Proof of live birth using postmortem multislice computed tomography ...

Forensic Sci Med Pathol (2013) 9:3–12 DOI 10.1007/s12024-012-9361-y

ORIGINAL ARTICLE

Proof of live birth using postmortem multislice computed tomography (pmMSCT) in cases of suspected neonaticide: advantages of diagnostic imaging compared to conventional autopsy Saskia S. Guddat • Rene´ Gapert • Michael Tsokos Lars Oesterhelweg

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Accepted: 13 June 2012 / Published online: 4 July 2012 Ó Springer Science+Business Media, LLC 2012

Abstract Proof of live birth is of major importance in suspected neonaticide cases. Although not without controversy the lung flotation test is the main method used to asses this in different jurisdictions worldwide. The present study examines the usefulness of postmortem multislice computed tomography (pmMSCT) in the detection of live birth signs. Body scans were conducted on four infants, one was stillborn, another died a day after birth and the other two were classified as neonaticides. The appearance of the lungs, gastrointestinal tract and vascular system of the liver was compared in these cases. Clear differences were discernable between the lungs of the stillborn and the 1 day old infant. The aerated lungs and air in the stomach and duodenum were clearly visible in the latter case while the stillborn infant lacked these signs. The two neonaticide cases demonstrated similarly aerated lung tissue to the 1 day old infant. The hepatic vessels did not show any putrefactive gas changes in any of the cases. The extent of aeration of the peripheral alveoli was easily observable on the pmMSCT, thus making it a useful tool in the possible differentiation between artificially and naturally aerated lungs. During the four autopsies the classic flotation tests were performed and similar positive aeration of the lungs in the two neonaticides was shown. The stillborn’s tests, on the other hand were negative for aeration. The results of this study clearly demonstrate the advantages of using

S. S. Guddat R. Gapert M. Tsokos L. Oesterhelweg Institute of Legal Medicine and Forensic Sciences, Charite´-University Medicine Berlin, Berlin, Germany R. Gapert (&) Human Anatomy Laboratory, UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland e-mail: [email protected]

pmMSCT before commencing a conventional autopsy in cases of suspected neonaticide. Keywords Pulmonary and gastrointestinal aeration Flotation test Virtual autopsy Forensic death investigation Biological imaging

Introduction Differentiating between live birth and stillbirth in a discarded newborn based on gross and microscopic autopsy findings is a challenging task for forensic pathologists. The main test, still in use in most jurisdictions, is the flotation test for lungs and the stomach including duodenum [1–5]. The history of the flotation test for lungs goes back to 1667 when the Dutch scientist Jan Swammerdam demonstrated that the aerated lungs of a neonate, who had breathed at birth, floated in water, while those of neonates that did not visibly draw breath sank [6–11]. The test was later expanded to include the stomach and duodenum to demonstrate air in the upper gastrointestinal (GI) tract, which would be swallowed by the infant during the first respiratory attempts [2–7]. The flotation test is not without controversy as different aspects have to be considered when a positive result is obtained, particularly the severe legal consequences of someone found guilty of neonaticide, in part or in whole, due to this test. In many cases the flotation test has to be excluded as proof of a live birth due to the presence of signs of putrefaction or the fact that cardio-pulmonary resuscitation (CPR) was carried out on the body of the newborn. In cases where putrefactive tissue changes are suspected a liver section flotation test may provide an evaluation of the level of decomposition present within the internal organs [2]. The liver section test as well as a spleen section test has been

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Forensic Sci Med Pathol (2013) 9:3–12

Table 1 Individual body data of four neonates including cause of death Case No.

Sex

CHL (cm)

Weight (g)

Circumferences (cm) Head

Chest

Abdominal

CRL (cm)

COD

PMI

1

#

51

2,950

30

31

27

31

Polytrauma

\24 h

2

#

49

3,260

35

34

31

30

Asphyxiation

\24 h

3

$

49

2,800

32

30

29

30

Unknown

5 days

4

#

48

2,720

31

29

25

30

Intrauterine infection

7 days

CHL crown-heel length, CRL crown-rump length, COD cause of death, PMI postmortem interval

recommended because putrefaction gases may develop in these organs at a similar rate as in lung tissue [2]. Materials and methods The bodies of four (n = 4) neonates were examined within a 6-month period in 2011/2012 at the Institute of Legal Medicine and Forensic Sciences (ILMFS), Charite´—University Medicine Berlin, Germany (Table 1). Each body was scanned using a 16-detector multisclice CT scanner (Toshiba Activion; Toshiba Medical Systems GmbH, Neuss, Germany) and a slice thickness of 0.5 mm with an overlap of 0.3 mm before autopsy commenced. Reconstructions of 2D and 3D volume-rendered images were carried out with the open-source image processing software OsiriX 4.1.1 64 bit [12]. The CT scans were analyzed and the results interpreted by a forensic pathologist who has many years of experience in the use of diagnostic imaging in a forensic setting. During the autopsies the classic lungs and the GI tract flotation tests were performed, with the modification of leaving the heart and lung bloc intact as suggested by previous authors [2, 13]. The test was considered positive if the lungs carried the weight of the heart and mediastinum when placed in water. A liver section flotation test was also conducted in each case. This test entailed the removal of a liver section, weighing approximately 25 g, predominantly from the right lobe of the organ. Police investigative reports described two of the cases as neonaticides, one case as an unknown cause of death after 1 day of life, and one as a stillbirth. The death of the stillborn child was confirmed in utero before delivery took place. The last two cases acted as control examples for the depiction of (a) the lack of live birth signs and (b) definitive signs of live birth during pmMSCT examination. The two neonaticide cases were compared against the two control samples.

backyard. The police and an emergency doctor were called to the scene but could only diagnose the death of the child. The garbage bag, including its contents, was sent to the ILMFS for evidence collection and conduction of an autopsy on the body of the infant. The bag was scanned in its entirety using pmMSCT before evidence collection and autopsy took place. The body of the infant was rescanned after its removal from the bag and before the autopsy commenced. pmMSCT results: The scans demonstrated the presence of a full-term neonate inside the bag. Aeration of both lungs reaching into the peripheral alveoli was clearly discernible (Fig. 1). A few gaseous extensions in the stomach

Case reports Case 1: Neonaticide Background: In late autumn 2011, the unidentified body of a male neonate was discovered in a blue garbage bag in a

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Fig. 1 Case 1—neonaticide: 3D CT reconstruction with visualization of aerated regions in light blue coloration. Air is visible inside the intracranial cavity due to open traumatic brain injury. The lungs exhibit homogenous aeration. A few air bubbles are also visible in the upper gastrointestinal tract. The large light blue object below the right arm is a towel exhibiting air trapped between the textile fibers


and duodenum were also visible but no signs of putrefactive tissue changes were found inside the hepatic vascular system. Air was also present inside the cranium, the spinal canal and the heart. Multiple traumata were detectable, notably severe open head and brain trauma, seriated rib fractures, a right hemopneumonthorax, fractured pelvis and cardiac air embolism. Air visible inside the heart is a vital reaction and in this case proof that the heart was beating before the infant died (Fig. 2). Autopsy results: The garbage bag was opened and the the body of a full-term newborn male with complete umbilical cord and no external signs of putrefactive changes was recovered. During the autopsy multiple traumata

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were recorded including the head and brain trauma, rib fractures, injuries to the right lung, injuries to the liver and a fractured pelvis. The flotation test of the heart and lung bloc was carried out and found to be positive (i.e. the lungs carried the weight of the heart). The flotation test of the gastrointestinal tract was also positive (i.e. the stomach and duodenum floated on the surface while the rest of the intestines sank to the bottom). The last test to be carried out was the liver section test which proved to be negative (the section sank to the bottom thereby excluding the presence of putrefaction gases). The cause of death was diagnosed as multiple traumata due to a fall from a height. Police investigation confirmed that the mother had thrown the newborn from the 5th floor of the house they were living in. Case 2: Neonaticide

Fig. 2 Case 1—neonaticide: 2D Coronal CT image of the child demonstrating visible gas content inside the heart (red arrows) as well as the lungs and upper gastrointestinal tract (blue arrows)

Background: In late autumn 2011, a midwife reported to the police that a full-term pregnant patient she had been attending to the previous day now showed no signs of pregnancy. Enquiries regarding what had happened to her child could not be answered by the patient in a meaningful way. The midwife decided to report this to the police and an investigation started. The patient eventually suggested the police search a dustbin which contained a large blue garbage bag. The bag was sent to the ILMFS for evidence collection and conduction of an autopsy on the body of the infant. A pmMSCT of the entire bag was performed before the collection of evidence and autopsy examination. The body of the infant was rescanned after its removal from the bag and before the autopsy commenced. pmMSCT results: The scans showed the presence of a full-term neonate among a variety of domestic waste including a metal pot, tin cans and food waste material (Fig. 3). Aeration of the right lung reaching into the peripheral alveoli was clearly visible, while the left lung exhibited partial aeration (Fig. 4). A gaseous extension in the gastrointestinal tract was also discernible (stomach and duodenum) but no putrefactive tissue changes were visible inside the hepatic vessels. No injuries were detected. Autopsy results: After opening the garbage bag, the waste material was sifted and the full-term body of a male neonate, including umbilical cord and placenta, wrapped in four towels, was recovered. No external signs of putrefactive changes were visible. The flotation test for the heart and lung bloc proved positive, as did the test for the stomach and duodenum (Figs. 5, 6). The liver section test proved negative thereby excluding the presence of earlyonset putrefaction of the tissues. No injuries were found but subpleural petechial hemorrhages and petechiae of the scalp were visible. It was therefore concluded that the cause of death was due to asphyxiation. The mother later confessed to smothering the infant.

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Fig. 3 Case 2—neonaticide: 3D CT scan of plastic garbage bag showing a variety of domestic waste and the complete body of a newborn

Case 3: Unknown cause of death Background: In autumn 2011, the mother of a 1-day old female neonate called the emergency services after discovering her lifeless child. The paramedics at the scene immediately carried out cardiopulmonary resuscitation (CPR) and an emergency doctor continued the treatment without success. The infant was declared dead and removed to the ILMFS for examination to determine the cause of death. The possibility of an unnatural death had to be considered; therefore a medico-legal autopsy was ordered by the state attorney. pmMSCT results: The scans showed no anomalies in the development of the organs, neither did they reveal any previous trauma. The lungs were aerated well into the peripheral alveoli and the visible air extension of the gastrointestinal tract including the descending colon was consistent with a neonate who had lived for at least 12 h

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Fig. 4 Case 2—neonaticide: 3D CT reconstruction with visualization of aerated regions in light blue coloration. Air is visible inside nasopharynx. The lungs exhibit signs of aeration. The air-extended stomach is clearly visible and a few air bubbles can also be seen in the duodenum. The placenta and remnants of the umbilical cord are visible just below child’s feet. A few air bubbles can be seen at the detachment site of the placenta

(Figs. 7, 8) [6]. The length of time which this infant had lived was independently confirmed by police investigations. No putrefactive tissue changes were discernible. Autopsy results: No external signs of putrefaction were visible. The organs did not exhibit any anomalies or injuries. Isolated pinpoint intrathoracic hemorrhages were discernible beneath the ectocardium, the capsule of the thymus and the visceral pleurae. Furthermore, liquid disintegration of the spleen was noted and smear samples taken for


Fig. 5 Case 2—neonaticide: main image: positive flotation test— lungs and heart bloc floating in water. The lungs are supporting the heart and mediastinum which are clearly suspended below the water surface. This is the classic positive sign of a live birth. Inset lungs and heart during the positive flotation test viewed from above. The lungs have a reddish-pink appearance and float on the water surface

bacteriological and virological analyses. All chemicaltoxicological, virological, microbiological, neuropathological, histological and bacteriological tests were negative. The flotation test was not carried out as this was a confirmed live birth. A morphological cause of death could not be ascertained and accidental or intentional asphyxia could not be ruled out beyond reasonable doubt.

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Fig. 6 Case 2—neonaticide: positive gastrointestinal flotation test— the stomach and part of the duodenum are floating on the surface while the rest of the intestinal tract sinks. This is a classic positive sign of live birth in conjunction with the lung flotation test

flotation test for the lungs, the GI tract and the liver was negative (Figs. 11, 12). The cause of death was attributed to intrauterine infection.

Case 4: Stillbirth Results Background: In spring 2012, a stillborn male neonate was delivered by Cesarean section after ultrasound examination showed that the child had died in utero. The decision of delivery via Cesarean section was taken due to the deteriorating condition of the mother. The mother passed away shortly after the Cesarean section from a pulmonary embolism. pmMSCT results: The scans showed a fully developed male neonate without any signs of a live birth (i.e. lack of aeration of the lungs and gastrointestinal regions). A small collection of air was discernible in the superior part of the nasopharynx (Figs. 9, 10). No developmental anomalies were detectable, and there were no pathological organ conditions or signs of external violence. Autopsy results: No external signs of putrefaction were visible. No anomalous conditions or pathologic changes were observable throughout the autopsy process. The

A comparative overview of the pmMSCT and autopsy data compiled from each case report is presented in Table 2.

Discussion Over recent years the analysis of postmortem CT scans and magnetic resonance imaging (MRI) has gained acceptance in institutes of legal and forensic medicine as an analytical tool in death investigation [14, 15]. The use of computed tomography to examine the developmental anatomy of fetuses and newborns has been demonstrated by Sakurai et al. [16]; while Brough et al. [17] analyzed the application of pmMSCT and 3D imaging for the anthropological examination of juvenile remains. Previous publications have advocated the use of conventional roentgenographic

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Fig. 7 Case 3—liveborn: 3D CT reconstruction with visualization of aerated regions in light blue coloration. The lungs exhibit signs of aeration. Advanced aeration of the gastrointestinal tract is visible

radiography in identifying aerated and non-aerated lungs as well as air inside the GI tract [2, 5]. Since the early seventeenth century the flotation test of lungs has been the main tool forensic pathologists have used to determine whether a child had lived separately outside the mother’s womb and had drawn breath. It is still the method of choice in many jurisdictions; in fact, the flotation test is a legally prescribed method of determination of live births in Germany, requiring every forensic pathologist to use it in cases of neonate deaths. This test has divided the medical community since it was first introduced into legal proceedings [3, 5, 8, 9, 18–23]. It is important to bear in mind the serious consequences for a person found guilty of neonaticide and any conviction based on the flotation test alone must be regarded with caution [24]. However, as this test is in use in a variety of

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Fig. 8 Case 3—liveborn: 2D coronal CT scan showing complete aeration of the lungs (blue arrows) and most parts of the gastrointestinal tract (red arrows). * The shadow of the heart overlaying the left lung

jurisdictions and accepted in court, attention must be paid to rigorous application of the test and solid interpretation of the results. Saukko and Knight’s attitude that the test is of limited value and should only be used as a ‘‘suggestive pointer’’ [13] is understandable in view of the many possible falsepositive and false-negative results which may be obtained when the test is administered incorrectly or under the wrong circumstances. Valid points for exclusion of the test in the presence of certain conditions and known facts have been made and should be kept in mind when determining live birth in newborn deaths. Some of the major exclusion points, for example, are putrefaction [2, 4, 6, 13], CPR [2, 4, 6, 7, 13] and, a rarely reported point, freezing/defrosting [2]. One of the problematic scenarios, which would have excluded the validity of the lung flotation results in the


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Fig. 10 Case 4—stillborn: 2D coronal CT scan showing complete lack of aerated areas

Fig. 9 Case 4—stillborn: 3D CT reconstruction with visualization of aerated regions in light blue coloration. Despite a small aerated area inside the nasopharynx there are no other signs of any gaseous contents detectable

past, is in cases where CPR has been performed. Kellett [1] argued that during resuscitation attempts artificially introduced air would produce some lung expansion, but this may not have the same appearance as lung expansion from natural respiration. Other authors confirmed Kellet’s argument, and stated that the main difference between artificially introduced air and naturally respired air lies in the extent of peripheral alveoli expansion, which is usually not achieved by mouth-to-mouth resuscitation efforts [2]. According to Kellett, during the traditional autopsy it is almost impossible to make this distinction morphologically [1] although histological examination may be of use in these cases.

However, pmMSCT results presented in this paper have demonstrated the visualization of complete aeration of some of the lungs in cases where a live birth was confirmed independently from the medico-legal examination, i.e. confirmation through the mother of the child and police investigative procedures. To the best of our knowledge the case studies presented in this paper demonstrate the first successful attempt at comparing postmortem multislice computed tomography (pmMSCT) scans of live birth signs with the traditional autopsy results of the flotation tests for lungs and the GI tract. Therefore, pmMSCT has an advantage over the conventional autopsy in the possible differentiation between complete aeration of the lungs and partial aeration. This demonstrates that pmMSCT may be used successfully as an additional tool to the flotation test when determining signs of live birth in a neonate. Four cases are a relatively low number to draw general conclusions from; however, the collection of a large

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Fig. 11 Case 4—stillborn: main image: negative flotation test—lungs and heart bloc at the bottom of the water-filled container. This is a classic negative result of the flotation test. Inset lungs and heart during the negative flotation test viewed from above. The lungs have a pale appearance and are lying at the bottom of the container

Fig. 12 Case 4—stillborn: main image: negative gastrointestinal flotation test—the whole GI tract is lying at the bottom of the waterfilled container. This is a classic negative sign of live birth in conjunction with the negative lungs and heart bloc flotation test. Inset GI tract during the negative flotation test viewed from above

Table 2 Overview of death circumstances and pmMSCT and autopsy aeration comparison results Case no.

Circumstances of death

Air—pmMSCT Lungs

GI

Other anatomical regions

Lungs

GI

Other anatomical regions

1

Neonaticide, mother threw infant from 5th floor, multiple trauma

Present, both lungs, aeration into peripheral alveoli

Present, inside stomach and duodenum

Present, inside cranium, spinal canal and heart ? vital reaction during traumatic episode

Present, both lungs floated and carried the heart and mediastinum

Present, stomach and duodenum floated

No visualization of air

2

Neonaticide, mother smothered the infant

Present, both lungs, full peripheral aeration of right lung, partial aeration of left lung

Present, inside stomach and duodenum

Present, placenta

Present, both lungs floated and carried the heart and mediastinum

Present, stomach and duodenum floated


3

Morphologically unknown cause of death of a 1-day-old infant

Present, both lungs, aeration into peripheral alveoli

Present, from stomach into descending colon

Absent

N/a, confirmed live birth

N/a, confirmed live birth


4

Stillbirth, intrauterine infection

Absent

Absent

Present, nasopharynx

Absent

Absent


GI gastorintestinal tract

123

Air—autopsy


number of cases with special circumstances within a reasonable amount of time can be difficult. This is particularly true when trying to study neonaticides with a short postmortem interval, the rarity of such cases accounting for the limitation of the sample size in this study. This study also demonstrates that pmMSCT can be used with ease to detect the presence or absence of putrefaction gases within the vascular system. The usual caveats pertaining to the flotation test should still be considered when applying the virtual method though. Our results suggest that the use of the virtual method in conjunction with the autopsy will provide additional strength to the differentiation of live births and stillbirths. Further analysis of future cases of known live births is recommended, including comparison of pmMSCT scans of suspicious cases to those of known stillborn neonates.

Key points 1.

2.

3.

4.

5.

Postmortem multislice computed tomography (pmMSCT) scans of four forensic infant cases were compared to conventional autopsy findings in order to evaluate the usefulness of pmMSCT in determining signs of live birth. It was possible to visualize the aeration of the lungs and GI tract effectively and the distinction between live birth and stillbirth signs using the pmMSCT was easily achieved. Although the sample size of the study was small, the extent of aeration of the peripheral alveoli was well observable in some of the lungs, indicating that pmMSCT may be an advantageous addition to an autopsy for differentiating between artificially aerated lungs (mouth-to-mouth resuscitation) and naturally aerated lungs (respiration). Differentiation between putrefaction gases within the hepatic vessels and natural aeration of the lungs and GI tract may be made using pmMSCT. The present study indicates that pmMSCT may be used as a non-invasive diagnostic tool in addition to autopsy procedures to aid in the differentiation between stillbirths and live births.

Acknowledgments Dr. Rene´ Gapert’s stay at the Institute of Legal Medicine and Forensic Sciences in Berlin was supported by a DAAD Research Scholarship (German Academic Exchange Service Research Grant A/11/75955). The authors would like to thank the anonymous reviewers for their helpful comments.

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