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Current technology and diagnostic imaging procedures are increasingly improving, but stillbirth may remain unexplained. Parents may refuse a postmortem investigation, even though the information it may provide about the current pregnancy and subsequent pregnancies could be highly beneficial. The possible comfort the results could deliver for the parents, especially the mother, is often hidden in the literature. We may automatically accept the parents' denial of an autopsy because our workload is huge, particularly in events such as the current pandemics. Culturally sensitive and competent discussions about why a postmortem examination is essential are critical in medicine. In this sense, an intense collaboration between the pathologist and the Pastoral and Spiritual Care department is critical.
Stillbirth is marked by strong emotional, mental, and behavioral responses. Managing with and adapting to the intrauterine fetal demise is sudden and unbearable when stillbirth is diagnosed. Crucial decisions after the stillbirth may substantially impact the recovery process. The autopsy has a vital role in improving medical diagnosis and therapy. In addition, it has social relevance for the individual, family, and society. Facing an increased workload, few physicians may continue to utilize the autopsy as a quality control measure. Even fewer are willing to discuss the autopsy results directly with the bereaved family. Nevertheless, despite controversies and reluctance, autopsies are crucial for the quality of a healthcare institution and are supported by postgraduate medical education policies.
The sensitive communication of physicians with bereaved families is crucial. The training of physicians facing the communication of tragic news and the skillful request of a postmortem investigation may increase the autopsy rates. Such activity must become embraced. Communication between the pathologist and families is the basis for fully understanding the benefits of autopsies.
The autopsy findings need to be discussed in the context of four interconnected dimensions of the grieving process associated with stillbirth: death and sorrow, trauma, medical issues, and post-traumatic stress disorder. These areas emphasize the complexity of the event. In 1969, Dr. Elisabeth Kübler-Ross introduced pioneering concepts about the grieving process that involved five stages (denial, anger, bargaining, depression, and acceptance). Her theories are applied to several issues involving trauma and/or loss, including those associated with death or organizational change [1].
There is a strong need for the pathologist of the 21st century to be involved in this multidisciplinary approach. However, we are aware that this process is not even. In a post-pandemic world, when communication failure during the pandemic has determined disastrous consequences, there is a need to improve the quality of communication between pathologists and clinicians and between pathologists and families. It has been recognized that culturally sensitive and competent discussions about the denial are critical. In addition, the proper discussion of the postmortem examination results is paramount. This situation usually does not help the parents, and often the mother is targeted by voluntary and involuntary feelings of guilt.
The use of culturally sensitive and inclusive language is crucial in undertaking the pathway for granting or refusing an autopsy and communicating the autopsy results. Parents may express frustration when they are denied mourning time, and this time needs to be explained by the pathologist. Spiritual and religious objections and thoughts toward the autopsy are not modern but old as autopsies. We, as pathologists, have the unique opportunity to comfort the family members and ease their grieving.
In 1997, Dent et al. reported bereaved parents' perceptions of care after their child's sudden, unexpected death and respect offered by voluntary and statutory agencies in 11 health districts in England and Wales [2]. The postal questionnaires targeted 185 families, but only 42 answered the questionnaire. Most parents identified inadequate community care, leaving them isolated from the community. This feeling is still present today. Stillbirth, when it occurs, is considered a guilty hallmark by both professionals and social media. The uncomfortable feeling of requesting an autopsy and the potential discomfort of provoking more distress may span decades. The consultant's degree of support has been recognized as the strongest and most important predictor of intention to request a postmortem examination. Parents and relatives seem to be often poorly informed about the surgical procedures or the imaging options. Policymakers may facilitate awareness of local autopsy services and radio-diagnostic options.
Couples suffering stillbirths are at higher risk of depression, anxiety, and stress [3, 4] and this was getting worst during the recent COVID-19 pandemic [5]. These recent articles are supporting our view and strengthen the need to talk with the pathologist. Pathologists are uniquely positioned to liaise with mothers, who may often develop depression, anxiety, and suicidal thoughts. The triad constituted by the midwife/obstetrician, pastoral and spiritual care member, and pathologist will enormously benefit both mothers and their families and the quality of our medicine.
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References
Kűbler-Ross E (1969) On death and dying. Macmillan, New York
Dent A, Condon L, Blair P, Fleming P (1996) A study of bereavement care after a sudden and unexpected death. Arch Dis Child 74(6):522–526
Sarkar A, Siwatch S, Aggarwal N, Singla R, Grover S (2022) The unheard parental cry of a stillbirth: fathers and mothers. Arch Gynecol Obstet 305(2):313–322. https://doi.org/10.1007/s00404-021-06120-9
Xue RH (2021) Letter to the editor on: “The unheard parental cry of a stillbirth: fathers and mothers.” Arch Gynecol Obstet. https://doi.org/10.1007/s00404-021-06249-7
Dong H, Hu R, Lu C, Huang D, Cui D, Huang G, Zhang M (2021) Investigation on the mental health status of pregnant women in China during the Pandemic of COVID-19. Arch Gynecol Obstet 303(2):463–469. https://doi.org/10.1007/s00404-020-05805-x
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Intramural (Medical University of Innsbruck, Tiroler Landeskrankenanstalten GmbH).
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CMS and TM conceptualized the study, collected the data, and interpreted the data. CMS drafted the initial manuscript and revised the manuscript. TM was responsible for the intramural funding and revised the manuscript. All authors meet the ICMJE requirements for authorship, approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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Sergi, C.M., Mullur, T. Communication in reporting the autopsy results is utmost. Arch Gynecol Obstet 307, 1655–1656 (2023). https://doi.org/10.1007/s00404-022-06667-1
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DOI: https://doi.org/10.1007/s00404-022-06667-1