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Human fetal whole-body postmortem microfocus computed tomographic imaging

Nature Protocols volume 16, pages 2594–2614 (2021)Cite this article

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Abstract

Perinatal autopsy is the standard method for investigating fetal death; however, it requires dissection of the fetus. Human fetal microfocus computed tomography (micro-CT) provides a generally more acceptable and less invasive imaging alternative for bereaved parents to determine the cause of early pregnancy loss compared with conventional autopsy techniques. In this protocol, we describe the four main stages required to image fetuses using micro-CT. Preparation of the fetus includes staining with the contrast agent potassium triiodide and takes 3–19 d, depending on the size of the fetus and the time taken to obtain consent for the procedure. Setup for imaging requires appropriate positioning of the fetus and takes 1 h. The actual imaging takes, on average, 2 h 40 min and involves initial test scans followed by high-definition diagnostic scans. Postimaging, 3 d are required to postprocess the fetus, including removal of the stain, and also to undertake artifact recognition and data transfer. This procedure produces high-resolution isotropic datasets, allowing for radio-pathological interpretations to be made and long-term digital archiving for re-review and data sharing, where required. The protocol can be undertaken following appropriate training, which includes both the use of micro-CT techniques and handling of postmortem tissue.

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Fig. 1: Microcomputed tomographic imaging.
Fig. 2: Key parts of the workflow for human fetal whole-body postmortem microcomputed tomographic imaging.
Fig. 3: Equipment needed.
Fig. 4: Fetal preparation.
Fig. 5: Tissue preparation with I2KI.
Fig. 6: Representative images of a fetus.
Fig. 7: Positioning and image parameters.
Fig. 8: Examples of issues occurring during micro-CT scanning that require optimization of the workflow.

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Data availability

Examples of data produced by following this protocol are included in the protocol. Further details of the data presented are not publicly available because the information could compromise research participant privacy/consent.

References

  1. Michalski, S. T., Porter, J. & Pauli, R. M. Costs and consequences of comprehensive stillbirth assessment. Am. J. Obstet. Gynecol. 186, 1027–1034 (2002).

    Article  PubMed  Google Scholar 

  2. MBRRACE-UK. Perinatal confidential enquiry: term, singleton, intrapartum stillbirth and intrapartum-related neonatal death. https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Intrapartum%20Confidential%20Enquiry%20Report%202017%20-%20final%20version.pdf (2017).

  3. Osborn, M., Lowe, J., Cox, P. G., Hargitai, B. & Marton, T. Royal College of Pathologists. Guidelines on autopsy practice: fetal autopsy (2nd trimester fetal loss and termination of pregnancy for congenital anomaly). https://www.rcpath.org/uploads/assets/b20ea503-7799-433c-99160653762f896c/Fetal-autopsy-2nd-trimester-fetal-loss-and-termination-of-pregnancy-for-congenital-anomaly.pdf (2017).

  4. Blokker, B. M., Wagensveld, I. M., Weustink, A. C., Oosterhuis, J. W. & Hunink, M. G. Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review. Eur. Radiol. 26, 1159–1179 (2016).

    Article  PubMed  Google Scholar 

  5. Blokker, B. M. et al. Conventional autopsy versus minimally invasive autopsy with postmortem MRI, CT, and CT-guided biopsy: comparison of diagnostic performance. Radiology https://doi.org/10.1148/radiol.2018180924 (2018).

  6. Lewis, C. et al. Factors affecting uptake of postmortem examination in the prenatal, perinatal and paediatric setting. BJOG 125, 172–181 (2018).

    Article  CAS  PubMed  Google Scholar 

  7. Osborn, M., Cox, P. G., Hargitai, B. & Marton, T. Royal College of Pathologists. Guidelines on autopsy practice: neonatal death. https://www.rcpath.org/uploads/assets/0a7c073e-c773-4941-a1e998df666e17e3/G168-Guidelines-on-autopsy-practice-Neonatal-death.pdf (2019).

  8. Sieswerda-Hoogendoorn, T. & van Rijn, R. R. Current techniques in postmortem imaging with specific attention to paediatric applications. Pediatr. Radiol. 40, 141–152 (2010).

    Article  PubMed  Google Scholar 

  9. Royal College of Obstetricians and Gynaecologists & Royal College of Pathologists. Fetal and perinatal pathology: report of a working party. https://www.rcpath.org/uploads/assets/19f28c61-2a55-4eba-a3d9bf652a803424/FetalAndPerinatalPath-Jun01.pdf (2001).

  10. Lewis, C. et al. Availability of less invasive prenatal, perinatal and paediatric autopsy will improve uptake rates: a mixed-methods study with bereaved parents. BJOG 126, 754 (2019).

    Article  Google Scholar 

  11. Kang, X. et al. Parental acceptance of minimally invasive fetal and neonatal autopsy compared with conventional autopsy. Prenat. Diagn. 34, 1106–1110 (2014).

    Article  PubMed  Google Scholar 

  12. Taher, M. B., Pearson, J., Cohen, M. & Offiah, A. C. Acceptability of post-mortem imaging among Muslim and non-Muslim communities. Br. J. Radiol. 91, 20180295 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  13. Lewis, C. et al. Minimally invasive autopsy for fetuses and children based on a combination of post-mortem MRI and endoscopic examination: a feasibility study. Health Technol. Assess. 23, 1–104 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Sonnemans, L. J. P. et al. Dutch guideline for clinical foetal-neonatal and paediatric post-mortem radiology, including a review of literature. Eur. J. Pediatr. 177, 791–803 (2018).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Arthurs, O. J., Taylor, A. M. & Sebire, N. J. Indications, advantages and limitations of perinatal postmortem imaging in clinical practice. Pediatr. Radiol. 45, 491–500 (2015).

    Article  PubMed  Google Scholar 

  16. Votino, C. et al. Virtual autopsy by computed tomographic angiography of the fetal heart: a feasibility study. Ultrasound Obstet. Gynecol. 39, 679–684 (2012).

    Article  CAS  PubMed  Google Scholar 

  17. Arthurs, O. J. et al. Diagnostic accuracy of post mortem MRI for abdominal abnormalities in foetuses and children. Eur. J. Radiol. 84, 474–481 (2015).

    Article  PubMed  Google Scholar 

  18. Arthurs, O. J. et al. Diagnostic accuracy of post-mortem MRI for thoracic abnormalities in fetuses and children. Eur. Radiol. 24, 2876–2884 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Arthurs, O. et al. Diagnostic accuracy and limitations of post-mortem MRI for neurological abnormalities in fetuses and children. Clin. Radiol. 70, 872–880 (2015).

    Article  CAS  PubMed  Google Scholar 

  20. Addison, S., Arthurs, O. J. & Thayyil, S. Post-mortem MRI as an alternative to non-forensic autopsy in foetuses and children: from research into clinical practice. Br. J Radiol. 87, 20130621 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Thayyil, S. et al. Post-mortem MRI versus conventional autopsy in fetuses and children: a prospective validation study. Lancet 382, 223–233 (2013).

    Article  PubMed  Google Scholar 

  22. Shelmerdine, S. C., Sebire, N. J. & Arthurs, O. J. Perinatal post mortem ultrasound (PMUS): a practical approach. Insights Imaging 10, 35 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Tuchtan, L. et al. Diagnosis of congenital abnormalities with post-mortem ultrasound in perinatal death. Diagn. Interv. Imaging 99, 143–149 (2018).

    Article  CAS  PubMed  Google Scholar 

  24. Shelmerdine, S. C., Sebire, N. J. & Arthurs, O. J. Perinatal post-mortem ultrasound (PMUS): radiological-pathological correlation. Insights Imaging 10, 81 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  25. Shelmerdine, S. C., Hutchinson, J. C., Arthurs, O. J. & Sebire, N. J. Latest developments in post-mortem foetal imaging. Prenat. Diagn. 40, 28–37 (2020).

    Article  PubMed  Google Scholar 

  26. Kang, X., Carlin, A., Cannie, M., Sanchez, T. C. & Jani, J. C. Fetal postmortem imaging: an overview of current techniques and future perspectives. Am. J. Obstet. Gynecol, https://doi.org/10.1016/j.ajog.2020.04.034 (2020).

  27. Jawad, N. et al. Body weight lower limits of fetal postmortem MRI at 1.5 T. Ultrasound Obstet. Gynecol. 48, 92–97 (2016).

    Article  CAS  PubMed  Google Scholar 

  28. Hutchinson, J. C. et al. Postmortem microfocus computed tomography for early gestation fetuses: a validation study against conventional autopsy. Am. J. Obstet. Gynecol. 218, 445.e441–445.e412 (2018).

    Article  Google Scholar 

  29. Shelmerdine, S. C. et al. Postmortem microfocus computed tomography for noninvasive autopsies: experience in >250 human fetuses. Am. J. Obstet. Gynecol. https://doi.org/10.1016/j.ajog.2020.07.019 (2020).

  30. Shelmerdine, S. C. et al. Characterization of Bardet–Biedl syndrome by postmortem microfocus computed tomography (micro-CT). Ultrasound Obstet. Gynecol. 53, 129–134 (2019).

    Article  Google Scholar 

  31. Hutchinson, J. C. et al. Clinical utility of postmortem microcomputed tomography of the fetal heart: diagnostic imaging vs macroscopic dissection. Ultrasound Obstet. Gynecol. 47, 58–64 (2016).

    Article  CAS  PubMed  Google Scholar 

  32. Dawood, Y., Strijkers, G. J., Limpens, J., Oostra, R. J. & de Bakker, B. S. Novel imaging techniques to study postmortem human fetal anatomy: a systematic review on microfocus-CT and ultra-high-field MRI. Eur. Radiol. https://doi.org/10.1007/s00330-019-06543-8 (2019).

  33. Eloot, L. et al. Quality control of micro-computed tomography systems. Radiat. Prot. Dosim. 139, 463–467 (2010).

    Article  CAS  Google Scholar 

  34. Li, K. Z., Gao, Y., Zhang, R., Hu, T. & Guo, B. The effect of a manual instrumentation technique on five types of premolar root canal geometry assessed by microcomputed tomography and three-dimensional reconstruction. BMC Med. Imaging 11, 14 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Gregg, C. L. & Butcher, J. T. Quantitative in vivo imaging of embryonic development: opportunities and challenges. Differentiation 84, 149–162 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Aslanidi, O. V. et al. Application of micro-computed tomography with iodine staining to cardiac imaging, segmentation, and computational model development. IEEE Trans. Med. Imaging 32, 8–17 (2013).

    Article  PubMed  Google Scholar 

  37. Jacob, R. E. & Carson, J. P. Automated measurement of heterogeneity in CT images of healthy and diseased rat lungs using variogram analysis of an octree decomposition. BMC Med. Imaging 14, 1 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Al Faraj, A., Shaik, A. S. & Alnafea, M. Intrapulmonary administration of bone-marrow derived M1/M2 macrophages to enhance the resolution of LPS-induced lung inflammation: noninvasive monitoring using free-breathing MR and CT imaging protocols. BMC Med. Imaging 15, 16 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  39. Chen, K. C., Arad, A., Song, Z. M. & Croaker, D. High-definition neural visualization of rodent brain using micro-CT scanning and non-local-means processing. BMC Med. Imaging 18, 38 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Thiboutot, J. et al. Current advances in COPD imaging. Acad. Radiol. https://doi.org/10.1016/j.acra.2018.05.023 (2018).

  41. Sanchez, S., Fernandez, V., Pierce, S. E. & Tafforeau, P. Homogenization of sample absorption for the imaging of large and dense fossils with synchrotron microtomography. Nat. Protoc. 8, 1708–1717 (2013).

    Article  CAS  PubMed  Google Scholar 

  42. Kallai, I. et al. Microcomputed tomography-based structural analysis of various bone tissue regeneration models. Nat. Protoc. 6, 105–110 (2011).

    Article  CAS  PubMed  Google Scholar 

  43. Schambach, S. J., Bag, S., Schilling, L., Groden, C. & Brockmann, M. A. Application of micro-CT in small animal imaging. Methods 50, 2–13 (2010).

    Article  CAS  PubMed  Google Scholar 

  44. Arthurs, O. J. et al. Comparison of diagnostic performance for perinatal and paediatric post-mortem imaging: CT versus MRI. Eur. Radiol. 26, 2327–2336 (2016).

    Article  PubMed  Google Scholar 

  45. Norman, W., Jawad, N., Jones, R., Taylor, A. M. & Arthurs, O. J. Perinatal and paediatric post-mortem magnetic resonance imaging (PMMR): sequences and technique. Br. J. Radiol. 89, https://doi.org/10.1259/bjr.20151028 (2016).

  46. Kang, X. et al. Post-mortem whole-body magnetic resonance imaging of human fetuses: a comparison of 3-T vs. 1.5-T MR imaging with classical autopsy. Eur. Radiol. 27, 3542–3553 (2017).

    Article  PubMed  Google Scholar 

  47. Staicu, A. et al. Potential clinical benefits and limitations of fetal virtopsy using high-field MRI at 7 Tesla versus stereomicroscopic autopsy to assess first trimester fetuses. Prenat. Diagn. 39, 505–518 (2019).

    PubMed  Google Scholar 

  48. Thayyil, S. et al. Post-mortem examination of human fetuses: a comparison of whole-body high-field MRI at 9·4 T with conventional MRI and invasive autopsy. Lancet 374, 467–475 (2009).

    Article  PubMed  Google Scholar 

  49. Pauwels, E., Van Loo, D., Cornillie, P., Brabant, L. & Van Hoorebeke, L. An exploratory study of contrast agents for soft tissue visualization by means of high resolution X-ray computed tomography imaging. J. Microsc. 250, 21–31 (2013).

    Article  CAS  PubMed  Google Scholar 

  50. Dunmore-Buyze, P. J. et al. Three-dimensional imaging of the mouse heart and vasculature using micro-CT and whole-body perfusion of iodine or phosphotungstic acid. Contrast Media Mol. Imaging 9, 383–390 (2014).

    Article  CAS  PubMed  Google Scholar 

  51. Dullin, C. et al. muCT of ex-vivo stained mouse hearts and embryos enables a precise match between 3D virtual histology, classical histology and immunochemistry. PLoS ONE 12, e0170597 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  52. Walton, L. A. et al. Morphological characterisation of unstained and intact tissue micro-architecture by X-ray computed micro- and nano-tomography. Sci. Rep. 5, 10074 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Gignac, P. M. & Kley, N. J. Iodine-enhanced micro-CT imaging: methodological refinements for the study of the soft-tissue anatomy of post-embryonic vertebrates. J Exp. Zool. B Mol. Dev. Evol. 322, 166–176 (2014).

    Article  PubMed  Google Scholar 

  54. Hopkins, T. M. et al. Combining micro-computed tomography with histology to analyze biomedical implants for peripheral nerve repair. J. Neurosci. Methods 255, 122–130 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  55. Kim, A. J. et al. Microcomputed tomography provides high accuracy congenital heart disease diagnosis in neonatal and fetal mice. Circ. Cardiovasc. Imaging 6, 551–559 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  56. Metscher, B. D. MicroCT for developmental biology: a versatile tool for high-contrast 3D imaging at histological resolutions. Dev. Dyn. 238, 632–640 (2009).

    Article  PubMed  Google Scholar 

  57. Metscher, B. D. MicroCT for comparative morphology: simple staining methods allow high-contrast 3D imaging of diverse non-mineralized animal tissues. BMC Physiol. 9, 11 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  58. Vickerton, P., Jarvis, J. & Jeffery, N. Concentration-dependent specimen shrinkage in iodine-enhanced microCT. J. Anat. 223, 185–193 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  59. Degenhardt, K., Wright, A. C., Horng, D., Padmanabhan, A. & Epstein, J. A. Rapid 3D phenotyping of cardiovascular development in mouse embryos by micro-CT with iodine staining. Circ. Cardiovasc. Imaging 3, 314–322 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  60. Lombardi, C. M. et al. Postmortem microcomputed tomography (micro-CT) of small fetuses and hearts. Ultrasound Obstet. Gynecol. 44, 600–609 (2014).

    Article  CAS  PubMed  Google Scholar 

  61. Sandaite, I. et al. Micro-computed tomography of isolated fetal hearts following termination of pregnancy: a feasibility study at 8–12 weeks’ gestation. Prenat. Diagn. https://doi.org/10.1002/pd.5719 (2020).

  62. Sandrini, C. et al. Accuracy of micro-computed tomography in post-mortem evaluation of fetal congenital heart disease. Comparison between post-mortem Micro-CT and conventional autopsy. Front. Pediatr. 7, 92 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  63. Hutchinson, J. C. et al. Virtual pathological examination of the human fetal kidney using micro-CT. Ultrasound Obstet. Gynecol. 48, 663–665 (2016).

    Article  CAS  PubMed  Google Scholar 

  64. Lombardi, S. et al. Micro-computed tomography: a new diagnostic tool in postmortem assessment of brain anatomy in small fetuses. Neuroradiology 61, 737–746 (2019).

    Article  PubMed  Google Scholar 

  65. Smith C. M. et al. HoloLens for medical imaging using post-mortem fetal micro-CT data. European Congress of Radiology Abstract. https://doi.org/10.26044/ecr2019/C-0153 (2019).

  66. Shelmerdine, S. C. et al. 3D printing from microfocus computed tomography (micro-CT) in human specimens: education and future implications. Br. J. Radiol. https://doi.org/10.1259/bjr.20180306 (2018).

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Acknowledgements

I.C.S. is funded by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2017-03-53). O.J.A. is funded by a National Institute for Health Research (NIHR) Career Development Fellowship (NIHR-CDF-2017-10-037). S.C.S. is supported by a RCUK/ UKRI Innovation Fellowship and Medical Research Council (MRC) Clinical Research Training Fellowship (grant MR/R002118/1), jointly funded by the Royal College of Radiologists (RCR). O.J.A. and N.J.S. receive funding from the Great Ormond Street Hospital Children’s Charity. This article presents independent research, and the views expressed are those of the author(s) and not necessarily those of the funding bodies or the Department of Health and Social Care. The authors acknowledge the help from our mortuary staff at Great Ormond Street Hospital: L. Ward, J. Parmenter, H. McGarrick, B. Czarny and D. Alvarez for their assistance and I. Haig, O. Larkin and B. Smit (Nikon, Tring, UK) for their technical advice. We also thank the parents who consented to and participate in this research.

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Authors and Affiliations

  1. Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK

    Ian C. Simcock, Susan C. Shelmerdine & Owen J. Arthurs

  2. UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK

    Ian C. Simcock, Susan C. Shelmerdine, J. Ciaran Hutchinson, Neil J. Sebire & Owen J. Arthurs

  3. NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK

    Ian C. Simcock, Susan C. Shelmerdine, J. Ciaran Hutchinson, Neil J. Sebire & Owen J. Arthurs

  4. Department of Histopathology, Great Ormond Street Hospital for Children, London, UK

    J. Ciaran Hutchinson & Neil J. Sebire

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Contributions

I.C.S., S.C.S. and J.C.H. developed and tested the methodology within the paper and drafted the manuscript. N.J.S. and O.J.A. supervised the work. All authors assessed the results, thereby optimizing the technique. All authors edited the paper and approved the final version.

Corresponding author

Correspondence to Owen J. Arthurs.

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The authors declare no competing interests.

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Peer review information Nature Protocols thanks Jorge Murillo-Gonzalez and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Key references using this protocol

Hutchinson, J. C. et al. Ultrasound Obstet Gynecol 47, 58-64 (2016): https://doi.org/10.1002/uog.15764

Hutchinson, J. C. et al. Am. J. Obstet. Gynecol. 218, 445.e441-445.e412 (2018): https://doi.org/10.1016/j.ajog.2018.01.040

Shelmerdine, S. C. et al. Am. J. Obstet. Gynecol. 224, 103.e1–103.e15 (2021): https://doi.org/10.1016/j.ajog.2020.07.019

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Supplementary Data 1

Postmortem examination consent form and guidance given to the consent taker used at Great Ormond Street Hospital, London, UK. Provided in Microsoft Word and pdf format.

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Simcock, I.C., Shelmerdine, S.C., Hutchinson, J.C. et al. Human fetal whole-body postmortem microfocus computed tomographic imaging. Nat Protoc 16, 2594–2614 (2021). https://doi.org/10.1038/s41596-021-00512-6

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