Estimating Gestational Age in Forensic Medicine
Estimating Gestational Age in Forensic Medicine
Estimating Gestational Age in Forensic Medicine
ROMAN AL MAMUN
Crown-heel length & weight of fetus and by noting morphological features, organ development and
appearance of ossification centers.
The parameter includes fetal crown-rump length, biparietal diameter, head circumference, abdominal
circumference,femoral length, foot length and appearance of fetal heel ossification centers.
Estimating gestational age when a fetus dies is a specialized task in forensic medicine .
Techniques for determining the gestational age of fetal or perinatal (around the time of birth) remains
are mainly aimed at calculating the time since conception, and at determining if a specific disease could
be the cause of fetal loss.
The World Health Organization has set the viability threshold at 20 weeks gestation.
Fetal death is defined as the death of a product of conception (fetus) before complete expulsion or
extraction from its mother, regardless of the duration of pregnancy.
Proper classification of the fetal age into the correct classification has important ethical, legal, and also
clinical implications.
Depending on the general condition of fetal remains, forensic specialists might face difficulties with age
estimation.
The whole skeletal length was probably the first marker used for fetal assessment and is considered
valuable for diagnosing various syndromes and skeletal dysplasias (abnormal development) as well as
for assessing fetal development.
However, even if still considered a marker of developmental age, the whole skeletal length may be
affected in post mortem (after death) assessment by the putrefactive (decomposition ) process.
In particular, body length increases slightly with maceration (tissue softening in liquid), whereas body
weight and head circumference seem to be unaffected.
For this reason, long bone length is considered a more stable and reliable marker than full-body
measurements.
Several investigators have produced linear regression formulas based on crown-heel length, crown-
rump length, or body diameters to determine gestational age.
The advent of ultrasonography allowed a more accurate determination of fetal gestational age (crown-
rump length or biparietal diameter and/or femur length).
This technology is useful in forensic measurement of bones from standardized post-mortem radiographs
in cases of questionable gestational age and can be compared with previous ultrasonographic
measurements.
One relatively accurate radiographic (x ray or other radiographic image) protocol for estimating fetal
gestational age at death is based on femur (the long bone in the leg) diaphyseal (shaft) length, and
compares images of fetal femur measurements with measurements of the same bones at autopsy .
As several organs show major changes in developmental patterns throughout fetal development,
maturation of fetal tissues and organs has been also proposed for gestational age estimation.
Histological maturation of several soft tissues (skin, thymus, lungs, thyroid gland, kidneys, adrenal
glands, and central nervous system) between 12–40 weeks gestation, and compared the estimated
gestational age with that obtained by long bone measurement.
Skin, lung, and kidney tissue (each with unique but distinguishable stages of development) were found
to be useful for a more accurate assessment of gestational age when integrated with long bones
measurements.
The growth of fetal long bones is affected by several conditions that might lead to growth retardation of
the fetus in the womb.
Macroscopic examination (with the eye)or radiographic (x ray) examination are the most common
methods used to estimate fetal age.
Examination of the tissues and organs is also important for a better definition of fetal age.
Term DEVELOPING OVUM is used for 1st 7-10 days after conception i.e. until implantation occurs.
The age of fetus can be determined by taking into account appearance of different characters at
different time.
1st ossification centre in a fetus appears in clavicle(4-5 wk), followed by maxilla(6 wk).
Midpoint at xipoid.
Nails are thick but do not extend to the tips of fingers & toes.
Gall bladder contains bile & caecum is seen in right iliac fossa.
Skin is red but not wrinkled & covered with soft hair.
Vernix caseosa is present over the flexures of joints & neck folds.
Length-45-50cm, wt-3-3.5kg
Head is about 28 cm in circumference & well covered with hair which is 3.5 cm long & dark.
Skin is covered with vernix caseosa which is readily seen in the flexure of joints & neck folds.
Vernix caseosa is white cheesy substance made up of sebaceous secretion & epithelial cells.
Being sticky, it can not be easily removed. It protects fetal skin against maceration while in liquor amnii.
Umbilical cord is fleshy with a normal spiral twist & a glistening surface of about 45-50 cm in length.
Vulva is closed & labia minora is covered by fully developed labia majora.
Radiographically, the mineralization of deciduous incisors starts at the 16th week of intrauterine life.
Before the mineralization of tooth germs starts, the tooth germs may be visible as radiolucent areas on
the radiograph; the subsequent radiographs of the mandible will depict the deciduous teeth in various
stages of mineralization as per the pre-natal age of the fetus.
One of the methods employed is:
They studied the early mineralization in various deciduous teeth as well as the permanent first molar.
The development is described in 10 stages, denoted by Roman numerals from I to X; the IXth stage
includes three stages and the Xth stage includes five stages.
• Tooth-to-pulp ratio
1. Biparietal diameter :
The fetal head was imaged in an axial section with the fetus in a direct occiput transverse position.
The instrument was set at medium gain so that parietal bones measure approximately 3 mm in
thickness.
The BPD was measured from the outer surface of the skull table to the inner margin of the opposite
skull table.
2. Head circumference :
The fetal HC was traced along the outer perimeter of the calvarium using the electronic digitizer at the
same level as for the BPD.
3. Abdominal circumference:
It was measured on the transverse image of the fetus at the level of liver.
A major landmark was the umbilical portion of left portal vein deep in the liver; fetal stomach
represented the second landmark.
The measurements were made from the outer edge of one side to the outer edge of other side.
4. Femur length :
It was measured along the long axis of diaphysis using a straight line from the tip of greater trochanter
to lateral epicondyle.
Introduction
Rule of Haase:
During the first five months of pregnancy the square root of the length gives the approx. age of the
fetus in months.
During last five months the length in centimeters is divided by five gives the age in months.
Specimen
Approx. Age
Can comment on internal organs and on level of muconeum whether it is in Duodenum/ Large
intestine.
Length is about 1 cm
Weight is about 10 gm
Weight is about 30 gm
Neck is formed
Length is about 30 cm
Length is about 35 cm
Length is about 40 cm
Length is about 45 cm
Ossification center are usually present in the lower end of femur, in Cuboid and Capitate bone.
Newer methods Assessment of Gestational Age from Hand and Foot Length:
Obstetricians have been using the fetal foot length to estimate gestational age.
Fetal hand and foot lengths have been found to highly correlate with gestational age and therefore
these parameters could be utilized to estimate gestational age.
The utilization of fetal hand length and foot measurements will serve as a useful adjunct data for
estimation of age in reliable manner.
Fetal foot length was measured in the plantar and longitudinal plane from the posterior heel to the tip
of longest toe and hand length was taken on palmar surface in longitudinal plane from wrist crease to
the tip of the middle finger.
All the measurements were done three times and the mean value was used in analysis.
The data was analysed using SPSS software by regression analysis.
Graphs were also plotted to determine pattern of growth and their correlation with crown rump length
if any.
Streeter first evaluated the fetal foot for gestational age assessment in 1920.
Hern’s then elaborated a strong relationship between fetal foot and gestational age.
The period of gestation estimated by measurement of fetal foot length appears to be in aggrement with
other ultrasound parameters.
The human fetal age was estimated from the direct measurements of femur and incisor teeth, and
strong correlations were found between fetal age, femoral, and teeth measurements.
Forensic medical experts, obstetricians, and pediatricians generally use head circumference (HC)
measurement as an age estimation parameter.
During the fetus period teeth are also indicators of age, which develops within the sockets of the
alveolar bones in the upper and lower jaws.
The crown and root size of the teeth develop linearly to a certain time, starting from the initiation of the
mineralization phase until the completion of the hard tissues due to the incremental deposition process
of dentinal, enamel, and cementum matrices with certain rates.
Teeth are major factors in age estimation of fetuses which starts growth during the prenatal embryonic
period and have several advantages over skeletal aging since they exhibit less variability than bones and
are more durable against external influences because of its hardness.
The hardness of teeth is approximately 5, whereas the bone hardness is 2–3, according to Mohs
hardness scale, which is the hardest tissue in the body.
HC was determined by the circular measurement passing over the glabella and the external occipital
protuberance with a nonelastic metric tape in centimeters and the tooth dimensions; labiolingual (LL),
mesiodistal (MD), crown height (CH), and root height (RH) were taken in millimeters as follows:
LL width, which is measured on the maximum dimension between the labial and lingual surfaces and on
the midsagittal location of the cementoenamel junction ; MD width,which is the maximum dimension
between the mesial and distal surfaces ; CH, which is the maximum measurement from incisal edge to
cervical on the midsagittal line; and RH between the cervical line and the edge of the developing root on
the midsagittal line of the labial root surface.
Additionally,CH and the RH were added to find the total tooth height (TH), [TH=CH+RH]
Ultrasonography is done in every ante natal case for measurement of various fetal parts.
gestational age.
During fetal autopsy, all the parameters for identification, may or may not be available particularly when
body is decomposed or mutilated and sometimes only few bones are available.
Then there is no other option except to find out the age from bones.
Measurement of length of bone and diameters at autopsy is very easy, less time consuming and a
cheaper way of finding out the age of the fetus.
Few useful measurements in the fetus are femur length, length of kidney, abdominal circumference and
head circumference.
Femur length and BPD have more value prior to 36 weeks but after 36 weeks head circumference and
femur length has more value.
Length of femur is also better parameter as compared to BPD for determination of age of fetus in the
third trimester.
The bi-parietal diameter and femur length correlated equally well with gestational age.
Ultrasound measurement of femur length and bi-parietal diameter are comparably accurate estimators
of gestational age when obtained in the first half of pregnancy
Both estimators, however, become less accurate later in pregnancy.
The correlation coefficient of gestational age versus fetal femur length is statistically greater than that of
the gestational age versus fetal biparietal diameter.
Measurement of the fetal femur appears to be a reliable method for assessing gestational age, which
Bi-parietal Diameter:
Average bi-parietal diameter of skull at 4th lunar month of pregnancy is 30.63 mm and
maximum at 10th lunar month is 87.43 mm.
Although technically post mortem examinations can be conducted only on legally viable
fetuses, most pathologists would perform perinatal post mortems on fetuses of a gestational
age greater than about 16 weeks or a body weight greater than 400g.
For fetuses between 400 g and 25 g a “mini-post mortem” can be performed and below 25 g a
longitudinal sectioning method can be employed.
Examination of the placenta is also an essential part of the autopsy of a perinatal case.
Most perinatal and neonatal autopsies are hospital cases; however, infant post mortems may
be medico–legal cases if the cause of death is not known.
In medico–legal post mortems, ancillary investigations are permitted only if they are required
to establish the cause of death, and it is the duty of the pathologist to see that such
investigations are completed.
Specific consent is required from the coroner or equivalent, and they are also responsible for
setting a time limit for sample retention, in discussion with the pathologist.
External Examination
In perinatal cases, the shape of the head, the facies, the palate,the number of digits, the
external genitalia, the patency of the anus, and the continuity of the spinal column should be
assessed.
A probe should be passed through each nasal orifice to exclude posterior choanal atresia and
into each external ear to ensure patency.
The eyes should be examined for evidence of icterus and conjunctival haemorrhage.
Evidence of external trauma should also be looked for, particularly with reference to the
obstetric and neonatal history.
All bruises, needle punctures, forcep blade marks, surgical incisions, and so forth should be
noted.
This allows later dissection to assess their siting and provides a means of resetting the site (by
placing cut end flush with skin again) if they are inadvertently moved during examination.
The apparent state of nutrition and any evidence of cyanosis, pallor, jaundice, oedema, and
meconium staining should be assessed. A search for
petechial haemorrhages should also be made, both on the skin (particularly of the head and
upper chest) and on the conjunctiva and mucous membranes of the oral cavity.
The shape of the thoracic cavity should also be assessed; a narrow cavity often indicates
pulmonary hypoplasia.
In the case of stillbirths, it is important to note whether the body is fresh or macerated, and if
maceration is present, the degree must be assessed to aid estimation of the time interval
between IUD and delivery.
There is a classification system to aid the estimation of the degree of maceration, but the
changes are also affected by the ambient temperature during body storage:
External Examination
External Measurements
The following careful measurements should be made with a ruler and a length of string, and
compared to tables of normal values to aid assessment of gestational age and allow assessment
of growth.
Essential
• Body weight
• Foot length
• Head circumference
Helpful
centres:
An assessment of organ maturation can also be useful.The external appearances of the cerebral
hemispheres (gyral formation) is little affected by growth, and various gestational ages.
In the brain, the density of the neuronal cells and the pattern of myelination can be useful.
Purkinje cells in the cerebellum appear at about 28 weeks and the periventricular layer begins
to disappear at about 30 weeks.
In the lung, the extent of alveolar formation, the persistence of small terminal airspaces lined
by cuboidal epithelium and the amount of residual parenchyma are all useful features that aid
the assessment of maturity.
In the kidney, the width of the glomerulogenic zone to the width of the definitive glomerular
zone correlates well with gestation and culminates in the disappearance of the nephrogenic
The presence and quantity of extramedullary haematopoiesis in the liver and the ratio of
stroma to parenchyma in the pancreas may also be useful.
The thickness of the fetal skin and the development of the subcutaneous fat may also be
helpful, but are obviously greatly affected by growth retardation.
The gall bladder is formed from the caudal part of the hepatic diverticulum in the fourth week
of gestation.
Initially, it is tubular, but it becomes saccular during the 11th week of gestation.
„„ The clavicle is the first bone to ossify in the body from two membranous primary ossification
centers during the 5–6th postovulatory week.
A secondary center forms in the sternal end between 15–17 years and fuses by 20–22 years.
In majority of the bones, primary centers of ossification appear between 7th and 12th weeks of
intrauterine life.
By the age of 11–12th week of IUL, there are 806 centers of ossification.
Stack’s method:
Stack evolved a method to estimate the age from the weight of the erupting teeth of fetus and
infant.
He provided a regression line of weight of growing dental tissues against age (from 5 months in
utero to postnatal age of 7 months).
28 (prenatal) 60
40 (prenatal) 460
2 (postnatal) 530
30 (postnatal) 1840
Boyde’s method:
This method, applicable mainly to estimate age of dead infants, is based on counting the
number of cross striations in the enamel of teeth (incremental lines) from neonatal line
onwards.
Neonatal line is formed soon after birth and can be seen in about 3 weeks, or by electron
microscopy 1–2 days after birth.
„„ Alveolar cavities which contain teeth are formed around the 3–4th month of intrauterine life
(IUL).
„„ At birth, rudiments of all the temporary teeth and the 1st permanent molars may be found
in jaw.
„„ Each tooth has a crown, neck and a root embedded in jaw bone.
„„ Teeth are composed of dentin covered on the crown by enamel and on the root by
cementum which is attached to the alveolar bone by periodontal membrane.
Tooth enamel is the hardest substance in the body containing primarily hydroxypatite
The first radiographic evidence is formation of a bony crypt followed by mineralization of crown
tips.
Mineralization proceeds from crown tips down the sides of the tooth.
„„ Root mineralization does not begin until crown formation is complete and root formation
ceases with the reduction of apical foramen.
As the root becomes longer, the crown erupts through the bone.
„„ Mineralization of deciduous dentition begins in utero, early in 2nd trimester, and root
formation of third molar may not be complete until 20 years of age.
„„ During eruption of a permanent tooth, the overlying root of its deciduous predecessor
simultaneously undergoes absorption, until only the crown remains.
The crown heel length carries importance. According to the Haase Rule (1895), the length
of a foetus up to 5th month (20th week) of gestation represents the square of its age in
months. Thus, a foetus of about 4 months will have a length of 16 cm.
Beyond 5th month, the length of the foetus measured in centimetres divided by 5 gives the age
in months.
Thus, a foetus of 35 cm length will be about 7 th month of age. This is known as Morison
Rule.Difficulties:
Gestational age assessment may be difficult in fetus with anencephaly, hydrocephalus, short limb
dysplasia, post mortem destruction or in mutilated case.