Sudden death due to right fallopian tube tear in ectopic pregnancy: an autopsy-based case report

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Introduction

Sudden death is characterized by an unexpected and often unwitnessed fatal event caused by natural factors and occurs within a few hours of symptom onset in an apparently healthy individual. Many of these deaths occur during sleep or at an unknown time. Notably, a consensus on the exact duration between symptom onset and death for an unexpected fatal event to be considered sudden remains to be established. According to the World Health Organization, sudden death is the occurrence of death within 24 hours of the onset of symptoms. Various studies have classified the causes of sudden death into two primary categories: sudden cardiac death and sudden noncardiac death [1, 2].

In a study of autopsy results from 534 bodies in Paris conducted between 1985 and 2009, the leading cause of deaths was cardiovascular disease, accounting for 66.1% of cases. Noncardiac diseases, including respiratory conditions, and neurological disorders accounted for 12.2% of cases each. Abdominal causes were responsible for 3.2% of cases, whereas no specific cause of death was found in 4.3% of cases. Specifically, abdominal causes were responsible for 17 death cases: 7 instances of gastrointestinal bleeding, 2 cases of acute pancreatitis, 2 cases of peritonitis, 2 cases of ischemic colitis, and 4 cases related to obstetric causes (2 ruptured ectopic pregnancies, 1 ruptured uterus, and 1 postpartum hemorrhage) [3]. Although ectopic pregnancies resulting in sudden death are rare, this finding highlights the potential for abdominal organ diseases, including ectopic pregnancy complications, to lead to sudden and life-threatening situations.

Sudden deaths should be treated as unnatural until proven otherwise. Examining sudden death cases is crucial for determining potential criminal involvement, processing life insurance claims, and establishing the cause of death (e.g., disease, violence, and poisoning) and for disease epidemiology purposes. One of the scientific methods involves conducting an external examination followed by an internal examination, also called an autopsy.

Description of the case

Circumstances of incident

A 26-year-old unmarried woman who was unemployed and lived alone in S., East Java, Indonesia, complained of feeling unwell and weak to witnesses at approximately 1:00 PM on November 19, 2023. She was visited by her boyfriend at around 2:00 PM. Later, at approximately 9:00 PM, the woman was found dead in her room by witnesses and local residents. No unusual circumstances were observed at the scene of the incident. The police sought the assistance of the forensic medicine department of Hospital N to conduct an autopsy on the discovered body. Comprehensive external and internal examination of the body commenced at 1:48 AM on November 20, 2023.

External examination

External examination determined that the individual had normal skin color, weighed 55 kg, and had a body length of 163 cm. Livor mortis was noted on the back of the neck, shoulders, and waist, which was purplish red in color and disappeared upon pressure. Rigor mortis was observed in the jaw, neck, and extremities, making it difficult to move. The conjunctiva of the upper and lower eyelids appeared pale. The abdomen was bloated, with a tympanic sound in the middle upon percussion and dullness on the right and left sides, and felt elastic upon palpation. The fingertips and nails were pale. A cloudy white fluid was found in the vulva area, indicating no signs of violence. No abnormalities or signs of violence were detected in the other areas of the body.

Autopsy findings

Internal examination showed 1,280 ml of blood fluid in the abdominal cavity, along with a 700 gram blood clot (Fig. 1).

Fig. 1. Bleeding in the abdominal cavity.

In the pelvic cavity (Fig. 2), the uterus was enlarged and rounded, measuring 7×7×6 cm, and was flat, firm, and rubbery to the touch. The outer wall was pale reddish, and the uterus wall was 2 cm thick. On the slices, the lining of the uterus cavity appeared to be thickened and was blackish red. Examination revealed a tear in the right fallopian tube. The right ovary measured 3.5×2.8×2.5 cm, weighed 8 grams, and was palpable and elastic. On the slice, dark red tissue surrounded by yellow tissue was observed. The cervix, with the surface of the outer wall appearing pale reddish. Vaginal examination showed no abnormalities or signs of violence, with a pore length of +10 cm. The urinary bladder was empty.

Fig. 2. Enlarged uterus measuring 7×7×6 cm (a, black arrow). A tear is noted in the right fallopian tube (white arrow); b — the uterine cavity to the vagina is opened. The uterine wall is 2 cm thick, and the mucosa of the uterine cavity is thickened and blackish red.

Laboratory test results

Clinical examination presented the following: quantitative β-hCG, 5224.07 mIU/mL; hemoglobin, 12 g/dL; and hematocrit, 46%. The microbiology laboratory found no sperm in the vagina. Moreover, the toxicology laboratory found no harmful foreign substances such as cyanide, insecticide/pesticide, alcohol, narcotics, and psychotropics. Furthermore, the histopathology laboratory (Fig. 3) identified decidua tissue in the uterus and detected a large corpus luteum in the right ovary and chorionic villi in the tissue of the right fallopian tube, indicating a tubal ectopic pregnancy. Additionally, pulmonary edema with dilated blood vessels, renal necrosis with dilated blood vessels, and gastric necrosis with infiltration of lymphocytes and neutrophils in the lamina propria were noted (Fig. 4).

Fig. 3. Photomicrography findings indicating tubal ectopic pregnancy: a — decidua tissue in the uterus (200×), b — extensive corpus luteum in the right ovary (100×), c — chorionic villi in the right fallopian tube (100×).

Fig. 4. Photomicrography findings indicating the occurrence of multipleorgan failure: a — pulmonary edema with dilated blood vessel congestion (100×), b — renal necrosis with dilated blood vessels (100×), c — gastric necrosis accompanied by infiltration of lymphocytes and neutrophils in the lamina propria (100×).

Final diagnosis

In the present case, the cause of death was natural, resulting from a ruptured right fallopian tube due to an ectopic pregnancy. The mechanism of death involved various processes, including tearing of the right fallopian tube, leading to bleeding in the abdominal cavity, hemorrhagic shock, organ failure, and ultimately death.

Discussion

Ectopic pregnancy is a serious pregnancy complication that can lead to high morbidity and mortality if not promptly identified and treated. It occurs when fetal tissue implants and develops outside the uterus. Anything that hinders the fertilized egg’s journey to the uterus can result in an ectopic pregnancy [4–6].

The incidence rate of ectopic pregnancies in the United States and Europe is 1%–2%, and the rate of ectopic pregnancies among all pregnancy-related deaths is 9%–13%. Furthermore, in developing countries, the rate of deaths caused by ectopic pregnancy is 10 times higher than that in developed countries [7]. Ninety-five percent of ectopic pregnancies occur in the ampulla, infundibular, and isthmic segments of the fallopian tubes [4, 8]. Less than 5% of ectopic pregnancies occur in the interstitial segment of the fallopian tubes, cervix, anterior segment of the lower uterus in cesarean scars, ovaries, and abdominal cavity (abdominal pregnancy) [4, 9].

The most common ectopic pregnancy complication is pregnancy rupture, which occurs in 15%–20% of ectopic pregnancies. It can result in life-threatening bleeding and often requires immediate surgery, which is possible with early diagnosis [5, 9, 10].

The present case is an example of an ectopic pregnancy complication that resulted in death. Despite the limited antemortem information, the victim was found dead at the crime scene after being seen alive by eyewitnesses within the last 7 hours. Information on the history of illness was extremely limited, and clinical information on the classic symptoms of ectopic pregnancy was lacking. The classic clinical symptoms of ectopic pregnancy include abdominal pain, amenorrhea, and vaginal bleeding [11]. In addition, there was no information that the victim was pregnant.

The findings of the external examination indicated no signs of violence. However, pallor was observed on the conjunctiva of both eyelids, as well as on the fingertips and nails, which are common indicators of anemia. Additionally, the victim’s enlarged abdomen demonstrated possible internal pressure within the abdominal cavity.

Following internal examination, the two groups of disorders were found to be interconnected. The examination results showed a relationship between the findings, elucidating the biomechanics, disease processes, and injuries affecting the victim’s body.

Initial observation indicated that the uterus was unusually large. The normal size of a uterus in a woman who has not given birth is approximately 7.8–8.1×3.4–4.5×1.8–2.7 cm [12]. Description of the uterus found, coupled with the blood β-hCG quantitative reaches 5224.07 mIU/mL, it can be caused by a pregnancy process. An absolute hCG ratio >1,500 IU/L without visualized intrauterine pregnancy may indicate ectopic pregnancy [13].

The second finding was a tear in the right fallopian tube, which was associated with the first finding. This was confirmed by histopathological examination of the uterus, right ovary, and right fallopian tube, which revealed decidua tissue in the uterus, extensive corpus luteum in the right ovary, and chorionic villi in the tissue of the right fallopian tube, indicating a tubal ectopic pregnancy.

The cause of tubal ectopic pregnancy can be attributed to changes in tubal motility, which can be affected by habits such as smoking or the use of hormonal contraceptives. Additionally, a history of changing sexual partners and the resulting infections can cause fallopian tube damage. Furthermore, patients with a history of infertility or a previous tubal ectopic pregnancy are at higher risk [6, 8, 14].

The third finding was abdominal bleeding. Postmortem findings demonstrated that the bleeding was caused by a tear in the right fallopian tube, with no other source of bleeding discovered. As a result of the bleeding, the abdomen appeared enlarged on external examination. This was later confirmed by observations at the first breach of the abdominal wall, when the intestines, particularly the large intestine, were spontaneously pushed out and a pool of blood formed on the sides.

The fourth finding was absence of urine in the urinary bladder, which was believed to be a result of decreased fluid during hemorrhagic shock. This was confirmed by hematology examination, showing a hemoglobin level of 1.2 g/dL and a hematocrit level of 4.6%. These values indicate significant blood loss.

When approximately 10% of blood is lost, the body tries to compensate. However, if the volume of blood drops further, especially by 25%–30%, the individual goes into shock. Then, the body is unable to supply enough oxygen to the vital organs. The cells begin using a different way to produce energy, which leads to lactic acid buildup. As the body attempts to adjust, it shifts blood from other organs to the heart and brain. This causes these organs to receive less blood, which can lead to worsening of lactic acid buildup. If not treated, this can lead to various problems with the heart, blood acid levels, and how well the body can work. This can then lead to multiple-organ failure and, ultimately, death [15].

The assessment of shock in the victim’s body was based on the abdominal cavity exploration, which revealed 1,280 ml of blood fluid and 700 grams of blood clots. The density of blood clots is +1.05 g/ml; hence, 700 grams of blood clots is equivalent to 666.7 ml of blood fluid (gram to milliliter conversion formula; ml=grams/density of object). Thus, the total blood volume of the corpse was 1946.7 ml. The estimated blood volume of the victim while still alive can be calculated using the formula 95 ml/kg×55 kg body weight, which equals 5,225 ml (estimated blood volume based on Body Mass Index category). The victim’s blood loss of 1946.7 ml falls into the moderate blood loss category or class III (31%–40% of body weight), which is not far from the class IV category (>40% of body weight), which is immediately life-threatening at 2,090 ml [16, 17].

As discussed previously, improper management of hemorrhagic shock can lead to multiple-organ failure and death. This is supported by histopathological examination of the victim’s organ tissue samples, which revealed edema in the lungs and renal and gastric necrosis. These findings are indicative of organ failure.

Evaluating the external genitalia of female corpses, especially those who die suddenly at a young age, is crucial in cases wherein pregnancy outside marriage is suspected. This examination is beneficial in gathering evidence to assist investigators in understanding the situation. In the present case, microbiology and toxicology tests were conducted. However, the tests yielded negative results.

Conclusion

Therefore, the victim’s sudden death was due to natural causes. Natural deaths refer to deaths not caused by murder, accident, or suicide. In the current case, the cause of death was a ruptured right fallopian tube in an ectopic pregnancy, which led to internal bleeding in the abdominal cavity, hemorrhagic shock, and organ failure.

Additional information

Funding source. This article was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. Syahroni S. Syahroni: conception of the work, writing the manuscript, revising it critically for important intellectual content; W.S. Ongko: conception of the work, writing and editing the manuscript; A. Yudianto writing the manuscript, revising it critically for important intellectual content.

Consent for publication. Written consent was obtained from the patient’s legal representatives for publication of relevant medical information and all of accompanying images within the manuscript in Russian Journal of Forensic Medicine.

About the authors

Syahroni S. Syahroni

Author for correspondence.
Email: syahronibinmukin19@gmail.com
ORCID iD: 0000-0003-3058-146X

MD

Wira Santoso Ongko

Email: wiraongko@gmail.com
ORCID iD: 0009-0006-1914-3986

MD

Ahmad Yudianto

Email: yudi4n6sby@yahoo.co.id
ORCID iD: 0000-0003-4754-768X

MD, Dr. (Medicine), Professor

References

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2. Fig. 1. Bleeding in the abdominal cavity.

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3. Fig. 2. Enlarged uterus measuring 7×7×6 cm (a, black arrow). A tear is noted in the right fallopian tube (white arrow); b — the uterine cavity to the vagina is opened. The uterine wall is 2 cm thick, and the mucosa of the uterine cavity is thickened and blackish red.

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4. Fig. 3. Photomicrography findings indicating tubal ectopic pregnancy: a — decidua tissue in the uterus (200×), b — extensive corpus luteum in the right ovary (100×), c — chorionic villi in the right fallopian tube (100×).

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5. Fig. 4. Photomicrography findings indicating the occurrence of multipleorgan failure: a — pulmonary edema with dilated blood vessel congestion (100×), b — renal necrosis with dilated blood vessels (100×), c — gastric necrosis accompanied by infiltration of lymphocytes and neutrophils in the lamina propria (100×).

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