Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.     

Accuracy of cause of death determination without forensic autopsy examination

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.     

Importance and Approach to Manner of Death Opinions in Opioid-Related Deaths

The majority of opioid-related deaths are accidental. However, the number of opioid-related suicidal deaths is likely under recognized. Presented here is a case of suicide by heroin overdose. The manner of death would have likely been deemed accidental if not for critical information shared by the decedent’s family during follow-up telephone interviews between the forensic pathologist and the decedent’s family, which included text messages that were sent by the decedent just before his death that were not known at the time of the initial medicolegal death scene investigation. This case highlights that when a forensic pathologist establishes an engaged relationship with the decedent’s family, the information elucidated can prove to be invaluable in reaching an informed opinion about the manner of death. For overdose cases, identifying an accurate manner of death allows the design of public health efforts that adequately address the health risks in the community. For aid in the determination of the manner of death for overdose cases, we propose a five-step checklist that may assist forensic pathologists and medicolegal death investigators when approaching similar cases.     

A Case of Toxic Shock due to Clandestine Abortion by Misoprostol self‐administration

Maternal mortality and morbidity are the leading causes of death and illness, respectively, among women of reproductive age in many countries throughout the world. Of all maternal deaths, those related to unsafe abortions are the most widely underestimated, but they are also the most largely preventable. Medical abortion is a safe and reliable method for termination of a pregnancy in early gestation, although it is important to be aware of signs and symptoms of severe infection and toxic shock syndrome after the medical termination of pregnancy; case studies in literature are rarely fatal events. We report the first case of septic shock syndrome following a clandestine pregnancy termination with a misoprostol‐only regimen (12 tablets 200 μg each). Autopsy findings and histopathological examination proved that the woman died from septic shock. This case suggests to improve the forensic investigations in case of unsafe, often clandestine, abortion is suspected.     

Trigemino‐Cardiac Reflex as Lethal Mechanism in a Suicidal Fire Death Case

In the vast majority of immediate fire deaths, the mechanism of death is inhalation of toxic gases (especially carbon monoxide), direct thermal injury, or neurogenic shock due to the redistribution of the body's blood volume produced by surface heat on the skin. We present a suicidal case that is unusual because the mechanism of immediate fire death could arguably be explained in terms of a primitive autonomic reflex/the trigemino‐cardiac reflex. Although this reflex is well known to surgeons and anesthetists, with possible lethal consequences in the course of invasive surgical procedures on the head and neck region, it is much less familiar to forensic pathologists.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.     

Detection of medical examiner cases from review of cremation requests

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.     

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.     

Hate crimes and the forensic pathologist

Hate crimes represent crimes committed against an individual or group on the basis of their race, ethnicity, national origin, religion, sexual orientation, gender, gender identity, or disability. For the forensic pathologist, a death related to a hate crime should be considered a high-profile case, one in which the pathologist should expect abundant public interest and scrutiny. In this article, an overview of hate crimes is presented, stressing the different types of hate crimes and the motives of those who commit such crimes. For death investigators and forensic pathologists, an awareness of these details will help them to recognize and appropriately anticipate issues that may be important in deaths related to hate crimes.     

Sudden Unexpected Deaths Due to Intracranial Meningioma: Presentation of Six Fatal Cases,Review of the Literature,and A Discussion of the Mechanisms of Death

Deaths due to meningiomas are routinely diagnosed in clinical practice because this neoplasm tends to present with the typical progression of neurological deficits. On the other hand, sudden unexpected deaths due to meningiomas are rarely described in the literature. The study presents six fatal cases of previously undiagnosed intracranial meningiomas from the Cook County Medical Examiner's Office from 1998 to 2014. The most common explanation of the mechanism of sudden death due to intracranial neoplasms is a rapid increase in intracranial pressure produced by the mass effect of the neoplasm. Other mechanisms of death include acute intracranial and intratumoral hemorrhage, and benign neoplasms that grow in the vicinity of vital centers altering neural discharge in autonomic pathways leading to cardiac suppression or lethal arrhythmia. Forensic pathologists must keep in mind that sudden unexpected death caused by intracranial meningiomas, although extremely rare, may be encountered in the forensic setting.     

Variability in cancer death certificate accuracy by characteristics of death certifiers

Death certificates are the source for mortality statistics and are used to set public health goals. Accurate death certificates are vital in tracking outcomes of cancer. Deaths may be certified by physicians or other medical professionals, coroners, or medical examiners. Idaho is one of 3 states that participated in a Centers for Disease Control and Prevention-funded study to assess the concordance between cancer-specific causes of death and primary cancer site among linked cancer registry/death certificate data. We investigated variability in the accuracy of cancer death certificates by characteristics of death certifiers, including certifier type (physician vs coroner), physician specialty, years of experience as death certifier, and number of deaths certified. This study showed significant differences by certifier type/physician specialty in the accuracy of cancer mortality measured by death certificates. Nonphysician coroners had lower accuracy rates compared with physicians. Although nonphysician coroners certified less than 5% of cancer deaths in Idaho, they were significantly less likely to match the primary site from the cancer registry. Results from this study may be useful in the future training of death certifiers to improve the accuracy of death certificates and cancer mortality statistics.     

The Interplay Between Diabetes and Pancreatitis: Two Case Reports of Sudden,Natural Deaths and a Review of the Literature

Diabetes mellitus (DM) is a common disease involving insulin resistance or deficit that, when left unchecked, may cause severe hyperglycemia and subsequent end‐organ damage. Acute pancreatitis (AP) is inflammation of the pancreas that can lead to significant morbidity and mortality. AP and DM both account for a significant amount of sudden deaths, and rarely both disease processes may be present in the same decedent, causing some difficulty in wording the cause of death statement. Although much research has been directed at studying the causes and risk factors for AP and DM, there is a complex interplay between these diseases that is not fully understood. This study presents two autopsy cases of sudden, natural deaths that illustrate this interplay, along with a review of the literature. An algorithm for differentiating AP and DM is then discussed in the context of the presented cases as a proposed aid for forensic pathologists in the certification of such deaths.     

Adolescent death: a 15-year retrospective review

Adolescents comprise an eclectic mix of people vitally important to society yet long-term comprehensive studies on the circumstances of their deaths are lacking in the pediatric forensic literature. The authors reviewed all forensic cases referred to the Medical University of South Carolina Forensic Pathology section over the fifteen years between January 1989 and December 2003. In accordance with the World Health Organization (WHO) definition of adolescents, only decedents 10-19 years of age were included. The authors examined the cause and manner of death, age, gender, and race of the victims in all cases. The toxicology results, perpetrator, death scenario and location, and victim traits were analyzed when available. For all adolescents, the most common manner of death was accident followed by homicide, suicide, natural, and undetermined. Within the adolescent population two distinct groups, 10-14 years old and 15-19 years old, were identified. Though both groups were similar in that they experienced a high number of accidental deaths, decedents of older age group suffered a higher percentage of violent deaths while decedents of the younger group were more likely to die of natural causes. Many of the accidental deaths in this review were preventable, including deaths due to motor vehicle collisions and drowning. In deaths due to homicide, the perpetrator was often known to the victim, whether as an acquaintance or family member. Toxicology testing was often positive in decedents of the older age group, while only rarely positive in decedents of the younger age group. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of adolescent death. The authors present their findings in this 15-year retrospective study to better aid forensic pathologists, death investigators, law enforcement, and epidemiologists.     

Fetal death following maternal trauma: two case reports and a survey of the literature.

When a fetus dies after its mother has suffered trauma, questions often arise about whether the fetal death was linked to the maternal injury. Many state statutes make it a criminal act to cause the death of a fetus by injuring the mother. The authors present two cases in which fetal death resulted from maternal trauma. In addition, we review the pertinent literature on this subject and offer guidelines that may help forensic pathologists evaluate these difficult and often emotionally charged cases.     

The Value of Outsourcing Selected Cases in a Medical Examiner Population: A 10‐Year Experience

Due to increasing caseloads and inadequate staffing, the burden on Coroner/Medical Examiner Offices to comply with recommended autopsy limits for forensic pathologists (FPs) has been difficult. Since 2006, pathologists at the University of Alabama at Birmingham have performed select autopsies for the Alabama Department of Forensic Sciences. Each case was reviewed by a state FP and scene investigator to determine appropriateness for referral. All referred cases received full postmortem examination including microscopic examination and collection of toxicological samples, and toxicology was ordered by the referring FP as appropriate. The final cause and manner of death were determined by the referring state FP after review of all findings. A majority of the 421 cases were ruled accidental deaths (233), most due to drug toxicity. Of the 178 natural deaths, 118 were attributed to cardiovascular disease. Outsourcing select forensic cases can be educational and an effective tool to manage workflow without compromising quality.     

Autoerotic deaths in the literature from 1954 to 2004: a review

Autoerotic death by hanging or ligature is a method of autoeroticism well known by forensic pathologists. In order to analyze autoerotic deaths of nonclassic hanging or ligature type, this paper reviews all published cases of autoerotic deaths from 1954 to 2004, with the exclusion of homicide cases or cases in which the autoerotic activity was not solitary. These articles were obtained through a systematic Medline database search. A total of 408 cases of such deaths has been reported in 57 articles. For each case, the following characteristics are presented here: sex, age, race, method of autoerotic activity, cause of death, and location where the body was found. Autoerotic death practioners were predominantly Caucasian males. Victims were aged from 9 to 77 years and were mainly found in various indoor locations. Most cases were asphyxia by hanging, ligature, plastic bags, chemical substances, or a mixture of these. Still, atypical methods of autoerotic activity leading to death accounted for about 10.3% of cases in the literature and are classified here into five broad categories: electrocution (3.7%), overdressing/body wrapping (1.5%), foreign body insertion (1.2%), atypical asphyxia method (2.9%), and miscellaneous (1.0%). All these atypical methods are further discussed individually.     

火场中尸体的法医学分析

火场中的尸体是法医病理工作者较常见的案件,在这种案件中,判断是生前烧死还是死后焚尸具有非常重要的意义。本文就相关文献关于火灾死亡案件的尸体内部、外部征象、现场特点、以及以COHb为主的实验室结果加以综述,目的在于阐明这些特征在实际案件中的作用和应用,为法医工作者解决此类案件提供参考。     

The utility of histology in assessing the cause of death in medico-legal autopsies in selected trauma deaths: Suspension-, immersion-, fire-, and traffic-related

The goal of a medico-legal autopsy is primarily to determine the cause and manner of death. To this end, the pathologist often uses auxiliary analyses, including histology. However, the utility of routine histology in all medico-legal autopsies is unknown. Earlier studies on the utility of routine histology have shown inconsistent effects, with some studies recommending it and others rejecting it. To study the degree to which histology informs on the underlying cause of death, we sent autopsy reports from suspension-, immersion-, fire-, and traffic-related deaths to senior board-certified forensic pathologists and had them assess the cause of death, first without knowledge of the histological findings and then with knowledge thereof. Fifty cases were identified in each of four subgroups: fire-, immersion-, suspension-, and traffic-related deaths. The autopsy reports were anonymized, and the histological findings and conclusions were removed. Two board-certified forensic pathologists independently reviewed the reports in each subgroup and assessed the manner and underlying cause of death (including their certainty of this assessment on a five-level scale) with and without access to histological findings. The probability of changing the underlying cause of death posthistology was low in all study groups. There was a slight increase in the degree of certainty posthistology in cases where the underlying cause of death was not changed, but only when the antehistology certainty was low. Our results suggest that histology does not meaningfully inform on the underlying cause of death in suspension-, immersion-, fire-, and traffic-related deaths except when antehistology certainty is low.     

A Retrospective Study of the Investigation of Homicidal Childhood Asphyxial Deaths

As one of the leading causes of traumatic deaths in newborns, infants, and young children, there is no anatomic or microscopic feature that is pathognomonic for asphyxial deaths. Instead, pathologists rely on investigation information, including confessions and/or witness statements, and potential evidence at the scene. Twenty cases of homicidal newborn, infant, and young children asphyxial deaths were reviewed, which included death and police investigation reports and autopsy reports, as well as histology slides of lung sections. This series of homicidal asphyxial deaths highlight that, in a vast majority of such cases, the final cause and manner of death rulings are dependent on confession by the perpetrator. Furthermore, this series highlights the possible role of histology to help forensic pathologists better certify asphyxial deaths. Finally, this series emphasizes important investigation points and considerations at autopsy during the investigation of asphyxial deaths in newborns, infants, and young children.