Investigations

Finding out Why: Investigations After a Pregnancy Loss or Death of a Baby

Most parents want to know why their pregnancy ended/baby has died. Sadly, we don’t always know why babies die. Investigations can be offered and these should be discussed with you. The availability and type of investigations vary depending on the hospital, region, and gestational age (how many weeks pregnant you were) at the time of your loss. It is important to consult with your healthcare professional for specific information related to you.

Finding Out Why

Post-Mortem Examination (Autopsy)

Purpose: A post-mortem, or autopsy, is when your baby’s body is examined to try to find a cause of death. The procedure involves an examination of the outside of your baby’s body, and might include x-rays, examining your baby’s organs, and looking at blood and tissue samples. It can sometimes include genetic testing to see whether your baby had a genetic disease if the pathologist carrying out the post mortem thinks it is necessary.

Considerations: A post-mortem requires your consent.  It can be emotionally challenging for parents. The post mortem may provide valuable information to inform future care but you may not find a reason why your baby died. For example, up to 60% of stillbirths are from unknown causes.

    • You can opt to have a complete, limited, or external post-mortem. You can read more in detail here what this means.
    • Please note you may wait 4 months to over a year for post mortem results depending on where you live and the pathology services available in your area. 

Links: It may be helpful to listen to information and the voices of other bereaved parents. Here are some videos for you to watch:

    • Held in our hearts co-produced a short video with parents discussing the decision making process of having a post mortem.
    • Tommy’s Charity have co-produced this animation, which includes parents talking about their experience of having a post-mortem for their baby.  

Placental Examination

Purpose: To investigate potential issues with the placenta that may have contributed to the death of your baby.

Process: This includes a specialist examination of the umbilical cord, membranes and placenta – the tissues that attach you to your baby and support your baby in pregnancy. This is to identify any abnormalities such as infection, inflammation, or problems with the blood circulation and vessels in the placenta.

Pre- 12 week pregnancy loss Histopathology testing

Histopathology is the microscopic examination of the appearance of cells and tissues to exclude any abnormalities. Histopathology testing is advisable, but not compulsory.

This examination of your pregnancy loss/baby is carried out to exclude a rare condition called Molar Pregnancy (Gestational Trophoblast Disease). In a molar pregnancy both pregnancy and placental tissue develop abnormally and can cause miscarriage.

There are two types of Molar Pregnancy:

1. A complete mole, where there’s a mass of abnormal cells in the womb and no foetus develops.

 2. A partial mole, where an abnormal foetus starts to form, but cannot survive.

This testing does not investigate other reasons why a miscarriage might have occurred, nor will it determine the sex of the baby.

Genetic and Chromosomal Testing

Purpose: To identify genetic abnormalities or chromosomal conditions that could have led to the loss/death of your baby.

Process: Analysis of the baby’s and sometimes the parents’ genetic material to detect genetic or chromosomal disorders like trisomies (Edward or Down syndrome) and other genetic disorders. This can be done with specialist examination of the umbilical cord and placenta – the tissues that attach you to your baby and support your baby in pregnancy. 

Karyotyping: If you have experienced a third miscarriage, testing your baby for abnormalities in the chromosomes (blocks of DNA) is recommended. If a genetic abnormality is found, you and your partner might also be offered genetic testing. If problems are identified, you can be referred to a clinical geneticist (gene expert). They’ll be able to explain your chances of a pregnancy not affected by a specific genetic abnormality in the future and whether there are any fertility treatments, such as IVF, that could help you have a baby. This type of advice is known as genetic counselling.

Blood Tests

Purpose: To identify maternal conditions that could have contributed to the loss, such as clotting disorders, infections, or autoimmune diseases.

Process: Blood tests can screen for infections (e.g., TORCH panel), clotting disorders (e.g., antiphospholipid syndrome), and other relevant conditions.

    • If you’ve had 3 or more miscarriages in a row (recurrent miscarriages), further tests are often used to check for underlying causes. However, no cause is found in about half of cases.
    • Your blood can be checked for high levels of the antiphospholipid (aPL) antibody and lupus anticoagulant. This test should be repeated if there is an indication that levels are high, a few weeks after the first test to confirm if levels are still high, and needs to be done when you’re not pregnant. These aPL antibodies are known to increase the chance of blood clots and change the way the placenta works. Blood clots and changes to the placenta can reduce the blood supply to the baby, which can cause a miscarriage.

Ultrasound/ Scans

Purpose: To provide information about the pregnancy and any structural abnormalities.

Process:

    • Review of previous ultrasound scans to assess any abnormalities in the uterus or baby.
    • A transvaginal ultrasound can be used to check the structure of your womb for any abnormalities. A second procedure may be used with a 3D ultrasound scanner to study your lower tummy and pelvis to provide a more accurate diagnosis.
    • An ultrasound scan can also check if you have a weakened cervix. This test can usually only be carried out when you become pregnant again, in which you’ll usually be asked to come for a transvaginal scan when you are in your second trimester.

Perinatal Mortality Review Tool Meeting (PMRT)

What is a PMRT?

A Perinatal Mortality Review Tool (PMRT) is a standardised, structured online tool used by hospitals to review and understand the care provided to mothers/parents and their babies when a baby dies before, during, or after birth where a baby has been born after 22 weeks of gestation.

Key points about the PMRT and the review process:

  •   Purpose: To provide a robust review of the care provided, ensuring every stage of the    pregnancy, birth, and aftercare is thoroughly considered.
  •   Standardisation: The tool offers a structured approach, ensuring consistency in how reviews are conducted across different hospitals.
  •   Data Collection: Information collected via PMRT is linked to the MBRRACE-UK system, which monitors and investigates maternal deaths, stillbirths, and infant deaths across the UK.
  •   Security and Confidentiality: Data collected through the PMRT is secure and not publicly accessible, managed by MBRRACE-UK at the University of Oxford.
  •   Bereaved Parents’ Involvement: Parents are informed about the review, can provide input, and ask questions, although they do not attend the review meetings. You may be offered a consultations to discuss the findings.
  •   Timing: The review may take several weeks or months, especially if a post-mortem examination is involved or if an investigation by the Maternity and Newborn Safety Investigations (MNSI) programme is also taking place. (This was the Healthcare Safety Investigation Branch (HSIB)prior to October 2023).
  •   Outcome: The findings from the review are discussed with the parents in follow-up appointments, providing closure and understanding of the events leading to the baby’s death.

Overall, the PMRT is an essential tool in improving the quality of maternity and neonatal care by learning from each case of perinatal mortality to prevent future deaths.

Discussion with Healthcare Professionals

It is crucial to have open and detailed discussions with your healthcare professional to understand which investigations are appropriate and available. They can provide personalised advice, explain the purpose and process of each investigation, and help you make informed decisions about your care. Depending on the timing of your loss, you may also be offered a debrief about your birth experience. This can be to see a consultant midwife, your named obstetrician or professional midwifery advocate.

Miscarriage Tool

(Miscarriage is a loss prior to 24 weeks)

Tommy’s Charity have produced a miscarriage support tool. This tool has been developed for people who have had 1 or more miscarriages and are considering a next pregnancy. The calculation does not take results of tests or investigations after miscarriage into account. If you’ve had these results may not be accurate.

Access the tool here.