Supine Hypotensive Syndrome as the Probable Cause of Both Maternal and Fetal Death

Abstract: Supine hypotensive syndrome is characterized by severe supine hypotension in late pregnancy, whose clinical presentation ranges from minimal cardiovascular alterations to severe shock, resulting from inferior vena cava compression by gravid uterus. We report a case of a 41‐year‐old 39‐week‐pregnant woman found dead supine. Autopsy revealed the following: cyanosis of the limbs; congestion of the jugular and subclavian veins; abundant abdominal subcutaneous fatty tissue; uterus displacing intestine and diaphragm; collapsed inferior vena cava; both femoral veins dilated and filled with blood; edematous and congested lungs; and placenta 790 g, fetus 3475 g, amniotic fluid 800 cm³. The diagnosis of supine hypotensive syndrome as the probable cause of death is supported by the position of the body and autopsy findings. This syndrome can be considered as the first stage of the physio‐pathological mechanism that led to death in the case presented herein and should be considered by pathologists as a cause of sudden death.     

Criminal liability of physicians: an encroachment on the abortion right?

The Supreme Court in 1973 in Roe v. Wade established that decision of first trimester abortion is left to the physician, exercising his best medical judgment, in consultation with the patient. During this period the state may not regulate abortion determination since there is no compelling state interest; therefore a physician performing abortion will be precluded from civil or criminal liability. In second trimester abortion the state has a compelling interest in the health of the mother and may regulate the procedure to protect maternal health; although a previable fetus may be able to survive the abortion, Roe v. Danforth definitively places the woman's right to an abortion above the life of the fetus during the previable stage; therefore the state cannot seek to safeguard the life or health of the fetus during the abortion. Third trimester abortion implies a viable fetus; thus, a compelling state interest in the potential life arises and the state may regulate and proscribe abortion except when necessary for the life and health of the mother. The determination of when viability has been achieved is a matter of judgment resting with the physician who has the choice of techniques and operating procedures which may or may not be fatal to the unborn. It is a question of either termination of pregnancy or destruction of the fetus. In this last case the legal responsibility placed upon the physician is very serious, and involving a risk of civil and criminal liability. Uncertainties as to the boundaries of legal abortion and the threat of criminal liability can only result in a reluctance among physicians to perform second and third trimester abortions, which is against the fundamental right to abortion guaranteed by the Constitution. The Supreme Court will have to elaborate upon the scope of the abortion right, whether it encompasses fetal destruction or only termination of pregnancy, because it directly affects the extent and quality of maternal and fetal care that must be rendered by a physician. If only termination of pregnancy is included the Court must resolve whether the woman's health interests predominate, or whether the physician can be required to enhance fetal survival. Physicians have a right to know the full extent of legal ramifications and implications of legally induced abortion.     

Maternal death due to unnoticed ectopic pregnancy during prostaglandin-induced abortion

The use of prostaglandin E2 (PGE2) for the termination of pregnancy is quite common and generally is considered safe. Among the complications reported are uterine rupture and dramatic pyrexic and cardiovascular response (6). A case is reported in which a woman with an ectopic pregnancy that had not been noted at ultrasonography was admitted for abortion with PGE2 with fatal outcome. At autopsy an insignificant uterine rupture was noted in addition to the main findings.     

Fatal postpartum spontaneous liver rupture: case report and literature review

Maternal hepatic rupture is a rare complication of pregnancy that can be fatal to both mother and child. This phenomenon is most often associated with preeclampsia/eclampsia and/or HELLP syndrome, which is defined by a collection of clinical features including hemolysis (H), elevated liver enzymes (EL), and a low platelet count (LP). These disease processes are typically identified and treated during pregnancy, often in the last trimester. The described case is unusual in that the decedent had no known history of preeclampsia/eclampsia or HELLP syndrome during this pregnancy, and she died suddenly several days postpartum of liver rupture with massive intraperitoneal hemorrhage following a routine cesarean section delivery and an uneventful hospital course. Similar cases are infrequent in the literature, which is reviewed in this report.     

Abortion laws in African Commonwealth countries

This paper provides an overview of the range of current (1981) abortion laws in the African Commonwealth countries, traces the origins of the laws to their colonial predecessors, and discusses legal reform that would positively provide for legal termination of pregnancy. The authors claim that the range of these laws demonstrates an evolution that leads from customary/common law (Lesotho and Swaziland) to basic law (Botswana, The Gambia, Malawi, Mauritius, Nigeria's Northern States and Seychelles) to developed law (Ghana, Kenya, Nigeria's Southern States, Sierra Leone, and Uganda), and, finally, to advanced law (Zambia and Zimbabwe). The authors call for treating abortion as an issue of health and welfare as opposed to one of crime and punishment. Since most of the basic law de jure is treated and administered as developed law de facto, the authors suggest decriminalizing abortion and propose ways in which to reform the law: clarifying existing law; liberalizing existing law to allow abortion based upon certain indications; limiting/removing women's criminal liability for seeking an abortion; allowing hindsight contraception; protecting providers treating women in good faith; publishing recommended fees for services to protect poor women; protecting providers who treat women with incomplete abortion; and punishing providers who fail to provide care to women in need, with the exception of those seeking protection under a conscience clause. The authors also suggest clarifying the means by which health services involving pregnancy termination may be delivered, including: clarification of the qualifications of practitioners who may treat women; specification of the facilities that may treat women, perhaps broken down by gestational duration of the pregnancy; specifying gestational limits during which the procedure can be performed; clarifying approval procedures and consents; and allowing for conscientious objections to performing the procedure.     

Shells and Bones: A Forensic Medicine Study of the Association of Terrestrial Snail Allopeas micra with Buried Human Remains in Brazil

Little is known regarding the scavenger fauna associated with buried human corpses, particularly in clandestine burials. We report the presence of 20 shells of the terrestrial snail Allopeas micra, within hollow bones of human remains buried for 5 years, during the process of collecting DNA material. The fact that a large number of shells of A. micra had been found in the corpse and in the crime scene supports the assumption that there was no attempt to remove the corpse from the area where the crime occurred. Despite this, our observations cannot be used to estimate the postmortem interval because there is no precise knowledge about the development of this species. This is the first record of a terrestrial snail associated with a human corpse and its role in this forensic medicine case.     

Attorney General v. X

In this case in which a 14-year-old girl said she had become pregnant after being raped by her friend's father, the Attorney General of Ireland had enjoined the girl and her parents from traveling to England for an abortion. A psychologist had testified that in her present state of mind, the girl was suicidal. The Supreme Court of Ireland held that the right to life supersedes all other rights, including the right to travel. However, if there is a real and substantial risk to the life of the mother which can only be avoided by termination of the pregnancy, then an abortion is permissible. The Court determined that the girl's risk of suicide satisfied this condition, and therefore the girl was allowed to terminate her pregnancy.     

Complicating Symmetric Peripheral Gangrene after Dopamine Therapy to Patients with Septic Shock

Dopamine is commonly used as a first-line agent in the treatment of patients with septic shock. The use of dopamine rarely causes symmetric peripheral dry gangrene. If the symmetric peripheral dry gangrene occurs in the patient after dopamine injection, it easily leads to disagreement between doctors and patients. A 60-year-old woman who had sudden septic shock was sent to intensive care unit (ICU). She was received dopamine injection according to the routine during treatment. Over the next 3 months, her limbs developed to dry gangrene and required amputation. The result shows that the occurrence of dry gangrene could only be associated with the long-term excessive use of dopamine according to the medical records. Although dopamine is a conventional drug for the treatment of septic shock, the forensic workers and clinicians must realize that vasopressors such as dopamine have been implicated directly or as a contributory cause in dry gangrene cases.     

A GIS‐based Quantitative Approach for the Search of Clandestine Graves,Italy

Previous research on the RAG color‐coded prioritization systems for the discovery of clandestine graves has not considered all the factors influencing the burial site choice within a GIS project. The goal of this technical note was to discuss a GIS‐based quantitative approach for the search of clandestine graves. The method is based on cross‐referenced RAG maps with cumulative suitability factors to host a burial, leading to the editing of different search scenarios for ground searches showing high‐(Red), medium‐(Amber), and low‐(Green) priority areas. The application of this procedure allowed several outcomes to be determined: If the concealment occurs at night, then the “search scenario without the visibility” will be the most effective one; if the concealment occurs in daylight, then the “search scenario with the DSM‐based visibility” will be most appropriate; the different search scenarios may be cross‐referenced with offender's confessions and eyewitnesses’ testimonies to verify the veracity of their statements.     

Soilwater Conductivity Analysis to Date and Locate Clandestine Graves of Homicide Victims

In homicide investigations, it is critically important that postmortem interval and postburial interval (PBI) of buried victims are determined accurately. However, clandestine graves can be difficult to locate; and the detection rates for a variety of search methods (ranging from simple ground probing through to remote imaging and near‐surface geophysics) can be very low. In this study, simulated graves of homicide victims were emplaced in three sites with contrasting soil types, bedrock, and depositional environments. The long‐term monthly in situ monitoring of grave soil water revealed rapid increases in conductivity up to 2 years after burial, with the longest study evidencing declining values to background levels after 4.25 years. Results were corrected for site temperatures and rainfall to produce generic models of fluid conductivity as a function of time. The research suggests soilwater conductivity can give reliable PBI estimates for clandestine burials and therefore be used as a grave detection method.     

Fat embolism syndrome associated with atraumatic compartment syndrome of the bilateral upper extremities: An unreported etiology

Fat embolism syndrome (FES) is a potentially life-threatening condition that develops when fat embolism leads to clinical symptoms and multisystem dysfunction. The classic triad of respiratory distress, neurologic symptoms, and petechial rash are non-specific, and the lack of specific laboratory tests makes the diagnosis of FES difficult. Although FES is most common after long bone fractures, multiple conditions some of which are atraumatic have been associated with the development of FES. We report a case of FES that occurred in the setting of a non-traumatic compartment syndrome of the upper extremities. The pathologic and clinical findings, pathophysiology, diagnostic challenges, and pathologic methods to properly diagnose FES are discussed with a review of the relevant literature. This case highlights the importance of the autopsy in making a diagnosis of FES in cases where death could otherwise be incorrectly attributed to multi-organ system failure, shock, or sepsis.     

Sudden Unexpected Death due to Hemophagocytic Lymphohistiocytosis Syndrome

The hemophagocytic lymphohistiocytosis (HLH) syndrome is a hyperimmune disorder characterized by lymphohistiocytic infiltrations, elevated cytokine levels in the blood, macrophage activation, and hemophagocytosis, frequently presenting with a febrile septic picture. This unusual disease is more common in infancy and childhood than adulthood. It is classified as primary or familial when a genetic defect is identified and secondary or acquired when triggered by certain infections, autoimmune disorders, or malignancies. If or when such patients expire, they typically do so within a hospital or under a physician's care and so such cases rarely come to the attention of forensic pathologists. We report on the unexpected deaths of two hospitalized adult cases of HLH brought to autopsy without a premortem diagnosis. Postmortem examination demonstrated marked hepatosplenomegaly and lymphadenopathy in association with hemophagocytosis. Although very uncommon HLH must be considered in infants, children, or adults who die unexpectedly with an undiagnosed septic presentation.     

The analysis of illicit methaqualone containing preparations by gas chromatography-mass spectrometry for forensic purposes

A validated gas chromatographic-mass spectrometric method for quantitative analysis of methaqualone (MTQ) in illicit preparations is reported. The method proved to have a coefficient of variation of below 5%. Four batches of seized tablets, two pairs with similar imprints, were analyzed. It was found that the average MTQ concentration in all four batches of tablets differed significantly (p = 0.01) rendering it impossible to conclude that, on the basis of MTQ concentration alone, the batches with a similar logo originated from the same manufacturer or manufacturing batch. Conversely, it can be said that in this case, the four batches originated from either different clandestine laboratories or manufacturing batches.     

Soil Fungi: Their Potential use as a Forensic Tool

As a grave is an anomalous environment and differs from its surroundings, criminal investigators employ different techniques for locating, recovering, and analyzing clandestine graves. In this study were identified the fungi found in the soil under corpses in decomposition with an aim at relating the copresence of human remains and different fungal species. Were isolated the fungi in three ways: soil washing, serial dilutions, and moist chamber growth. Dichotomomyces cejpii, Talaromyces trachyspermus, Talaromyces flavus, and Talaromyces sp. were the representative species found—with those belonging to the ammonia group, whose fungi are the first in the succession of cadaver decomposition directly in the ground. The mycobiota found at the present study area clearly differs to mycobiota identified in control sample and from previously described species for other areas of Buenos Aires Province, Argentina. Further forensic examples of this type are needed to develop fully the detailed use of mycology as a forensic tool.     

A clandestine burial in Costa Rica: prospection and excavation

Abstract:  This case report describes the search for a clandestine grave in Costa Rica for which the police sought the assistance of an archaeologist. An anonymous informant suggested that the victim had been kidnapped and murdered, placed in a shallow grave in the woods, then covered with lime and cement. A search of the area to detect conventional signs of burial (e.g., slumping, different plant growth) resulted in excavation of unrelated features of past disturbance. Different aspects of the grave including the deposition of cement powder over the body prevented its initial discovery. Improvisation of conventional archaeological excavation methods and use of police familiar with archaeological excavation resulted in the location of the grave and exhumation of the victim without loss of important contextual evidence that supported testimony on the cause of death. The taphonomic effects of high-lying ground water and lime in the tropical burial environment are briefly discussed. Recommendations such as the construction of a temporary sump to lower the ground water level in the grave during excavation are made to assist in similar investigations in the future.     

Raman Spectroscopy as a Simple,Rapid, Nondestructive Screening Test for Methamphetamine in Clandestine Laboratory Liquids

Raman spectroscopy has found increased use in the forensic controlled substances laboratory in recent years due to its rapid and nondestructive analysis capabilities. Here, Raman spectroscopy as a screening test for methamphetamine in clandestine laboratory liquid samples is discussed as a way to improve the efficiency of a laboratory by identifying the most probative samples for further workup among multiple samples submitted for analysis. Solutions of methamphetamine in ethanol, diethyl ether, and Coleman fuel were prepared in concentrations ranging from 0.5% to 10% w/v, and Raman spectra of each were collected. A concentration‐dependant Raman peak was observed at 1003 per cm in each solution in 4% w/v and greater solutions. Case samples were analyzed and also found to reliably contain this diagnostic peak when methamphetamine was present. The use of this diagnostic indicator can save the forensic controlled substances laboratory time and materials when analyzing clandestine laboratory liquid submissions.     

Prenatal diagnosis,genetics and reproductive decision-making

Recent developments in genetic science will potentially have a significant impact on reproductive decision-making by adding to the list of conditions which can be diagnosed through prenatal diagnosis. This article analyses the jurisdictional variations that exist in Australian abortion laws and examines the extent to which Australian abortion laws specifically provide for termination of pregnancy on the grounds of fetal disability. The article also examines the potential impact of pre-implantation genetic diagnosis on reproductive decision-making and considers the meaning of reproductive autonomy in the context of the new genetics.     

The effects of corrosive substances on human bone, teeth, hair, nails, and soft tissue

Abstract: This research investigates the effects of household chemicals on human tissues. Five different human tissues (bone, tooth, hair, fingernails, and skin/muscle/fat) were immersed into six different corrosive agents. These agents consisted of hydrochloric acid, sulfuric acid, lye, bleach, organic septic cleaner, and Coca‐Cola^® soda. Tap water was used as a control. Tissue samples were cut to consistent sizes and submerged in the corrosive liquids. Over time, the appearance, consistency, and weight were documented. Hydrochloric acid was the most destructive agent in this study, consuming most tissues within 24 h. Sulfuric acid was the second most destructive agent in this study. Bleach, lye, and cola had no structural effects on the hard tissues of the body, but did alter the appearance or integrity of the hair, nails, or flesh in some way. The organic septic cleaner and tap water had no effect on any of the human tissue tested during the timeframe of the study.     

Further observations on the speed of death in hanging

Given that most fatal hangings are suicidal and occur in locations that have been selected to conceal this activity (thus maximizing the chances of a lethal outcome), there has been very little corroboration of the speed with which unconsciousness and death may occur. A 35-year-old male is reported who committed suicide by hanging immediately after talking to his spouse. Police investigations confirmed her reliability as a witness indicating that lethal anoxia in this case had occurred within a very short time (most likely in less than 1 min) of suspension. The speed with which death may result from hanging not only gives an insight into fatal pathophysiological mechanisms, but also provides useful information for situations where a lethal outcome is to be avoided, or is not intended. For example, individuals at risk of suicide who are being monitored in institutional facilities need to be constantly under direct visual surveillance as significant hypoxia can be rapidly induced, parents and caregivers with infants and children in potentially unsafe sleeping environments need to realize how swiftly death or irreversible anoxic brain damage may occur from neck compression, and those who engage in recreational asphyxia should be informed just how quickly a fatal outcome may ensue.     

Sudden Death in Marfan Syndrome

Marfan syndrome is an autosomal dominant genetic disorder of the connective tissue. The most serious complications of this syndrome are defects of the heart valves and aorta. Aneurysms of thoracic aorta are known to develop in Marfan syndrome. Other causes for development of aneurysms of the thoracic aorta are trauma, infections, valve and arch anomalies, genetic disorders, and atherosclerosis. These aneurysms upon rupture may lead to sudden deaths. They are usually detected during routine screening or follow‐up of such persons suffering from Marfan syndrome and upon death will be certified by the treating physician. Thus, an autopsy surgeon rarely comes across such deaths. One such case of sudden death due to cardiac tamponade consequent upon rupture of dissecting aortic aneurysm in a 33‐year‐old male who complained of throbbing pains in the chest, radiating to back, became breathless, cyanotic and died on the way to hospital is being presented here.