Stillborn or liveborn?Potential diagnostic role of gross pathological examination of the placenta

Authors

Abstract

Aim In this study we aimed to evaluate the role of gross pathological examination of the placenta and umbilical cord in determining whether the dead baby was stillborn or liveborn.
Methods The study was conducted on a total of 50 post-delivery cases attending the Obstetrics and Gynecology Department, at El-Shatby University Hospital, Alexandria, including two groups: The first group was the live-born group (25 newborns; vaginal or cesarean delivery), and the second group was the stillborn group (25 confirmed intrauterine fetal death cases with gestational age ≥ 20 weeks).
Results Greyish/brownish umbilical cord discoloration was a strong indicator of stillbirth (sensitivity 56%, specificity 100%). Fibrin plaques on the placental fetal surface were common in stillborn cases. Pale maternal placental surfaces and parenchyma marked stillbirth, often associated with infarction.
Conclusion Gross placental pathology assessment, including the umbilical cord and placental surfaces, is critical in determining live birth vs. stillbirth. These findings aid forensic understanding and inform obstetric care.

Keywords

Introduction

Differentiating between stillborn and liveborn infants is crucial in forensic pathology due to its multifaceted medicolegal implications. It plays a pivotal role in legal contexts, potentially affecting cases of neonaticide, civil suits, and the child’s legal status, impacting inheritance and insurance claims. This distinction is also integral in medical practice, influencing treatment protocols, the accuracy of medical records, and, subsequently, public health policies and resource allocation. Furthermore, it enriches scientific research by providing accurate data for studying the causes and preventive measures for stillbirths and early infant deaths ^1,2.
Distinguishing between stillborn infants and live births can be challenging for perinatologists and pathologists. Discerning perinatal death involves various observations, dissections, special techniques, and extra tests. These steps aid forensic pathologists in forming a reliable final opinion ³.
Worldwide, there are about 3 million stillbirths annually and more than 7178 stillbirth cases daily, most occurring in underdeveloped nations ⁴. In Egypt, there were more than 23000 stillbirth cases in 2019, about 9 cases per 1000 births ⁵.
Fetal mortality can occur at any gestational age. The Centers for Disease Control and Prevention (CDC) defines “stillbirth” as fetal death at or after week 20 of pregnancy, while the World Health Organization (WHO) considers it as fetal demise at or after 28 weeks gestational age ⁵.
Due to the potential legal ramifications of determining live births, a definitive answer remains elusive, and it is safer to assume stillbirth ³. This study evaluated the importance of gross placental pathology assessment, including the umbilical cord and amniotic membranes, in distinguishing between stillbirth and live birth.

Materials and Methods

The study had a case-control and involved 50 post-delivery cases from El-Shatby University Hospital, Alexandria, Egypt, within the Obstetrics and Gynecology Department.
These cases were categorized into two groups:
- Live-born group: 25 newborns of either vaginal or cesarean delivery
- Stillborn group: 25 confirmed intrauterine fetal death cases with gestational age ≥ 20 weeks
Exclusion Criteria of Liveborn Cases- Cases of twins or multiple pregnancies.
Inclusion Criteria of Stillborn Cases
- Intrauterine fetal death cases with gestational age ≥ 20 weeks diagnosed by the absence of fetal heartbeat and absence of fetal movements with ultrasonographic examination.
Exclusion Criteria of Stillborn Cases- Intrauterine fetal death before completing 20 weeks of gestational age.
- Cases of twins or multiple pregnancies.
Methods- A detailed history and clinical data will be taken from all mothers who participated in the study and the medical records of the cases.
- Placenta and umbilical cord were collected from every case in both liveborn and stillborn groups.
3. Umbilical cord specimens were grossly examined, and data of the insertion type, coiling index (calculated as the number of coils divided by the cord length in centimeters), length, diameter, presence of knots, and discoloration were recorded.
4. The placental surface and parenchyma were grossly examined regarding color and appearance, and any abnormal findings, like the presence of infarction of fibrin plaques, were recorded.
Mothers (or partners) included in the study provided informed consent after understanding the study’s purpose and procedures. Complete confidentiality was maintained throughout the study.
Statistical Analysis of the DataThe sample size was determined using One-Way ANOVA with PASS version 20, and data was analyzed with IBM SPSS version 20.0. Qualitative data were shown in percentages, and categorical data were analyzed using the Monte Carlo correction and Chi-square test. Normality was checked with the Shapiro-Wilk test. Paired t-tests and the Mann-Whitney test compared quantitative data. Data were expressed as range, mean, standard deviation, median, and IQR, with significance at the 5% level. The chi-square test evaluated categorical variables, with corrections applied for expected counts below 5. The ROC curve displayed sensitivity against specificity.
Ethical ApprovalApproval for the study was obtained from the Research Ethics Committee of the Faculty of Medicine, Alexandria University (IRB NO: 00012098, FWA NO: 00018699, Serial protocol Date: 2021-02-18, No: 0201450).

Results

The study enrolled 50 post-delivery cases (a group of 25 live-born cases and a group of 25 stillborn cases).
History TakingMothers’ age ranged from 21 to 45 years, with a mean age of 31.16 ± 5.30 years. There was no statistically significant difference between either studied group regarding the age of their mothers, where t= 0.158 and P= 0.875. Regarding the mode of delivery (vaginal or cesarean) (P=0.157), mother’s medical, family history (P=1.000), and body mass index (BMI) (P=0.481), there were no statistically significant differences between the two studied groups.
Umbilical Cord Gross ExaminationRegarding the umbilical cord gross examination, the current study found no statistically significant difference between the two groups under investigation regarding the coiling index (P=0.845), the insertion site (P=0.279), the umbilical cord length (P=0.120), diameter (P=0.168), and the presence or numbers of either true or false knots (P=0.559) (Table 1).
The study revealed that greyish/brownish discoloration of the umbilical cord (Figure 1) was a helpful sign in the diagnosis of stillbirth cases, where it did not appear in any live-born case and occurred exclusively in 56% of stillborn cases. Both groups had a statistically significant difference regarding this studied parameter (X2 = 19.444 and P <0.001). This parameter was sensitive and highly specific in the diagnosis of stillborn at a sensitivity of 56%, specificity of 100%, and accuracy of 78%.
Placental Surface Gross ExaminationAlthough gross examination of the fetal surface of the placenta. On the other hand, the presence of fibrin plaques revealed a statistically significant distinction between the two groups under study (X2 = 5.128, P= 0.024). Fibrin plaques (Figure 2) were found in 17 stillborn cases (68%), compared to only nine live-born cases (36%). The gross examination of the maternal surface of the placenta demonstrated a statistically significant difference in its appearance. Eight out of 25 stillborn cases (32% of cases) were pale, compared to only one live-born case that showed pallor, where (X2 = 7.473, P= 0.026) (Table 2).
Placental Parenchyma Gross ExaminationThere was a highly statistically significant difference between the two studied groups regarding the color of placental parenchyma (X2 = 22.222 and P <0.001), where 68% of stillborn cases (n=17) had pale placental parenchyma compared to only one live-born case that showed pallor of placental parenchyma. Furthermore, 32% of stillborn cases (n=8) showed infarction of placental parenchyma compared to only 8% of live-born cases (n=2). This difference showed a statistical significance (X2 = 4.500 and P = 0.034) (Table 3, Figure 3).

Discussion

Determining whether the infant was live-born or stillborn has attracted great attention in forensic literature for its potential legal consequences ³.
The current study aimed to assess the role of gross pathological examination of the placenta, including the umbilical cord, in determining whether the dead baby had been stillborn or liveborn. This research is pivotal in enhancing the differentiation between stillborn and liveborn infants, with substantial forensic, legal, and medical implications. By conducting a gross pathological examination of the placenta and umbilical cord, the study offers critical insights that can assist in legal investigations. It highlights specific pathological markers, such as umbilical cord discoloration and fibrin plaques on the placental surface, that are instrumental in identifying stillbirths, thereby contributing to the enhancement of maternal and infant health care, legal clarity, and the enrichment of scientific knowledge on pregnancy outcomes.
Typically, the umbilical cord has a white, opaque, shiny appearance with spiraling two complete coils per 10 cm ⁷. Hammad et al., 2020 ⁶ stated that umbilical cord abnormalities account for 19% of cases of stillbirth.
In the present study, the umbilical cord gross examination revealed that there was statistically significant difference between the studied groups regarding greyish/brownish discoloration of the umbilical cord, which was a helpful sign in the distinction between live-born and stillbirth cases. Roberts et al., 2022 ⁷ explained that brown/red color is associated with fetal death over at least six hours and is primarily due to red blood cell lysis and hemosiderin formation. Longer fetal death retentions cause a clay-gray discoloration.
Even though there was no discernible statistically significant difference between the two study groups in both the length and diameter of the cord, the present study showed that in the live-born, the range of the length of the cord was 30-63 cm, whereas in stillbirth, it was 18-87 cm. Jaiman, 2015 ⁷ reported a correlation between long or short cords and developmental problems.
The mean value of gestational age of stillborn cases in the present study was 31.56 ± 5.24 weeks. Sixteen stillborn cases out of 25 had short cords (18-40 cm). Pinar and Carpenter, 2010 ⁸ stated that most of the cord’s length had been reached by the end of the second trimester (28 weeks). Lowered fetal movement can cause short umbilical cords (<40 cm at term). This can be seen in oligohydramnios, uterine anomalies, amniotic bands, or structural or functional limb defects.
Moreover, the present study showed no significant statistical difference between the studied groups in the cord diameter. In the live-born, the cord diameter ranged from 10-20 mm, whereas it was 4-25 mm in stillbirth. Thick cords tend to be related to maternal diabetes, raised BMI, and fetal hydrops. Nakamura et al., 2022 ⁹ explained that massive edema is frequently connected to abrupt alterations in the fetal heart rate patterns and can lead to vascular impairment. Binbir et al., 2012 ¹⁰ reported that thin cords are commonly associated with intrauterine growth restriction (IUGR).
The placental examination is crucial to the autopsy in fetal or neonatal death situations. In 48% to 51% of cases, pathological abnormalities in the placenta alone could determine the cause of fetal death. In 69% of stillbirth situations, placental findings may help determine the cause of death ¹¹. Another review reported that placental abnormalities were responsible for death in 35% to 88% of stillbirth cases ¹².
In the present work, the gross examination of the fetal surface of the placenta showed a statistically significant difference between the two studied groups regarding fibrin plaques, where they were found in 17 stillborn cases (68%) compared to only nine live-born cases (36%). Lampi et al., 2022 ¹³ suggested that the amount of fibrin influences pregnancy outcomes in the placenta. Severe massive perivillous fibrin deposition in the placenta was correlated with a higher risk of prematurity, small for gestational age, and intrauterine fetal demise.
Furthermore, a statistically significant difference was found regarding the appearance of the placental maternal surface. Eight out of 25 stillborn cases (32% of cases) were pale, compared to only one live-born case that showed pallor. In addition, a highly statistically significant difference was found between the two studied groups regarding the color of placental parenchyma, where 68% of stillborn cases (n=17) had pale placental parenchyma compared to only one live-born case that showed pallor of placental parenchyma. If the placenta is edematous and pale, this may indicate fetal hydrops ⁵. Congenital Cytomegalovirus (CMV) infection and fetal thrombotic vasculopathy can also cause the placenta to be pale ⁸.
Furthermore, the current work revealed that 32% of stillborn cases (n=8) had infarction of placental parenchyma compared to only 8% of live-born cases (n=2); this difference showed statistical significance.
Infarcts can be frequently seen in the placentas of healthy living fetuses. In stillbirths, the center of the placenta may contain placental infarctions. Infarcts typically have a lobular structure and a clear boundary and may occupy the entire placenta thickness. Many perinatal pathologists recognize infarction as the cause of mortality if more than 50% of the placental mass is infarcted ⁸.
Infarction happens when a placenta area experiences a complete interruption of maternal vascular perfusion ¹⁴.
Tiwari et al., 2021 ¹⁵ found significant observations in the stillbirth cases, including anomalous fetuses, distal villous hypoplasia, placental parenchyma infarction, retroplacental hemorrhage, arterial thrombosis, fibrinoid necrosis of artery, and retroplacental hemorrhage.

Conclusion

A gross pathological examination of the placenta, including the umbilical cord, has a significant role in the distinction between stillborn and live-born infants before proceeding into further histopathological or histochemical investigations. The pathological evaluation of the placenta can provide information that will assist in the mother’s ongoing obstetric treatment and understanding of the mother’s previous obstetric history. It may offer explanations for sudden fetal/neonatal deaths.
RecommendationsThe interpretation of placental findings in the forensic setting should not be separated from the clinical details of the pregnancy, mother, and fetus/neonate. Thus, the present study recommends evaluation and examination of the placenta as a mandatory part of all perinatal or maternal autopsies. In this context, consultation with pathology experts with expertise in placenta examination is required.

Declarations

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About This Article

Received:

July 30, 2023

Accepted:

October 25, 2025