Medico-Legal autospy in abortion deaths

In a routine autopsy the usual practice is to open a body with a chin to downwards. However, in a criminal abortion, it is necessary to follow a different order if evidence of air embolism- the commonest cause of sudden death in such cases- is not to be destroyed.

Air embolism occurs when a syringe is used to squirt soapy fluid from a bowl into the uterus to separate the membranes. Unless special care is taken to avoid it, the fluid level in the bowl drops until the sucking valve in the syringe is uncovered and so sucks in air. The raw lining membrane of the uterus is then exposed to frothed fluid and air is forced into the veins causing air embolism.

The autopsy should be done as soon as possible. Once the gas forming organisms develop, they closely mimic air embolism and vitiate the findings. When air embolism is suspected, if facilities permit, an x-ray of chest and abdomen should be taken.

The examination should commence from the vulva. Marks of violence on the external genitalia should be carefully noted. Containers should be kept ready to collect any fluid still lying within the vagina, cervix and uterus. The fluid may contain the even the partly displaced products of conception. Air may be present in the cavity of the uterus and it is possible to demonstrate the presence of both air and soapy fluids in the veins of the wall of the uterus from which they reach the heart.

Air bubbles can be demonstrated in the uterine and ovarian veins, inferior vena cava and right heart, pulmonary arteries, left heart and systemic arteries. The presence of air in the circulatory system causes mechanical obstruction to the outflow of blood. Cerebral and coronary air embolism are responsible for death. Soap can be demonstrated in the wall of the uterus, lungs and blood by histopathological and chemical examinations.

A small primary incision is made above the pubis to inspect the uterus and the adnexa for evidence of crepitation, injury, or necrosis. Inferior vena cava is inspected for gas bubbles. The incision is then extended upwards without cutting any large blood vessel. The pericardial sac is opened to inspect coronary vessels for evidence of segmentation. It is not always necessary to open the heart and large blood vessels under water or with the body immersed in a water bath as commonly believed. The skull vault is then removed carefully puncturing the meninges, and meninges reflected without injuring the blood vessels coursing over the lateral surface of the brain. The veins and basal arteries are then inspected for evidence of air embolism. After removal of the brain, the autopsy is continues in the usual manner taking care to remove the pelvic organ en masse for a thorough examination.

In the investigation of abortion deaths, special attention should be paid to:

1. Visit the scene

Undisturbed photograph or sketch of the scene is important. The state of underclothing should be noted. They should be air dried if wet and saved for further examinations by Forensic Science Laboratory (FSL) if necessary. Search should be made for material that might have been used, such an instruments injection ampoules, abortifacient jellies, pills, douche apparatus and the like, all of which should be preserved as evidence.

2. Examine the women for evidence of pregnancy

The medical officer should note carefully the presence or absence of signs of pregnancy which may be visible upon the exterior of the body. In a primi-para, the expression of fluid from the breast may be of indirect value in diagnosis of pregnancy. The female genital tract is removed as per special technique. The cavity of the uterus should be examined for a placental site or for remains of foetus, placenta or membranes, and ovaries examined for the presence of corpus luteum. It is always advisable to remove a piece of tissue for histopathological examination from what is thought to be placental site so that the presence of chorionic villi may be identified microscopically. The possibility of post-mortem delivery as a result of putrefactive gases generated in the abdomen must be kept in mind.

3. Determine the method of abortion

The findings depend upon the period of gestation had reached, mode of abortion practised, and the time elapsed between its performance and death.

The methods in common use are:

Instruments:

If abortion has resulted from an instrumental method such as dilation and curettage, the teeth marks made by the volsellum may be seen on the cervix and the scraping marks seen on the inside of the uterus. When a sharp pointed instrument is used to perforate the membranes injuries to cervix, fundus and vagina are common. Contrary to popular belief, injury to fornices is not common. The whole genital tract should be carefully examined for injuries such as punctures or lacerations indicating the introduction of an instrument. The nature of the injuries may indicate if the instrument was penetrating and sharp pointed or blunt and if it was self-introduced or with help from someone else. The damage is usually great and infection common in self-practised instrumentation. The damage is less when skilled help is available. This differentiation is not difficult if Simpson’s advice is remembered: It is possible that even a clean, apparently skilled introduction of an instrument in the cervix of the uterus might be affected by a woman herself unaided, but only remotely possible; the less the damage the more likely it is that help was given; the more gross the injury the more probable it is that it was the clumsy unaided effort of the woman herself. Special attention should be directed to the condition of pelvic contents. An examination should be made for evidence of uterine or extra uterine infection. Septic endometritis, infection of the uterine wall, broad ligaments and pelvic connective tissues may follow upon instrumental interference, even without apparent damage, due to unclean instruments and dirty surroundings. The uterine infection manifests itself by foul smelling discharge. The extent and spread of the infective process should be noted to get an idea of time since abortion. It is advisable to weight of nulliparous uterus in about 40gms and size 7.5 x 5 x 2.5 cms. The weight of multiparous uterus is about 60 gms and its size increased by 1cm or more than the nulliparous uterus.

Abortion Stick:

This is a thin wooden or bamboo stick about 15 to 20 cms long or a twig of similar length from some irrigant plant such as madar. When the stick is used it is equipped at one end with cotton wool or a piece of rag soaked in an irritant substance such as marking nut juice or paste prepared from white arsenic, red lead or asafoetida. The twig may be used by itself as an abortion stick. Locally, there may be excoriation, bruising and perforation in the upper part of the vagina or the uterus as a result of irritation from the stick substance and the violence perpetrated during the introduction of the stick. If the stick is found, it should be preserved as evidence. It may also be submitted for toxicological examination. Sepsis is common.

Syringing fluids:

The mucous membrane of the vagina may show signs of irritation or erosion from the caustic substances and strong antiseptics that may have been used. The cervical canal and the cavity of the uterus should be examined to see if there is any fluid, and if so, its nature. If the focus is still present, the mucus plug in the cervix should be examined to see if it is displaced, disintegrated or lost. When there is suspicion that a poisonous substance has been locally used, it is necessary to submit specimens of vagina, or uterus and its appendages for toxicological examination.

Drugs:

Where there are no signs of local injury and should there be reasons to suspect that drugs have been used and since most of the drugs are irritants, the condition be carefully examined and appropriate viscera preserved for chemical analysis.

4. Examination of the aborted material

During abortion, the whole ovum (in early pregnancy) or portions of the ovum may be expelled from the uterus. Small portions of an ovum may be expelled in blood clots, and all material passed should therefore be examined microscopically. Nothing should be accepted as a result of conception if it does not show some constituent part of an ovum. If a foetus is passed during an abortion, an attempt should be made to estimate its approximate age. Hess’s rule states that the square of the number of calendar months of gestation gives the crown-heel length of foetus in centimetres.

As for example, if the age of the foetus is 3 months, its length will be 9 cms. After the fifth month, however, the number of months should be multiplied by five, which gives the length in centimetres.

As for example, at the age of 6 months, the length is 30 cms. The average accepted weight of foetus is about 400 gms at twenty weeks’ gestation, and this increases by about 400 gms every four weeks until thirty six weeks’ gestation when an infant should weight 2 kgs. During the last four weeks of pregnancy, the infant increases in weight by about 200 gms each week. Thus, at full term, the average weight of an infant is about 3 kgs. However, the length gives a more accurate assessment of the period of gestation, being far less variable than weight. Portions of material found within the uterus should be subjected to detailed naked eye and microscopic examination.

5. Examination of the aborted material

Death may occur: (a) immediately from shock (b) within a short period from (i) haemorrhage, or (ii) embolism, and (c) after several days from infection. The forensic pathologist is generally concerned with immediate deaths or deaths within a short period.

• Shock may occur immediately from reflex vagal inhibition due to stimulation of the trigger area, namely the cervix of the uterus. There are usually no injuries, no disease and no poisoning to account for the cause of death. History, when available, is helpful.
• Haemorrhage results from internal injuries or perforation of the uterus. The uterus and pelvic organs are pale and anaemic if death took places as a result of haemorrhage but they are likely to be congested if death took place during mensuration. This distinction is important in dealing with defence pleas that haemorrhage was due to mensuration and not criminal abortion.
• Ehen sepsis is suspected as the cause of death blood sample and swaps from cervix and uterine cavity should be submitted for bacteriologic culture. The organisms most commonly responsible are: Esch. Coli, CI. Welchii, haemolytic streptococci, and anaerobic streptococci. Of these, only CI. Welchii are of forensic interest. They may cause fulminating septicaemia within 18-24 hours. The resulting fatality in such a short period after the event constitutes somewhat obscure death which but for autopsy cannot be recognised as due to abortion.

By: Navin Kumar Jaggi & Gurmeet Singh Jaggi