Hypoplasia of Medullary Arcuate Nucleus in Unexpected Late Fetal Death (Stillborn Infants): A Pathologic Study

Abstract

Objectives. To evaluate the frequency, morphology, and pathogenesis (primary or secondary) of the abnormally developed medullary arcuate nucleus (ARCn) in stillbirths. Methods. We examined 26 stillbirths (24 antepartum, 2 intrapartum) that had a gestational age between 25 and 40 weeks and a normal karyotype. All of the stillborns were described as well-developed, with body length and weight proportional to their gestational age. Each case was submitted to complete autopsy examination, which included a systematic gross and microscopic evaluation of the body, the placental disk, and the umbilical cord and membranes. The brainstem was the particular focus of the histologic examination. The study of the various nuclei (nucleus hypoglossus, dorsal vagus motor nucleus, tractus solitarii nucleus, nucleus ambiguus, trigeminal tractus and nucleus, arcuate nucleus, and ventrolateral reticular formation and its neurons and parabrachial/Kölliker-Fuse complex) was performed on transversal serial sections through the entire pons and medulla oblongata. The histologic analysis was supplemented by volumetric reconstruction and immunohistochemical detection of both apoptosis and proliferating cell nuclear antigen. Results. Histologic examination showed abnormalities of the medulla oblongata ARCn in 9 fetuses (35%). In 8, a marked hypoplasia was evident, characterized by a volume reduction of the nucleus accompanied by neuronal depletion, whereas in 1 fetus the nucleus was completely absent (agenesis). The absence of gliosis, the negativity of the proliferating cell nuclear antigen analysis, and the similarities in apoptotic indices between the hypoplastic and well-developed arcuate are in keeping with a primary developmental defect. This anomaly is frequently associated with hypoplasia of the reticular formation and chronic hypoxia. Conclusions. A high frequency of hypoplasia of the ARCn occurs in fetuses who have died “sine causa,” ie, in a similar manner to that observed in sudden infant death syndrome. Chemoreceptors, although not involved in reflexogenic oxygenation in fetal life, become of vital importance intrapartum and postpartum; therefore, whenever impaired in the course of development, chemoreceptors may underlie cardioventilatory abnormalities critical to sudden infant death syndrome.