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

Abstract

Background: Ectopic pregnancy complications, particularly when they cause rupture, can lead to a sudden and critical situation. In cases of sudden death, it is important to approach it as an unnatural death until proven otherwise through scientific means. Autopsy, conducted by a forensic and medicolegal pathologist, is a key method for establishing the cause of death.

Case presentation: We have reported a suspected case of unnatural death being investigated by the police. A young, unmarried woman living alone was found dead in her room, with no clear medical history. The forensic autopsy was performed to establish the cause of death in this case. The findings revealed an enlarged uterus, a tear in the right fallopian tube, and a blood β-hCG level of 5,224.07 mIU/mL. Supported by histopathological findings in the form of an overview that supports the existence of tubal ectopic pregnancy. There is severe internal bleeding in the abdominal cavity due to a tear in the right fallopian tube, leading to hemorrhagic shock because of a loss of 1,946.7 ml of blood. As a result, the patient experiences Multiple Organ Failure (MOF), indicated by lung edema and kidney and stomach necrosis observed in the histopathological examination.

Conclusions: The victim's sudden death was a result of a natural cause. The cause of death is determined after eliminating other possibilities.

Full Text

Title

AUTHORS

Syahroni¹, Wira Santoso Ongko², Ahmad Yudianto³

Affiliations

¹Department of Forensic Medicine and Medicolegal, Faculty of Medicine, Airlangga University, Surabaya, Indonesia.

²Department of Forensic Medicine and Medicolegal, Faculty of Medicine, Airlangga University, Surabaya, Indonesia.

³Department of Forensic Medicine and Medicolegal, Faculty of Medicine, Airlangga University, Surabaya, Indonesia.

 

Keywords: Autopsy; Cause of Death; Fallopian Tubes; Forensic Pathology; Pregnancy, Ectopic

To cite this article

Syahroni, Ongko WS, Yudianto A. Sudden death due to right fallopian tube tear in ectopic pregnancy: An autopsy-based case report. Russian Journal of Forensic Medicine. 202X;X(X):XX–XX. doi: https://doi.org/10.17816/fmXXX

Received: XX.XX.20XX

Accepted: XX.XX.20XX

Published: XX.XX.20XX

 

background

The occurrence of sudden death is characterized by a fatal event that is unexpected and often unwitnessed, caused by natural factors within a few hours of the onset of symptoms in an apparently healthy individual. Many of these deaths occur during sleep or at an unknown time. It's important to note that there is no consensus on the exact duration between the onset of symptoms and death for an unexpected fatal event to be considered sudden. Sudden death, as defined by the WHO, refers to 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 Non-Cardiac Death. ^1,2

According to a study of autopsy results from 534 bodies in Paris and conducted between 1985 and 2009, the leading cause of death was cardiovascular diseases, accounting for 66.1% of cases. Non-cardiac diseases, including respiratory diseases, accounted for 12.2% of cases, while neurological diseases accounted for another 12.2%. Abdominal causes were responsible for 3.2% of cases, and in 4.3% of cases, no specific cause of death was found. Specifically, abdominal causes were responsible for death in 17 cases (3.2%). These cases included 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 While ectopic pregnancies resulting in sudden death are rare based on research, this finding highlights the potential for abdominal organ diseases, including complications from ectopic pregnancy, to lead to sudden and life-threatening situations.

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

description of the case

A 26-year-old unmarried woman who was not employed and lived alone in Surabaya, East Java, Indonesia, complained of feeling unwell and weak to witnesses at approximately 01:00 PM on Sunday, November 19, 2023. She was visited by her boyfriend at around 02:00 PM. Later, at approximately 09:00 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 have sought the assistance of the forensic medicine department at Dr. Soetomo Hospital Surabaya to conduct an autopsy on the discovered body. The comprehensive external and internal examination of the body commenced at 01:48 AM on Monday, November 20, 2023.

From the external examination, it was found that the individual had normal skin color, weighed 55 kg, and had a body length of 163 cm. There was livor mortis 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 both the upper and lower eyelids appeared pale. The abdomen appeared bloated, with a tympanic sound in the middle upon percussion and dullness on the right and left sides. It felt elastic upon palpation. The fingertips and nails appeared pale. A cloudy white fluid was found in the vulva area, showing no signs of violence. No abnormalities or signs of violence were found in other areas of the body.

From the internal examination, in the abdominal cavity, 1,280 ml of blood fluid was found, along with a 700-gram blood clot (Figure 1).

In the pelvic cavity (Figure 2), the uterus is enlarged and rounded, measuring 7 x 7 x 6 cm. It feels flat, firm, and rubbery to the touch. The outer wall appears pale reddish, and the uterus wall is 2 cm thick. On the slices, the lining of the uterus cavity seems to be thickened and is a blackish-red color. An examination revealed a tear in the right fallopian tube. The right ovary measures 3.5 x 2.8 x 2.5 cm, weighs 8 grams, and is 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 revealed no abnormalities or signs of violence, with a pore length of +10 cm. The urinary bladder is empty and does not contain urine.

In the clinical examination: quantitative β-hCG: 5,224.07 mIU/mL, hemoglobin: 12 g/dL, hematocrit: 46%. The Microbiology Laboratory found no sperm in the vagina. The Toxicology Laboratory found no harmful foreign substances such as cyanide, insecticide/pesticide, alcohol, narcotics, and psychotropics. In the Histopathology Laboratory (Figure 3), a diagram of decidua tissue in the uterus was identified, the right ovary has a large corpus luteum, and chorionic villi are present in the tissue of the right fallopian tube, indicating a possible tubal ectopic pregnancy. Additionally (Figure 4), there is pulmonary edema with dilated blood vessels, the kidneys show necrosis with dilated blood vessels, and the stomach has necrosis with an infiltration of lymphocytes and neutrophils in the lamina propria.

The final diagnosis. The cause of death in this case was natural, resulting from the tearing of the right fallopian tube due to an ectopic pregnancy. The mechanism of death involves a series of 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 identified and treated promptly. It happens when fetal tissue implants and grows outside the uterus. Essentially, 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 among all pregnancies in the U.S. and Europe is 1-2%, with the rate of ectopic pregnancies among all pregnancy-related deaths being 9-13%. It's also significant to consider that in developing countries, the death rate due to ectopic pregnancy is 10 times higher than 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 even the abdominal cavity (abdominal pregnancy). ^4,9

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

The case mentioned above is a clear example of a complication from an ectopic pregnancy 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. There is very limited history of illness and no clinical information on the classic symptoms of ectopic pregnancy in this case. The classic clinical symptoms of ectopic pregnancy include abdominal pain, amenorrhea, and vaginal bleeding. ¹¹ There was no information that the victim was also pregnant.

According to the findings of the external examination, no signs of violence were detected. However, pallor was observed on the conjunctiva of both eyelids, as well as on the fingertips and nails of the extremities, which are common indicators of anemia. Additionally, the victim's enlarged abdomen suggests possible internal pressure within the abdominal cavity.

Upon completing an internal examination, we have confirmed that the two groups of disorders are interconnected. The examination results have unveiled a relationship between the findings, shedding light on the biomechanics, disease processes, or injuries affecting the victim's body.

The initial observation indicated that the uterus was larger than usual. Normally, the size of a uterus in a woman who has not given birth is about 7.8-8.1 x 3.4-4.5 x 1.8-2.7 cm. ¹² Description of the uterus found, coupled with the blood β-hCG Quantitative reaches 5,224.07 mIU/mL, it can be caused by a pregnancy process. An absolute hCG ratio above 1500 IU/L without visualized intrauterine pregnancy may indicate possible ectopic pregnancy. ¹³

The second finding was a tear in the right fallopian tube, which is connected to the first finding. This was confirmed by the results of the histopathological examination of the uterus, right ovary, and right fallopian tube, which showed 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 initially 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 damage to the fallopian tubes. Furthermore, patients with a history of infertility or a previous tubal ectopic pregnancy are also at higher risk. ^6,8,14

The third finding is bleeding in the abdominal cavity. According to postmortem findings, this bleeding was caused by a tear in the right fallopian tube, with no other source of bleeding discovered. As a result of the bleeding, giving the abdomen an enlarged appearance on external examination. This was later reinforced by the 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 indicated an absence of urine in the urinary bladder, which was thought to be a result of decreased fluid in a process of hemorrhagic shock. This was confirmed by the results of the hematology examination, showing a hemoglobin level of 1.2 g/dL and a hematocrit level of 4.6%. These values indicate a significant loss of blood.

When about 10% of blood is lost, the body tries to compensate, but if the volume of blood drops even more, especially by 25 to 30%, the person goes into shock. Then, the body can't supply enough oxygen to the vital organs. The cells start using a different way to make energy, which leads to lactic acid build-up. As the body tries to adjust, it shifts blood from other organs to the heart and brain. This makes those organs get less blood and can lead to lactic acid build-up getting worse. If this isn't treated, it can lead to a lot of problems with the heart, blood acid levels, and how well the body can work. This can then lead to the failure of multiple organs and, in the end, death. ¹⁵

The assessment of shock in the victim's body is based on the findings from the abdominal cavity exploration, which revealed 1,280 ml of blood fluid and 700 grams of blood clots. The density of the blood clots is +1.05 g/ml, so 700 grams of blood clots is equivalent to 666.7 ml of blood fluid (gram to milliliter conversion formula; ml = grams/density of object). This puts the total blood volume of the corpse at 1,946.7 ml. The estimated blood volume of the victim while still alive can be calculated using the formula 95 ml/kg x 55 kg body weight, which equals 5,225 ml (estimate of blood volume based on BMI category). The victim's blood loss of 1,946.7 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 (more than 40% of body weight), that is immediately life-threatening at 2,090 ml. ^16,17

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

Investigating the external genitalia of female corpses, especially those who die suddenly at a young age, is important in cases where pregnancy is suspected without a valid marriage bond. This examination helps gather evidence to assist investigators in understanding the situation. In this specific case, microbiology and toxicology tests were conducted, but they yielded negative results.

 

Conclusion

Based on the information provided, it can be concluded that the victim's sudden death was due to natural causes. Natural death is when death is not caused by murder, accident, or suicide. In this case, the cause of death was a ruptured right fallopian tube in an ectopic pregnancy, leading to internal bleeding in the abdominal cavity, hemorrhagic shock, and organ failure.

 

additional information

Funding: "No funding."

Conflict of interest: "The authors declare no obvious and potential conflicts of interest related to the content of this article."

Contribution of authors:

“Syahroni - substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, and drafting the work or revising it critically for important intellectual content;

Wira Santoso Ongko - substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work;

Ahmad Yudianto - drafting the work or revising it critically for important intellectual content."

"All of the authors read and approved the final version of the manuscript before publication, agreed to be responsible for all aspects of the work, implying proper examination and resolution of issues relating to the accuracy or integrity of any part of the work".

The patient's informed consent: “Written informed consent was obtained from the deceased relative to publish this case report and accompanying images.”

Acknowledgment: “The authors would like to thankful to the faculty of medicine, Airlangga University for providing the opportunity to present this case report.”

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Figures

Figure 1. Bleeding is visible in the abdominal cavity.

Figure 2. A) Enlarged uterus with a size of 7 X 7 X 6 cm (black arrow). There is a tear 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 in blackish-red color.

Figure 3. Photomicrography findings indicating tubal ectopic pregnancy: A - decidua tissue in the uterus (200x); B - extensive corpus luteum on the right ovary (100x); C - chorionic villi on the right fallopian tube (100x).

Figure 4. Photomicrography findings indicating the occurrence of MOF: A - pulmonary edema with dilated blood vessels congestion (100x); B - the kidneys have necrosis with dilated blood vessels (100x); C - The stomach has necrosis accompanied by infiltration of lymphocytes and neutrophils in the lamina propria (100x).

Information about the authors

*Syahroni, MD;

address: Jl. Mayjen Prof. Dr. Moestopo No.  6 – 8, Surabaya, East Java, Indonesia;

ORCID: https://orcid.org/0000-0003-3058-146X;

Wira Santoso Ongko, MD;

ORCID: https://orcid.org/0009-0006-1914-3986;

Ahmad Yudianto, MD, Sp.FM, Subsp. SBM(K), SH, MKes, Dr. (Medicine), Professor;

ORCID: https://orcid.org/ 0000-0003-4754-768X

* Corresponding author.