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Though nor usually a forensic problem, deaths associated with pregnancy (other than criminal abortions) are intensively investigated in a-number of countries. The pathologist has an important role in furthering the understanding of the causes of death in pregnancy and after childbirth. A good autopsy is essential, with full histological examination and other ancillary investigations where necessary. Only in this way can the full range of causes of death be recognized, especially amniotic fluid embolism, which is a histological diagnosis.

 

According to a recent estimation, about 26 million legal and 55 million illegal abortions are carried out yearly throughout the world. Forensic pathological interest in pregnancy revolves almost exclusively around deaths associated with abortion, either criminal or legally induced. The term 'therapeutic abortion' is used in many countries, including Britain, where there is no abortion on demand, as in some countries. The description 'legal termination of pregnancy' is a wider definition for all but illegal (that is, criminal) abortions. The autopsy investigation of deaths from legal abortions has much in common with that into fatalities associated with surgical and anesthetic procedures.

 

Though in many countries medical termination of pregnancy ('therapeutic abortion') is legal, a large area of the world still prohibits any form of abortion, either totally or except for the preservation of life of the pregnant woman. Even in those states where legal termination is ~possible, criminal abortions are still carried out, albeit on a small scale.

 

The reasons for this survival are varied, but are either because of restrictive grounds for legally available termination or to some sections of society that do not wish to avail themselves of the legal provisions. Whatever the cause, criminal abortion is associated with a considerable risk of both morbidity and mortality, especially in countries with a lower level of medical and social care. When carried out with proper facilities, legal abortion has an extremely low mortality rate, being less than the mean death rate associated with pregnancy. The usual methods are vacuum aspiration, dilatation and curettage, or hysterotomy in later pregnancy. A few deaths are reported from time to time, the causes including:

 

·       pulmonary embolism from leg vein thrombosis

·       mishaps associated with anesthesia

·       disseminated intravascular coagulation and cerebral damage (including 'butterfly' hemorrhagic infarction in the basal ganglia) when abortion was induced by intrachorionic injection of hypertonic saline or glucose after the twelfth week

·       air embolism following vacuum aspiration - only two cases have been reported and the mechanism is obscure, one theory being that 'elastic rebound' of the aspirated uterus sucked air into the cavity

·       bleeding or infection, which failed to respond to treatment

 

The intention is to disturb the pregnancy sac so that, once damaged, it will be expelled by uterine contractions. This usually consists of dilatation of the cervical canal, which in itself also tends to dislodge the pregnancy. All manner of instruments have been used, from surgical dilators to bicycle spokes. A favorite in the hands of paramedical abortionists is the bougie or stiff catheter. When used by doctors or nurses with anatomical knowledge and sterile instruments, the risk is small, but lay persons often have no idea of the relationship of uterus to vagina. The instrument is then often pushed into the posterior fornix in the misguided belief that the cervix lies axially with the vagina. The vault of the vagina can be perforated and the instrument may even be passed through coils of intestine as far as the liver. Penetration of the lower or mid-vagina can also occur. If the cervix is entered, then the canal may be punctured and the instrument emerges through the side. The external os may be badly injured by repeated, clumsy attempts to introduce too thick an object into the undiluted canal. If successfully passed into the cavity of the uterus, it may be pushed right up through the fundus, again to damage the contents of the peritoneal cavity.

 

The dangers of which instrumentation are bleeding and infection. Perforation of the wall of vagina or uterus may cause severe bleeding, which may be internal or external. Sepsis can supervene in the peritoneal cavity or pelvic tissues either directly from a dirty instrument or from transfer of vaginal, skin or bowel organisms. Another less common danger of the use of instruments (including syringes) is cervical shock. The mere act of dilating the cervix with an instrument in an unanesthetized patient may trigger a vagal reflex, the efferent pathway being via the parasympathetic nervous system, causing a cardiac arrest. This is known to be a more potent mechanism in states of fear, apprehension and nervous tension, which obviously will apply to many candidates for a criminal abortion.

 

Women anxious to lose their pregnancy have resorted to extremes of physical activity and even violence in efforts to dislodge the fetus. Frenzied exercise, horse-riding and severe purging with laxatives were usually ineffective, and some unfortunate women went on to seek violent treatment from husbands or consorts. Punching and kicking of the abdomen were most common, and death from visceral rupture, such as liver, spleen or intestine, has been reported. Ironically, the uterine contents were usually undisturbed. A wide variety of substances, applied locally or taken by mouth, have been used since time immemorial to induce miscarriage. Some have a sound pharmacological basis, others are dangerous, and yet more lie in the realms of folk medicine. Substances applied locally include phenols and Lysol, mercuric chloride, potassium permanganate, arsenic formaldehyde and oxalic acid. All have their own dangers, both from local corrosion and systemic effects if absorbed. A necrotic pseudo membrane may form in the vagina and severe damage to the cervix may also ensue.

 

Potassium permanganate was a substance that appeared during the last war and persisted for some years, though only a few were fatal. It can cause local necrosis in the vagina and, if absorbed, can have fatal systemic effects including renal failure. Permanganate can cause profuse vaginal bleeding from necrosis, which may give the impression that abortion is threatened and lead an unsuspecting doctor to carry out a curettage. 'Utus paste' is a mixture of soap, myrrh resinoid and potassium iodide, and was used earlier in the century for legitimate abortions, but soon became popular with the criminal abortionist. Another similar product containing elemental iodine, is 'Interruption'; both were used for late abortions and the induction of labor when the fetus was dead. These pastes are squeezed into the cervical canal through an applicator and the halogen component acts as an irritant which causes eventual expulsion of the chorionic sac.

 

Substances taken by mouth or injection are legion. The old classification into 'ecbolics' and 'emmenagogues' is now quite redundant and most of the lists of substances are of historical interest only, as their efficacy is either nil or the dose needed to produce abortion is perilously near the fatal level. These include pennyroyal, tansy, rue, savin, laburnum, colocynth, aloes, castor oil, nutmeg, hellebore, cantharides, cotton root, wintergreen and turpentine. Many of these may cause purging, gastrointestinal irritation and general illness if taken in quantity, but have no specific action whatsoever on the uterus. There are other substances that have more chance of causing uterine contractions, though many of them are effective only on a late pregnancy, not at the usual time of 1-3 months when most abortions are sought. Quinine can be dangerous, as the dosage required for any effect on the utcrus is likely to cause cinchonism. Ergornetrine has been known from ancient times to lead to abortion, though like most drugs its effectiveness is greater later in pregnancy. Excess dosage may cause peripheral vascular spasm and gangrene. Its availability to doctors and mid-wives is similar to pituitary extract, oestrogens, and - more recently - prostaglandins. Heavy metals, particularly lead, were used for abortion in the past. Plasters coated with a lead compound 'diachylon' were scraped to recover the metallic substances and ingested. Though abortion sometimes occurred, illness and death from acute and subacute lead poisoning was more common; this method has also become of historical interest only.

 

Some deaths associated with childbirth or pregnancy are caused by the entry of amniotic fluid into the maternal circulation. The fluid contains fetal squames, lanugo, lipoid from the vernix, meconium, cells from chorion and amnion, and other cellular detritus. The solid elements are usually impacted in the lung capillaries, but rarely have been found in the systemic circulation, including embolization into the kidney, liver and brain. In addition to the solids, the actual fluid itself (which is naturally undetectable histologically) is blamed for the 'allergic' response that may cause such profound collapse, leading to death. Amniotic fluid embolism is also one of the most potent causes of disseminated intravascular coagulopathy.

 

 

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