Utility of Fetal Autopsy To Estimate Time of IUFD in Maternal Trauma
Utility of Fetal Autopsy To Estimate Time of IUFD in Maternal Trauma
Utility of Fetal Autopsy To Estimate Time of IUFD in Maternal Trauma
Case Report
A R T I C L E I N F O A B S T R A C T
Keywords Forensic pathologists determine cause and manner of death in sudden and unexpected deaths. Fetal autopsies can
Intrauterine fetal demise be challenging because they are rare, fetal death can occur in the context of maternal injuries, and examination
Fetal death findings are usually affected by postmortem changes. We present a case involving a 26 week gestational age fetus
Timing of fetal demise
with intrauterine demise in the context of maternal assault. In the assault, the assailant compressed the abdomen
Intrauterine retention time
of the mother while striking her. The fetus was determined to be dead by ultrasound after the mother arrived at a
Maternal assault
hospital. The fetus was delivered by induction the following day. Examination of the fetus showed mild
maceration, and microscopic examination of various organs showed findings compatible with a fetal death of no
more than 48 h prior to delivery. Taking the circumstances, gross findings, and microscopic findings into ac
count, the cause of death was determined to be the result of compression of the mother’s abdomen during the
assault. This case highlights the importance of accurate timing of intrauterine fetal demise particularly as it
relates to maternal trauma.
Coroner’s/Medical Examiner’s Offices (CMOs) investigate sudden A pregnant woman was transported to a local hospital after being
and unexpected deaths. This investigation typically includes gathering assaulted. According to the investigation, on the day of the assault, at
information about circumstances surrounding a death and performing approximately 1100 h, the assailant “sat” on the mother’s abdomen
postmortem examinations/autopsies. Medical examiners/forensic pa while striking her. The victim reported the assault, and first responders
thologists (FPs) rely on all of this information to form their opinions arrived at the scene and transported her to the hospital, where she and
about cause and manner of death. CMOs assume jurisdiction of any her fetus were evaluated. Medical records from the hospital documented
sudden or unexpected death that occurs in a violent context, and for several bruises on the mother, and ultrasound of the fetus at 1520 h
most CMOs, this includes the death of fetuses whose deaths could be showed absence of fetal heart tones (intrauterine fetal demise; IUFD).
from trauma sustained by the mom. The investigation of fetal deaths Labor was induced, and a 26 week, 3 day gestational age stillborn fetus
presents a great challenge for FPs for a few reasons: fetal deaths in the was delivered the following day at 1130 h (approximately 24 h after the
context of violence are rare, many modes of maternal violence do not assault occurred). Jurisdiction was assumed by the CMO, and the fetus
necessarily translate to visible injuries on the fetus, and various post and placenta were brought to the CMO for examination.
mortem changes invariably take place between a traumatic event, de The fetus was received for postmortem examination encased in
livery, and subsequent examination of the fetus. The case reported here extraplacental membranes. The placenta was separate, and the umbili
provides an example of how postmortem examination can reveal gross cal cord had been previously clamped and transected. Fetal examination
and microscopic findings to correlate the timing of fetal death with a showed a small for gestational age (SGA) fetus with a mass of 550 g
traumatic event. (511–1195 g expected for 26 weeks, approximately 3rd percentile;
Fig. 1)[1]. External examination showed a structurally normal fetus with
red-brown discoloration of the umbilical stump and mild maceration
* Corresponding author at: Department of Pathology, University of Alabama-Birmingham, 1670 University Blvd, Birmingham, AL 35233, United States.
E-mail address: [email protected] (D.S. Atherton).
https://doi.org/10.1016/j.hpr.2021.300586
Received 30 November 2021; Received in revised form 21 December 2021; Accepted 23 December 2021
Available online 4 January 2022
2772-736X/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.S. Atherton et al. Human Pathology Reports 27 (2022) 300586
3. Discussion
Fig. 2. (A) Placenta showing chronic chorionic villous ischemia with focal perivillous fibrinoid (H&E, 4x). The inset (40x) shows villi with increased nucleated red
blood cells and intravascular karyorrhexis. (B) Myocardium showing loss of nuclear basophilia in inner half of myocardium (H&E, 60x). (For interpretation of the
references to colour in this figure legend, the reader is referred to the web version of this article.)
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D.S. Atherton et al. Human Pathology Reports 27 (2022) 300586
Table 1 the intravascular leukocytes and/or endothelial cells in the fetal capil
Sensitivity, Specificity, and Positive Predictive Value (PPV) of Examination laries of the chorionic villi correlate with a post-demise interval of ≥ 6 h,
Findings as it Relates to Retention Time. and that multifocal (but not extensive) stem villous luminal abnormal
External Fetal Exam Retention Sensitivity Specificity PPV ities correlate with a post-demise interval of ≥ 48 h. In our case, the
Findings Time findings of intravascular karyorrhexis without stem vessel abnormalities
Desquamation ≥ 1 cm ≥6h 86% 100% 1.00 suggests a demise to delivery interval of 6–48 h.
Desquamation of face, back ≥12 h 80% 100% 1.00 Taking all these findings in aggregate, these examination findings
or abdomen estimate the time of IUFD to be between 24 and 48 h prior to delivery.
Desquamation ≥ 5% of body ≥18 h 80% 100% 1.00
Since delivery occurred at 1130 h on the day after the assault, this es
Desquamation 2 or more of ≥18 h 90% 92% 0.90
11 zones timates the time of fetal death to be between 1130 h on the day prior to
Mummification ≥2 wks 100% 100% 1.00 the assault and 2330 h on the day of the assault. Ultrasound confirmed
Fetal Organ Histology Retention Sensitivity Specificity PPV IUFD at 1520 h on the day after the assault, so death could not have
Time occurred after that. This creates an approximate 27 h window prior to
Kidney: Loss of tubular 97% 89% 0.97
ultrasound-confirmed death in which death could have occurred, and
≥4h
nuclear basophilia in ≥ 1%
of cells the assault was within this calculated window. This time frame is shown
Liver: Loss of hepatocyte ≥24 h 100% 92% 0.89 in Fig. 4.
nuclear basophilia in ≥ 1% In cases involving a growth restricted fetus and findings of placental
of cells
underperfusion, as in this case, stillbirth is often assumed to have a
Myocardium: Inner half loss ≥24 h 94% 100% 1.00
of nuclear basophilia in ≥ placental cause. However, the correlation in this case between the
1% of cells estimated time of fetal demise and the timing of the assault is suggestive
Myocardium: Outer half loss ≥48 h 100% 96% 0.91 that the two events were related. The assault in this case involved
of nuclear basophilia in ≥ increased pressure on the mother’s abdomen, potentially increasing the
1% of cells
intrauterine pressure enough to overcome fetal and placental compen
Bronchus: Loss of epithelial ≥96 h 100% 97% 0.91
nuclear basophilia in ≥ 1% satory measures in this presumably already susceptible fetus, with
of cells resulting fatal hypoxia/ischemia of the fetus.
Liver: Loss of nuclear ≥96 h 91% 100% 1.00 Umbilical cord and/or chorionic vascular compression are well-
basophilia in 100% of cells
known etiologies for reduction in blood flow both to and from a fetus.
GI tract: Loss of nuclear ≥1 wk 90% 100% 1.00
basophilia in 100% of cells [5] Umbilical cord compression most commonly occurs as a result of the
Adrenal: Loss of nuclear ≥1 wk 100% 100% 1.00 cord become entangled around a fetus’s neck (a “nuchal” cord), the
basophilia in 100% of cells umbilical cord forming a knot, or from prolapse during uterine con
Trachea: Loss of chondrocyte ≥1 wk 89% 100% 1.00 tractions during labor and delivery. Chorionic vascular compromise
nuclear basophilia in ≥ 1%
most often occurs in cases of velamentous or marginal cord insertion or
of cells
Kidney: Loss of nuclear ≥4 wks 100% 98% 0.88 in cases of monochorionic twins with amniotic fluid pressure imbalance.
basophilia in 100% of cells If unrecognized and untreated, this reduction in blood flow can lead to
of any type fetal hypoxia, bradycardia, permanent brain damage and even death.
Placental Histology Retention Sensitivity Specificity PPV
[6,7] The exact length of time required to cause permanent brain
Time
Intravascular karyorrhexis ≥6h 94% 100% 1.00
damage or death after reduction or obstruction of fetoplacental blood
Stem vessel luminal flow cannot be certain. In cases of subacute or chronic obstruction to
abnormalities fetal flow, histopathologic changes may be identified, and these were
Multifocal (10–25% of stem ≥48 h 94% 100% 1.00 ruled out in this case. However, in acute obstruction there may be no
villous vessels)
correlative fetal or placental findings in vessels or placenta.
Extensive (greater than 25% ≥2 wks 78% 98% 0.88
of stem villous vessels)
Extensive villous fibrosis ≥2 wks 100% 93% 0.75 4. Conclusion
Patient consent
Patient consent was not available as the case involved fetal remains;
we confirm that no identifying data are included in the manuscript.
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D.S. Atherton et al. Human Pathology Reports 27 (2022) 300586
Fig. 4. A diagram showing a span of three days with the gray portion being the 48 h prior to delivery. Death could not have occurred after the ultrasound (the dotted
line). The assault occurred within the estimated window of fetal death.
Declaration of Competing Interest [2] D.R. Genest, M.A. Williams, M.F. Greene, Estimating the time of death in stillborn
fetuses: I. Histologic evaluation of fetal organs; an autopsy study of 150 stillborns,
Obstet. Gynecol. 80 (4) (1992 Oct) 575–584.
The authors declare that they have no known competing financial [3] D.R. Genest, Estimating the time of death in stillborn fetuses: II. Histologic
interests or personal relationships that could have appeared to influence evaluation of the placenta; a study of 71 stillborns, Obstet. Gynecol. 80 (4) (1992
the work reported in this paper. Oct) 585–592.
[4] D.R. Genest, D.B. Singer, Estimating the time of death in stillborn fetuses: III.
External fetal examination; a study of 86 stillborns, Obstet. Gynecol. 80 (4) (1992
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