we suspect that there may be abnormalities relating to the bones, but predominantly it’s an MR-based investigation that occurs following termination of pregnancy. And as far as the postmortem neuroimaging is concerned, I prepare a report after reading the MRI. Then I call up Nick and request him to come down to the radiology department to view the images.

00:14:22:09 - 00:14:51:20

Dr Ajay Taranath

I find that a very stimulating exercise because it brings the pathology information that I would have probably not been able to make a diagnosis on if it was not for the pathology information. And then we discuss the various findings on the MRI. And also occasionally we have discussed a case where we’ve said maybe cutting the brain in another plane might allow us to visualise the pathology better than the traditional method of doing the autopsy.

00:14:51:22 - 00:15:11:05

Dr Ajay Taranath

It’s very rewarding this discussion, and I have learned that things that I did not know the answer to, now I know because I have found that, on pathology, it has turned out to be something. And I know that that something has this sort of signature pattern on the MRI, something that I might have not given importance to in the past.

00:15:11:07 - 00:15:22:23

Dr Ajay Taranath

The fact that we get good images is because we are able to increase the time of acquisition on the dead fetus and there is no risk of movement and you get images with a lot of detail in it.

00:15:22:23 - 00:15:45:19

Dr Nick Manton

Sometimes if the baby is delivered and there’s a complex abnormality of the brain, there’s an arrangement in the hospital now where the baby can go straight from delivery to radiology to have its scan done, even if that’s on a weekend or in the evening, to sort of minimise the postmortem deformation of the shape of the head, etc that can happen with refrigeration etc.

00:15:45:19 - 00:15:55:05

Dr Nick Manton

And then we do the autopsy later. You know, the more normal time, I guess.

00:15:55:07 - 00:16:05:02

A/Prof Trishe Leong

Ajay, you’ve already touched on this in one of your previous answers. But what role do you see radiology playing in the perinatal autopsy process?

00:16:05:04 - 00:16:40:23

Dr Ajay Taranath

It plays, like I said earlier, it’s a complementary role and it’s no way seeking to replace the traditional autopsy. A classic example of the value of imaging in the autopsy situation would be where we’ve seen a corpus callosum on the postmortem MR. But by the time it’s cut and the autolytic processes take over, it is not possible to see it on opening the skull vault and I actually was invited into the autopsy room once by Nick, and I had the live demonstration of the calvarium being opened and not being able to see the corpus callosum.

00:16:40:23 - 00:17:12:07

Dr Ajay Taranath

It had just fallen apart. And the MRI that preceded that showed the corpus callosum. So it has a sort of value in certain situations and helps in directing investigations along, say, the infection pathway or a genetic or metabolic pathway. I believe that radiology has a lot to learn from the traditional autopsy and the imaging and the histopathology images that come, sometimes very closely mimic the radiology images.

00:17:12:08 - 00:17:34:13

Dr Ajay Taranath

Once I could understand the histopathology images, not that I can understand it very well, but once I’ve been prompted that this is that, then I can correlate my findings with the histopathology images. For example, a heterotopia that I see on MR imaging and once it’s pointed out to me on the histopathology that this is how it looks, it makes a lot of sense.

00:17:34:15 - 00:17:40:10

A/Prof Trishe Leong

So how involved are both of you with families who’ve suffered the loss of a baby?

00:17:40:12 - 00:17:52:17

Dr Ajay Taranath

At the Women’s and Children’s Hospital, the radiology department is not involved in counselling or talking to parents after they have suffered the loss of a baby, so I haven’t done that at all.

00:17:52:19 - 00:17:54:22

A/Prof Trishe Leong

How about you, Nick?

00:17:54:24 - 00:18:25:20

Dr Nick Manton

I’ve been involved occasionally in discussions with parents before and/or after an autopsy examination on their baby. I mean, one form of engagement with the family that we not meeting them in person is when you write a plain language report, which I don’t actually get asked to do all that often. Not as often as you’d think. I find those reports a lot harder to write than the medical report because you don’t know the educational background or understanding that the family might have.

00:18:25:22 - 00:18:52:07

Dr Nick Manton

So they always go out with a letter to the obstetricians saying, you know, can you please read this? And, if it’s not worded properly, I can make whatever changes. I have met families occasionally before/after or and/after doing the autopsy. And I’ve always found that to be a very rewarding experience. It’s not an easy situation to meet a family for the first time when they’ve just lost their baby.

00:18:52:07 - 00:19:15:02

Dr Nick Manton

And you’re about to perform a fairly, you know, invasive examination, I guess. But I’ve always found when that has happened that parents have always appreciated the opportunity to talk through things and have their questions answered and I think subconsciously, I wouldn’t say you try harder, but if you’ve met the parents, you it just puts a different slant on things.

00:19:15:07 - 00:19:27:24

Dr Nick Manton

Very much so. But it doesn’t happen very often. I’ve probably only ever done it about three or four times and I remember those people very, very clearly. Even still, even today.

00:19:28:01 - 00:19:50:20

A/Prof Trishe Leong

So, Nick, you mentioned, say, 3.4 FTE of pathologists in your particular department. In our previous episodes about perinatal pathology, we’ve talked about the shortages of perinatal pathologists in Australia. Do you do feel that, in South Australia, 3.4 is enough for the sort of service that you need to provide?

00:19:50:22 - 00:20:14:07

Dr Nick Manton

We’re coping okay at the moment, I would say. I mean, it’s hard to attract pathologists in this area. I think that’s mainly because it’s such a specialised area and Trainees often don’t have a lot of exposure to it during their training. It can be seen as a very niche area in pathology. You know, there’s not that many perinatal pathologists around and job opportunities don’t come up all that often.

00:20:14:07 - 00:20:44:24

Dr Nick Manton

So there can be a reluctance, particularly for newly qualified pathologists, to commit to this area of work. I think as part of the National Stillbirth Action and Implementation Plan that’s happening now. There has been additional federal funding made available to increase the number of perinatal pathologists nationally. It’s one of the goals of that plan. I think generally this is not enough to cover a full-time position, but I think states have been topping up.

00:20:45:01 - 00:21:11:01

Dr Nick Manton

You know, to create additional FTE, to make these additional positions more viable and attractive to people. My state here in South Australia provides perinatal autopsy services to the Northern Territory as well. So we have to see over the next couple of years how that impacts on our workload and staffing requirements because we know that insufficient staff leads to a blowout of turnaround times.

00:21:11:01 - 00:21:31:24

Dr Nick Manton

And I think it’s important that these reports that we finalise go out in a timely fashion. You know, if it’s a year, two years later, it becomes a little bit more academic, I think. And you need to maintain your staffing to be able to generate those autopsy reports in a timely fashion. So we’ll just have to wait and see a little bit over the next.

00:21:32:01 - 00:21:39:14

Dr Nick Manton

So, I mean, that’s a three-year period that that funding is available and we’re not quite sure what will happen after that, but we’ll have to wait and see.

00:21:39:16 - 00:21:52:15

A/Prof Trishe Leong

So, if you’ve got a job going and you’re trying to convince one of the new graduates to maybe consider taking up perinatal pathology, Nick, this is your opportunity. What would you say to them?

00:21:52:17 - 00:22:14:06

Dr Nick Manton

Well, I think it’s an excellent time to be coming into the field of perinatal pathology, really, with that National Stillbirth Plan and with the additional funding and recognition and promotion of the work we do. It’s hoped that perinatal autopsy rates will go up over the next few years. That’s the goal. And there will be a growing need for pathologists in this area in all likelihood.

00:22:14:06 - 00:22:38:19

Dr Nick Manton

So it’s a fascinating area to work in. I see things all the time that I’ve never encountered before, which can be a bit unsettling, but it’s also very challenging. And it’s rewarding also to know that, you know, the work you do is so helpful and important for families who have experienced a perinatal loss. I don’t think you can underestimate the importance.

00:22:38:21 - 00:22:58:10

Dr Nick Manton

So I would say to any Trainee or young pathologist considering this area as a career option, don’t be frightened to take on a role in perinatal pathology. Perinatal pathologists as a group I think are wonderful people to work with and be mentored by and I know most of them. And I think I can say that about all of them.

00:22:58:12 - 00:23:25:12

Dr Nick Manton

And although it’s a specialised area, the material that you see within perinatal pathology is extremely broad. So, you know, we deal with everything from central nervous system disorders to every organ system in the body. And the types of disorders you come across really vary a lot depending on the gestation and the clinical settings. So it’s really a very, very interesting area to work in.

00:23:25:14 - 00:23:42:10

A/Prof Trishe Leong

Well, I think that’s a great ad for the specialty, Nick, and a good note to wrap up on. Thank you very much, Dr Nick Manton and Dr Ajay Taranath for your time today and your valuable insights into the realm of perinatal pathology.

00:23:42:12 - 00:23:43:18

Dr Nick Manton

Thank you, Trishe.

00:23:43:20 - 00:23:46:07

Dr Ajay Taranath

Thank you, Trishe.

00:23:46:09 - 00:23:58:23

A/Prof Trishe Leong

So, as we conclude, we hope this episode has provided valuable insights into the vital work, of perinatal pathology and inspired future pathologists and radiologists to consider this field as a meaningful career option.