Under The Microscope: I Won’t Carry It On

 

 

Though nor usually a forensic problem, deaths associated  with pregnancy (other than criminal abortions) are intensively investigated in a-number of countries. In Britain, the Department of Health has had an ongoing 'Confidential Enquiry into Maternal Deaths' running for many years, which publishes valuable reports at 3-yearly intervals that have helped to clarify both the clinical and pathological aspects of the problem. 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 20 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 anaesthetic 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.

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 anaesthesia;

-          disseminated intravascular coagulation and cerebral damage (including 'butterfly' haernorrhagic 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.

This has a much wider range of causes. The risks vary according to the skill, experience and facilities of the abortionist. When this is carried out by a doctor with aseptic and antiseptic methods, together with antibiotic cover if needed, the risk may be small compared with the crude methods of a lay person using makeshift instruments. The most common methods together with the associated dangers to health and life are as follows.

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 favourite 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  object into the undilated canal. If successfully passed into the cavity of the uterus, it may be pushed right up through the fundus, again to darn- age the contents of the peritoneal cavity. The dangers of such 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 unanaesthetised 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.

A rubber pump, usually a Higginson enema syringe, is used to introduce fluid under pressure into the cavity of the uterus. This strips the chorionic sac from the wall of the uterus, exposing the placental bed. If sufficient detachment is achieved, then abortion will occur. It was formerly a popular method of abortion, both by women themselves and by abortionists. The main danger - part from the usual risks of bleeding and infection from damage to the tissues by the stiff nozzle - was air embolism, and in the first half of this century it was a major cause of abortion deaths. The intention was to introduce a fluid such as water-soap solution or disinfectant through the cervix by means of the syringe nozzle, the other end, which carried a one-way valve, being dipped in a receptacle of the fluid. As the level in the receptacle dropped, the inlet tube rose above the surface and the syringe began to inject air instead of fluid, often as soapy foam.

Another crude method was to introduce a 'tent' into the cervical canal. This was a strip of substance that absorbed water and became greatly enlarged, such as Laminaria digitale or slippery elm (Ulmusfilva Michx). These vegetable materials are hard and compact when dehydrated, so that a strip about 3-8 cm long could be slid into the cervix. When water was absorbed from the surrounding tissues, the cervical canal became widely dilated and abortion might take place. The risks were perforation of the cervix and also infection, especially if the strip tore into the tissues. The substances used, often crude vegetable material, could be the source of infecting microorganisms including anaerobes.

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.

The suction method most often used in therapeutic abortion has also come to be used for illegal operations, mainly by medical or nursing personnel. A large syringe attached to a catheter or length of plastic tubing can produce suction within the uterus sufficient to rupture the chorionic sac and precipitate abortion. The method is safe as long as aseptic methods are used, though, if evacuation is incomplete, some products of conception may be left behind that can form a nidus for infection.

Whatever method is used to evacuate the uterus, the risk of haemorrhage or sepsis is always present. Where an instrument, tent or syringe is used, any remaining fragments of placenta or other products of conception may form a substrate for infection. The organisms involved in sepsis are varied, the most dangerous being non-haemolytic streptococci and Clostridium perfringens, though coliforms and staphylococci may also be responsible. The uterus becomes swollen, spongy and discoloured. The serosal surface seen at autopsy may be brownish - especially in clostridial infections - and the endometrium may be ragged, foul-smelling and even purulent. Signs of septicaemia may develop with an enlarged, soft spleen, prominent lymph nodes and hepatorenal failure. The kidneys may show bilateral cortical necrosis in extreme cases. In clostridial septicaemias there may be a characteristic bronze coloration of the skin. This may have a mottled or 'rain- drop' appearance.

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 pseudomembrane may form in the vagina and severe damage to the cervix may also ensue.

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, cot- ton 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 uterus 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.

Acknowledgements:

www.aived.nl    AIVD – @Erik Akerboom ©

www.politie.nl  Politiekorpschef  @Janny Knol©

www.politie.nl WEB Politie - @Henk van Essen©

 

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