How to build a fetal postmortem imaging service – guiding principles and our experience

When a pregnancy ends in loss, families and doctors face a profound and difficult question: what happened? For decades, the most reliable way to find answers has been a traditional autopsy, a careful examination of the body to understand the cause of death and any physical abnormalities. This process provides crucial information that can guide parents through their grief and help them understand the risks for future pregnancies. Yet, despite its value, many parents choose to decline this procedure. Reasons vary widely, from religious and cultural beliefs to a deep desire to protect their child from further intrusion or to avoid delays in funeral arrangements. Because so many families say no to a traditional autopsy, there is a growing need for a different kind of answer—one that offers critical medical insight without the invasiveness of a full dissection. This is where the concept of a "virtual autopsy" enters the picture, using advanced imaging technology to look inside the body after death, offering a less invasive alternative that can still reveal the truth.

A team of doctors and researchers from Mount Sinai Hospital and the Hospital for Sick Children in Toronto has shared their experience in building a service dedicated to this very purpose: fetal postmortem imaging. Their work outlines the practical steps required to create a program that uses ultrasound, magnetic resonance imaging (MRI), and specialized X-ray scanning to examine stillborn fetuses. The authors describe how they navigated the complex logistics of setting up such a service, from securing funding and defining who does what, to ensuring the dignified and safe transport of the baby's body between departments. They did not just propose a theory; they built a working system, starting with a focused approach that looked primarily at the brain in cases where a traditional autopsy was also planned. This allowed them to compare the images directly with the physical findings, validating that the pictures could indeed provide accurate diagnostic information.

The journey to establish this service began with a recognition that it is not a simple matter of turning on a machine. It requires a multidisciplinary team where maternal-fetal medicine specialists, radiologists, pathologists, and geneticists work in close lockstep. The researchers found that clear rules and a shared understanding of roles were essential. For instance, they had to decide who would speak with the grieving parents to get permission for the imaging, and who would physically move the body from the delivery room to the scanning area. They discovered that the timing of these movements is critical. If the body is moved to the morgue too early, the tissues can begin to break down, which ruins the quality of the images. Conversely, if the family needs more time with their baby, the schedule must be flexible enough to wait, even if it delays the scan. The team learned that the most successful programs are those that prioritize the family's need for time and connection while maintaining a strict chain of custody to ensure the correct body is always being examined.

In their specific experience, the team at Mount Sinai and SickKids started small to manage costs and complexity. Since the imaging of stillborn infants is not currently a billable medical service in their region, they relied on research grants to fund the expensive MRI scanner time and the staff needed to run it. They initially limited their service to cases where a prenatal MRI had already been done and where a traditional autopsy was also planned. This strategy allowed them to focus their resources on the brain, an area of high clinical interest, while they built confidence in their methods. They used a dedicated messaging system to track the baby's location in real time, ensuring that porters, doctors, and technicians all knew exactly where the body was and when it needed to move next. This coordination prevented the body from being accidentally sent to the morgue before the necessary scans were completed.

The technical side of their work involved creating standard ways to take the pictures so that the results would be consistent and reliable. They developed specific protocols for how long to scan and which views to capture, tailoring these settings to the size of the fetus and the age of the pregnancy. For the MRI scans, they aimed for a duration of about 40 to 60 minutes to get high-quality images without overextending the family's wait time. They also utilized ultrasound for a quick look at the heart, lungs, and abdomen, and used a specialized type of X-ray called micro-CT for very small fetuses, particularly to examine the bones of the head. A key lesson they learned was the order in which these tests must be done. If a scan requires a special dye to make the tissues visible, that dye can change how the body looks on other machines. Therefore, they established a rule to perform the ultrasound and MRI first, before any procedures that might alter the tissue for the X-ray.

One of the most significant findings from their experience is that while the technology works, the human element is just as important as the machines. The success of the program depended heavily on the relationships between the different hospital departments and the willingness of staff to adapt their routines. The maternal-fetal medicine specialist played a central role, acting as the main link between the family and the technical teams, often being the one to explain the option of imaging to the parents. The researchers also noted that while their internal checks showed that the imaging matched up well with the physical findings, the program still faces a major hurdle: financial sustainability. Currently, the service relies on temporary research funding, and the authors argue that for this type of care to become a standard part of medical practice, it needs official recognition and a way to be billed like other medical services.

Ultimately, the paper presents a roadmap for other hospitals that wish to offer this compassionate alternative to traditional autopsy. It shows that with careful planning, a collaborative spirit, and a deep respect for the families involved, a virtual autopsy service can be built even with limited resources. The team demonstrated that by starting with a focused scope and gradually expanding their capabilities, they could provide valuable diagnostic information that helps parents understand what happened to their child. Their work suggests that as more institutions adopt these methods and as the financial models evolve, postmortem imaging could become a standard, accessible tool for families navigating the difficult aftermath of pregnancy loss, offering answers with dignity and care.