Value of fetal autopsy after medical termination of pregnancy

We carried out a retrospective study of 352 medical terminations of pregnancy (MTP) carried out in a large French administrative region over two consecutive years. We analysed the indications for MTP and then compared the prenatal ultrasound diagnosis with fetal autopsy findings in order to demonstrate the value of pathological examination of the fetus in prenatal diagnosis and genetic counselling as well as the need to check by autopsy the quality of ultrasound screening. Preliminary analysis of the indication for these MTP showed that in 69.9% ultrasound screening had been carried out, revealing mainly brain abnormalities (22.2%) and heart defects generally associated with chromosomal abnormalities (32.1%). Prenatal findings were in agreement with autopsy results, showing no false-positive prenatal diagnoses. However, in 7.9% of cases in which brain abnormalities were detected, confirmation was not possible at autopsy because of tissue autolysis, showing the need for optimal conditions of expulsion. In 35.8% of cases, confirmation of the diagnosis by autopsy was not useful for management but still added to medical knowledge and demonstrated to the mother the reality of the defects. In 50.9%, the autopsy findings were decisive for genetic counselling.     

Immunostaining by complement C9: a tool for early diagnosis of myocardial infarction and application in forensic medicine

Before the first 12 hours, diagnosis of early myocardial infarctions is always difficult for forensic pathologists. We tested complement C9 expression in 121 formalin-fixed and paraffin-embedded heart samples by an immunohistochemical procedure. The heart specimens were separated into four groups: 33 cases in group 1 with typical ischemic damages histologically located, 20 cases in group 2 with death related to myocardial infarction on the basis of ischemic presentation on electrocardiogram but no obvious histological ischemic damage, 35 cases in group 3 with severe coronary disease without cause of death found at the autopsy, and 33 cases in group 4 without sign of myocardial infarction and without coronary disease. In the first group, all 33 heart samples showed a well-defined C9 expression in the necrotic areas. The second group in 17 of 20 cases showed positive areas for C9 expression. In the other three heart specimens, only few stained cells were observed whereas the painful symptoms had begun less than 1 h before death. The third group showed C9 immunopositive areas in six of 35 cases, few stained cells in 8 cases, and no C9 deposition in the 21 other cases. The last group showed no staining area. To avoid nonspecific C9 staining due to tissue autolysis, we studied C9 expression during a controlled putrefactive process in four cases included in group 1; staining was found only in infarcted myocardial areas, and was observed up to ten days. Specificity of C9 expression was evaluated to be 100% [89.4 to 100%] and sensitivity to be 85% [62.11 to 96.79%]. In conclusion, evaluation of immunohistochemical expression of C9 appears to be a highly sensitive and specific marker of early myocardial infarction, useful in forensic medicine if survival is more than 1 h after the beginning of myocyte damage.     

Unexpected natural death secondary to intra-abdominal bleeding: report of one idiopathic spontaneous intraperitoneal hemorrhage case

A 39-year-old woman was found dead at home. She was single, foreign national, chronic alcoholic, and had given shelter to a compatriot for three days. This man found the deceased in her bed, after a night of heavy drinking. The emergency medical team observed numerous recent blue ecchymoses of the upper limbs. Because of the unclear circumstances, a medicolegal autopsy was ordered by the public prosecutor. Massive hemoperitoneum was diagnosed with no visible internal traumatic injury. Autopsy revealed hepatic and pancreatic abnormalities secondary to chronic alcoholism, which were confirmed by pathological study. The source of the hemoperitoneum was not identified despite careful visceral and vascular examination. The authors concluded that death was secondary to idiopathic spontaneous hemoperitoneum or abdominal apoplexy. The forensic literature on unexpected death due to massive nontraumatic intra-abdominal hemorrhage in association with liver cirrhosis is sparse, with only five cases reported, including the present case.     

Fetal Age Estimation Using Orbital Measurements: 3D CT-Scan Study Including the Effects of Trisomy 21

Abstract:  This study evaluates a new method of fetal age estimation based on orbital measurement and including the potential trisomy 21 of the fetus. Six orbital and one facial CT-scan measurements were taken on 71 fetuses ranging from 14 to 41 weeks of gestational age. Forty-eight fetuses were "normal" and 23 fetuses presented the Down syndrome (trisomy 21). The anatomy/imagery correspondence was evaluated comparing our results to those obtained by direct bone measurements on the same fetuses and revealed no significant differences between the two kinds of measurements. Moreover, a multiple linear stepwise regression was realized to estimate fetal age and showed that the "trisomy 21 parameter" is not conserved in the final determination model. Therefore, we conclude that the good radio-anatomical correspondence offers an interesting alternative to direct bone measurement (necessitating dissections) and allows a reliable fetal age determination, whatever is the trisomy 21 condition of the fetus.     

Pellagra: a rare disease observed in a victim of mental and physical abuse

Lesions of the brain stem and cerebellum due to nutritional deficiencies are mostly seen in chronic alcohol abuse and more rarely in severe malnutrition. We report the case of a 27-year-old woman, found dead in the family flat. She presented cachexia (167 cm, 25 kg) and multiple hematomas of the limbs. Postmortem examination revealed lesions due to peritonitis. Neuropathological examination showed severe atrophy of the corpus callosum and central neuronal chromatolysis, which are observed in pellagra. Inflammatory colitis or celiac disease was not found. Toxicological analysis was negative, in particular no alcohol absorption. Pellagra, which is due to nicotinamide deficiency, is a disease rarely seen in this country. In this case, nutritional deficiency was the consequence of failure to eat in a context of abuse. The woman was born of an incestuous relationship and presented intellectual retardation due to poor affective relations with her mother.     

Validation of a radiographic method to establish new fetal growth standards: radio-anatomical correlation

In forensic medicine, specialists might face difficulties when estimating age at death from fetal remains. Depending on the state of preservation, this age assessment is essentially based on the diaphyseal size of long bones. In a previous work, for the measurement of fetal femoral ossified shafts, we already established a simple and reliable method using a radiographic protocol. Since we previously stated that radiographic measurement values were closer to real anatomical size than ultrasonographic ones, in the present study we decided to check the importance of the difference between radiographic and anatomical measurements. Therefore, we dissected 30 pairs of fetal femurs and compared the difference between the two kinds of measurements (in percentages). This difference seemed to be slight (4.027%), but it was large enough to entail significant differences (p < 0.001). In order to provide a correction factor for radiographic measurements, we established a linear regression formula, which was tested on another sample of 30 pairs of dissected femurs. As a consequence of the good results, we improved the linear regression using a powerful statistical tool: the bootstrap. Finally, we obtained a simple equation that allowed us to figure out the real anatomical size with an R2 of 99% and a mean relative difference of 0.153% (with a standard error of 0.252 mm, and therefore a 95% confidence interval with limits of -0.35 and 0.657 mm). This difference did not entail any significant differences (p = 0.498), and therefore, we concluded that with the proposed correction, radiographic measurements can easily be used by forensic specialists in their daily tasks or to establish new growth standards in order to best fit their population of interest.     

An unusual case of post-mortem redistribution of ethanol

We report an unusual case of post-mortem redistribution of ethanol in a woman diver who died by drowning in seawater. The ethanol concentrations were right heart blood 0.60 g/l, left heart blood 2.08 g/l, femoral venous blood 0.63 g/l, gastric contents 5.87 g/l, bile 0.83 g/l. The mechanisms of post-mortem redistribution of ethanol described in the literature, that is, early redistribution from the stomach or the lung parenchyma in the case of inhalation of gastric contents, are inadequate to account for the degree of variation observed between the measurements. We believe that this difference in concentration is explained by the presence of seawater in the pulmonary alveoli at the time of death.     

Postmortem assessment of fetal diaphyseal femoral length: validation of a radiographic methodology

Depending on the general condition of fetal remains, forensic specialists might face difficulties concerning age estimation. Reference tables and regression equations are helpful devices in this task, although they are generally applied for complete fetuses or fetal remains including soft tissues. However, the problem of age estimation stays for osseous remains, both for entire bones and ossified parts, since most of the reference tables come from ultrasonographic measurements, which are not easily reproducible on fetal osseous remains. Furthermore, the ultrasonographic measurements contain slight errors in comparison to the real anatomical ones. This study describes a radiographic protocol and a measurement technique that facilitate and improve bone measurements, and therefore, facilitate age estimation, too. A qualitative criterion, namely a clear-cut bony endplate, was defined and tested. Its reliability (repeatability and reproducibility) turned out to be good, showing nonsignificative differences to the threshold of 0.05, with average errors of 0.26 and 0.44 mm respectively. Moreover, concerning the test of eventual size differences between the right and left femurs showed a P value < 0.0001. The test of the qualitative criterion was based on the comparison of the radiographic in situ femur measurements and the radiographic measurements of the same bones after dissection. The results were satisfactory, since an average error of 0.58 mm was obtained, which did not give any significant differences to the threshold of 0.05. It was concluded that this methodology provides an easy and precise new measurement tool for forensic practice, and can allow us to establish some nonultrasonographic tables, which fit our population.     

Age-at-death estimation based on the study of frontosphenoidal sutures

Determination of age at the time of death based on the observation of cranial sutures has led to numerous studies with sometimes contradictory results. The initial hypothesis being that suture closure is part of an age-related physiological process, the conflicting results have been interpreted by various authors as secondary to the choice of sutures, under the co-existing influence of pathological factors or genetic factors, or even independent of age. Despite these differences, macroscopic methods remain much used in anthropology and in forensic medicine. In our work, we evaluated the value of the degree of closure of the frontosphenoidal suture in estimating age at death of mature subjects, with the secondary objective of establishing a linear regression which could be used in routine practice. The study concerned bone specimens from individuals whose age, sex and medical history were known. Macroscopic observation was carried out on the ectocranial and endocranial sides according to four stages of closure previously defined. 290 sutures were taken from a population of whom two-thirds were men. The method can be repeated and reproduced and the regression established shows the confidence range for average error to be +/-1.5 years. While this result is of interest in terms of precision in prediction for a group of people, the prediction range is too great (+/-23 years) to be applicable to a single individual as part of a forensic procedure.